Know Your Heart

KNOW YOUR HEART By : Dr. Sanat Trivedi Edited by: Dr. Neha Pujara

KNOW POSSIBILITIES OF GETTING HEART DISEASES..

KNOW YOUR RISK FACTORS

KNOW THE TREATMENT

KNOW STEPS FOR THE PREVENTION OF HEART DISEASES.

YOUR HEART INTRODUCTION It is not yet proved that the Heart is the centre for human emotions and love. But it is the well known fact that heart is the vital organ of the human body. And malfunction of the heart can disrupt the life. Heart is the central pumping station in the body, which continuously and regularly supplies blood to all the organs of the body. Blood is vital for all the organs because it carries oxygen and nutrition for all the organs. Because of number of known and unknown factors, the rate of heart diseases is rising very fast. To-day it is one of the main killer disease of the world. In earlier times it was believed that the person gets heart disease after the age of fifty. But the recent statistics have shown that even younger population is not immune to the attack of heart diseases. Heart disease is the gift of modern civilization. So it is imperative to know about the heart, its diseases and its effect on normal life, so proper actions can be taken for its prevention, cure and management.

HUMAN BODY Human body is very complicated and complex living organism. It is made up of different parts and organs. Different parts and organs form different systems in the body. Coordinated action of each system in the body leads to ultimate goal of survival and reproduction. Human body can be compared with well equipped machine. In the machine there are different parts. Each part of the machine plays its definite role. Actions of all the parts are so coordinated that, it finally results in one definite action of the whole machine. Take the example of the car. There are number of parts in the car, each part has its own action. The coordinated action of all the parts finally results in the smooth running of the car. Same way human machine is also one well equipped machine. There are various parts, organs and systems in the body. Each organ and the system perform definite action. And their actions are well coordinated to fulfill the aim of life. As the machine can not function without power or energy, in the same way the body also can not function without energy. In the human body the energy is required for the various actions of the muscles, organs, and systems. This energy is supplied by the food. Food taken by the man is digested and metabolized by the body, and ultimately it is converted into the energy. The same energy is

utilized by various organs and muscles of the body.

Different Systems of the body. In human body there are various systems which are responsible for various functions. Gastro-intestinal system is made up of esophagus, stomach, intestine, and various glands. The main function of this system is to digest food, and convert it into simple organic chemicals like carbohydrate, fat, and protein. Carbohydrate is utilized by the body for the ready supply of energy. Protein is used for the growth and repair of the body. And fat is the store of energy. Nervous system controls and coordinates functions of all the system in the body so that body acts as single functional unit. It controls and coordinates internal body functions without conscious knowledge of the person. In addition to that it is also responsible for receiving all the information from out side world. This information are received through eyes, nose, ears, skin and tongue in the form of visual, olfactory, auditory, tactile, and taste sensations. This information are received and analyzed by the brain. After analyzing the information, the brain orders the body to respond accordingly.

Urinary system is meant for removing toxic and waste materials from the body. Genital system is meant for the purpose of reproduction. Respiratory system is responsible for oxygenation of the blood. All the impure blood returns to the right part of the heart. From there it is taken to the lungs. In the lungs the blood is purified i.e. oxygenated. The purified blood is again taken to the left side of the heart, from where it is distributed to the various parts of the body.

Circulatory System is supposed to supply blood to various systems, organs, and other parts of the body. Blood carries oxygen, glucose, various hormones, and different elements, which are vital for normal functioning of different parts and organs. Blood is supplied to various parts of the body through the network of arteries and veins.

Heart Heart is the central pumping station, which regularly pumps blood to the various parts of the body. Heart with the network of arteries and veins are known as cardio- vascular system. It is meant for distributing the blood to various parts of the body. The arteries are small tube like muscular structure, which carry blood to the various parts of the body. Veins are small tube like structures which bring blood back to the heart from various organs. Heart is central pumping station made up of special muscle which is known as cardiac muscle. Heart is divided into four chambers. Upper two chambers are known as auricles; out of which right chamber is known as right auricle and left chamber is known as left auricle. Lower two chambers are known as ventricles. Out of which right chamber is known as right ventricle and left chamber is known as left ventricle. Heart muscle contracts and expands at regular interval. The contraction and relaxation of the heart is known as heart beats. Normally in one minute heart beats for 72-76 times. When heart muscle contracts it pushes blood in to arteries. The blood from the left ventricle is pushed in to aorta. Aorta is the main and biggest artery which originates from the heart. From aorta the blood is

carried further to various parts of the body with help of arterial network. The bigger arteries further divide in to smaller arteries which are known as arterioles, which further divide to form smallest canals which are known as capillaries HUMAN HEART

Arteries and Veins Arteries are the tubular structures which carry the blood from the heart to the peripheral structures and organs and veins are tubular structures which bring blood from the peripheral structures and organs to the heart. Arteries are thicker, muscular and more elastic, while the veins are comparatively thinner and contain valves. In the artery the blood is pushed forward by the rhythmic movements of the muscles. In the veins there are no muscular movements to push the blood, but the blood is propelled forward by the actions of the valves. ARTERY

VEIN

Capillaries Capillaries are smallest tributaries of the arterial network. The size of the lumen of the capillary is approximately 8-10 micron. The capillaries are very small and thin walled. They pass through various tissues and cells. At this place blood glucose is utilized to produce energy. In the process the glucose component of the blood is converted in to carbon, water and energy. Energy is utilized by the tissues and cells for their routine functions. The free atom of the carbon joins with the oxygen of the blood and forms carbon dioxide. The blood containing higher percentage of the carbon dioxide is taken back to the right auricle of the heart through network of veins. Then blood flows to the right ventricle [right lower chamber of the heart]. From right ventricle blood is pushed into in the pulmonary artery. The pulmonary artery carries blood to both the lungs. In the lungs the impure blood gets purified.

