Category: Guide to Preventing and Treating Heart Disease

Lack of blood ?ow to the heart (myocardial ischemia) usually causes symptoms such as angina, a sensation of pressure in the chest; shortness of breath; or light-headedness. Ischemia may lead to a heart attack (myocardial infarction), as some part of the heart is deprived of blood for a period long enough for the heart muscle tissue to die. It is impor- tant to recognize these symptoms and seek medical help urgently, espe- cially if you have any risk factors for coronary artery disease. Prompt medical help, in which the blocked arteries can be opened quickly with medications or a procedure such as angioplasty (which compresses the plaque on the artery walls), can minimize damage to heart tissue.
Insuf?cient blood supply can also cause cardiac arrest—when the heart stops abruptly. Cardiac arrest most often occurs when a person’s heart rhythms are disturbed. The electrical impulses that control heart rhythms become either too fast (tachycardia), chaotic (?brillation), or in rarer cases, extremely slow (bradycardia). A person in cardiac arrest is in extreme danger. To reverse cardiac arrest, the person’s circulation should be maintained by cardiopulmonary resuscitation (CPR), and the heartbeat must be restored with an electrical shock (defibrillation). Brain death begins in just 4 to 6 minutes after a person’s heart stops.
In some people the main effects of a heart attack are seen in the pericardium, the layer of protective tissue around the heart (see “Pericardi- tis,” ).
The worst possible outcome of a heart attack is sudden cardiac death. Any form of heart disease can cause sudden death. But in most victims (about 90 percent) two or more major arteries are blocked by plaque, and the heart also shows scars from previous attacks. Sudden cardiac death can occur without a warning sign.

Ischemic Cardiomyopathy

Cardiomyopathy is a term for disease of the heart muscle  that results from a condition that impairs the muscle tone of the heart and reduces its ability to pump blood. One form of the disease, called

ischemic cardiomyopathy, starts as a result of damage from blockage in a coronary artery supplying a portion of the muscular walls of the heart. This damage leads to the inef?cient pumping that is characteris- tic of cardiomyopathy. Frequently, cardiomyopathy is diagnosed by an echocardiogram (see page 132). The echocardiogram measures the ejection fraction, which is the amount of blood pumped with each heartbeat. In people with cardiomyopathy, this number is low, meaning that not enough blood is being pumped. Often the heart will dilate (widen) to compensate, so people with cardiomyopathy often have an enlarged heart.
Treatment for ischemic cardiomyopathy focuses on restoring the heart’s pumping ability with medications and opening the blocked arter- ies to improve blood supply to the heart. Other types of cardiomyopathy include a viral cardiomyopathy, in which the heart is damaged by a virus, and toxic cardiomyopathy, in which the heart is damaged by some out- side agent—for example, alcohol. If the heart has been severely and irreparably damaged by the disease, doctors may recommend a heart transplant .

