Heart is a pump made up of specialised muscles. Its function is to pump blood to all parts the body. It pumps 11 pints of blood each minute. Heart is divided into two parts. The right side of the heart pumps blood from all over the body to lungs so that it is oxygenated. The left side of the heart circulates this oxygenated blood from the lungs to brain, limbs, stomach kidneys, liver and the rest of the body and most importantly to the heart muscle itself.

Heart Arteries (Coronary Arteries)

Special heart muscle called `Myocardium needs oxygenated blood supply for its proper functioning. The arteries that provide blood to these muscles are called `Coronary Arteries`. There are three major arteries of heart, which are further divided into smaller ones so that all parts of the heart are supplied with oxygen.

Causes of Coronary Heart Diseases (CHD)

There are many factors that may cause CHD and heart attack. These are called “Risk Factors”. You may have one or more of these factors. More the number of risk factors, greater will be the chance of CHD. It is quite important to be aware of your risk factors.

Risk Factors:

• Smoking
• Hypertension
• Hyperlipedaemia
• Lack of Exercise
• Obesity
• Stress
• Family history
• Diabetes and specially insulin resistant states.

What is Heartache (Angina)?

With narrowing of coronary arteries, the amount of oxygenated blood that can be pumped into the heart tissues is reduced. Heartache occurs whenever the amount of oxygenated blood reaching the heart muscle is less than required for the force of contraction of the heart muscle for instance, during the exercise.

It is difficult to describe this pain. It seems as if there is some pressure or heaviness on the chest. Often pain radiates to throat, neck, jaws and arms. These symptoms are often regarded as a bad digestion. This pain generally starts from the left side of the chest and is accompanied with sweating and a feeling of impending death.
Heartache (angina) may happen during exercise, emotional stress or in cold weather and exposure to cold wind. You must stop whatever you may be doing when the heartache occurs and when prescribed take nitroglycerine as directed. You should avoid activities that cause heartache and do not expose yourselves to stress, weather etc. that you know cause heartache.

What is unstable coronary artery disease (UCAD)?

If you have rest pain or easily provoked chest pain or persistent long duration pain, and the ECG or enzymes are not diagnostic of a heart attack then you are regarded to be suffering from UCAD. This condition is highly unstable and may develop into a heart attack. Its treatment is differs from that of heart attack. In particular, clot-busting drugs are not administered. They may cause harm. GTN, heparin, aspirin and beta-blockers are administered. Urgent angiography may be performed if the progress is unsatisfactory.

What is Heart Attack?

Heart attack is caused when the coronary arteries are blocked with a blood clot. Once oxygen supply to the heart tissue is terminated then the heart will start to suffer, and if the blood clot is not removed in a short time the heart tissue thus deprived of oxygen, dies. It is therefore vitally important to reach the hospital and receive a clot-busting drug within an hour of start of the pain, especially if the pain lasts for more than twenty minutes. The best way is to call a paramedic ambulance. These carry special equipment and drugs for relief of pain and safe transport to the hospital. They also carry Aspirin for immediate administration. Aspirin prevents further clot formation.The permanent damage to heart tissues is called heart attack or myocardial infarction. The outlook depends upon the amount of heart tissue permanently destroyed and hence the urgency of clot-busting drug administration.

Your Stay in the Hospital

In the beginning, you will be asked to take bed-rest. It is very likely that you are connected
to a heart-monitoring device. This monitor keeps a record of the activities of heart. Once you start feeling better, and the doctors and nurses are satisfied that you are safe to have the monitor disconnected it will be removed and you will be asked to walk.

Before leaving for home, you will practice more frequent walking. But if you feel pain or breathlessness, you must inform the nurse immediately for further treatment. Usually you will have no further symptoms and you will be allowed to go home after six days. During your stay in the hospital, many tests may be performed. Your additional treatment will depend on the result of these tests and your symptoms (pain and breathlessness etc.)