Lungs There are two lungs in the body. One lung occupies the left side of the thorax and second one occupies the right side of the thorax. The lungs are sponge like structures. Like sponge it contains numerous small cavities. These cavities are filled with air when air is inhaled. These cavities are named as alveoli. Alveoli are nothing but small air spaces. Alveoli open into small tube like structure which is known as bronchioles. Bronchioles open into bigger tube known as bronchus. There are two bronchi which open into the trachea which in turn opens into the space called larynx, which ultimately opens into the nose. In ordinary respiration, fresh air is inhaled through nose. Fresh air reaches to the alveoli through various air passages. In the alveoli the fresh air comes in contact with impure blood [blood with high percentage of carbon dioxide.] And here process of exchange of oxygen and carbon dioxide takes place. Carbon dioxide part of the blood is exchanged with oxygen part of the fresh air. In

this way the impure blood gets purified .[oxygenated]. Now blood contains higher percentage of oxygen. The same blood returns to left side of heart through pulmonary veins. With the contraction of heart, again same blood flows in to the body to supply fresh oxygen and glucose to various parts of the body. In short the function of cardio-vascular system and respiratory system are as following. A] Heart pumps the blood regularly so that it reaches to all parts and organs of the body. B] The blood carries glucose and oxygen. C] The glucose part of the blood is utilized for the production of energy. D] Same energy is utilized for the normal functions of the muscles and organs. E] During the process of energy production, carbon particles are released. F] The same carbon particles join with free oxygen in the blood and forms carbon dioxide. G] Blood carrying carbon dioxide returns to right upper chamber of the heart. From there it passes to lower chamber and then to the lungs. H] In lungs the blood is oxygenated. And the same blood returns to heart. I] Again heart pumps the blood to various parts of the body. This cycle repeats 72 to 76 times in a minute. With the effect, the body parts and organs get the required energy regularly for their normal functions.

Heart and coronary arteries Heart is also one type of special muscle. It is known as cardiac muscle. For its normal function the cardiac muscle also requires energy. The same is supplied to cardiac muscle through coronary arteries. Coronary artery originates from the base of aorta. It supplies blood to cardiac muscle. There are two main coronary arteries. These are known as right coronary artery and left coronary artery. The right artery supplies blood to the right side of the heart and left artery supplies blood to the left side of the heart. Heart is the central pumping station. With each contraction it pushes blood in to network of arteries. Arteries are small pipe like structures, made up of small muscles and tissues, which are responsible for supplying blood to various parts of the body. In normal circumstances heart pushes 70 to 80 c.c. of blood with one contraction. Heart contracts 72 to 76 times in a minute. With the result it pushes 5 to 6 liter of blood in a minute, this much blood is enough for normal requirement of the body. But during manual labor, exercise, running or climbing the stairs, body muscles require more energy. They require more blood. With the effect heart pumps more blood by increasing the force of contraction and increasing the rate of contraction. The heart beats can be

raised to 150 or 180 per minute, during running or severe exercise. With the effect it can push 30 to 40 liter of blood per minute. When heart functions at higher rate and with more force, its own requirement of the energy will be also raised. It itself will also require more blood for fulfilling its own demand. In normal circumstances there is no difficulty for supplying extra blood to heart muscle, because the coronaries are potent enough to supply extra blood to the heart muscle. But if coronaries are not potent enough to carry extra amount of blood, then heart will not get enough blood, which will hamper its function.

Coronary Block These are the arteries which supply blood to heart muscle. There are two main coronary arteries.

Right coronary supplies blood to the right side of the heart and the left artery supplies blood to the left side of the heart. These two main arteries are further divided into smaller branches which supply blood to the smaller portion of the heart.

In normal circumstances coronary arteries are potent enough to supply required blood to the heart muscle. It is potent enough to supply blood to the heart muscle during rest [when demand of blood is less] or during physical labor [when demand of blood is more]. Healthy coronary arteries can meet the demand of the heart during the resting period or during physical labor. But if the coronary artery is blocked due to some reasons then it can not meet extra demand of the heart, which ultimately leads to heart attack or myocardial infarct. For any reason, if the heart does not get enough supply of blood then it may not be in a position to function normally, which ultimately may hamper whole body function, because in such abnormal situation the body will not get enough blood for fulfilling its demand of blood. If the coronary

arteries are completely blocked then blood supply to the heart muscle will stop and heart will stop beating leading to sudden death. If only right artery is blocked then the right portion of the heart will not get blood and hence the function of the right side of cardiac muscle will be paralyzed. In the same way if the left artery is blocked then the blood will not reach to the left portion of the heart and the function of the corresponding left side of the cardiac muscle will be paralyzed.

Block of small coronaries: It may happen that the main artery is not completely blocked but it may be partially blocked. At the same time other small branches or tributaries are not blocked. In that case the function of the small portion of the heart will be affected. That small portion of the heart will stop functioning. This is pathological death of the heart muscle. When portion of the heart muscle does not get enough blood, the muscle fiber will not get enough nutrition. With the effect those heart cells will die. These cells are the specialized cells which are meant to contract and relax at regular intervals. When those cells will not get enough nutrition then it will become dead cells. In the course of time these dead cells will be replaced by fibrous tissue. These fibrous tissues are not elastic and it

can not contract as normal cardiac muscle fibers. It is like scar on the heart muscle. This is called cardiac infarct in medical terms. Cardiac infarct may be small or big depending upon the block in the specific artery. If block is in the bigger artery then the infarct will be bigger, while if the block is in the smaller artery then it can be smaller infarct. Malfunctioning of the heart depends upon the size and position of the infarct. Once an infarct develops in the heart, it will not be in position to function at full potential. Cardiac infarct lowers the capacity and efficiency of the heart. Such a heart can function in ordinary circumstances of resting period, but when blood demand is more during any type of physical labor or exercise, then it can not function to fulfill higher demand of the body. ******

Partial block of the coronary arteries: It may happen that the coronary artery may not be fully blocked but it is partially blocked. The blockage of the artery can be 50%, 60% or more. In the partial block the artery can supply small amount of blood. Again this much amount may be sufficient for the heart to work in ordinary circumstances. It may be sufficient for normal functioning of the heart i.e. normal rate of 76 beats/minute with normal force, but it can not

meet higher demand of blood during physical labor, exercise or mental excitement. So the person with partial block of the coronary arteries will get chest pain during physical labor, exercise or mental excitement. This is known as angina pectoris in the medical terms. Angina pain in the medical terms is described as ‘cry of the heart for more blood’. If this situation persists for longer period of time, then gradually heart muscle will get weak. Angina pectoris is the primary sign of coronary artery block. Gradually this block will be increasing. It may become complete in course of time resulting in the cardiac failure or cardiac infarct.