Pericarditis

Pericarditis is an inflammation of the pericardium, the membrane surrounding your heart. The pericardium actually has two layers, one of which is attached to the heart’s muscular walls and the other which lines the cavity of the chest in which the heart is located. Fluid between the two layers enables the heart to move as it beats, yet stay in position. When pericarditis inflames the membrane, the amount of fluid increases and the heart’s movement (particularly its ability to ?ll with blood) can become restricted. About 10 percent of people who have had a heart attack develop pericarditis, as a result of the death of tissue. Peri- carditis occurs more often in men than in women. Infection, often due to a virus, is a common cause of pericarditis, especially in young adults. In many cases the causes of pericarditis may be unknown. Other causes of pericarditis include cancer or radiation therapy for cancer, injury to the chest, prior chest surgery, autoimmune disease, kidney failure, or use of medications that suppress the immune system.
The most common symptom of pericarditis is a sharp, stabbing pain in the center or the left side of the chest, and it sometimes radiates to the neck or shoulder. It can easily be mistaken for a symptom of a heart attack. Your doctor can begin to diagnose pericarditis by listening to your description of the pain and how it began. He or she can also listen with a stethoscope for characteristic rubbing sounds in your chest, which sometimes can be heard when the in?amed layers of the pericardium rub against each other as the heart beats. A chest X-ray may show an accumulation of ?uid around your heart, which can be con?rmed by an echocardiogram . An electrocardiogram can show changes that indicate pericarditis. Occasionally, periocardiocentesis—a pro- cedure in which a sample of ?uid is withdrawn and analyzed—is needed to help determine the cause of the pericarditis.
Pericarditis is usually treated with pain relievers and anti-in?ammatory medications such as aspirin or ibuprofen. When the condition is the result of a heart attack, pericardi- tis usually responds well to treatment and you are likely to recover in 1 to 3 weeks.
However, if the condition causes an accumulation of ?uid around your heart that is seriously restricting your heart’s ?lling ability (a rare but life-threatening disorder called cardiac tamponade), your doctor may perform pericardiocentesis (either with a needle or as minor sur- gery) to remove the excess ?uid. Examination of the extracted ?uid can help determine the cause of the cardiac tamponade. Repeated accumu- lations of ?uid may require surgery.
Complications of pericarditis are rare, but the infection can cause arrhythmias or even a heart block (when the electrical impulses triggering heart rhythm fail to perform).
Constrictive pericarditis can also develop, in which the in?ammation causes the pericardium to thicken and develop scar tissue (adhesions) between the pericardium and the heart. The pericardium becomes in?exible, and heart failure can result. In such cases, surgical removal of part or all of the pericardium is the only remedy.
There are other complications after a heart attack, depending on where the damage is located in the heart and how severe it is. The heartbeat may slow markedly, requiring a pacemaker. Arrhythmias or heart failure may also occur.

Considering Your Options

If testing shows that you have blockages in your coronary arteries, if you have angina, or if you have a heart attack, your physician may recom- mend treating your condition with lifestyle changes, medications, or procedures such as angioplasty or bypass surgery. In making a treat- ment recommendation, he or she will consider the overall pumping strength and electrical sta- bility of your heart, as shown by testing, and also the severity of your symptoms. Deciding which treatment or combination of treatments is best for you is complex, but you and your doctor may discuss these strategies:
• Lifestyle changes. Lifestyle changes such as eating a healthy diet, getting regular exercise, and quitting smoking are proven to be beneficial in reducing the risk of heart attack, improving angina, or slowing the progression of disease after a heart attack. These factors are essential to support any other treatments you may receive. Your doctor will provide you with information and support, but only you can follow through.
• Medications. Medications such as beta- blockers, calcium channel blockers, ACE inhibitors, or statins (cholesterol-lowering drugs) can improve your heart’s function and treat contributing factors such as high blood pressure and high cholesterol. They may relieve symptoms such as angina and may play an important role in controlling inflammation and preventing the plaque ruptures that lead to some heart attacks. They also may be prescribed after surgery to support your heart during recovery.
• Angioplasty. If one or more of your arter- ies is substantially blocked, angioplasty  will clear the blockage and restore blood flow. If you are having a heart attack, angioplasty at the time of the heart attack may help minimize heart damage. It is a considerably less invasive, less risky, and less expensive procedure than bypass. But some arteries are not suitable for angio- plasty because they are too small. Other blockages are too dense or too large to pen- etrate with angioplasty. During angioplasty, a stent may be placed in an artery in an attempt to keep it from closing up .
• Bypass. Bypass grafting is the best approach for some people with severe angina or extensive blockages. Your doctor may recommend bypass surgery if your left main coronary artery, which supplies the left ventricle (the major pumping chamber), is significantly blocked, because any problem with angio- plasty could cause serious damage to the heart muscle; if you have several major coronary arteries blocked; or if you have had previous angioplasty procedures. Bypass also may be necessary if you have another condition such as heart failure or diabetes.

