The symptoms of ischemic heart disease (lHD), angina and myocardial infarction

Chest pain or angina pectoris occurs only on exertion in the mild cases; when chest pain occurs even when resting the disease is more advanced. Although "angina" means pain, some patients with th‘s condition develop only a discomfort in the central region of the front of the chest on exertion. This could take the form of a tightening, pressing or burning sensation. Pricking pain and sharp stabbirg pain is unlikely to be anginao Difliculty in breathing on exertion, and, if severe, even at rest . When the heart is failing to perform its functions adequately, patients are said to be in “heart failure”; then, in addition to difflculty in breathing on exertion, they develop swelling of the body, especially around the ankles, congestion of the liver and lungs, and find it difficult to breathe even at rest. Sometimes there is a sudden obstruction to the blood supply to the heart. This is due to damage at the site of deposits of atherosclerosis. This cuts off the blood supply to a part of the heart muscle, which will then cease to function. lf that happens, serious and sometimes fatal complications occur. This is referred to as a "heart attack" or myocardial infarction. These patients may get severe chest pain, which may radiate to the neck or arms; they are usually bathed in sweat, and find it dfficult to breathe. This is an emergency, and they have to be rushed to hospital.

Rarely, there may be no chest pain obvious difficulty in breathing; this is referred to as a "silent heart attack". Other symptoms of IHD include, undue fatigue; this could be the first symptom of ischemic heart disease in many cases, flatulence and eructations. When the lower part of the heart which touches on the diaphragm - the muscular wall that separates the chest cavity from the abdomen - is affected, the symptoms can be mainly “gastric”. Most persons think that they are suffering from gastric acidity; in fact, the symptoms are indistinguishable. Left sided chest pain which is pricking or gnawing in nature is rarely a symptom of heart disease. Pain in the area of the left nipple region is generally of muscular origin. Also, chest pain, which is fleeting, i.e lasting only a few seconds like a flash of lightning is not a symptom of ischemic heart disease.

Investigations and treatment

Investigations such as ECG, chest X-ray, Echo-cardiograph, cath lab studies - angiogram, blood tests (ESR, SGOT,Troponin) are helpful in the management of both IHD and myocardial infarction. A test, troponin gives an accurate indication of damage to the heart muscle. Lipid profile and C reactive proteins are useful in the long term management. Treatment is best undertaken by a physician experienced in heart disease. An injection streptokinase is given within 6 hours of a heart attack to dissolve the clot; early administration of streptokinase has reduced the fatality rate. In recent times cardiologists have developed measures to restore the blood supply to the heart by sophisticated forms of therapy, such as angioplasty, which is a skilled technique by which a catheter is introduced through a blood vessel in the periphery to the site of the narrowing or blockage (in the coronary artery) which has been predetermined by an angiogram done earlier; then the diseased segment of the artery is dilated, usually by a process of "ballooning" it ; however it is reported that there is a high rate of recurrence, about 30%, within a period of 6 months. Coronary bypass is also a major surgical operation where blood vessels from a different part of the body are used to bypass the block. This major surgery would give a new lease of life.

Chelation therapy is claimed to reverse and/ or slow the process of atherosclerosis. The treatment consists of a series of intravenous injections of an amino-acid, called EDTA. It is being used to clear blocked arteries, such as those of the heart, brain and legs. its mode of action is not yet fully understood. Though it is certainly less expensive than angioplasty or bypass surgery. It is still only in an experimental stage. Soluble aspirin daily (dose,1/2 tablet: 1 tab is 300mg), which is known to prevent the risk of clotting of blood over the deposits in the arteries is used in the long term prevention of IHD.

Blood pressure and hypertension

High blood pressure (HBP) is known as hypertension. Blood pressure (BP) is a measure of the tension (force) within the arteries (blood vessels). BP depends on several factors such as the force of contraction of the heart muscle, the amount of blood pushed out of the left side of the heart, and the degree of resistance of the large , medium and small blood vessels to the flow of blood; this last factor is called the peripheral resistance. When the heart muscles contract (this is called systole) the pressure rises; in between contractions (i.e. during diastole) the pressure gets less. BP is measured with an instrument called the sphygmomanometer (BP apparatus). It is important to record the BP in resting conditions over a period of time: more than one measurement should be taken lt is also necessary to take measurements with the person lying down, seated and standing; this is because posture influences the BP which tends to fall on standing. There are other more sophisticated types of apparatus, such as digital and electronic instruments. The reading is in millimeters of mercury. There are two measurements of BP: systolic BP, mainly due to the contraction of the heart, diastolic BP mainly due to the peripheral resistance. In adults, the usual systolic BP is around 120, and it may rise to about 140 in older people; the diastolic BP is around 80; in children it is less. If the systolic BP is over 140 or if the diastolic BP is over 90, treatment becomes necessary. When a person is tense or excited, the arterioles become constricted, and this causes an increase in the BP. In the majority of cases the exact cause of HBP is not known, and it is then referred to as primary or essential hypertension. 

Causes of hypertension

Factors known to cause HBP include kidney disease, some disorders of adrenal glands that produce hormones, abnormalities of large blood vessels (such as the aorta and main renal arteries), complication of diabetes, side effect of drugs such as prednisolone and drugs used for certain types of arthritis, excessive salt intake and stress and strain(emotional factors) are linked to HBP.

