A Primer on C.A.D.

By Dr. Herm Valenzuela, M.D.

Topics on coronary artery disease and related subjects come almost quarterly because together with stroke are the most common causes of fatalities (more than all types of cancer combined). BTW skin cancers are still the most common form of cancer world-wide than all of the other body cancers combined accdg to the W.H.O.

This week's consultant is Dr.Giovanni Ciuffo, professor & surgeon in the Cardiothoracic Dept. at Mount Sinai M.C. (NYC); with my addenda from other refs.

"No one is exempt from heart disease, an umbrella term used for those diseases that affect the heart and blood vessels; heart disease (coronary artery disease) and cardiovascular diseases are often used interchangeably," Dr Ciuffo states.

"The most recent studies show that up to 50% of the world population will eventually be affected by significant heart disease," he added. About 80 M Americans suffered from heart disease in 2006 and about 865,500 died of this in 2005; about 410,000 men & just under 455,000 women accdg to the A.H.A.

"There was a whole misconception- that women are immune to C.A.D." says Dr. Ciuffo, "The reality is that one woman in three will die of a heart attack and they worry more about breast cancer," he added. Many patients are familiar with the classic symptoms, or what Dr.Ciufo calls "distress signals;" when a portion of the heart does not receive enough blood or is severely impaired by a leaky or calcified valve, it screams for help with chest pain and/or a sense of pressure, often asso. with shortness of breath, palpitations, fainting or leg swelling."

Angina: refers to symptoms such as chest ache/pain or discomfort caused by reduced flow to the heart. It is often the first sign of heart disease (H.D.); usually caused and made worse by exercise or exposure to cold weather and eased by rest and getting to a warmer environment. Some signs that angina is very serious to call 911:

1. Chest pain or discomfort that is very bad in the pain scale of 5 or more/10, gets worse and last longer than 10 minutes- don't wait for another 5!

2. Pain & discomfort along with weakness, heartburn-like symptoms with sweating and/or fainting and/or palpitations.

3. Pain & discomfort that does not go away when taking nitroglycerine (NTG) pills.

4. Pain & discomfort that is worse than you have ever had before

Thus: If you have P & D while planting seedlings in the spring, mowing your lawn in summer, raking the garden leaves in Autumn or shoveling ice in winter- call 911 or better yet have someone drive to the nearest E.R. while someone, if possible, notify the medical staff there and your PC Provider later but be ready for your list of medications. And..

5. I can't help myself adding this: Beware of the "Rockefeller Syndrome!"

Types of angina:

Common or stable A: Is a disorder of chest discomfort that usually occur in unexpected pattern, changes only slowly, e.g. under mental/emotional stress, running to catch a bus, suddenly exerting to walk uphill, etc. Resting or relaxing usually eases the discomfort.

Unstable A: May first appear as a very severe episode or a frequently recurring bouts of P & D; is unexpected and may wake a person in the night.

Variant A(Prinzmetal A): Is quite rare, but causes discomfort at rest due to coronary artery spasm that decrease the blood flow to the heart. If after this attack is gone or abated somehow and an ECG is done, it is usually normal. Hence a E.S.T. (exercise stress test) may reveal the condition or better yet a 24-hours continous ECG (Holter monitor) is indicated.

Microvascular A: results from poorly functioning smaller branches of the coronary arteries, when seen is common with diabetics.

Ischemia (fr. C-V Disorders, SourceBook, 3rd Ed, 2005): Is the term used when any part of a body organ is not getting enough blood like T.I.A= transient ischemic attack in the brain.

Silent ischemia: Cardiac ischemia happens when an artery becomes narrowed or blocked for a shorttime preventing 02 rich blood from reaching the heart. If ischemia is severe or lasts too long, it cancause a heart attack (myocardial infarction) and can lead to death of the heart tissue. In certain cases there is no pain hence called "silent ischemia" but may also disturb the heart's rhythm and pumping ability causing fainting or sudden cardiac death (SCD)- more on this later.

How common is silent ischemia (S.I.)?