How arteries get blocked? Arteries are small tube like structures through which blood flows to the various parts of the body. The walls of these tubes are made up of small muscles and smooth layers of cells. The inner lining of these walls are covered with special lining which is known as endothelium. This inner lining is very smooth so that blood flows smoothly through these tubes. The arteries are also elastic in nature. So it expands when blood flow is higher than normal. Due to certain conditions the arteries can loose its elasticity and can become rigid in nature. Not only that but it becomes narrower. Process of hardening and narrowing is known as atherosclerosis. This is as such a degenerating process. Human blood contains blood cells and

plasma. The cells are white blood corpuscles, red blood corpuscles and platelets. The fluid part of the blood is known as plasma. The plasma contains glucose and cholesterol in addition to various other elements. Glucose is produced from carbohydrate and cholesterol is produced from fat. Being fatty, cholesterol is viscid in nature. During normal flow of blood, it sticks to the walls of the arteries. When the concentration of the cholesterol is higher in the blood, the same process is enhanced. Small fat globules of cholesterol stick to the walls of the artery. Gradually it is converted into a small solid mass which is known as plaques. When multiple plaques are deposited on the walls of the arteries, those arteries get rigid and becomes narrower. This is the process of atherosclerosis. Due to atherosclerosis, artery looses its elasticity, not only that, but its lumen is reduced in size. The process creates resistance in the smooth flow of blood. The end result will be increase in the blood pressure. Atherosclerosis is mainly due to ageing. The process of atherosclerosis can be compared with blockage of domestic water pipe line. In the house there are various pipe lines through which water is supplied to the various parts of the house

like kitchen, bath room, lavatory, etc. when the pipe lines are freshly installed; there will be easy flow of water. But gradually there will be deposition of salts and different elements on the inner linings of the pipes. With the result the inner linings of the pipes will loose its smoothness and will become narrow. End result will be difficulty in normal flow of water. With the result water supply to the different parts of the house will be reduced. Same process is observed in the atherosclerotic arteries. Because of narrowing of the arteries, the blood flow to the various parts of the body is reduced. This finally effects functioning of various systems. When the block is in the coronary artery it effects the functioning of the heart. Atherosclerosis is mainly due to ageing process. There are other factors also which enhances the process of atherosclerosis. These factors are: A] Diabetes B] Obesity C] Heredity D] High cholesterol in blood E] High LDL and low HDL level in blood F] High level of triglycerides in blood

A] Diabetes. Diabetes is the disease where level of blood glucose is higher then normal. Normally there is 80-110 mg. of glucose per 100c.c. of blood. The level of blood glucose is maintained by body hormone known as insulin. But when due to some reason insulin looses its efficiency, it fails to maintain normal blood sugar level. In diabetes the blood sugar level remains higher then normal. It is observed that the process of atherosclerosis is quicker in the case of diabetic patient than in the normal person. B] Obesity: In obese persons, the fat content is more in comparison to the normal person. With the result they are more likely to get high blood cholesterol level. High blood cholesterol enhances the process of atherosclerosis. C] Heredity: It is also observed that atherosclerotic changes are more common in the members of the same family. It is presumed that some genetic factors play major role in the formation of atherosclerosis.

D] High cholesterol in the blood: Normally blood cholesterol level in the blood is 150 mg. per 100 c.c. of blood. When there is higher cholesterol level in the blood, there are more chances for fat globules to form the plaques. Such plaques are responsible for atherosclerosis. E] High LDL and low HDL level in the blood: Cholesterol is one type of fat. The fat in the cholesterol can be in the form of high density lipoproteins [HDL] or it can be low density lipoproteins [LDL]. As such HDL reduces the chances for atherosclerosis while LDL enhances the chances for atherosclerosis. F] High level of triglycerides: It is also observed that person having high level of triglycerides in the blood, are more prone to get early atherosclerosis. In addition to these factors there are some other factors like tobacco consumption and alcoholism which also plays some role for enhancing the process of atherosclerosis. Atherosclerotic changes affect all arteries of the body, including coronary arteries, because the factors which affect the common arteries, affect the coronary arteries too. When there is

atherosclerosis in the coronary artery, its inner lumen gets reduced. And that process results in partial or complete block of the coronary artery. And that reduces the blood flow to the cardiac muscle and damages the cardiac muscle. The extent of the damage is proportional to the extent of the block in the coronary artery. Damage to the heart ranges from mild anginal attack, to massive heart attack which leads to sudden death. Angina pectoris In angina pectoris patient gets pain in chest on exertion. The pain may be as mild as little discomfort in the chest, or it can be as severe as stabbing pain with profuse perspiration and difficulty in breathing. Generally pain is felt on the left side of the chest. This pain may be referred to the left shoulder or on left arm. Such a pain is known as referred pain. Angina pectoris is caused due to insufficient blood supply to the cardiac muscle. This happens when one of the coronary artery is partially blocked, and blood supply to the cardiac muscle is partially reduced. The blood supplied in such circumstances may fulfill the demand of the heart in ordinary circumstances but when blood demand is more due to physical labor or mental excitement, the available blood supply will fall short of the actual demand. The heart can not get more blood because of the coronary block. Extra blood demand of the heart can not be fulfilled. The person gets chest pain. It is known as