When a specific cause is identified it is called secondary hypertension. ln either of these categories, the HBP may either take a benign (not serious) course, or a malignant (serious) course. The benign form if untreated for several years can lead to the malignantform. ln mild cases symptoms may include headache, giddiness and shortness of breath. However, it is very important to remember that quite often HBP does not cause any symptoms. Therefore it may not be detected until complications arise. Some patients mav have severe early morning headache at the back of the head and chest pain. Due to persistent HBP resulting from the absence of treatment or poor control of BP, serious complications may occur. These include enlargement of the heart, heart failure, heart attacks, kidney failure, strokes.

Treatment for hypertension

There are a variety of anti-hypertensive drugs available, which could very satisfactorily control even the highest BP; however, patient's compliance is very necessary. If there is a secondary cause for HBP, this cause should be attended to. Renal (kidney) failure is a known complication of HBP. While HBP can lead to kidney failure, all forms of kidney diseases may cause HBP, which will in turn damage the kidney further, leading to either acute or chronic kidney failure, in which case supportive treatment such as peritoneal dialysis, hemodialysis (cleaning of blood) or kidney transplant may be required. lt is advisable to get the blood pressure checked at least once a year if you are above forty years of age, even if you feel quite well.

Rheumatic fever, Arthritis, Chorea and Heart disease

Rheumatic fever occurs in children and young adults, as a complication of a bacterial infection of the throat by an organism called streptococcus. This disease is more prevalent in poor countries and in communities living in overcrowded damp houses with poor ventilation; in such conditions, throat infections tend to spread easily from person to person. The complication referred to above is an "allergic" (immunological) response to the streptococcal infection. A common manifestation of the disease is pain and swelling of large joints such as the knee joints, ankle joints and elbow joints. This is called Rheumatic Arthritis. The pain and swelling may move from onejoint to another, within a few days. Some children with acute rheumatic fever become jittery and develop abnormal movements. This is called Rheumatic Chorea; in some of them the heart is also affected. Affection of the heart is called Rheumatic Carditis. This condition leads to inflammation (congestion and swelling) of all parts of the heart, especially of the heart valves - mitral and aortic. This results in a disorder of the heart function. At this stage a doctor would hear (with a stethoscope) an abnormal heart sound which is called a murmur. Sometimes the rhythm and regularity of the heartbeats become abnormal; this worsens the pumping action of the heart. The heart muscle may also get involved leading to enlargement of the heart. When the heart is seriously affected, the patient would become breathless on exertion, and this may gradually progress breathlessness at rest. These are the symptoms of acute heart failure.

With adequate treatment most of these patients recover completely. Some however develop permanent damage to the valves, resulting in chronic rheumatic heart disease. In a few years, the mitral valve may develop a stricture, which causes a difficulty in pumping the blood through the mitral valve; this condition is referred to as mitral stenosis. Or it may develop incompetence, resulting in a leak of the blood from the left ventricle to the left atrium; this condition is referred to as mitral incompetence or mitral regurgitation. Similarly if the aortic valve is affected, aortic stenosis or aortic incompetence may result. These disorders of the valves usually get worse with advancing years and may lead to chronic heart failure. In a child with rheumatic heart disease each subsequent episode of acute rheumatic fever carries a greater risk of further heart damage. In a patient with chronic damage to the heart valves, surgery has to be considered. Either the narrowed valve orifice has to be dilated or the valve may have to be replaced. In some countries, facilities for replacement of heart valves are limited. Rheumatic fever “licks the joints, but bites the heart”.

Treatment and Prevention 

It is of vital importance for rheumatic fever to be prevented. How could this be achieved? At the individual level, all throat infections (sore throats) thought to be of bacterial origin should be treated with an appropriate course of antibiotics - usually penicillin or erythromycin. At the community level, measures should be taken to minimize streptococcal throat infection through better housing (good ventilation) and good nutrition. Secondly, any patient who develops painful swelling of a joint or joints should seek medical treatment where tests could be carried out to diagnose or exclude rheumatic fever. Soluble aspirin, in large doses, is the drug of choice at this stage of the disease. Thirdly, in a patient with rheumatic fever, prevention of further attacks of streptococcal infection is important. This is achieved by giving the patient either injections of long-acting penicillin once in 3-4 weeks, penicillin tablets by mouth twice a day morning and night. This course of treatment should be continued up to at least 21 years of age or 5 years after the last episode, whichever is longer. In a patient with established rheumatic heart disease, it is recommended that this preventive treatment with penicillin be continued lifelong. Unfortunately, there is yet no vaccine available for protection against streptococcal infections. Research is being carried out in certain countries to develop such a vaccine. A child with rheumatic heart disease could lead a normal life, except that physical activity may have to be restricted in certain patients. This is an individual matter and specific advice regarding this should be obtained from the doctor treating the patient. In those who have established rheumatic heart disease, dental procedures, such as extractions and fillings, should be carried out under the cover of antibiotics to prevent complications. This prevents organisms from getting into the blood stream and infecting damaged heart valves - a serious complication called endocarditis or subacute bacterial endocarditis. There is an additional burden on the heart during pregnancy in women who have rheumatic heart disease. For this reason a doctor should be consulted preferably before the pregnancy.