Nisar Ahmed a 46 years old shopkeeper, a chronic smoker with sedentary life style experienced squeezing chest pain with burning sensation after dinner. He thought it was "wind formation" and took a few tablets of antacid and went to bed. He remained restless for a few hours and could not sleep. His wife noticed him to be very pale and drenched with sweat. She rang up her brother and was preparing to take him to a nearby nursing home. He suddenly collapsed and became pulse less. Poor wife panicked and called a doctor from neighbor hood who pronounced him dead. Cause of death "A Heart Attack".
Heart attack (Acute myocardial infarction) is the most dreaded complication of coronary artery disease with a 30 days mortality rate of approximately 20%. An estimated number of patients getting heart attacks in Jammu and Kashmir based on conservative projections would be at least 2 lacks annually. The incidence of this dreadful "widow maker" disease is definitely on the rise. We are seeing heart attacks occurring at younger ages. The reasons for this upsurge seems to be life style changes, stress, tobacco consumption, lack of exercise, obesity, increasing incidence of diabetes, high blood pressure and air pollution.
The basic underlying problem in these patients is narrowing of blood vessels due to deposition of cholesterol and related fatty acids in the walls of the vessel supplying all the nutrients including oxygen to the heart muscle. Heart attack results from sudden clot formation over a narrowed portion of the blood vessel. This results in total cessation of blood supply to the heart muscle leading to a permanent damage and death of the cells in that region within 4-6 hours. If the attack involves more than one third of the total heart muscle mass it lead to catastrophic complications like heart failure, rupture of heart and sudden death due to electrical instability.
How to Recognize a Heart Attack:
The recognition of the symptoms is of utmost importance. The common mode of presentation is chest discomfort usually centrally located. It can often radiate towards arms, shoulders or jaw. The discomfort makes the person very restless and it continues for more that 10 to 15 minutes. It is often accompanied by drenching sweats, giddiness and marked pallor. Shortness of breath or gasping for air is also a common presenting mode. There are some patients who present with upper abdominal discomfort mimicking "gas and belching" accompanied by restlessness and sweating.
The pulse rate of these patients often is very slow or very fast and accompanied at times by very low blood pressure.
Such persons should be immediately put to rest and taken to the nearest facility where an electrocardiography (ECG) can be performed. This is the best way to diagnose a heart attack. Additional blood tests like (Troponin and CPK ) are also useful adjuncts but the gold standard test is ECG.
Once diagnosed the best place to treat a heart attack is a hospital with the facility of a coronary care unit (CCU). This is because sudden disorders of heart rhythm are frequent in the first 12 to 24 hours after a heart attack. Prompt recognition and treatment at the bedside can be life saving.
Importance of Time in the Management
The management of a heart attack should be very prompt & the central theme of the treatment consists of restoring the patency of the blocked artery as soon as possible. Aspirin administration in the form of a chewable tablet of 300 to 350 mgs as soon as possible can reduce the mortality by as much as 20%. This measure can be adopted as soon as possible even on a clinical suspicion even at home. ECG diagnosis confirmation is also not necessary.
The sheet anchor of the management in a heart attack besides pain relief is to restore the blood flow in the culprit artery. A number of pharmacological agents called thrombolytic agents or "clot busters" (streptokinase, urokinase & tpa) are very helpful and should be administered as soon as possible.
These drugs are given by trained and competent medical personnel under ECG monitoring. The maximum benefit comes if these are used within first few hours. The first hour after a heart attack is also called "Golden Hour" and patients who receive injection of clot busters within this period recover dramatically. The benefit of using these agents after 6 hours of the onset of chest pain is very little.
There is a sub group of patients who have had a massive attack leading to left ventricular failure or cardiogenic shock, a condition characterized by very low blood pressure not responsive to usual therapy. These sick patients do not do well even after using these drugs and have a very high mortality (75-90%) on standard therapy.
This group and patients who present to hospital more than 6 hours of chest pain are best taken care of by coronary angioplasty and stent placement at the site of blocked artery. Facilities for these procedures are rather limited in our state at present. We should therefore concentrate on early recognition of the heart attack and treat them by rapidly administering life saving drugs. These facilities need to be extended to peripheral health centers because transfer to bigger hospitals is time consuming and defeats the purpose. All District hospitals and equivalent centers should have the facility of recording and interpreting an ECG. This would help in early recognition and an urgent transfer to the nearest hospital with facility of treatment using clot buster drugs. The state should work out a plan of health care so that centers with the requisite facility are identified in every town with a population more than 30,000.
After initiating the basic treatment and stabilizing the patients they can be transferred to secondary and tertiary centers. Many of these patients need to be evaluated further by investigations like echocardiography, stress test, coronary angiography etc. Based upon the total clinical picture coronary angioplasty or bypass surgery is recommended to some of these patients. Long term medicines to prevent future events under medical supervision are of utmost importance.
What more do we need to do?
We need to strengthen peripheral hospitals for managing acute heart attack patients. The facility to do and interpret an ECG is the bare minimum. Paramedical and medical staff needs intensive training in this regard.
We should simultaneously develop an infrastructure where coronary angiography facilities along with angioplasty can be performed round the Clock in specialized centers. Author has been one of the pioneers of the treatment of very sick patients with heart attack with angioplasty and has extensive experience reported in the literature. One of the most gratifying ways to treat a very sick patient with a heart attack who presents after 3 to 4 hours of the onset of chest pain is angioplasty at the earliest.
Facilities to undertake this treatment are available in a few centers in Jammu and Srinagar for the last few years. These need to be improved further. Unfortunately because of time delays, reluctance on the part of referring physician and other logistic reasons this form of treatment is still not practised as often as it should be.
It is high time that public and physician awareness programme should be initiated aggressively so that these sick patients could be transferred to appropriate centres at the earliest. Time is muscle as far as the management of acute heart attacks is concerned. Treatment given after 6-12 hours after the onset of symptoms of heart attack is generally ineffective because permanent damage to heart muscle has already occurred. The magnitude of this problem is enormous and with improving facilities for medical treatment with the slogan of "health for all by year 2010" aggressive management strategies for patients with acute myocardial infarction need urgent attention of the policy makers of our state.
(Prof. Upendra Kaul is Director Cardiology Fortis Hospital and Escorts Heart Institute, New Delhi)