crying of the heart for more blood. The pain subsides by rest within 5-10 minutes. Anginal pain is best treated by the drug known as glycero-nitrates. Glycero-nitrates act on the coronary artery by dilating the artery. With the result normal blood supply is restored to the heart muscle. In the case of angina pectoris there is no damage to the cardiac muscle. But cardiac muscle’s potential capacity to function during higher physical or mental activities is lost. Angina pectoris is the red signal for the future more severe heart attack. It gives the indication that one or more than one coronaries are partially blocked. ***** Cardiac infarct: In this case the arterial block is complete and more sustained; there may be loss of blood supply to the some portion of the heart muscle for longer period. Because of the total cut of blood supply to the heart muscle, that portion of the heart tissue will die and will be replaced by fibrous tissue in course of time. That dead portion of the heart will not be able to function normally. Cardiac infarct means permanent scar formation on the heart muscle In the case of cardiac infarct there will be severe pain on the left side of the chest with

profuse perspiration. This pain may be referred to the left shoulder or to the left arm. There may be difficulty in breathing. Blood pressure may fall with increased pulse rate. The pain will not subside on its own within short period or during rest. The drug like glycero-nitrates will not be very effective. In such case the patient should be immediately shifted to the intensive cardiac unit of the hospital and patient should be kept under expert guidance of cardiologist. The heart will loose its normal efficiency to work. The loss of efficiency will be in proportion to the extent of damage to the heart. So even after recovery from the attack the patient has to take more precautions. Now his heart has lost its normal potency to work. The heart can only work at a much lower potency. So the patient has to be very careful while performing any physical activities.

Massive heart attack When there is sudden and complete block in one of the main coronary arteries, there will be complete loss of blood supply to the major part of the heart muscle. The damage to the heart muscle will be so high that the remaining part of the heart will not be in position to work. The heart will stop beating and there will be sudden death of the patient. Such type of block can also occur due to sudden spasm of main coronary artery or such block can be due to loose embolus suddenly

blocking the pathway of the blood. Massive heart failure can be due to failure of electrical system of the heart.

Risk factors for coronary heart disease The blockage of coronary artery is the main cause of heart attacks and heart failures. So it is imperative to know the causes of arterial blocks. This is mainly due to atherosclerosis of the artery. The atherosclerosis is an inevitable aging process. In addition to the age of the person, there are number of other factors which are responsible for speeding up the process of atherosclerosis. These factors are Diabetes Obesity Hereditary High cholesterol level in the blood High LDL and low HDL in the blood High level of triglycerides in the blood. In addition to these factors which are directly responsible for speeding up the process of atherosclerosis, there are other risk factors which are responsible for causing coronary heart disease [CHD]. these factors are

Smoking: Tobacco consumption in any form enhances the chances for CHD. Nicotine in the tobacco is harmful to the various body systems. Several medical surveys done all over the world has proved that the incidences of CHD are more in the smoker’s group as compared to non-smoker’s group. It is not very clear that how smoking affects coronary blood flow to the heart. The exact pathophysiology of the effect of smoking is not known. But it is proved statistically that smokers are at greater risk than non-smokers. The main element in the tobacco is nicotine. It causes temporary high blood pressure and increases the heart rate. But its effect on the process of atherosclerosis is not yet fully known.

Mental stress Chronic mental stress disturbs the fine balance of the internal system of the body. Chronic mental stress also disturbs internal hormonal system. with the effect the body resistance is reduced. All these factors are responsible for increasing the risk of getting coronary arterial disease. It is observed that a person living stressful life is at a higher risk to get CHD.

There are two types of personalities in the society. These are Type A and Type B personalities. Persons with personality A are very ambitious people. They are very eager to get success in the life. They desire to climb the ladder of success in a short period of time. Such persons can not accept defeat in their life. They are never contented with the available wealth. Their main aim is to get more and more. Such persons are always under mental stress. These types of persons are at a higher risk for CHD.

Alcoholism Alcohol when taken in small amount can be helpful for preventing CHD; However regular alcohol consumption in high quantity can cause harmful effect on number of organs including heart.

High blood pressure High blood pressure is also due to atherosclerosis in the arteries. The same atherosclerotic changes in the coronary arteries will cause lack of blood supply to the heart muscle, which ultimately will lead to CHD.

When there is high blood pressure, the cardiac muscle has to apply more force for pushing the same amount of blood to peripheral organs. It is like pushing the water in to the pipe lines when lumens of the pipe lines are narrow. When high blood pressure remains for a longer time it weakens the heart muscle. In some cases the heart muscle will get enlarged. This is known as cardiomegaly in the medical terms.

Sedentary life style Lack of regular physical labor can cause number of diseases. As such human body is designed by nature for doing regular physical labor. In the ancient period, regular house work and occupational work were enough to give required physical labor. So people were comparatively healthier. In modern days because of the modern gadgets and the change of life style, the people are not regularly exposed to required physical labor. With the result their lives have become more sedentary. There are number of advantages of doing regular exercise. It is observed by a number of surveys that those who are doing regular physical exercise are less prone to CHD. It is the natural rule that those organs and muscles, which are not used by the body for longer period, loose its strength and efficiency. For body muscle to remain fit it requires to be exercised regularly. The

body muscle will loose their power, strength and tone if it is not used regularly. The same rule applies to the heart muscle also. The heart muscle also requires regular exercise to remain fit. Like other body muscles it is not possible to directly give exercise to the heart muscle. But one can exercise his cardiac muscle indirectly. When the person starts exercising, his body muscles require more energy. This energy can be supplied to the muscles by supplying more blood to the muscles. For supplying more blood the heart has to beat at a higher rate and more forcefully. With the result indirectly the heart muscle gets exercise. Secondly when the heart beats faster and forcefully, the blood will flow in the arteries and veins with more speed and more force. Because of the faster and forceful blood flow in the arteries and veins, it flushes those fat globules and plaques from the walls of the arteries. With the result it helps in keeping the arteries clean, potent and elastic, which ultimately reduces the chances of CHD. Not only that but regular exercise helps in lowering the level of cholesterol in the blood. This indirectly helps for preventing CHD. All the factors mentioned above are considered as risk factors in the medical terms. The person having only one risk factor may get or may not get CHD. He may live his whole life without any heart trouble, but the person having two risk factors, carry higher chance to have CHD. It is observed that the person having two risk factors is 50-60-%

more prone to have CHD. In the same way a person carrying three risk factors are 80-90% more liable to get CHD.

