Symptoms of a heart attack

Symptoms of a heart attack may be widely varied, from the classic "elephant on the chest" feeling of crushing pain, to the nausea and heartburn mistaken for indigestion. In some patients, the symptoms may only be sudden fatigue or an oppressive feeling of impending death

Misconception 1 Most heart attacks are due to sudden blockage of heart vessels which are severely blocked

Not true. Until the early 90’s cardiologists believed this to be true, but when studies were conducted with clot dissolving medications such as streptokinase, it was discovered that about 65-70% of heart attacks were due to the so-called “insignificant” narrowing of arteries which are less than 5o% blocked. Recent studies have established that most heart attacks are caused by rupture or erosion of an unstable plaque. The culprit lesions are usually mild blockages of <50%. An unstable plaque has the following characteristics:- Thin fibrous cap which can tear, ulcerate or rupture, and a soft lipid core. When an ulceration or tear in an unstable cholesterol plaque happens, there is sudden clot formation and complete blockage of the artery.

Misconception 2 Atherosclerosis or hardening of the arteries, which causes heart disease, begins at about the age of 40.

Not true. Many people believe so but the truth is atherosclerosis starts as early as childhood, and is already evident by the time a person reaches 20. A recent study looking at the prevalence and extent of atherosclerosis in the adolescents and young adults found that ......in 2876 autopsies of accident victims age 15-34 years old, fatty streaks was seen in the aorta in 99.93%, and atherosclerosis was already evident in the heart arteries in 50% of teenagers age 15-19 yrs old.(Strong JP ET al JAMA1999; 281:725-35)

Misconception 3 If you keep your cholesterol level within normal ranges, you will be safe from getting a heart attack

Not true. A high cholesterol level is a definite risk factor for heart disease. However most patients with heart attacks have normal or borderline cholesterol levels (200-220mg/dl, 5.2-5.6 mmol/L) and only 30% have high cholesterol levels. (ref: Rumberger et al Mayo Clinic Proc 1999; 74:243-252) One should not be complacent even if one has a normal cholesterol level.

In the Framingham Heart Study, an epidemiological study on prevalence of heart disease, the percentage distribution of serum cholesterol levels in males who did or did not subsequently develop coronary heart disease was almost identical

Misconception 4 Majority of heart attacks occur in people with chest pains and these signs will appear weeks before the actual event.

Not true. Most people think that if they have no symptoms they do not have heart disease. This is the reason why heart disease is called the Silent Killer.
In a study on what were the first signs or symptoms of heart disease, typical angina or chest pains occurred in only 10%of patients, 70% had no warning signs, in 35% death was the first and last symptom. (Thaulow - American Journal of Cardiology; 1993:72:629 )

Misconception 5 Your treadmill stress ECG was normal, therefore you don’t have heart disease and will not get a heart attack

Not true. This is because signs and symptoms of coronary artery disease will appear only when the narrowing is greater than 75% Many people feel reassured when they have a negative treadmill exercise stress test and doctors traditionally use this test to detect coronary artery disease.

But what does the American College of Cardiology and American Heart Association GUIDELINES FOR EXERCISE TESTING tell us about this test? Stress testing detects abnormality in heart function caused by obstructive narrowing of heart arteries of GREATER than 75%.

The Guidelines states that Exercise Stress Testing is most useful for diagnosis of obstructive coronary artery disease in a dult patients with an intermediate pretest probability of CAD, based on gender, age, and symptoms. In other words, adults with chest pains. But unfortunately it is not useful if you do not have any symptoms. It is also important to realize the test’s limitations. How sensitive and accurate is the exercise test? This test will pick up 68% of patients with blocked coronary arteries but 32% can be missed,

Misconception 6 If you have no risk factors and lead a stress free lifestyle, then you will not develop heart disease

Not true. Conventional risk factors listed below, of which cholesterol is but one, puts a person at 2-3 times increased risk of having coronary artery disease.

