Healthy cholesterol levels

Measures to lower the blood cholesterol level

1.     Take a proper diet. Take food that is low in saturated fat and cholesterol such as fruits, vegetables, skinless poultry, lean meat, fish, rice, cereals, and vegetable oil.

2.     Maintain an appropriate weight.

3.     Exercise accordingly as advised by your doctor.

4.     If the cholesterol levels do not reach the minimum goal despite this measure, then doctor may put the patient on medication to lower cholesterol.

Vegetarian recipes

Benefits of being vegetarian

Human beings who eat exclusively a vegetarian-fruit diet for many decades infrequently have the diseases so commonly observed in meat eaters. Diseases very uncommon in vegetarians include : 

1. coronary artery disease (heart attack and angina), 

1. hypertension (high blood pressure), 

1. breast cancer, 

1. colon cancer and possibly cancer

1. prostate gland, 

1. obesity, 

1. peptic ulcer, 

1. diverticulitis and osteoporosis, 

1. gall stone, 

1. kidney stone. 

1. Bowel syndrome etc.

Saturated Fats

What is a saturated fat?

Any fat that solidifies in room temperature is a saturated fat. The saturated fat can be identified by its being solid at room temperature; the polyunsaturated and menstruated fats are fats are soft or liquid at room temperature. All three fatty acids are very high in calorie. The average American adult consumes a diet containing nearly 40% of the calories from fat, one third of which is of the saturated variety.

A reduction of the percent of calories from fat from 40% to 10% can reduce the blood cholesterol level around 150 mg/dl. This level can only be achieved by those who strictly follow the vegetarian diet. The diet of the Japanese historically has consisted of a 10% of calories from fat diet and significant ischaemic heart disease has seldom been observed. Today Japanese are consuming a diet averaging approximately 23% of calories from fat and the consequences have been a significant increase in the frequency of heart attack. Thus for diets to be very effective in lowering the blood total and LDL cholesterol levels, the percentage of calories from fat must be reduced to 20% and ideally 10%.

Types of fat

Saturated fat: Increases total and LDL cholesterol level, so, high risk.

a.      beef fat

b.     mutton fat

c.     egg yolk

d.     palm kernel oil

e.      coconut oil

Monounsaturated oil: Either lower or have a neutral effect on the total cholesterol level, so, no risk.

a.      olive oil

b.     peanut oil

Polyunsaturated oil: Decreases the total and LDL cholesterol level, so, no risk and the best oil to consume.

a.      Soyabean oil

b.     Corn oil

c.     Safflower oil

d.     Cottonseed oil

e.      Fish oil

f.       Sesame oil

Good Cholesterol

Cholesterol and heart problem

Cholesterol is a complex fatty substance produced by the liver for various functions in the body. The cholesterol in our food also contributes to the cholesterol level in our body. An excess of cholesterol results in the deposition of cholesterol in the arteries resulting in narrowing and hardening of he arteries called atherosclerosis (blockage). Too much cholesterol can slowly build up on the inner walls of arteries feeding the heart. Together with other substances, cholesterol forms plaque (early blockage) a thick bard coating that gradually clogs the artery over time. Cholesterol in the blood is carried in two main forms, low density lipoprotein (LDL) or band cholesterol and high density lipoprotein (HDL) or good cholesterol. LDL cholesterol is called bad cholesterol as it is associated with blockage formation and HDL cholesterol is called good cholesterol as it is thought to remove excess LDL (bad cholesterol) from blood. The only absolute, unequivocal, independent atherosclerotic (blockage formation) is an elevated blood level of total cholesterol or LDL cholesterol, a low HDL cholesterol level or both. What constitutes an elevated total cholesterol level is debated. If an elevated level is that minimal level above which atherosclerotic events occur, then that level would be approximately 150 mg/dl. The risk of getting heart disease substantially increases above the level of 200 mg/dl. Framingham study clearly demonstrated that higher total cholesterol or LDL Level and the lower HDL cholesterol levels are predisposing factors for the heart attack. International epidemiologic studies have shown that populations with blood cholesterol levels less than 150 mg/dl for decades have a near absence of angina or heart attack. A certain critical blood level of total cholesterol is necessary before a block approximately 150 mg/dl. As the level increases above this value, the risk of an atherosclerotic event (angina or heart attack) increases roughly proportional to the level and to the amount of time that this level has been present.