Investigations Chest pain may be due to various reasons. It can be due to muscular sprain, or can be due to arthritic changes in the costo-condral junctions or can be due to some pathology in the lungs or can be due to gas trouble in the stomach. As such all the pains in the chest are not due to CHD. So before treating the patient, it is imperative to diagnose the case to find out the real cause of the pain. There are certain investigations which help for correct diagnosis.

E.C.G.: E.C.G. or electrocardiogram is the measure of the electrical activity of the heart. The heart muscle is supposed to generate definite pattern of electricity. The electricity produced by the heart is very low in magnitude so it requires special instrument to measure the same. The instrument meant for recording the electrical waves of the heart is known as electrocardiogram machine. This machine records the electrical graph produced by the heart. This graph is known as electrocardiograph.

Normal heart shows definite pattern and the shape of the graph. But if there is any abnormality in the heart muscle or abnormality in the function of the heart it will show definite changes in the E.C.G. From the recorded changes in the E.C.G., doctors can diagnose the pattern of abnormalities in the heart. In the case of CHD, there will be definite changes in the ECG. It may also happen that the blood supply to the heart muscle is reduced for only short period of time. Hence when the patient gets chest pain for a short period of time there may be no pain in the chest when he contacts the doctor. If ECG is taken at such time it may show definite changes or it may not show any changes in ECG. In such circumstances normal ECG may mislead the doctor, and doctor may miss the correct diagnosis. In such circumstances it is advisable to perform treadmill test.

Treadmill test It is observed that during resting period, the heart beats with normal force at the rate of 70-76 per minute. But during exercise or physical labor it

beats faster with more force. In these circumstances the heart muscle will require more blood for its energy supply. If the coronary arteries are healthy and potent there is no difficulty. But if the coronary arteries are narrowed or partially blocked then it will not be possible for heart to get more blood. In such cases it will show certain ECG changes. Not only may that but during this period the patient gets pain in the chest. This is known as angina on exertion. The treadmill test or the stress test is designed on the same principle to understand how the heart responds under physical stress. The treadmill machine is designed to perform exercises in definite measured quantity. The machine is like a simple static walker commonly used in any gymnasium. The speed and gradient of the walking platform is adjustable. The whole system is computerized. The patient’s pulse rate, BP, and ECG are automatically recorded during the test. The patient is asked to walk on the machine. The speed and the gradient of the walking platform are adjusted by the doctor as per the standard norms. The patient is supposed to walk on the machine for 8-10 minutes. During this period his ECG, pulse rate and BP is recorded. From the reading of the ECG, and the pattern of pulse rate and BP, the doctor can diagnose coronary insufficiency. Sometimes the patient may get chest pain during the test, in such circumstances the doctor will stop the machine

and the patient will be asked to take rest. The treadmill test is more reliable than the simple ECG recording. This is because in recording an ECG at rest, it is not possible to know status of heart during exercise. While in tread mill test one can know the status of heart during rest as well as during exercise. Besides one can also measure the potential capacity of the heart for performing physical labor or exercise.

X-ray - chest X-ray of the chest will give the indication of the status of the heart muscle. If the patient is having high blood pressure for a long time, his heart muscle will be weakened and enlarged. Enlarged heart can be easily detected by an x-ray picture.

Blood test Most of the blood tests do not give the direct evidences of CHD, but it gives the indirect picture of the blood which can cause thickening of the blood vessels. It is presumed that if blood contains certain elements which are more than normal, then such a situation can be responsible for hastening the process of atherosclerosis. And atherosclerosis is the main cause for all types of CHD. Most important of these tests are lipid profile of the blood.

Lipid profile of the blood By this test one can know different types of lipids (fats) in the blood. The normal cholesterol is around 150-175 mg per 100 cc of blood. If blood shows higher level of blood cholesterol then it can cause atherosclerosis of the blood vessels. Other important factors are HDL and LDL. HDL means high density lipoproteins and LDL means low density lipoproteins. It is presumed that HDL is a helpful factor and LDL is a harmful factor. So if level of HDL in the blood is higher and that of LDL is lower then it is desirable, but if the condition is reversed then it is dangerous. Not only absolute level of the HDL and LDL should be known but one should know its ratio in the blood. The third important factor to be considered is the level of triglycerides in the blood. A higher level of triglycerides in the blood is not desirable. VLDL means very low density lipoproteins. If the level of VLDL in the blood is higher than normal then the person carries higher risk for coronary artery disease. So it is an important test to measure the risk factor in the individual.

Lipoprotase little –A or LA The level of LA also indicates the possibilities of getting CHD. So it is advisable to get this test done for the assessment of patient’s condition.

Homocysteine Homocysteine is an intermediary by-product which is produced when human body metabolizes (breakdown) an essential amino acid known as methionine. Normally methionine is found in large quantities in meat, eggs, milk, cheese, white floor and canned foods. Methionine is an essential amino acid require by the body for its repair, growth and survival. In normal process body convert these foods in to methionine and cystine. [Another amino acid]. This chemical reaction is successfully carried out with the help of certain enzymes. Body also needs folic acid, vitamin B12 and vitamin B 6 for the completion of this reaction. If there is absence or deficiency of these components, then the reaction will not be completed and there will be production of homocysteine. This homocysteine is not helpful to the body. It some how enhances the process of atherosclerosis. Higher the level of homocysteine there is greater the risk of getting atherosclerosis. With the result there is higher the risk of CHD. So it is desirable to have a low level of homocysteine

in the blood. It is desirable that homocysteine level should be below 7 micromoles/ liter of blood. It is desirable to check the level of homocysteine in the blood of the patient to know the extent of risk of getting CHD.

