injured, and can no longer act as an adequate barrier to
cholesterol and other substances collecting in the inner walls of
the blood vessels.
Cholesterol
Cholesterol has become one of the most important issues in the
last decade. Reducing cholesterol intake can directly decrease
one’s risk of developing heart disease, and people today are more
conscious of what they eat, and how much cholesterol their foods
contain.
Cholesterol causes atherosclerosis by progressively narrowing
the arteries and reduces blood flow. The building up of fatty
deposits actually begins at an early age, and the process
progresses slowly. By the time the person reaches middle-age, a
high cholesterol level can be expected.
Smoking
It has been proven that about the only thing smoking do is
shorten a person’s life. Despite all the warnings by the surgeon
general, people still manage to find an excuse to quit smoking.
Cigarette smoke contains carbon monoxide, radioactive
polonium, nicotine, arsenious oxide, benzopyrene, and levels of
radon and molybdenum that are TWENTY times the allowable limit for
ambient factory air. The two agents that have the most significant
effect on the cardiovascular system are carbon monoxide and
nicotine.
Nicotine has no direct effect on the heart or the blood
vessels, but it stimulates the nerves on these structures to cause
the secretion of adrenaline. The increase of adrenaline and
noradrenaline increases blood pressure and heart rate by about 10%
for an hour per cigarette. In simpler words, nicotine causes the
heart to beat more vigorously. Carbon monoxide, on the other hand,
poisons the normal transport systems of cell membranes lining the
coronary arteries. This protective lining breaks down, exposing the
undersurface to the ravages of the passing blood, with all its
clotting factors as well as cholesterol.
Multiple Risk Factors
The five major risk factors described above do more than just
add to one another. There is a virtual multiplication effect in
victims with more than one risk factor. (Chart: Risk Factors)
DIAGNOSIS
It is very important for patients to tell their doctors of the
symptoms as honestly and accurately as possible. The doctor will
need to know about other symptoms that may distinguish angina from
other conditions, such as esophagitis, pleurisy, costochondritis,
pericarditis, a broken rib, a pinched nerve, a ruptured aorta, a
lung tumour, gallstones, ulcers, pancreatitis, a collapsed lung or
just be nervous. Each of the above mentioned is capable of causing
chest pain.
A patient may take a physical examination, which includes
taking the pulse and blood pressure, listening to the heart and
lung with a stethoscope, and checking weight. Usually an
experienced cardiologist can distinguish it as a cardiac or
noncardiac situation within minutes.
There are also routine tests, such as urine and blood tests,
which can be used to determine body fat level. Blood test can also
tests for:
Anemia – where the level of haemogoblin is too low, and can
restrict the supply of blood to the heart.
Kidney function – levels of various salts, and waste products,
mainly urea and creatinine in the blood. Normally these levels
should be quite low.
There are other factors which can be tested such as salt
level, blood fat and sugar levels.
A chest x-ray provides the doctor with information about the
size of the heart. Like any other muscles in the body, if the heart
works too hard for a period of time, it develops, or enlarges.
An electrocardiogram (ECG) is the tracing of the electrical
activity of the heart. As the heart beats and relaxes, the signals
of the heart’s electrical activities are picked up and the pattern
is recorded. The pattern consists of a series of alternating
plateaus and sharp peaks. ECG can indicate if high blood pressure
has produced any strain on the heart. It can tell if the heart is
beating regularly or irregularly, fast or slow. It can also pick up
unnoticed heart attacks. A variation of the ECG is the
veterocardiogram (VCG). It performs exactly like the ECG except the
electrical activity is shown in the form of loops, or vectors,
which can be watched on a screen, printed on paper, or
photographed. What makes VCG superior to ECG is that VCG provides
a three-dimensional view of a single heart beat.
DRUG TREATMENT
Angina patients are usually prescribed at least one drug. Some
of the drugs prescribed improve blood flow, while others reduce the
strain on the heart. Commonly prescribed drugs are nitrates, beta-
blockers, and Calcium antagonists. It should be noted that drugs
for angina only relief the pain, it does nothing to correct the
underlying disorder.
Nitrates
Nitroglycerine, which is the basis of dynamite, relaxes the
smooth fibres of the blood vessels, allowing the arteries to
dilate. They have a tendency to produce flushing and headaches
because the arteries in the head and other parts of the body will
also dilate.