An estimated 4 M Americans, mostly men over 65 have episodes of S.I People who have had previous heart attack or those who have diabetis are specially at risk. Heart muscle disease (cardiomyopathy) that is cause by S.I. is among the 4 most common cause of heart failure in the U.S. Other risk factors are hypertension, obesity and alcohol/drug abuse. Since it is "silent" however, most researchers have found that if you have noticeable chest discomfort and you have the major C.A.D risk factors, you may also have episodes of S.I. hence, a comprehensive C-V evaluation is indicated.

Sudden Cardiac Death (SCD): Fr. the Cleveland Clinic Heart Center-2004.

SCD is an unexpected death caused by a loss of cardiac function, occurs mostly in adults in their mid-30s to 40s; 1-2 children per 100K per year mostly due to congenital heart disease. In the elderly, it is the largest cause of "natural death" in the U.S. causing about 250K deaths each year. 80% ofSCD is asso. with C.A.D. and about half of the fatalities are sudden. Causes: Most SCD are caused by arrhythmias (abnormal heart rhythms) i.e.: Ventricular Fibrillation (V-Fib) which is a "fluttering" or "quiverring" of the main heart muscles (ventricles) that goes on an erratic, disorganized "firing" of conducted impulses. Death will occur w/in minutes if left untreated. Ventricular tachycardia (V-Tach)- this is an abnormally rapid heart rhythm that does not propel enough blood to the circulation and usually occur after a heart attack or in an unstable angina. Risk factors of SCD: History of heart defects w/ or w/o syncope. History of some major ECG abnormality like extremely slow heart beats or a heart block. Obesity & diabetis; First to 16 months after a coronary event.

Hypertrophic cardiomyopathy = an increase growth in thickness of the left ventricle.

Dilated cardiomyopathy = an abnormal enlarged heart may be the cause of SCD in 10% of cases.

Emergency treatment of SCD: The AHA (American Heart Asso.) promotes using the 4-steps called "The Chain of Survival" which may prolong life by 90% if initiated early on with f/up in the E.R. or CCU.

> Quick access to emergency care is essential; call 911!

> Early CPR: If performed properly CPR can help save lives as the procedure keeps blood & 0 circulating until emergency medical help arrives.

> Early defibrillation: In most adults, SCD is related to V-Fib and quick application is necessary to return the heart's rhythm to normal. Frequently, there are public access to defibrillators (AEDs= automatic external defibrillators) and if one or more of you are so inclined- it is very easy to learn how to apply it and the life you save maybe close to you ! Usually the ARC (American Red Cross) offers
instructions how to use AEDs

> Early advanced care: Most patients require hospital care to prevent future events.

I'm not going to present clinical/laboratory tests & treatment options: In October 2003 the NIH rec. key steps to help prevent/manage C.A.D: the major message is to control the various risk factors. The most important are: Control diabetis- It affects 17 M Americans and up to 75% develop heart & bood vessel diseases; can also lead to strokes, kidney failure, blindness and various forms of neuropathies. Manage hypertension and control Lipids- lower LDL-cholesterol & triglycerides and elevate HDL-cholesterol. Overweight & Obesity increases the risk not only of heart disease but also stroke, gall-bladder disease, arthritis, breast & colon cancer. Maintain a healthy BMI= body mass index. Here's how (if you don't own an abacus): 1). Multiply your weight in pounds by 703. 2). Divide the answer (fr step 1) by your height in inches. 3).Divide the answer (fr. step 2) by your height in inches again to get your BMI (Heck, if you're "bad" in 'rithmetic, like me- your PC Provider has a graph and just check where you are! Normal is 18.5 to 24.9; Overweight is 25-29.9 and Obese is 30 and >.

Lastly, to my lady friends: Parting words from Dr.Ciuffo: "Women are far more likely to present with irregular symptoms (of heart disease) then men, and sometimes these symptoms are non-specific and hard to diagnose. They can just have this profound sense of frustration but deny chest ache/pain. They say, ' I'm really tired; I can't lift my arms up' and it can be a heart attack. One key warning sign is if you notice a sudden drop-off in your physical ability level; if you get short of breath suddenly (especially if you don't smoke or have a history of COPD), if you remember that 1-3 months ago you can easily climb up the stairs, and now it's a big deal, then something must be going on!"

Herm C. Valenzuela, M.D. (Ret)
Brooklyn, N.Y. 11234 (Nov. 2009)