Blood sugar Glucose is the one of the constituents in the blood. As such energy to the various parts of the body is supplied through glucose. The level of blood glucose is maintained by the help of insulin. Insulin is produced in the body by an endocrine gland known as the pancreas. In the case of diabetes the insulin can not effectively function. With the result the blood level of glucose will be higher than normal. Normal blood glucose level is 80-110 mg per 100 cc of blood. In the case of diabetes it is higher than normal. In the case of diabetes there is high risk for CHD.

Angiography This is the special procedure to know if there is any blockage in the coronary arteries. There are certain dyes which are opaque or translucent to certain specific types of rays. Such specific rays can not pass through such dyes. Hence when pictures are taken after passing the dye certain abnormalities in the arteries can be seen. The same

principle is applied for the procedure of angiography. A special dye is passed through the coronary arteries. There is special technique for injecting the dye in the coronary arteries. After injecting the dye the pictures of the heart and its blood vessels are taken. The picture or the angiograph will show the exact position of the heart, coronary arteries and the potency of those arteries. An expert cardiologist can read the angiograph and can decide the extent of the arterial block. This is a very exact and a helpful test for assessing the arterial block. It is a pre-requisite before performing either angioplasty or by-pass surgery of the heart.

Treatment Coronary artery disease can be treated by different methods. The choice of the treatment depends upon a number of factors like age of the patient, severity of the disease, potency of the arteries, condition of the heart, accompanying diseases like blood pressure and diabetes, patient’s life style, and the most important factor which is the affordability of the patient.

Rest The first and most important step is to take rest. This is the most important treatment in the case of any heart disease. In the case of CHD, there is a limited supply of blood to the heart muscle. So one should not create any such condition where the heart requires more blood. So any type of physical and mental stress is to be avoided. And the patient is given complete rest. The main and the first symptom of the CHD is pain on the left side of the chest. So whenever there is pain on the left side of the chest, especially in the elderly patient, it is presumed to be CHD, unless it is proved otherwise. So in such cases the primary duty of the family members is to give rest to the patient and call the doctor. There are incidences noted in the medical history, that the symptom of pain in the chest is taken lightly by the family members and some times by the patient himself. Such cases are considered as simple muscular pain or pain due to gas in the stomach. With the result some home remedies are given to the patient. The patient does not take enough rest. With the result the patient inflicts more injuries to the heart. Then it becomes difficult to treat such patient even by an expert cardiologist. So it is strongly advised that whenever there is any doubt of CHD, the patient should be given complete rest.

Medical Treatment Once the diagnosis is established by the doctor, he will start appropriate treatment. In the beginning the doctor tries to treat the patient by medicines. Such medicines are prescribed which can keep the coronary artery potent and will not allow further contraction of these arteries. The most effective medicines available are nitrate salts which are supposed to dilate coronary arteries. There are various salts of nitrates, available. It can be isosorbide-5 mononitrate, dinitrate, or trinitrate. The tablets are available in the market with their trade names like sorbitrate, carditrate etc. this tablets can be taken orally or can be kept under the tongue. In addition to the nitrate varieties, aspirin is also supposed to dilute the blood and prevent coagulation of the blood. Aspirin can be given in the mild doses for a longer period. If the patient is having high blood pressure or diabetes then those diseases should be treated by suitable medicine. In the same way the patient with high cholesterol should be treated for the same by anti-cholesterol drugs, change of diet and proper exercise. The patient with high cholesterol should avoid diet with high fat value. Not only that but he should be encouraged to carry out regular exercises to control cholesterol in the blood. The

type of the medicine and its dose should be decided by the doctor. It is advisable that the patient or his family members should not make any change in the medicine or its dosage without the prior permission of the doctor.

Angioplasty If the potency of the coronary artery is not sufficient to allow the required amount of blood to flow to the heart muscle and when it is known that the medicine will not be effective for restoring the potency of the coronaries, then the next alternative is to perform angioplasty. Angioplasty is a semioperative procedure, in which the potency of the coronaries is increased by mechanical method. An expert cardiologist can only perform this procedure. In the beginning the exact location and extent of the coronary block is assessed with the help of angiography. Once the exact location of the block is determined, then the block is removed

with the help of a special procedure known as Balloon Angioplasty. Once the block is removed the cardiologist will keep a small instrument called stanch within in the lumen of the artery to prevent it from collapsing. The stanch will keep the artery potent and will not allow the artery to contract in future. Angioplasty is helpful in certain patient but it may not be helpful in more severe cases. In such cases the treatment available is by-pass surgery.

By-pass surgery This is the operative procedure where alternative path way is formed by planting fresh artery from another part of the body. After the operation the blood will flow to the heart muscle through newly formed pathway. This is a major operation and is carried out by the expert cardiac surgeon.

How to prevent coronary heart disease? It is always better to prevent the disease than to treat it. Coronary heart diseases can be prevented by taking certain steps and by changing life style. As a rule any disease can be prevented by preventing its causes. There are two types of preventions, primary prevention and secondary prevention. Primary preventions are the preventive steps for those who have never suffered with heart disease, while secondary preventions are the preventive steps meant for the patients who have had the attack of CHD.

Primary Prevention Primary Preventive steps can be thought for two types of the persons.

1] Preventive steps for the persons who are normal and who has never suffered with CHD. 2] Preventive steps for the persons with higher probability of getting the disease.

Primary prevention in normal person In the case of CHD there are ten risk factors which are directly or indirectly responsible for causing CHD. These main risk factors are A) Age B) Family history C) Obesity D) Mental stress E) High cholesterol level in the blood F) High blood pressure G) Diabetes H) Tobacco consumption I) Alcohol consumption J) Sedentary life style If one looks at all these risk factors, it will be seen that first two factors are inevitable. It is not possible to reduce the age of the person nor is it possible to change personal family history of heart diseases. But it is possible to control effectively the other eight factors. Let us examine these eight factors in more detail.