To keep a normal cholesterol level normal and to return an elevated level to normal, dietary intake of cholesterol, fat and total calories must be restricted or one or more lipid-lowering drugs must be administered or both. The average adult in the United States consumes approximately 500 mg of cholesterol daily. Nearly 50% of the direct cholesterol consumed by adults in the United States comes from the visible and no visible eggs eaten, so giving up eggs eliminates nearly half of the direct cholesterol intake. Bovine muscle (beef) accounts for nearly 30% of our direct cholesterol intake, so giving up flesh beef, mutton eliminates about one third of our direct cholesterol intake. Bovine products (butter, ghee, cheese etc) contain high amount of bad cholesterol, so they should be eliminated from the daily food. Most adults in the United States consume more than 100 gm of fat daily. Ideally men should consume no more than 60 gm and women no more than 50 gm of fat daily. There are two problems with the fat: 1. all fats possess a saturated component  2. all fats are high in calories. Saturated fat are dangerous for heart patients and their presence in the food must be curtailed.

What to do when having a heart attack

What to do in a heart attack?

If you have the kind of chest pain just described, you may be having a heart attack. So seek medical assistance immediately. Many people delay seeking medical help thinking the pain will go away. This could be fatal. More than half of all deaths from heart attack occur in the first few hours. Valuable time may be lost in initiating proper treatment. The earlier a heart attack victim gets to the hospital the better are the chances of survival and more importantly the possibility of saving extensive muscle damage.

If you suspect that you are having a heart attack take the following steps:

1.    If you are not sure whether the chest pain is a heart attack or not, call your doctor immediately and describe your symptoms carefully.

2.    If your doctor can not be reached, go to the nearest hospital at once.

3.    Do not drive to your doctor/hospital on your own. Instead, ask your immediate family member/driver or friends to take you to the hospital.

4.    Avoid exertion and stay calm.

5.    If you have been a heart patient before and have nitroglycerine tablet (GTN) or GTN spray with you, sit down or lie down and put one GTN tablet underneath your tongue or spray GTN inside mouth. If the pain is not relieved within 5 minutes, you can take another GTN tablet or GTN spray. If there is still on improvement, you should then seek medical attention immediately.

Heart attack pain

Anginal pain vs Heart attack pain

Anginal pain usually starts after exertion and is relieved by rest. In contrast heart attack pain may start at rest and even during sleep. Heart attack pain is more severe than anginal pain and it is not relieved by rest. Anginal pain usually responds to GTN tablet under tongue or GTN spray but Myocardial infarction (heart attack) pain remains unabated even after taking multiple GTN tablets. So if you are a known case of angina pectoris and if your pain does not respond to 2/3 GTN tablets please consult your doctor or go to the nearest hospital immediately.

What is Angiogram

Coronary angiogram

This is the most important test to which a patient with cardiac disease can be subjected. Currently the risks of angiography are minimal. Coronary angiogram is expected to document not only the presence of blockage in the coronary artery but it also documents the location, severity and type of the blockage and provide guidance regarding the modality of treatment e.g. drugs only, balloon treatment or by-pass operation. Coronary angiogram is a invasive test and carries a little risk but it is regarded as the gold standard for the diagnosis of block in the coronary artery. The procedure is very simple but this test can only be done in a cardiac catheterization laboratory. This test is not possible in an ordinary hospital operation theater. The procedure is carried out under local anesthesia, either through groin (upper part of thigh) or through arm. The test is performed using special plastic tubes called catheters. These catheters are introduced inside the arteries through a small needle puncture and general anesthesia is not required. The patient only feels pain during giving local anesthesia and during needle prick. When the catheters are moved and manipulated in the blood vessels and the heart, the patient will not experience pain. The catheters are advanced through the puncture site to the origin of the coronary arteries supplying the heart. After cannulation special dye (contrast media) are injected inside the coronary arteries by hand injection. Multiple pictures of the coronary arteries are taken during injection of dye in side coronaries. Coronary blockages are not visible in conventional X-ray films and only it can be seen during dye injection. All the three arteries (left anterior descending artery, LAD; Left circumflex, LCX and right coronary artery, RCA) can be visualized during coronary angiogram. Before coronary angiogram doctors always remain in doubt regarding the appropriate type of treatment required by the patient. The information from the angiogram would allow the selection of the best form of treatment for the patient, be it medical, balloon angioplasty (PTCA) or coronary by-pass operation.