Some Frequently Asked Question

What would happen to my affected heart?

The part of the heart that is permanently damaged will never recover. Other parts may recover completely or need opening of the coronary arteries to help the healing process. That is why you will have further tests during hospital stay and soon thereafter, depending on your symptoms and progress. In time other blood vessels grow into the poorly oxygenated muscle. This is called “Collateral Circulation”. This is nature’s way to help with the healing process. Often, therefore, there is no need to do any more than wait until this process is complete.

What is the difference between heartache and heart attack?
Heartache is a warning, whereas, heart attack is a tragedy. There is no damage involved in heartache, while the tissues are dead in heart attack; this condition is also called Myocardial Infarction.

How is diagnosis possible?

ECG:

It records the electrical activity of the heart. With this technology, heart rhythm and diseases can be detected. A normal tracing does not exclude CHD.

Chest x-rays:

The x-ray is performed to see the size and shape of heart and lungs.

Echocardiogram:

This will measure the size of your heart and outline the size of the heart damage as well power and capacity of the heart. This is an ultra sound scan of the heart through which the activity of heart chambers and valves is assessed. You will be asked to have this test done before discharge or as an outpatient as deemed appropriate.

Blood Tests:

Through these tests, Dr can diagnose heart attack. As well as those kidney functions, haemoglobin, liver functions and the level of fats in the blood is measured. After a heart attack, heart cells enzymes leak into the circulation. These are called “Cardiac Enzymes”. The quantity of these enzymes in the blood increases after a heart attack. One of these is called creatine kinase (CK). Its isoenzyme is CKMB. This can quantitatively estimate the size of the damage. However for this purpose one needs frequent half hourly measurements of this enzyme over 24 hours, hence it is not routinely estimated.

Another very sensitive and specific enzyme is troponin-t or i. Some times it is measured when CK is not sufficiently raised. It is also measured in assessing outlook and management of patients who are experiencing repeated rest or easily provoked pain. This enzyme rises very early and if it is normal until four hours after suspected heart attack, then the outlook is regarded to be good and the patient is discharged home from the admission room, to be investigate on an outpatient and a rapid access basis.

Exercise Tolerance Test:

This test allows assessment of diagnosis and the best treatment. It assesses the degree of deficiency of your oxygenated blood supply to your heart. It depends both on the CHD as well as the collateral circulation. For this test you are connected to a special ECG and blood pressure monitor and asked to walk on a machine, called “treadmill”.

This test may be carried out during your stay in the hospital or as an outpatient after at most, four weeks. You will be given an appointment for this test.

M.U.G.A Scan

This test is performed after administration of a radioactive substance (isotope), such as, thallium or technetium into your vein. Your heart muscle takes up either of this substance provided the muscle has a blood supply. If there has been a blockage to the coronary artery, or significant narrowing of an artery than that part of the heart muscle, will either receive no or a reduced amount of blood. Subsequently a gamma camera takes pictures of your heart muscle. Any part of the heart muscle that has no or reduced uptake (perfusion) of isotope, will either not appear on the picture or will be only faintly photographed. The isotope is often injected during exercise or after administration of drugs that increase requirement of oxygenated blood to the heart muscle. After a period of rest pictures are repeated. This is in order to see if some parts of the heart take up the isotope during rest. It allows us to assess the perfusion and function of the heart, both at rest and during exercise.

Angiogram:

This test takes x-ray pictures of the coronary arteries and the heart and its valves. In this procedure, a very fine tube is inserted into the vein of an arm or leg, under a local anaesthetic. The tube is slowly introduced into the coronary arteries and the heart cavities. Afterwards, a special chemical that is opaque to the x-ray is injected into the arteries or the heart cavities in order to take their movie (cine) pictures, on a disc using a digital camera. Usually this test is carried out as a day case, occasionally you may have to stay overnight, especially if it is decided to deal with the problem straight away.