Obesity Obesity is the resultant outcome of over eating and lack of exercise. In the modern era, the personal life style has considerably changed. In the olden days the people were getting enough exercise indirectly from the day to day house work and the type of occupation. Women had to perform all the house work manually, while for the men, most of the occupations were such where the person had to do physical labor. Besides in those days, there were no good transport facilities available, so the person had to walk a considerable distance for reaching the place of work. With the result there was no need for extra exercise to keep oneself fit. But now the scenario has changed. Now the transport facilities have improved, and are within the reach of ordinary person. So most of the time, person has not to walk for reaching to any place. At the same time there are a number of gadgets available in the market, which relieves the person from physical labor, resulting into lack of sufficient exercise. At the same time the food habits have not changed. The people have not reduced their caloric intake. On the contrary people have started taking high caloric and fatty foods. The net result of taking high caloric food and lack of enough exercise is obesity and over weight. The percentage of obese people is increasing very fast in the population. The

incidences are more frequent in the rich and the upper class of people. So the percentage of CHD is also higher in the rich and the upper class of people. Standard height-weight tables are easily available in the market. From those tables, one can easily check whether his weight is normal or not. If the body weight is more than 10 % of the standard weight, then it is risky. In such case one should start taking measures for reducing it. Weight can be reduced by effectively increasing calorie consumption and at the same time reducing calorie intake. Calorie consumption can be increased by starting regular exercise. Most effective and simple exercise is walking. Everyday walking for 50-60 minutes can effectively reduce the risk of CHD. Our diet contains three main components. These are protein, fat and carbohydrate. The fat component of the diet carries double the calories than protein and carbohydrate, so one should avoid food that containing more amount of fat in the diet. Broadly speaking one should reduce 1015% of the total calories and avoid taking any fatty foods like oil, ghee, butter and cheese. For reducing diet it is better to consult a dietician or the doctor.

Mental stress Mental stress is the second important factor which is responsible for the increased rate of CHD. As such mental stress is the gift of modern life style. In the past people used to be more contented. They were satisfied with the available means and resources. Most of the people were happy and satisfied with their available income. They used to manage their expenditures within the available resources. But now the scenario has totally changed. A person’s expectations from life have been raised considerably. He is not satisfied with what he is having and what he earns. He expects to live more comfortable and luxurious life. Modern world is the world of competition. Everybody is anxious to climb the ladder of success in a very short period of time. The person is always envious of the comfort and luxury his neighbors, friends and relatives are enjoying. He is never contented with what he possessed. With the result he has to work hard, he has to spend more energy. He works more than his capacity. He spends more time for achieving his desired goals. Knowingly or unknowingly, the modern man becomes a part of an unending rat race for achieving materialistic goals. The end result is more mental strain and no rest. Progress and Success are desirable in life but it should not be at the cost of mental and physical health.

As far as possible one should decide his goals which are achievable without mental strain. If goals are very high then one has to spend much time and energy for achieving the same which ultimately cause mental strain. One should also know the methods of relaxation. There should be some period in the day when one can stop the work and can relax completely. It is advisable to take rest of fifteen minutes after continuous four hours of work. In the same way after six days work one should have complete relaxation for a day. On such a day one should not think about one’s occupation and office related work. One should be mentally away from the routine work. One can go for movie, or can spend the time with the family or friends, or can read, or can engage his mind for some hobby which interests him and at the same time can give him inner pleasure. As such engaging oneself in some personal hobby like reading, writing, photography, music or painting, can be a very good relaxation for the mind. The best way of mental relaxation is regular meditation. One should learn the technique from the experts and should perform it regularly every day at a fixed time. Meditation is very helpful for mental relaxation as well as it enhances mental capacity.

High cholesterol High cholesterol in the blood is common in people who are obese. It is directly related with the food habits. The person who is taking high fatty diet is more likely to get high cholesterol in the blood. So for controlling the cholesterol level in the blood, one should reduce the fat content in the diet. Avoiding oil, ghee, butter, and cheese in the diet will help reducing the cholesterol in the blood. Besides this one should also exercise regularly. If the person is obese and over weight, then he should take all the measures to reduce his weight. If the level of blood cholesterol is very high then it is advisable to take anti-cholesterol drugs. This drug should be taken under medical advice.

High blood pressure High blood pressure adversely affects the heart. Because of high blood pressure heart is under constant stress. This is because heart has to function under high pressure which weakens the heart muscle. The normal blood pressure is 120/80 mm of Hg. The systolic pressure is 120mm of Hg and diastolic pressure is 80mm of Hg. If the blood pressure is 140/90 mm of Hg, then it is considered as borderline high blood pressure. When the blood pressure is 160/100 mm of Hg it is considered as moderately high blood pressure.

And when the blood pressure is above 160/100 mm of Hg then it is considered as a very high blood pressure. Borderline high blood pressure can be comfortably controlled by change in the diet and regular exercise. But in the case of moderate to severe high Blood Pressure, it is advisable to take antihypertensive drugs. The drugs should be taken under medical guidance. Most of the time high blood pressure is without any signs and symptoms with the effect in most of the cases the blood pressure is not detected immediately. But it is detected accidentally. As it is a silent disease without any visible signs and symptoms, people try to avoid medication. As such high blood pressure is considered as a silent killer. It gradually erodes the heart muscle. So it is advisable to get it checked regularly. And whenever there is indication of high blood pressure, one should take appropriate regular treatment for the same. Avoidance of treatment or irregular treatment enhances the risk to life and is not desirable.