The risk of coronary angiogram is very minimum and no question of being afraid. Patient remains in full sense during the procedure and the patient can talk with his cardiologist during the test and can see the angiogram procedure in television screen during the procedure. The whole test is usually completed within 15 to 30 minutes. The patient can be discharged from the hospital after 24 hours of the procedure. Now a day’s coronary angiogram are carried out on an outpatient basis and no need for hospital admission. Being a invasive procedure there are some risk inherent in the procedure. The risk of death is about 2 in 1000 procedures, myocardial infarction (heart attack) 1 in 200, stroke 1 in 200, ventricular arrhythmias (irregularities of heart beat) 1 in 100 and blood vessel complications e.g. thrombosis, bleeding etc 1 in 100 cases.

 Risks of coronary angiogram

Complications                                            Percentage

Death                                                          0.11%

Myocardial infarction (heart attack)              0.05%

Cerebrovascular accident (stroke)                 0.07%

Arrhythmia                                                  0.38%

Vascular complications                                 0.43%

Contrast reaction                                         0.37%

Heaenodynamic complications                      0.26%

Perforation of heart                                      0.03%

Other complications                                     0.28%

Total of major complications                        1.70%

[ Modified from ACC/AHA guidelines for Coronary angiography J Am Coll Cardiol 199; 33(6) : P-1760]

The skill and experience of the operator, the catheterization laboratory staff, and the preprocedure and post procedure staff are also important factors in reducing complications. Operator experience is clearly related to lower complication rates. This fact has led American College of Cardiology to recommend a minimum operator volume of 150 diagnostic catheterization per year. This is also true for coronary angioplasty facilities. Recent studies have suggested that laboratory volumes of >200 angioplasty cases per year and 75 cases per operator are necessary to minimize complications and maximize success.

Can you have heart attack without chest pain

Can you have heart attack without chest pain?

Yes, this is possible. In certain instances you may have heart attack without chest pain. In some patients, particularly in the elderly, myocardial infarction (heart attack) is manifested clinically not by chest pain but rather by symptoms of breathlessness, vomiting tendency, profuse sweating and severe weakness. So, if an old man suddenly develops breathing difficulty or sweating or sudden onset of weakness, the possibility of heart attack requires to be excluded. Unrecognized or silent myocardial infarction (heart attack) occurs more commonly in patients with diabetes. Sudden onset of breathlessness or severe weakness in a diabetic patient is alarming and it requires thorough heart check up.

Quit smoking

Stop smoking right now. 

Follow the following instructions to quit smoking. 

1. Get rid of all your cigarettes, discard matches and lighters.
2. Take deep breaths, when ever you feel the urge to smoke. Hold your breath for 10 secs then release slowly.
3. Exercise to relieve tension-walk instead of riding when ever possible.
4. Think of negative image. You  associate with smoking when you feel tempted. Select your worst memory connected to smoking. Think of breathlessness when running.
5. Reward yourself, with apple slices instead of smoking. Eat three meals a day.
6. spend time with friends who don't smoke.
7. Go publicly with plans to quit smoking. 

Life after heart attack

What is time important After Heart Attack

Undue delay in seeking medical advice after heart attack can lead to unfortunate fatal outcome. Everybody must realize that first few hours after heart attack is crucial. Most of the deaths occur in this period and proper treatment can prevent fatal outcome. So please do not make great mistake. There are few scientific reasons why heart attack patient must go to hospital immediately:

1.    Deaths due to electrical instability (irregularity of heart beat) are very high during early hours of heart attack and this can be immediately treated by counter electric shock (DC shock) if you are inside a coronary care unit. This type of irregularity is fatal if not treated urgently. If you are inside a coronary care unit this fatal electrical instability can be managed even by a nurse or medical technician. A timely action may save your life and it is usually completely reversible.