Methods of Treatment:

Angioplasty:

If an angiogram reveals serious narrowing of coronary arteries, then a special tube, with a balloon on its head, is guided into the narrow part of the artery/ies. The balloon is thereafter filled with air by gradually increasing volume of air till desired opening of the artery is achieved. Usually it results in efficient blood supply. Usually a coil of a stiff material (a stent) is left in place to keep the artery open and prevent it from collapsing during the healing process. Various drugs are prescribed to prevent recurrence of obstruction (occlusion). You have to stay in hospital until you are safe to be allowed home (usually after 24 hours). There is a greater tendency for arteries thus treated to block again. An operation may then be required or a decision may be taken to operate rather than try the angioplasty.

Coronary artery by-pass Operation (CABG)

If drugs do not improve symptoms, or angioplasty fails or cannot be performed, then CABG is considered. The narrow portion of heart arteries is by-passed by means of veins taken from legs or an artery taken from inside your chest or forearms. This is quite a lengthy operation but the results are often very good. In this operation, surgeon has to cut through your chest bone (sternum). A little pain may be experienced while the chest bone and underlying tissues as well as leg or arm cuts heal. Infection, damage to the heart or kidneys, bleeding within the operated areas and stroke or minor damage to the brain are some of the complications of this operation. The actual risk in you will be evaluated before operation and you will be informed of this risk before surgery. Please confirm that you understand all these risks specific in your case before you give your consent to this operation. Patient has to stay a week or so in hospital after this operation and within 6-8 weeks are likely to return to lead a normal and active life once again.

Role of heart nurse (CRN):

This nurse will see you during your stay in the hospital and help you recover in association with other professionals such as dieticians, physiotherapists, pharmacists, etc. This nurse will regularly attend to you for several weeks or months after you discharge, till you are well or as best as you can be. Various medicines will be given to you during your stay in hospital some of which you will be asked to continue to use after you are discharged. A discharge letter will contain a list of medicines. You must contact your family doctor before you run out of these medicines. You do not have to go to see your doctor. The drugs can be issued according to the letter sent by the hospital. You must not go to the surgery until you are declared fit to do so by the CRN or your medical attendant. Medicines have different names: one official and the other commercial. Commercial name is used for trade purposes. You need not to worry about it. But please, confirm at the chemist that you are supplied with the same drug with which you were discharged to continue to take at home.

Types of Medicines:

Thrombolytics:

Some patients receive a “Clot Busting” medicine as soon as possible after a heart attack. Its function is to dissolve the clotted blood. The most frequently used medicine of this group is called `Streptokinase`. This group of drugs is not suitable for every patient. If you are given one of these drugs, then a card will also be handed over to you indicating that you have received this substance. You must keep this card with you. It will be required if you need to receive similar treatment again. These drugs may cause bleeding by dissolving clots elsewhere in the body. This is likely to happen if you have had a recent bleed such as from stomach ulcer or piles.

It may also cause bleeding from recently operated sites. Usually no bleeding occurs after six months of major surgery. After minor injury or surgery firm healing usually takes place within less than a month. You must inform the doctor of any such possible cause of bleeding. This drug is never given during pregnancy, in this situation an urgent angioplasty is undertaken. If you have had a stroke you must inform the doctor, even though you may have completely recovered. It is also not given if you are receiving certain drugs such as anti clotting agents. You must take all your drugs with you and show them to the doctor. It is for your safety lest bleeding and perhaps fatal bleeding occurs.

Glycerin Tri-intrates (G.T.N):

This medicine is used for heartache. It temporarily widens the blood vessels of the body, thus allow the heart to contract against decreased resistance. If there is spasm of the coronary arteries than it will open those vessels as well. It dilates veins and thus reduces amount of blood returning to the heart, thus reducing the work of the heart. The chest pain or other symptoms of oxygen deficiency to the heart are thus ameliorated. It may sometimes cause an excessive drop in blood pressure. If you feel light-headed after it then sit or lie down till light-headedness goes away, and do not use it again without discussing it with you doctor.