Clearly, knowing the signs of a heart attack and responding quickly are important. If people live long enough to reach the hospital, their chances of dying are dramatically reduced. Treatment to open clogged arteries is most effective within the ?rst 60 to 90 min- utes after symptoms (such as chest pain) occur. If the blood ?ow is completely shut off, permanent damage to heart muscle occurs in about 20 minutes. So every minute counts, both to save your life (or someone else’s) and to improve the quality of life after the attack.
Calling 911 or the emergency services (?re depart- ment or ambulance) in your area should be your ?rst step, before doing anything else. Paramedics can begin treatment immediately, even before you reach the hos- pital. If your heart actually stops beating, paramedics have the knowledge and equipment to begin advanced life support and to restore a heartbeat. Also, a heart attack victim who arrives by ambulance gets faster treatment at the hospital, because emergency medical technicians begin treatment as soon as the ambulance arrives.
Take an aspirin if you have one on hand. Chew it; don’t swallow it. If you’re unsure whether you person- ally should take aspirin, wait until the paramedics arrive. If you’re alone, unlock your door, then sit down or lie down while you wait for the ambulance.

What to Do If Symptoms Occur

Many people delay going to a hospital, sometimes for as long as 2 hours after they ?rst notice symptoms. Some people are just hoping the symptoms will disappear, some don’t want to feel embarrassed by a false alarm, some think that a “real” heart attack would be dramatic and unmistakable, and some don’t realize the enor- mous advantage of immediate treatment. Although these feelings are understandable, doctors urge you to seek help at the ?rst signs of a heart attack, so that effective treatment begins as soon as possible.
It’s easier to respond quickly to symptoms—either your own or some- one else’s—if you have thought through the steps you will take before an emergency arises. First, of course, you have to learn the warning signs. Talk to your doctor about your personal risk of a future heart attack and how you should respond—for example, whether you should take aspirin or use nitroglycerin. If you are at risk, talk with your family, friends, and coworkers about the warning signs and the best response. Find out who, if anyone, knows cardiopulmonary resusci- tation (CPR) and alert him or her to the possible need for it. If 911 serv- ices are not available, keep the numbers for your area’s emergency medical services (?re department and ambulance) next to the telephone. Find out which hospitals nearby have 24-hour emergency cardiac care.
When you arrive at the emergency room, a doctor or other staff may ask you questions about your symptoms. If you are able to respond, the information you give them will help guide your treatment. Questions may include:

• When did you ?rst notice symptoms?
• What were you doing at the time?
• Were the symptoms most intense right away, or did they build up gradually?
• Did you notice any symptoms other than the ?rst or most intense ones?
• On a scale of 1 to 10, how would you rate the discomfort you felt?
• What medicines have you taken today?
• What medicines do you usually take?

Chest Pain

Most people would probably name chest pain as the symptom they associate most closely with heart attack. But very often the symptom that a person experiences from a blockage in the coronary arteries is not a sharp or stabbing pain. People who have experienced a heart attack often go to great lengths to say that the sensation they had was not exactly pain, but rather an uncomfortable feeling of squeezing or pressure (angina pectoris; ).
The somewhat confusing fact is that chest pain may be caused by a heart condition other than heart attack, and it can also result from problems having nothing to do with the heart, such as gallbladder dis- ease, a muscular disorder, or a digestive problem. The most important distinguishing feature of pain caused by coronary artery disease is prob- ably a link to some sort of stress, either physical or emotional—an indication that the heart’s increased need for oxygen is not being met. Chest pain at rest deserves immediate medical attention, especially in a person with risk factors for heart attack. The ?rst episode of chest pain in a per- son’s life may be the sign of an impending heart attack, so don’t delay seeking medical help.
For reasons that are not at all clear, women with heart disease are more likely to experience symptoms other than chest pain—such as shortness of breath, indigestion, or fatigue—making diagnosis more complex. People with diabetes also may not experience typical chest pain. Some people may have jaw pain or arm pain that for them is the equivalent of chest pain—a sign of a heart attack. If you have experi- enced symptoms of heart attack before, the important point is to learn to recognize them when they occur so that you can respond without hesitation.
A form of chest pain related to heart disease may also be caused by in?ammation of the outer surface of the heart, the pericardium. Like in?ammation anywhere in the body, an in?amed pericardium swells and causes pressure on nerve endings that may result in pain when you breathe in, when you move in certain ways such as leaning forward, or when you lie down. Even though not all chest pain indicates a heart attack, you should still get medical help if you experience any kind of a chest pain that lasts for as long as 5 minutes. It is de?nitely better to be safe than sorry.