2.    Heart attack is always due to blockage of one of one of your coronary artery (blood solidifies inside your coronary artery and this solidification of blood is called “thrombus”). Now a day’s medicines are available which can dissolve the thrombus/clots and restore normal coronary artery flow and prevent further damage. These medicines are called thrombolytic agents (which dissolves thrombus). These agents are expensive but they are very rewarding. These agents are now available in our hospitals. So, it is a real hope against extensive heart damage. They can reduce the fatality by 45% along with aspirin. But this injection is only effective if they are given in the early hours of heart attack. There are some evidence that if these injections are given within one hour they may completely reverse the heart attack. These medicines are usually administered within 6 hours of the heart attack. After 6 hours their efficacy is doubtful. So, if you report to hospital after 6 hours you are certainly going to miss this magic bullet.

3.    At the inception of heart pain you may have minimum damage to your heart muscle, so, if you report to hospital early the further damage may be prevented by using drugs like intravenous injection of heparin and GTN/Isosorbide dinitrate. Early intervention preserves your heart function. So, seek medical attention immediately after suspecting heart attack.

Danger of smoking

Dangers of smoking

It goes without saying that smoking is a very and habit. In spite of knowing the truth. More than eighty percent people l of our country is in the habit of smoking. It is smoking which is the cause of many fatal diseases. It causes cancer, heart attack chronic, bronchitis and much other disease it is said that one puff of cigarette smoke cantinas fifteen billions partials of injurious matters. Nicotine is one of them. Ti prevents the free flow of blood through the veins of human bodies. It reduces the supply of oxygen in the body of the smoker. It damages our lungs and harms the nerves, damages the brain and sometimes spoils the character. A Smoker can harm a non-smoker. If a non-smoker stands by the side of a smoker at time of smoking, it can be as dangerous as to the smoker. Because at the time of taking breath, he takes the smokes of cigarettes which is harmful for his body. It is a matter of joy that there is no smoker in our family.  All the members of our family are aware of the eyes, offend the nose and unsettle the mind. For this reason, I think smoking in public places should be banned. 

Ischaemic heart disease

What is silent Ischaemic Heart Disease

Some times it may happen that you have gone to a doctor for routine heart check up but you do not have any chest pain or previous history of heart disease and after doing ECG your doctor tells you that you are having heart disease. Sometimes ECG may be done for other reasons like preoperative risk stratification or to fill up insurance company protocol or reemployment check up or during annual confidential report time and it is found that your ECG is abnormal. If you do not have any chest symptoms but your ECG reveals abnormality, you must have a thorough cardiac checkup. If you do not have chest pain it does not mean that you can not have block in your coronary artery. Some people in spite of having block in heart circulation do not have chest pain. This means that you have disease but your “warning system” is defective. Silent ischaemia is one of the causes of sudden death. Why some patient get severe pain and other do not is not well recognized. But probably it is due to the variability of individual pain threshold. Pain threshold varies from person to person. Some are afraid of taking a simple injection but some can stitch there own wound him. Possibly some patients do not have angina in spite of having significant ischaemic changes in ECG.

          If your ECG is abnormal it does not always mean that you are having blocked but it is a genuine called normal variant ECG (that means functional deviation from the normal status). Even then if you're ECG is found to be abnormal at routine check up, you must undergo adequate examination to exclude or to establish coronary artery block. You must remember that a fire may remain hidden under ashes for a long time but it may burst at any time. So, beware of it and do not neglect.

Effects of Smoking Cigarettes

Smoking kills the heart

Cigarette smoking is one of the major public health hazards in the developed and developing countries. It has been estimated that a 25 years old male who smokes twenty cigarettes per day will shorten his life by 8-10 years compared to his non-smoking counterpart. Others evils such as cancer and lung diseases aside, smoking are one of the most important risk factors of coronary artery disease (CAD). Epidemiological studies in USA showed that; overall age adjusted 6-year risk of CAD death was 2.3 time higher for cigarette smokers compared to non-smokers. As for the females, smoking and use of oral contraceptives carried a joint impact of a ten-fold increase in CAD compared to their counterparts.