Glyceryl trinitrate is a short-acting drug in the form of
small tablets. It is taken under the tongue for maximum and rapid
absorption since that area is lined with capillaries. It usually
relieves the pain within a minute or two. One of the drawbacks of
trinitrates is that they can be exposed too long as they
deteriorate in sunlight. Trinitrates also come in the form of
ointment or “transdermal” sticky patch which can be applied to the
skin.
Dinitrates and mononitrates are used for the prevention of
angina attacks rather than as pain relievers. They are slower
acting than trinitrates, but they have a more prolonged effect.
They have to be taken regularly, usually three to four times a day.
Dinitrates are more common than trinitrates or tetranitrates.
Beta-blockers
Beta-blockers are used to prevent angina attacks. They reduce
the work of the heart by regulating the heart beat, as well as
blood pressure; the amount of oxygen required is thereby reduced.
These drugs can block the effects of the stress hormones adrenaline
and noradrenaline at sites called beta receptors in the heart and
blood vessels. These hormones increase both blood pressure and
heart rate. Other sites affected by these hormones are known as
alpha receptors.
There are side effects, however, for using beta-blockers.
Further reduction in the pumping action may drive to a heart
failure if the heart is strained by heart disease. Hands and feet
get cold due to the constriction of peripheral vessels. Beta-
blockers can sometimes pass into the brain fluids, and causes vivid
dreams, sleep disturbance, and depression. There is also a
possibility of developing skin rashes and dry eyes. Some beta-
blockers raise the level of blood cholesterol and triglycerides.
Calcium antagonists
These drugs help prevent angina by moping up calcium in the
artery walls. The arteries then become relaxed and dilated, so
reducing the resistance to blood flow, and the heart receives more
blood and oxygen. They also help the heart muscle to use the oxygen
and nutrients in the blood more efficiently. In larger dose they
also help lower the blood pressure. The drawback for calcium
antagonists is that they tend to cause dizziness and fluid
retention, resulting in swollen ankles.
Other Medications
There are new drugs being developed constantly. Pexid, for
example, is useful if other drugs fail in severe angina attacks.
However, it produces more side effects than others, such as pins
and needles and numbness in limbs, muscle weakness, and liver
damage. It may also precipitate diabetes, and damages to the
retina.
SURGERY
When medications or any other means of treatment are unable to
control the pain of angina attacks, surgery is considered. There
are two types of surgical operation available: Coronary Bypass and
Angioplasty. The bypass surgery is the more common, while
angioplasty is relatively new and is also a minor operation.
Surgery is only a “last resort” to provide relief and should not be
viewed as a permanent cure for the underlying disease, which can
only be controlled by changing one’s lifestyle.
Coronary Bypass Surgery
The bypass surgery involves extracting a vein from another
part of the body, usually the leg, and uses it to construct a
detour around the diseased coronary artery. This procedure restores
the blood flow to the heart muscle.
Although this may sound risky, the death rate is actually
below 3 per cent. This risk is higher, however, if the disease is
widespread and if the heart muscle is already weakened. If the
grafted artery becomes blocked, a heart attack may occur after the
operation.
The number of bypasses depends on the number of coronary
arteries affected. Coronary artery disease may affect one, two, or
all three arteries. If more than one artery is affected, then
several grafts will have to be carried out during the operation.
About 20 per cent of the patients considered for surgery have only
one diseased vessel. In 50 per cent of the patients, there are two
affected arteries, and in 30 per cent the disease strikes all three
arteries. These patients are known to be suffering from triple
vessel disease and require a triple-bypass. Triple vessel disease
and disease of the left main coronary artery before it divides into
two branches are the most serious conditions.
The operation itself incorporates making an incision down the
length of the breastbone in order to expose the heart. The patient
is connected to a heart-lung machine, which takes over the function
of the heart and lungs during the operation and also keeps the
patient alive. At the same time, a small incision is made on the
leg to remove a section of the vein.
Once the section of vein has been removed, it is attached to
the heart. One end of the vein is sewn to the aorta, while the
other end is sewn into the affected coronary artery just beyond the
diseased segment. The grafted vein now becomes the new artery
through which the blood can flow freely beyond the obstruction. The
original artery is thus bypassed. The whole operation requires
about four to five hours, and may be longer if there is more than
one bypass involved. After the operation, the patient is sent to
the Intensive Care Unit (ICU) for recovery.
The angina pain is usually relieved or controlled, partially
or completely, by the operation. However, the operation does not
cure the underlying disease, so the effects may begin to diminish
after a while, which may be anywhere from a few months to several
years. The only way patients can avoid this from happening is to
change their lifestyles.