Diabetes Abnormal rise of blood sugar level is known as diabetes mellitus. Like blood pressure, this also remains undetected and silent for a long period of time. In most of the cases it is detected accidentally. By the time it is detected it might

have done enough damage to the heart and other body parts such as kidneys, eyes, joints, etc. Hence it is advisable to check one’s blood sugar regularly especially after the age of 40 years. Normal fasting blood sugar level is 80-110 mg per 100cc of blood. If it is 120 mg then it is borderline high. The blood sugar level between 130-160 mg is considered as moderately high and blood sugar above 160mg is considered as very high. Borderline diabetes can be controlled by change of diet and regular exercise. But for the moderate and severe variety one should take appropriate medicine. Medicine should be taken under medical guidance. In the diet one should reduce total calories, carbohydrate and fatty food. It is advisable to discuss the diet with either one’s family doctor or a dietician.

Tobacco consumption Tobacco in any form is harmful to the heart. Most of the time people either smoke or chew the tobacco. There are number of surveys which have proved that cigarette smoking enhances the chance of getting CHD, so one should leave smoking or tobacco chewing.

Alcohol It is observed that alcohol consumption damages the heart muscle. Moderate alcohol consumption can be helpful by providing tranquility to mind and inducing undisturbed sleep. But if it is taken in large quantity, then it is harmful to the heart.*******

Sedentary life The people with a sedentary life are more prone to heart disease. This is proved beyond doubt by a number of medical surveys. Regular exercise not only boosts up the general resistance but it reduces the chance of atherosclerosis. Lack of regular exercise predisposes to diabetes and high blood pressure, which further enhances the chances of CHD. The endurance of the heart is less in those who are living a sedentary life. Regular exercise helps in cleaning process of the arteries. The person who is engaged in regular exercise is less likely to become obese, which further helps to prevent CHD. In addition to directly affecting cardiovascular system, it indirectly restores the health by • weight loss • lowering blood pressure • making bones stronger and reducing the risk of osteoporosis

• elevating level of good cholesterol or HDL in blood • decreasing bad cholesterol or LDL in blood • decreasing level of triglycerides in the blood • improving sensitivity to insulin • increasing immunity i.e. general body resistance to fight the disease • Increasing self confidence. Daily exercise of 40-50 minutes will reduce the chances of CHD. Exercise can be brisk walking, cycling or swimming. There is no need to attend sophisticated health club for the purpose of exercise. One can perform the same exercise at home also. One should perform the exercise in such a way that his heart rate is raised to the desired level. The desired level of heart rate can be known by applying the formula. The formula for finding desired heart rate is [(220-age of the person) x 0.8]. For example if the age of the person is 50 years then his desired heart rate will be [(220-50) x 0.8] = 136. The person whose age is 50 yrs should perform the exercise in such a way that his heart rate will be raised to 136 beats per minute. In short if the person takes care of above mentioned risk factors, he can considerably reduce his chances of getting CHD.

Use of anti-oxidants It is already explained that all the parts of the body gets energy through blood glucose. During this energy production from blood glucose through certain chemical reaction, there is production of water and CO2. During this chemical reaction there will also be production of free oxygen radicals. These free oxygen radicals are injurious to the arteries. It produces oxidative stress which is responsible for causing atherosclerosis. There are certain elements which are known to reduce free oxygen radicals. They are known as anti-oxidants. If these anti-oxidants are taken regularly, it will reduce the risk of CHD.

Vitamin E Vitamin E is a powerful anti-oxidant. It is a fat soluble vitamin. Being fat soluble it attaches itself with LDL. Ultimately it prevents LDL to cause atherosclerosis in the arterial wall.

Vitamin C Vitamin C is a water soluble vitamin. It protects the inner lining of the arteries known as

endothelium. With the result it protects the arteries from further damages. Numerous studies have shown that supplementation of vitamin C in the diet, reduces the risk of CHD. Vitamin C is available in all citrus fruits like orange, lime, amla, tomato, and grapes. Vitamin C can be taken in the form of tablets also.

Glutathione Glutathione is a strong anti-oxidant. It is known to prevent CHD. It is available in selenium, vitamin B12, niacin, and N-acetyl L-cystene. These are the vitamins collectively known as vitamin Bcomplex.

Bioflavanoids This is also a useful anti-oxidant supposed to help in reducing the risk of CHD. This element is present in a number of fruits and vegetables. The more varied the color of the fruits and vegetables; there is greater variety of bioflavanoids. In addition to the above mentioned anti-oxidants; grape juice and red wine are also useful for reducing the risk of CHD. Red wine and grape juice has the products known as polyphenols which is supposed to decrease the formation of oxidized LDL cholesterol. Not only that but it also helps to protect the integrity of endothelium

of the arteries, so regular intake of red wine and grape juice reduces the risk of CHD.

Folic acid, vitamin B6 and vitamin B12 Folic acid, vitamin B6 and vitamin B12, are helpful for reducing homocysteine level in the blood. Homocysteine is responsible for causing atherosclerosis. Regular intake of these three vitamins will reduce the level of homocysteine in the blood; ultimately which will reduce the risk of CHD. In short for the prevention of coronary heart diseases, one should keep four factors in mind. A] Balanced diet, with low intake of saturated fatty acids. B] Moderate and regular exercise. C] Regular intake of anti-oxidants and vitamins. D] Stress free life style.

Prevention in the persons with higher risk The persons are considered at higher risk of getting CHD, when the person lives with minimum two risk factors or in the routine trade mill test it is detected that his coronary arteries are partially blocked. In such persons the Probability of getting heart disease is higher than in normal persons. Such high risk persons should take care

of all the risk factors. In addition it is advisable for them to take small doses of aspirin regularly. It is also advisable for them to take anti-cholesterol drug regularly under expert medical guidance.

Secondary prevention Secondary preventions are meant for those who had CHD and have recovered from that. Such person should take care of all the risk factors. In addition they should perform regular exercise as per advice of the doctor. As their heart is damaged the capacity of the heart to withstand physical labor is reduced. So they should fix the upper limit for their exercises so that it remains within the capacity and endurance of his heart. They are also advised to take regular medicines as per the advice of his physician. Last but not the least, most powerful tool for preventing and controlling the heart diseases is

strong will to live normal life