The damage from smoking is ‘dose related’. Pipe and cigar smokers were said to have less propensity to heart disease while use of efficient filters were thought to reduce the risk of smoking. But the only certain way to protect your heart is to quit smoking! Remember, when you quit smoking, you spare the “passive” (involuntary smokers who work in the same office with the smokers, spouses of smoker etc.). Passive smokers are also prone to develop heart attack, lung cancer etc. The good news is that you could reverse many of the adverse effects of smoking by quitting now. Within 2 years of quitting smoking, the heart attack risk is reduced to half that in smokers. Within 10 years, the risk of heart disease is the same as that in non-smokers. Quitting smoking now greatly reduces serious risk to your death.

Kicking out the smoking habit does not come easy. Determination is the most important factor to success. Set an auspicious date to quit smoking and tell your close friends (particularly the smoking ones) and relatives about it to enlist social support. List the long-term health benefits of quitting smoking, and if this seems too remote think of the immediate rewards such as cleaner breath and improved stamina and money saving. Many people who succeeded in kicking smoking began to gain weight. They regained their appetite, and tended to snacks when they carved for cigarettes. So keep a stock of low- calorie snacks on hand when you watch TV or read. Others turn to regular exercises to over come the craving.

The are a variety of interventions to reduce smoking. On an average, about 5 percent of smokers will discontinue the habit for 1 year after receiving a physician’s advice, although the rate of quitting will be higher in more highly motivated cohorts. Nicotine gum or trans dermal patches may increase the 1 –year likelihood of smoking cessation by 30 to 100 percent. Nicotine withdrawal can be managed by tapering cigarette smoking, gradually changing to lower nicotine cigarettes and substituting chewing of nicotine gum. Nicotine gum is prescribed as needed, up to 30 doses per day. The average patient uses 10 doses per day and the frequency of dosing declines over a 1 to 3 month period.

The association between hart disease and smoking is well known to lay public. Myocardial infarction (heart attack) or  by pass surgery is a sufficient impetus for 20 to 60 per cent of patients to stop smoking.

Group counseling can increase rate of quitting. Public programs also are effective, with television advertisements against smoking among the most cost effective.

Stop smoking right now. 

Exercise in the morning for Heart

Exercise but when, Morning or Afternoon?

The time of onset of myocardial infarction (heart attack) and other ischaemic heart events and arrhythmic episodes (irregularities of heart) display a circadian rhythm (variation of time of occurrence) with peak occurrence in the early morning between 6 am and noon. This may be related to morning surges of hormone cortisol, increased blood level of catecholamine and greater platelet agreeability that occurs in the morning as compared with the afternoon. Since exercise may also precipitate ischaemic heart events, it has been postulated that it is safer to exercise in the afternoon than in the morning. But there was no statistically significant difference between the risks of exercising in the morning vs. the afternoon. The risk of untoward cardiac events during regular exercise is low in patients with heart disease, whether they exercise in the morning or the afternoon. Data suggest that the answer to the clinical question of when patients with heart disease should perform regular, sub maximal exercise is clear: AM and PM are both safe.

Recommended Physical Activity

 Physical activity recommended

The previous recommendation was 20 to 60 minutes moderate to high intensity endurance exercise three or more times per week. But recent recommendations differ from the earlier report. It is now recommended that adult should accumulate 30 minutes or more of moderate –intensity physical activity on most, preferably all days of the week. Adults who engage in moderate-intensity physical activity-ie, enough to expend approximately 200 calories, per day, can expect many of the health benefits. To expend these calories, about 30 minutes of moderate-intensity physical activity should be accumulated during the course of the day. One way to meet this standard is to walk 2 miles briskly.

Intermittent activity also confers substantial benefits. Therefore, the recommended 30 minutes of activity can be accumulated in short bouts of activity : walking up the stairs instead of taking the elevator, walking instead of driving short distances, pedaling a stationary cycle while watching television. Those who perform lower-intensity activities should do them more often, for longer periods of times or both. People who prefer more formal exercise may choose to walk or participate in more vigorous activities, such as jogging, swimming or cycling for 30 minutes daily. Sports and recreational activities, such as tennis of golf, can also be applied to the daily total.

Most adults do not need to see their physicians before starting a moderate-intensity physical activity program. However, men older than 40 years and women older than 50 years who plan a vigorous program or who have either chronic disease or risk factors of cardiovascular disease should consult their physician to design a safe, effective program.