Angioplasty
This operation is a relatively new procedure, and it is known
in full as transluminal balloon coronary angioplasty. It entails
“squashing” the atherosclerotic plaque with balloons. A very thin
balloon catheter is inserted into the artery in the arm or the leg
of a patient under general anaesthetic. The balloon catheter is
guided under x-ray just beyond the narrowed coronary artery. Once
there, the balloon is inflated with fluid and the fatty deposits
are squashed against the artery walls. The balloon is then deflated
and drawn out of the body.
This technique is a much simpler and more economical
alternative to the bypass surgery. The procedure itself requires
less time and the patient only remains in the hospital for a few
days afterward. Exactly how long the operation takes depends on
where and in how many places the artery is narrowed. It is most
suitable when the disease is limited to the left anterior
descending artery, but sometimes the plaques are simply too hard,
making them impossible to be squashed, in which case a bypass might
be necessary.
SELF-HELP
The only way patients can prevent the condition of their heart
from deteriorating any further is to change their lifestyles.
Although drugs and surgery exist, if the heart is exposed to
pressure continuously and it strains any further, there will come
one day when nothing works, and all that remain is a one-way ticket
to heaven.
The following are some advices on how people can change the
way they live, and enjoy a lifetime with a healthy heart once more.
Work
A person should limit the amount of exertions to the point
where angina might occur. This varies from person to person, some
people can do just as much work as they did before developing
angina, but only at a slower pace. Try to delegate more, reassess
your priorities, and learn to pace yourself. If the rate of work is
uncontrollable, think about changing the job.
Exercise
Everyone should exercise regularly to one’s limits. This may
sound contradictory that, on the one hand, you are told to limit
your exertion and, on the other, you are told to exercise. It is
actually better if one exercise regularly within his or her limits.
Exercises can be grouped into two categories: isotonic and
isometric. People suffering from angina should limit themselves to
only isotonic exercises. This means one group of muscle is relaxed
while another group is contracted. Examples of this type of
exercise include walking, swimming leisurely, and yoga; some harder
exercises are cycling and jogging.
Weight Loss
The more weight there is on the body, the more work the heart
has to do. Reducing unnecessary weight will reduce the amount of
strain on the heart, and likely lower blood pressure as well. One
can lose weight by simply eating less than their normal intake, but
keep in mind that the major goal is to cut down on fatty and sugar
foods, which are low in nutrients and high in calories.
Diet
What you eat can have a direct effect on the kind of condition
you are in. To stay fit and healthy, eat fewer animal fats, and
foods that are high in cholesterol. They include fatty meat, lard,
suet, butter, cream and hard cheese, eggs, prawns, offal and so on.
Also, the amount of salt intake should be reduced. Eat more food
containing a high amount of fibre, such as wholegrain cereal
products, pulses, wholemeal bread, as well as fresh fruits and
vegetables.
Alcohol, tea and coffee
Alcohol in moderation does no harm to the body, but it does
contain calories and may slow the weight loss progress. People can
drink as much mineral water, fruit juice and ordinary or herb tea
as they wish, but no more than two cups of coffee per day.
Cigarettes
It has been medically proven that cigarettes do the body no
good at all. It makes the heart beat faster, constricts the blood
vessels, and generally increases the amount of work the heart has
to do. The only right thing to do is to quit smoking, it will not
be easy, but it is worth the effort.
Stress
Stress can actually be classified as a major risk factor, and
it is one neglected by most people. Try to avoid those heated
arguments and emotional situations that increase blood pressure, as
well as stimulate the release of stress hormones. If they are
unavoidable, try to anticipate them and prevent the attack by
sucking an angina tablet beforehand.
Relaxation
Help your body to relax when feeling tense by sitting or lying
down quietly. Close your eyes, breathe slowly and deeply through
the nose, make each exhalation long, soft and steady. An adequate
amount of sleep each night is always important.
Sexual activity
It is true that sexual intercourse may bring on an angina
attack, but the chronic frustration of abstinence may cause more
tension. If intercourse precipitates angina, either suck on an
angina tablet a few minutes beforehand or let your partner assume
the more active role.
TYPE-A BEHAVIOUR PATTERN
There is a marked increase of coronary heart disease in most
industrialized societies in the twentieth century. This may have
resulted, in part, because these societies reward those who
performed more quickly, aggressively, and competitively.
Type-A individuals of both sexes were considered to have the
following characteristics:
(1) an intense, sustained drive to achieve self-
selected but often poorly defined goals.
(2) a profound inclination and eagerness to compete.
(3) a persistent desire for recognition and