The G.T.N. is either a tablet or a spray. It is placed under the tongue and it works speedily. Any unused tablets should be discarded after eight weeks of opening the bottle. It should be kept out of sunlight. It may be taken to prevent development of symptoms before exposure to severe cold or before exercise or walks that induce symptoms. This is called prophylactic (preventive) use. If it causes severe headache then remove it from the tongue and discuss it with your doctor for a smaller strength or a different medicine.

Aspirin:

This medicine is taken to prevent further heart attack. As this medicine reduces the effectiveness of blood platelets the blood takes longer to start to clot. Sometimes this medicine may lead to stomach problems. If this happens inform your doctor. It is given as a small dose tablet of 75 or 150 mg.

Beta-blockers:

These groups of drugs minimise the effect of those hormones that increase the speed or force of your heartbeat. Exercise and excitement can increase these hormones. Beta-blockers counter these unwanted effects of stress, exercise and anxiety. Their side effects include numbness and coldness of hands and feet. These drugs are harmful in those who have asthma or some forms of bronchitis.

Cholesterol lowering agents:

These are extremely important drugs. They reduce the likelihood of occurrence of a heart attack by at least 30%. It is given to all that have had a heart attack unless they cannot take it. It is desirable to achieve LDL cholesterol of less than 3.0 mmol, and HDL cholesterol of greater than 1.1 mmol.

Angiotensin converting enzyme inhibitors:

These drugs help in the healing process. They are always prescribed to those patients who develop heart failure, and also for those who have had a large infarction, unless they cause side effects. You might be given some other medicines after heart attack. Clearly if you have other diseases in particular high blood pressure and diabetes you will be given appropriate therapy for a very strict control of these co existing conditions. If you fail to understand why these medicines have been prescribed, you must ask the doctor or the nurse.

Reasons of heart attack

The reason of heart attack has so far been unknown. “Risk Factors” play a major role in its causation. According to research, more the risk factors, greater the risk of a heart attack. It is of utmost importance that you become aware of these and try your best to reduce those risk factors that are related to you.

Hereditary or family factors:

You cannot change your genes but you can certainly control the factors affecting them.

Smoking:

Carbon monoxide and nicotine are two of the most important harmful ingredients of cigarettes. Nicotine increases the heart rate and B/P. Carbon monoxide and nicotine accelerate the process of blood clotting. Those who give up smoking have less chances of heart attack. It is not that non-smokers never suffer a heart attack but their risk is much less.

Hypertension:

Permanently increased blood pressure adversely affects the heart muscle and the blood vessels. The walls of arteries are damaged and constricted. In England, one out of every five men may be suffering from hypertension. Because it is often without symptoms it may be missed. We therefore advise you to get your blood pressure checked, and at least once a year once you reach an age of fifty years.

Stress:

Evaluate those situations that may lead you to stress. and avoid adopting dangerous methods of dealing with stress, e.g. drinking too much alcohol, smoking and over-eating. Take time off to relax and take up such hobbies that divert your attention from stressful situations.

High Cholesterol Level:

People having higher level of cholesterol in blood have greater risks of heartache and heart attack. Cholesterol is a natural essential constituent of our body. Cholesterol is produced from ingested saturated fats in the liver. If you are told that you have an excess of fat in your blood, then, it is important that you should take diet having less saturated fat in it. The reason for raised cholesterol is defective uptake of cholesterol from the blood into the body cells that need cholesterol for their metabolism. This is an inherited defect. It may be mild or severe. Blood is collected after fasting for at least 12 hours. It is measured for total LDL and HDL cholesterol. Triglycerides and glucose may be measured from the same sample and this helps exclude diabetes, a common risk factor.

What is Saturated Fat?