Multidetector CT

MDCT (Multidetector CT)

Coronary artery blockage now can be diagnosed by non invasive method without doing coronary angiogram by using Multidetector CT scan. Recent Developments in computed tomography enable for the first time to perform dedicated examinations of the heart using helical CT. The applications of MDCT in cardiology are multiple: assessment of coronary calcification, assessment of the coronary arteries and arteriosclerotic changes, direct visualization of intracardiac thrombi and pericardial effusion.

"X" Syndrome

What is Syndrome “X”?

If the medical scientists can not dig out the cause of any disease or fail to solve any other medical problem they use the term “X”. In reality X means cause is not known. Some people get angina or angina like chest pain without any blockage in their coronary artery. This is called syndrome “X”. Their rest ECG is usually normal. In 20% of cases their stress test may be positive for heart pain. These patients complain of chest pain but their coronary angiogram is normal without any block. Now question is that why these people get angina like chest pain though does not have any block. There are certain explanations; in coronary angiography we can only see the large arteries but we can not see smaller arteries so there is possibility that these patients are having disease in these small vessels which can not be seen in angiogram. Second possibility is that these patients may have abnormal vasodilator reserve which means that can not dilate and constrict their coronary arteries like normal people. This type of chest pain with normal ECG and normal coronary angiogram is frequently found in women. This can lead to multiple medical consultations and be responsible for a great deal of anxiety. Some researchers have found that 66% of patients with chest pain simulating heart pain with normal coronary artery have some psychiatric (mental) disorders. Their long term prognosis is very good. They usually do not develop heart attack. These patients require assurance and proper antagonist group of drugs like nifedipine, diltiazem, amlodipine work excellently in this situation. Tricyclic antidepressant may be effective in some patients. Behavioral therapy may teach the patient with pain how to function more effectively.

Heart pain

Types of Heart pain

Doctors usually divide the heart pain (angina pectoris) into two categories:a.     Stable angina
b.     Unstable angina

Stable refers to the predictable appearance of chest discomfort with a certain amount of exertion. For example, walking fast or up a slight incline usually produces symptoms, but they never occur when you are walking at a slow pace on level ground. It disappears promptly with rest, and its severity, duration, and precipitating causes do not usually change over a period of years. In contrast unstable angina is alarming. Sometimes it is the harbinger of death  So it requires immediate attention. In layman term unstable angina means when the patient gets chest pain at rest.

          Canadian cardiac society (CCS) classifies heart pain into 4 categories:

1.    CCS class-1 angina- This means the patient gets chest pain only during marked physical exertion and promptly relieved by rest.

2.    CCS class-2 angina- It occurs after moderate exertion and relieved by rest.

3.    CCS class-3 angina- Chest pain occurs after mild physical exertion. Even routine household activities may precipitate such type of angina.

4.    CCS class-4 angina- Class 4 angina means pain at rest.

Unstable angina is class 4 angina. Unstable angina describes two situations. In one, pain occurs in patients with no background of prior symptoms. In the other case of unstable angina, individuals with previously stable angina will experience changes in their symptoms, the pain may be more severe, lasting longer, or it may appear with less exertion than before.

Except these types of angina there are some special varieties of chest pain. If patient gets pain just after taking food, it is called postprandial angina. Chest pain after taking food is very suggestive of significant ischaemic heart disease (IHD). Some patients awake from sleep at night due to chest pain, this type of pain is called nocturnal angina. Patient may experience pain in lying condition, which is termed as angina decubitus. Emotional stress may precipitate heart pain, called variant or Prinzmetal angina.

Stable angina does not require urgent medical attention; however, unstable angina needs immediate care. Furthermore, the circumstances under which angina takes place also will govern how the problem should be treated. For example, chest discomfort that is noted only rarely, and then only with extremes of exertion, need not be handled with the same urgency as angina triggered by walking across a room.

Coronary Artery disease

How to predict risk of heart attack

Risk factors of coronary artery disease

You are at a greater risk for angina pectoris (heart pain) and Myocardial infarction (heart attack) if you/your

1.    are male

2.    smoke cigarettes

3.    have high blood pressure

4.    have diabetes

5.    are inactive

6.    are overweight

7.    have high blood cholesterol

8.    father/mother have coronary heart disease

9.    are of Type A personality (very ambitious and competitive).

 

What is risk factor?