Angina Pectoris

Angina, or angina pectoris, is the term that describes the typical chest discomfort or pain that signals an inadequate ?ow of blood to the heart, most often the result of a blockage in the coronary arteries. Many people who have experienced angina struggle to characterize it, but they often describe it as a constricting pressure or fullness; a squeez- ing, crushing, or burning sensation; or a dull pain in the center of the chest. It may radiate out to the arms, shoulder, back, neck, or jaw. But it may also be con?ned to a small area of the chest, and it can last several minutes. Alternatively, it goes away and returns over a period of minutes. However, pain that lasts less than 30 seconds or more than 30 minutes is usually not anginal pain.
Angina usually occurs when the heart demands more blood for a variety of reasons: physical exertion, such as walking uphill or having sexual intercourse; mental or emo- tional stress, including fright or anxiety; cold temperatures; or even eating a meal that trig- gers digestive activity. When pain brought on by exercise is relieved by rest, angina is suspected by your doctor. Many people have “stable angina”—that is, they have episodes of angina that occur in a fairly predictable pattern. This is the reason behind stress testing as a way to reproduce a person’s chest pain symptoms during exercise: to help diagnose coronary artery disease. Usually, a person with stable angina can relieve the symptom with rest or nitroglycerin, or both.
Unstable angina is a form of chest discomfort that occurs for the ?rst time in that person or occurs when the person is at rest. It can be more severe and prolonged than stable angina. The blockage in the arteries that brings on unstable angina may be atherosclerosis, a blood clot, in?ammation, or infection. The experience of unstable angina is an emergency situation. If you have new, unpredictable, or increasingly severe chest discomfort, go to a hospital emergency department imme- diately for evaluation.
A variant form of angina, sometimes called Prinzmetal’s angina, dif- fers from other types because it is not related to physical or emotional stress. It usually occurs when the person is at rest or asleep, often between midnight and 8 o’clock in the morning. Variant angina is a symptom of coronary artery spasm, which may occur in an open artery or in an artery already blocked by atherosclerosis. The spasm occurs close to the blockage and obstructs blood ?ow to the heart muscle.
Angina can occur more rarely as a symptom of other heart condi- tions such as valve disease, cardiomyopathy (disease of the heart muscle; , or extreme high blood pressure. Angina may be treated with nitroglycerin or other medication .

Shortness of Breath

Shortness of breath is another common symptom of a heart attack that can be dif?cult to differentiate and describe. Dif?culty breathing can take the form of feeling unusually breathless with exertion; experienc- ing rapid or shallow breathing; or feeling short of breath at rest. Some people report that they feel conscious of the need to draw breath.
Of course, it is normal to feel short of breath for a while after stren- uous exercise. Anxiety can cause hyperventilation, a form of rapid or shallow breathing. An overweight person may breathe more heavily just from the exertion of carrying extra weight, or someone who is out of shape may feel short of breath with even limited exercise. You are the best judge of when your shortness of breath feels abnormal.
If you feel short of breath at what for you is a moderate level of exer- cise, or if you become short of breath while at rest, or if your breathless- ness occurs with chest pain, don’t hesitate to get medical help.