This type of fat is attained from animal products. For instance, beef, pork, saturated margarine, butter, full fat milk and cheese. Total amount of fat intake especially saturated
fat should be reduced.

Easy Changes:

• Use fat-free or low fat milk instead of full fat milk.
• Use low fat spreads.
• Always cook meat after removing visible fat. Whenever possible, avoid fried foods. For frying, use as little oil as possible.
• Grill your food instead of frying. Cook without oil or fats.
• Avoid cakes, pies, sugar, chips etc.
• Use white meat, and fish especially oily fish, in place of burgers and pies.
• Take low fat cheese, e.g., Edam or cottage. Do not use high fat cheddar.

Fiber in Diet

While reducing the quantity of fat in your diet, increase intake of fibrous foods. Fiber is not digestible and may help reduce or prevent constipation. It also suppresses rapid absorption of fats and sugar into blood. Most frequent sources of fiber are beans, pea, vegetable, fruit and cereals like weetabix and porridge. Eat as much vegetables and fruits as you can.
Do not remove the skin from fruit and vegetable as they contain more fibers.

Other healthy dietary habits

Salt:

Most of us take too much salt. It may raise blood pressure in some people and cause heart problems. Try to use less salt or do not take it at all. Refrain from edibles containing high quantity of salt, for example peanuts, hazelnuts and crisps etc.

Sugar:

Sugar is an instant source of energy. But it has no other merit. Decrease your intake of sugar. Drink tea or coffee without sugar. Use low calorie drinks. Take fewer sweets, cakes, biscuits and chocolates.

Weight:

If you are over weight then, you might run an increased risk of hypertension. So it is better to keep your weight under control. If you want to decrease your weight, start taking less fat diet and increase your physical activities. This will reduce your weight. Your target of reduction should be around 1-2 pounds in a week. Check your weight weekly at the same time of day.

Stress:

A little bit of stress forms part of our daily life. Within suitable limits, we all need it for improved results. However, excessive and permanent stress maybe harmful. It is worth remembering that factors causing stress in one may induce stress in others around such stressful persons. It is important to avoid stressful situation and behaviour.

What happens after discharge from hospital?

You will experience mixed feelings after discharge from hospital. You will be happy for getting discharged from hospital and worried for being away from the instant availability of expert doctors.

Role of Your Family doctor (GP):

Your family doctor will take care of you after you are discharged. A letter for your G.P will be given to you having all information about your heart attack, treatment and medicines.

Outpatient Department:

You will be asked to return to the hospital at least once to see a senior doctor or an experienced member of the team. The proposal will be given or sent to you by post. If it does not reach you within a month contact the department in writing. Telephone calls may be missed.

Weekly Instructions after Heart Attack

First Week:

Take complete rest for some days, and start routine matters like taking bath and shaving. It is important for you to take rest and do not see too many visitors because this is a tiresome process. You can walk upstairs but slowly, take 6-8 hours rest every night. Snoozing for one hour after lunch is a good idea. After some days, go outside for walking, walk at a slow pace for five minutes and abstain from climbing up-hill.

Second Week:

Now you can increase walking (almost 10 minutes twice a day), abstain from walking immediately after taking meal. If possible, do not walk in cold air. In this week you can perform your routine house works like dishwashing, light dusting etc. It is important to take rest when you feel tired. You will be amazed that you get tired very soon. This should not make you worry. It will be recovered with time.

Third Week:

Exceed the process of walking to 15 minutes. You can start doing hours chores e.g., cooking, washing etc. You can go out for shopping but you should not carry weight. You are now allowed to do a little gardening also like cleaning bushes and watering plants. This week you can start social activities e.g., dining-out.

Fourth Week:

Increase the process of walking from 20 to 30 minutes. It is important that you increase this process slowly and steadily. You can also increase household duties. If you feel pain in chest or panting in any of this process then stop doing it. It is important to accomplish these stages slowly and successfully.
Other Questions.

