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.

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