A risk factor may be defined broadly as any habit or trait that can be used to predict an individual’s probability of developing coronary heart disease (1). A rise factor so defined may be a causative agent of the disease. A more limited and specific definition is that a risk factor is a causative agent or condition that can be used to predict an individual’s probability of developing disease. In most instances, a risk factor is the trait that predicts of development of clinically significant disease within a population. In most of the cases, it is involved in the causation of the disease. There are four very important risk factors for the causation of heart attack. These are cigarette smoking, high blood pressure, diabetes mellitus and high blood cholesterol level (2-5).

Risk factors of heart attack?

Increasing knowledge of risk factors in coronary artery disease has enabled us to identify them in individuals and in communities. It is therefore possible and desirable to correct or modify them so as to reduce the incidence of heart attack. There are two types of coronary risk factors; non modifiable risk factors and modifiable risk factors. Those risk factors which you can not reverse are called non-modifiable risk factors or in other words, you are born with some of those risks. Those risk factors which you can correct by drugs or by changing lifestyle are called modifiable risk factors.

A.   Non-modifiable risk factors include:

1.    Masculine gender

2.    Increasing age

3.    Family history of heart attack

B.   Modifiable risk factors include :

1.    High blood pressure

2.    Diabetes mellitus

3.    Smoking

4.    High blood fat

5.    Overweight

6.    Physical inactivity

7.    Stressful life

The effect of combined factors is not an additive but a multiplying one. For example a person with untreated high blood pressure is twice as likely to get heart attack compared with someone with normal pressure. If he also suffers from diabetes his chances of developing heart attack is five fold; and if he is also a heavy smoker, her is nine times more likely to get ischaemic heart disease (6). Modification of risk factors has already been proven to be effective in reducing the incidence of coronary heart disease in population studies. For an individual, preventive measures must be targeted towards modifying his risk factors in a manner which is practical and acceptable. If he has high blood pressure, is a heavy smoker and has high blood fat, all three factors can be tackled all together. For the community the approach must be multifactor and sustained.

Blood supply of the heart

Blood supply of the heart

The heart is located in the chest just behind the breast bone and between the two lungs. It is composed of muscle called myocardium (heart Muscle). Myo- means muscle and cardium means heart. The heart is externally covered by a sheath called pericardium. Two third of heart is in the left side of the chest and one third on the right. Heart is a muscular organ about the size of a fist. The heart is a compact, hollow, muscular organ of a some what conical or pyramidal form possessing, therefore a base, apex, and a series of surfaces and borders. An average adult heart measures about 12 cm from base to apex, 8 to 9 cm transversely at its broadest part, and 6 cm from base to backwards. Its weight, in the male, varies from 280 to 340 gm (average 300gm), while in the female, from 230 to 280 gm (average 250gm). The adult weight is achieved between 17 and 20 years (1). The heart is divided by vertical septa into four chambers, the right and left atria and the right and left ventricles. In simple way, atrium means blood receiving chambers and ventricles means pumping chambers. Right heart chambers (both right atria and right ventricle deal with deoxygenated impure) blood and left sided chambers (both left atrium and ventricle) deal with oxygenated (pure) blood. The impure blood arrives in right ventricle by way of right atrium and right ventricle pumps the blood in the lung circulation through pulmonary artery. The impure blood gets pure in the lungs and comeback to left ventricle through left atrium. Then left heart pumps the pure blood through out the body.
          Heart also have four values, they are mistral value or bicuspid valve (bicuspid means two doors), tricuspid valve, aortic valve and pulmonary valve. Valves are not affected by coronary artery disease. Heart disease may involve coronary artery or it may involve the valves. But one should not confuse coronary artery disease with valvular heart disease. They are two separate entities. Valvular heart disease is the end result of rheumatic heart disease but coronary artery disease means the obstruction in the coronary blood flow.

     Though the heart supply the nutrition of the whole body but it also needs nutrition (food) for its own survival. Heart needs food in the form of oxygen. Oxygen is supplied to the heart’s own muscle through coronary arteries. When these arteries are blocked by some means heart itself does not get enough energy to supply whole body. This situation is called ischemic heart disease or coronary artery disease. When doctor talks about ischemic heart disease (heart attack), he usually specifies the disease of left ventricle. Right and left atrium's are usually not affected by the ischemic heart disease and right ventricle is very rate victim. Left ventricle has thicker wall (8-11mm). If left ventricle does not get enough blood then patients feel pain particularly during exercise.