Light-headedness and Other Symptoms

Some people feel light-headed—like they might pass out—as a symp- tom of a heart attack. (This sensation is different from dizziness, which makes you feel as if you or your surroundings are whirling.) Light- headedness can also signal other heart conditions, such as heart rhythm problems or problems unrelated to your heart.
Women are more likely than men to have atypical or more vague symptoms of heart attack such as light-headedness, nausea or queezi- ness, or fatigue, rather than chest pain. Researchers have only relatively recently recognized this gender difference, and the reasons for it are not yet clear. Genes, hormones, or lifestyle differences may be at work. Both women and their doctors need to be aware of the nature of a

woman’s symptoms and respond quickly to the possibility of heart attack. It is vital to keep in mind that heart disease is the leading cause of death for women, just as it is for men.

Silent Ischemia

A person can have an episode of ischemia (lack of blood to the heart) without angina or other symptoms, a phenomenon called silent ischemia. If the ischemia is severe or lasts too long, it may cause a heart attack with all the attendant dangers of heart damage or cardiac arrest, even if there is no chest pain. For many people the ?rst sign of heart dis- ease may be a cardiac arrest. Cardiologists estimate that 3 to 4 million Americans have silent ischemia every year. The resulting damage to the heart muscle is a leading cause of heart failure (when the heart’s pump- ing action is inadequate). Most people who have episodes of angina or chest pain are likely to have episodes of silent ischemia, too. Although there is no way to know when silent ischemia occurs, an exercise stress test (see page 125) indicates how the blood ?ow in your coronary arter- ies is affected by exercise, and Holter monitoring (see page 124) records an episode of silent ischemia if it occurs while you wear the monitor.
Treatment for silent ischemia is aimed at improving the ?ow of blood to your heart and reducing your heart’s need for oxygen—just like the treatment for any other symptoms of coronary artery disease. Your doctor will recommend lifestyle changes, medications, or perhaps ulti- mately surgical procedures such as angioplasty to reach these goals.

Coronary Artery Spasm

Chest pain may result from a spasm of the artery. Some people’s coro- nary arteries have a tendency to go into spasm periodically (doctors are not sure why). The spasm, called a vasospasm, temporarily constricts the passageway and blocks blood ?ow to the heart. A spasm usually occurs in a coronary artery that is already blocked by atherosclerosis, but it can occur in an otherwise healthy vessel.
The spasm is temporary, but it can cause a heart attack, irregular heart rhythm (arrhythmia), or even sudden cardiac death. The major symptom of coronary artery spasm is a variant form of angina that is particularly painful and often occurs at the same time each day. To treat coronary artery spasm, your doctor may prescribe a medication called a calcium channel blocker , which relaxes the smooth muscle in the artery walls and eases the discomfort of angina. In some cases, a nitrate may be prescribed also.

Heartburn or Heart Attack?

It’s not always easy to distinguish between the chest discomfort of a heart attack and the burning sensation of heartburn (acid reflux). About one out of ten people who go to an emergency department complain- ing of chest pains has heartburn. Either symptom occurs in the general area of the chest, may have a burning quality, and may occur after a big meal. The location of the pain may be a clue: heart attack pain is likely to radiate from the chest into the shoulder, arm, or neck, especially on the left side, while heartburn usually stays more centered and travels into the neck or throat. But don’t take any chances. Remember that most of the damage done by a heart attack occurs in the first hour or so. Get to an emergency department quickly if you have any doubt about the nature of your discomfort.

What Is a STEMI?

You may hear or read about the danger of a STEMI—an ST elevation myocar- dial infarction. This technical term describes a severe heart attack in which an artery is completely blocked. An ST elevation is a characteristic rise in a partic- ular segment of the waves seen in an ECG reading for a person who is having symptoms of a heart attack. Cardiologists identify certain parts of the wave by the letters of the alphabet from Q through T. Injured heart muscle does not conduct electrical impulses normally. The characteristic wave patterns on an ECG show how the electrical impulses are being affected by the injury, and what part of the heart appears to be affected. Also, problems with the heart’s rhythm can be detected. An ST elevation when you have chest pain is a strong indication of a heart attack. Also, a non-Q-wave heart attack may be indicated by a drop in the pulse rate; this type of attack is called minor but may indicate that a major heart attack is imminent.
What does your doctor want you to know about STEMI? A STEMI is likely to be preceded by chest pain, shortness of breath, or feelings of weakness, nausea, or light-headedness. If you have these symptoms for 5 minutes or more, call 911 or your local emergency number immediately. The sooner you get help, the more likely you are to survive and to return to an active lifestyle. Every minute counts.