Going for swimming: Do not jump into pool rather step slowly into it and put water on your body so that your body may adjust the change of temperature.

Playing Golf: It is good to play only a half round of this game in the start.

Fishing: Catch small fishes and abstain from climbing on lofty rocks. We do not suggest you to take part in squash or in those games in which competition is very tough.

Driving: You are not allowed to drive for 4 weeks. You will have to take DR's permission for driving. When you start driving, do not travel on motorway or other busy roads. Do inform your insurance company about your heart attack, otherwise, your policy will be invalid.

Travel: You can enjoy tourism but at times it becomes a source of stress. The journey should be comfortable. During the journey, refrain from picking up heavy luggage. Use trolleys in airports and request help from airport crew.

General instructions:

• Try (if weather permits) to go for walking daily.
• Abstain from walking against the wind. Otherwise, your heart has to put more effort and its beat will also increase.
• Take 30 minutes rest after eating meal. This gives opportunity to your heart to pump blood towards digestive system. Plan your things in advance. Do not try to finish entire work in one go rather take a whole day to complete it.
• If you feel tired then stop working and rest for about 30 minutes.
• Do not carry heavy things and try to keep within the limit of your body weight.

What Happens after heart attack?

Instantly after heart attack, you will feel worried about your future. Following instructions will slowly help you to live a normal life.
Emotions after heart attack:

Heart attack is not merely a physical disease but it can bring changes in psychology of a person. You may feel the following thing, for example, irritation, helplessness, tiresome, weariness, stress, anger, depression and lack of interest. These feelings are common after heart attack. Your family members will also feel the same. They also feel worried and some may feel it more and, thus, the problem is aggravated. Your friends and family members may help you out. Be honest about your mental condition and face it openly. Keep this in mind that you are not disabled and you can live your life normally.

Cardiac Rehabilitation:

This programme helps in making your heart strong. It aims at bringing your life back to normalcy after heart attack. With the help of this program, you will exercise regularly. It schedules your exercise keeping in view your medicines and risk factors of your stress. The duration of this programme is 6 weeks, and the patient can join this programme after 4 weeks of heart attack. During stay in hospital, your doctor will let you know whether you can join this programme or not (some patient cannot take part in it due to other diseases).

Sexual Relations:

Questions relating sexual problems are neither asked due to shyness nor are they answered satisfactorily. That’s why, they do not start normal sexual relations due to shame and fear. These relations can be started after 3-4 weeks of heart attack, (provided that you are fit and willing to do it). Do not fear that this process might cause heart attack once again.

The risk of a second heart attack through sexual relations is negligible, provided you do not experience pain during the sexual activity and do not feel guilty. According to research, the burden felt during sexual activity on heart is equal to the burden felt while climbing up-stairs. If you feel pain in chest during sexual intercourse (coitus), stop this activity and take GTN tablets.

It is worth mentioning here that engaging in sexual activity other than with one`s life partner places a greater stress on your heart. One may not feel a sexual urge within first few weeks of heart attack. It may be due to irrational fear but with the passage of time, this fear dies down and you become confident.

Some easy suggestions:

• Abstain from sharing bed immediately after the meal.
• Keep yourself from copulation when you are tired or worried.
• Make sure that your bed is warm and comfortable. If it is not, buy an electric blanket.
• Many couples are agreed upon the fact that stimulation of each other’s sex organs preceding intercourse is good for confidence building.
• If you think you have some problems regarding making love, contact your doctor or the nurse. Negligence can worsen the situation and may cause estrangement in mutual relations.
• The use of contraceptive pills and heart diseases has a delicate link with each other. This risk is more in unhealthy people. Female patients should consult their doctors before using contraceptive pills.

For more information, contact British Heart Foundation

Tel: 020 7935 0185

Fax: 020 7486 5820

Email: internet@bhf.org.uk, or visit their web site: http://www.bhf.org.uk/