Blood supply of the heart

There are two coronary arteries which supply blood (nutrition) to heart muscle. They are right coronary artery and left coronary artery. Left coronary artery is further divided into two big branches, Left anterior descending artery and left circumflex artery (LCX). So, in reality heart is supplied by three big arteries, right coronary artery (RCA), left anterior descending artery (LAD) and left circumflex artery (LCX). When your doctor tells about IHD he means that some of your coronary artery is not functioning well due to blockage. All the three big arteries are equally important for all person. Even a significant block in one artery may cause severe symptoms. When patients visit his doctor for consultation, doctor off and on uses the terms single, double and triple vessel disease. What does it mean? If one of your artery is significantly blocked it is called single vessel disease (SVD), if two of your arteries are blocked it is called double vessel disease (DVD) and if all of your three arteries are blocked then it is called triple vessel disease (TVD).          Left ventricular ejection is very important for the longevity of the patients with heart disease. What does ejection fraction actually mean? In a simple way it implies the strength of the left ventricle. During each heart beat left ventricle pumps certain amount of blood to other parts of the body. This is called ejection fraction. Ejection fraction indicates the strength of your heart, how efficiently your heart can pump blood. During diastole (when ventricle relaxes) blood collects inside the ventricle. The amount of blood that collects inside the ventricle at the end of diastole is about 130 ml. During heart contraction heart pumps about 65% of this incoming volume. Normal ejection fraction (EF) varies from 55% to 75%. If EF is less than 50% it indicates early impairment of heart muscle strength. If EF is in between 35 to 45%, heart function is moderately impaired and if EF is less than 35%, it means that heart pumping is severely impaired.Does all chest pain come from heart?If you get chest pain, it is not always true that you are having heart disease. Your chest does not only contain heart. In fact chest comprises a number of structures other than heart and all of them may cause pain. Some of them mimic heart pain. A number of different conditions may cause chest pain; some are harmless while others are serious. Pain that is not originating from the heart the heart is called no cardiac chest pain. The source of pain may be from any structure within the chest cavity such as the esophagus (food cannal; through which food from the mouth enters into the stomach), lungs of airways.          The most common source of chest pain is the chest wall. Typically such pains are transient, lasting form few minutes to few days, reaching peak intensity within few hours, are often produced by certain positions of the body, relieved or intensified by movement of the chest such as breathing, and tender (painful to touch) and this type of pain is usually sharply localized (1). This type of pain is not associated with significant breathlessness, sweating or vomiting. Sometimes viral infection may cause chest pain. Such pain is usually accompanied by low grade fever, dry cough and prostration, which are unusual in heart pain. Ischaemic heart pains usually do not produce fever at its inception. Some times pain usually do not esophagus mimics cardiac pain. Esophagus pain is one of the important causes of chest pain. But this type of pain is burning in nature, has got relation with food intake, typically occurs while the subject is at rest rather than during exercise and is usually relieved by antacid. In addition, the patient often has accompanying symptoms such as gas and acid eructation (2-4). Chest pain originating from within the chest may be from the lungs or from the pleura (covering membrane of the lungs) (5). Breathing deeply intensifies such type of pain. If patient holds breathing pain disappears. Usually there are other clues that it is coming from the lungs; often the patient has a cough or an illness with fever. Chest muscle pain is also some times confused with heart pain. If pain originates from the muscle it is called myalgia chest. This type of pain is localized without any radiation, intensifies with change of body posture and surrounding area is painful to touch. Such pain promptly respond to simple analgesic like paraectamol, aspirin or other NSAID eg  indomethacin, diclofenac , ketoprofen etc. Some times pain may be felt in the area where rib bone meets with the cartilage. This is called costochondritis (1). It is much localized pain and the overlying skin sometimes becomes reddish. Chest pain also may originate from the nerve roots coming out of the spinal cord.          Each of these sources of chest pain has its own characteristics; however some general features of non cardiac chest should be brought to your attention. So the doctor must exclude the possibilities of no cardiac pain during evaluation of a patient with chest pain.