Age

Sex

Family History

Cigarette smoking

Obesity

Hypertension

Diabetes mellitus

Physical Inactivity

Cholesterol

High LDL Cholesterol

Low HDL Cholesterol

Conventional risk factors help to identify only 70% of heart patients . 30% of heart attack patients do not have any conventional risk factors . Conventional risk factors are also poor predictors of future heart attacks or death. (Wald et alLancet 1994;343:15-19; Grover et al JAMA 1995; 274:801-806)

Misconception 7 After balloon angioplasty or bypass surgery a heart patient is “cured” and will not suffer from any more heart attacks

Not true. Angioplasty or bypass surgery alleviates symptoms but does not cure the atherosclerotic plaque disease. The plaque is still present and the patient is still at risk. That is the probably the reason why no long term follow up study has shown that angioplasty and bypass surgery in stable angina patients improved survival nor prevented future heart attacks compared to medical therapy alone. (Ref: RITA trial, AVERT trial)

The information contained here is not a substitute for medical advice or treatment or replaces consultation with your doctor.

COMMON MISCONCEPTIONS ABOUT HEART DISEASE

Most heart attacks are due to sudden blockage of heart vessels which are severely blocked

Atherosclerosis or hardening of the arteries, which causes heart disease, begins at about the age of 40.

If you keep your cholesterol level within normal ranges, you will be safe from getting a heart attack

Majority of heart attacks occur in people with chest pains and these signs will appear weeks before the actual event.

Your treadmill stress ECG was normal, therefore you don’t have heart disease and will not get a heart attack

If you have no risk factors and lead a stress free lifestyle, then you will not develop heart disease

After balloon angioplasty or bypass surgery a heart patient is “cured” and will not suffer from any more heart attacks

Recovering at home after Heart attack

Once at home, you should resume normal life with improved health and fitness habits as soon as possible. But you should attempt this in a safe and effective manner.

How can I do this?
Join or enrol in a cardiac rehabilitation scheme. Your own doctor may be able to refer you to such a scheme in your neighbourhood, or your local health authority may be able to provide you with information. It is important for you to realise that cardiac rehabilitation is not just supervised exercise. It should also include information on risk factors, counselling, training in relaxation and stress management. A good programme will also try to involve your family whenever possible. Some heart attack patients may not be medically suitable for such programmes, so you will need to ask your doctor about it.

What are the benefits of undertaking a comprehensive cardiac rehabilitation course?
Until the mid 1960’s, prolonged complete bed rest was advised following a heart attack, but complications arose through patients being inactive, e.g. the formation of blood clots in the veins. Many patients who have taken part in comprehensive rehabilitation programmes will have a lower rate of further heart attacks, fewer will smoke, their blood pressure will be under control, and they will be enjoying an improved quality of life.

Is exercise safe after a heart attack?
Generally speaking – YES!

So how do I know how much exercise to take?
You don’t! So play it safe rather than be sorry. Begin with light exercise (walking), and initially do not go beyond the point of being moderately breathless, while still being able to conduct a conversation. Ideally, it would be best to enter a medically supervised and regular rehabilitation scheme. Without question, it would be most unwise to begin vigorous exercise following your heart attack as this could cause more problems.

Finally, have a positive outlook. Keep a check on yourself and don’t hesitate to ask for medical advice. Beware of the risks that cause heart disease and try to reduce them. Watch what you eat and drink. Make time for relaxation. Take regular light to moderate exercise, and try to join a cardiac rehabilitation programme. Remember – “a problem shared is a problem halved.”

Life After a heart attack or heart surgery

Over the last decade or so there have been numerous advances made in the field of medical science. New and improved medicines, and surgical interventions, are giving patients a much greater chance of making a full recovery.

So having recovered from your heart attack you must be determined to reduce the risk of any further problems by modifying your lifestyle, replacing bad habits with good ones.

If you are a smoker, make every effort to stop

Smokers have up to four times the risk of dying from a heart attack when compared with non-smokers. Most doctors will have access to quit smoking support, so speak to your GP

Keep a check on your blood pressure

High blood pressure makes the heart work harder, accelerates fatty blockages of the arteries and increases the risk of further heart attacks. High blood pressure can be controlled with exercise, medication changes in diet. To keep a check on your blood pressure, ask your GP to measure it for you.