Calling for Emergency Help

If you or someone you know might be hav- ing a heart attack, call 911 or the emer- gency services number for your area. More than 90 percent of the United States now has 911 service, but in some communities the emergency number is that of the fire department, police department, or town hall. Keep the number handy at home for all family members. If you call for emer- gency services from a cell phone, be sure to mention the location you’re calling from because the location can’t be traced quickly, as it can from a landline. Also, if you use cable or broadband service for Internet-generated calls, find out whether your service will give you access to a 911 service or to some other administrative service office that does not handle emer- gency calls.

Warning Signs of Heart Attack

Heart attacks may start with relatively mild symptoms. Call 911 or the emergency medical services in your area if you experience any of these symptoms for as much as 5 minutes:
• Chest discomfort. An uncomfortable feeling—such as pressure, squeezing, or a sensation of fullness—in the center of the chest that lasts for a few minutes or that goes away and then comes back. The feel- ing may not be truly painful.
• Discomfort in other parts of the upper body. The uncomfortable feeling or pain may spread to one or both arms, the back, the neck, the jaw, or maybe the stomach.

• Shortness of breath. Difficulty breath- ing often occurs with or just before chest discomfort. It may be the only sign of a heart attack.
• Light-headedness, cold sweats, nau- sea, or indigestion. Some people, par- ticularly women, experience these symptoms, and some report having a sense of impending doom.
If you have heart attack symptoms and for some reason cannot call 911 (or the emergency number for your area), have someone else drive you to the nearest hospital immediately. Never drive yourself unless you have absolutely no other choice.

A heart attack occurs when a blockage in the coronary arteries those that supply the heart itself—shuts off the ?ow of oxygen- rich blood to heart muscle tissue. Without oxygen and nutrients, the heart muscle will begin to die. Prompt medical attention can restore blood ?ow and limit the extent of damage, but dead tissue cannot be restored. The lack of blood supply, called ischemia, can weaken your heart or stop it altogether. If there is a prolonged decrease in blood sup- ply, tissue dies, so this is an urgent matter. The severity of the heart attack depends on how much tissue is damaged and where in your heart the damage occurs.
Several different mechanisms can cause a heart attack:
• Atherosclerosis, in which the walls of the arteries thicken and accumulate fatty deposits called plaque, can narrow or block one or more arteries supplying a section of heart muscle.
• A blood clot can form within the artery and stick to the walls of the narrowed coronary artery, already thickened with plaque, and stop the blood ?ow.
• A blood clot also can form in the coronary artery itself, as a result of atherosclerotic plaque that cracks open, emptying its choles- terol and other components into the bloodstream.

• A coronary artery can temporarily spasm, narrowing the artery and restricting or stopping blood flow. These spasms most commonly occur in a blocked artery but may occur in a normal one.
The most common mechanism begins when a fracture develops within atherosclerotic plaque, exposing the inside of the plaque. This causes platelets to stick to the site of the rupture, triggering a cascade of events resulting in the formation of a blood clot that blocks the artery. This explains why aspirin, which helps reduce stickiness of platelets, is effective in reducing the risk of heart attack.
Every year in the United States, about 1.2 million people have heart attacks, and more than 40 percent of those people die before they reach a hospital. As scary as these numbers may sound, they are substantially lower than the ?gures of 25 years ago. Today, many Americans are doing a better job of reducing their own risk of heart attack. Doctors have made major advances in treatment, so that a person who gets medical help quickly is much more likely to survive a heart attack. A heart attack survivor has a much better chance of getting fully rehabilitated than ever before. The survival rates for men after a heart attack have improved in recent years, but this has not yet occurred for women. See also chapter 16, Women and Heart Disease.