Cut down on your total fat intake and do not drink too much alcohol

It is not necessary to become obsessed about food, but try to cut down on your total fat intake, avoiding saturated fats, e.g. red meat, lard, and dripping. Cut down on sugary foods, and go easy on salt, as too much can contribute to high blood pressure. Restrict alcohol intake to smaller quantities. Too much alcohol increases weight, raises blood pressure, increases irregular heart rhythms, and promotes fatty blockages in blood vessels.

Check your weight and avoid becoming “obese”

Becoming obese (very fat) tends to increase blood pressure, blood sugar levels and the fats within the blood itself. Check on your body fat by “pinching an inch”, together with watching what you eat and increasing weekly exercise.

Anxiety, tension and stress

Many patients suffer anxiety and tension following a heart attack or surgery, but normally these feelings are short-lived. The value of learning to relax properly can help. This can be achieved by sitting in a peaceful environment and deliberately concentrating on relaxing the major muscles of the body. Coupled with this, slow, controlled breathing will often help to instil a feeling of ease and relaxation.

Sometimes heart disease can run in families

If your parents suffer, or have suffered, from coronary heart disease, diabetes or high cholesterol, it could be more likely that you will. The important question, though, is have you inherited these problems, or just the bad habits that cause them? Remember that your family doctor can give you valuable advice here, together with making the positive changes that have already been recommended on these pages. There are several other factors that can influence the likelihood of heart disease, like age, gender, race, diabetes, and may be out of your control. However, realising that they exist will make you more aware of possible risks when assessing your own situation.

Some myths about heart disease

Some helpful advice following a heart attack or heart surgery

Having a heart attack means I am at greater risk of having another.

Not necessarily. About 35% of all patients who survive a heart attack fall into a lower risk category and are unlikely to suffer another heart attack. Ideally each person should be assessed individually and many positive steps can be taken to avoid further heart trouble.

Because of my heart attack, my whole life will change. I will never be able to return to normal.

Wrong! The heart can recover quickly. Heart attack victims do not have to become “cardiac cripples” and with the right lifestyle modifications, can enjoy a better quality of life than before the attack.

A heart attack will have a really negative effect on my sex life.

Wrong again! The average amount of energy expended during sex is equivalent to walking up a flight of stairs and sexual intercourse, contrary to popular belief, is a rare cause of sudden death.
Now I have experienced a heart attack, it is too late to change for the better.

Still wrong! It is never too late to reduce your risk factors, e.g. improve your diet, increase exercise, and stop smoking.

Cholesterol free means total fat free.

Not true! Because the saturated fat content of food also helps to raise blood cholesterol. Some foods advertised as cholesterol free can be high in saturated fats.

To gain benefit from exercise, it has to be really strenuous.

Guess what, wrong yet again! Moderate levels of physical activity are all it takes to reduce the risk of dying from heart disease. Some exercise specialists have been guilty of “over prescribing” exercise, which can discourage people, particularly heart attack patients.

In my youth I always exercised regularly, and this will protect me.

Absolutely not! Even professional sports-persons have later suffered from heart disease, due to adopting a sedentary lifestyle. Exercise is like a current account, and you cannot hope to put on deposit what you did years ago. You need to exercise sensibly and regularly, at least three times a week for 20-30 minutes. The exercise should make you breathe harder, while still being able to talk. There is convincing evidence that regular, sensible exercise training can reduce the risk of dying from heart disease, even after a heart attack.

Heart disease runs in my family, so there is little I can do to avoid heart problems.

Not necessarily so! It may be the bad habits that are the culprits, in that they have been followed for many years within a family.

I will know when my heart condition gets worse – I will have chest pains.

Again, that is not necessarily the case. Studies have shown that up to 10% of all middle-aged men can suffer from a condition called silent ischaemia. This means that your heart is not getting enough oxygen, but you are not aware of it. So it is best to keep in touch with your doctor, and to keep a check on your cardiac health.

My worries about heart disease are over since my heart surgery (angioplasty or coronary artery bypass surgery).

Definitely not true! If you follow the same bad habits that originally allowed you to develop heart disease, then you may damage the heart again.