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)

Tina and Tekka

What I consider to be my favorite watercolor is this one of my daughter Tina and Tekka, her dog. Tina and I played tennis one summer day on a Saturday morning at our local sports club. After tennis, we went to our house for lunch in our backyard. It was a nice sunny day. Tina was relaxing, sipping a glass of red wine in our backyard while Louise, my wife was preparing lunch. I looked out and saw a beautiful composition of Tina and Tekka. I happened to have my camera in my pocket and pulled it out to take a photo. With the hills in the background, I thought it would be a good composition. When I first saw the photo on my computer screen, I knew I had to paint it. I had been looking for a good subject for a watercolor painting and I knew this was it. I took my time to paint this one. After about a month, I finished my work. I am very happy with the results.

Zack

Zack the Steward

On the morning of November 27, 1959 at Sangley Point, Philippines, I was very excited when I took the oath to enlist in the US Coast Guard. There were 25 of us and we all knew that after our swearing in process we would be confined on base and could no longer go home. We had a short indoctrination after swearing in and we learned we were steward recruits. I felt homesick already. I had to accept the fact that the next time I could see my family again would be when my four-year enlistment was over or sooner if found to be unfit to serve. We all looked pretty scared not knowing what to expect. We filled out more enlistment paperwork until around noon when it was time for us to go to lunch.

A petty officer marched us to the mess hall. This was the first mess hall I had ever seen. Everybody formed a line to get their food. It was cafeteria style. Everything looked delicious. There were green salads, fried chicken and roast beef for the main course and assorted cakes and ice cream for dessert. I couldn’t believe my eyes, seeing all the food. I was thinking that if this would be the way I could expect to eat every day then I wouldn’t feel so bad about being homesick. Now I could forget about having fish heads and rice for a meal. I filled up my food tray with everything that looked good, not knowing what it would taste like. I was disappointed that there was no rice, only mashed potatoes. In the salad area I saw my favorite fruit ‘duhat’ (a Philippine sweet dark berry) so I took a bunch, and I heard the server at the other side of the line say “You are in for a big surprise”. When I sat down to eat my meal and tasted a duhat fruit, it was so bitter I almost threw up. Later on I found out what I believed to be duhat were olives. Overall, it was a good meal, the best I had ever had.

Being a steward recruit was the lowest position one can be in the Coast Guard. While at Sangley Point waiting to be shipped out, we participated in work details picking up trash all around the base, cleaning the mess hall after each meal, dumping garbage, etc. Then while we were on the USNS Barrett enroute San Francisco, we were assigned to the galley as mess cooks. It was a relief when we arrived at Fort Mason and were transferred to the USPHS Hospital for quarantine where we hardly did any manual labor.

The twenty-five of us steward recruits merged with seaman recruits in boot camp at Government Island. Our company was LIMA 29 comprising of whites, blacks and Filipinos, and our Company Commander was BM1 Roche, a Frenchman. It was a gruesome 8 weeks of recruit basic training. There were no racial issues that I can remember. Some recruits dropped out for one reason or another. All 25 Filipinos made it through boot camp only to endure four more weeks of steward training before they were sent to their first duty stations. After steward training I received orders for US Coast Guard Air Station in St Petersburg, Florida.

Being the most junior steward in St Pete was not fun. Besides being homesick, I had to constantly take orders from the old timers Busabos, Manese and Amano to do all the menial work. I had very little time to myself. I spent my free time writing letters, playing the ukulele, and sometimes dabbling in art.

When I was on duty one evening, I just finished serving the evening meal to the duty officers. The Mess Treasurer, LT(jg) Bain, who was in charge of all the stewards, walked in the pantry on his way out to his quarters. I had left my artwork on a small table in the middle of the room and he stopped to examine it. I think I had some pencil sketches and maybe a rough watercolor piece. He complimented me on my work. The next day, he called me in to his office to talk to me about an art project. The wardroom had a mural of Coast Guard ships and sailors in action at sea in the old days and the mural was in bad shape as the paint was peeling off. He asked me if I could touch up the mural as a VIP visit from the District Office was scheduled and he wanted the wardroom to look good. At first I hesitated, but then I realized doing something I enjoyed during working hours would be much better than washing dishes, cleaning toilets and making up officers’ beds. I accepted; Busabos and the gang didn’t like it because now, they would have to do the menial work normally assigned to me while I was working on this project.

It took me about three days to complete the mural project. The VIP’s came and left. They saw my work as we served them lunch in the wardroom during their visit. Later, Mr. Bain congratulated me for the fine job I did in fixing the mural. He said he received a lot of compliments from the District staff who saw it.
Now many on base heard about my art skills. I got assigned other art projects, including painting signs and notices outside the Coast Guard Exchange building.

The Coast Guard did not enlist me as an artist. When there were no more jobs to utilize my art skills on base I did my steward chores. I guess my performance as a steward was satisfactory because Busabos recommended me for promotion from E2 to E3 when I met my time in grade requirement. I learned that the only way to be successful in the Coast Guard was to continually strive for promotion until you have served 20 years then you can retire. To advance in the steward rating was almost impossible. The Coast Guard needed more stewardsmen (the workers) than steward petty officers (the supervisors). In the steward rating, it would take typically five years to get promoted to E4 (Petty Officer Third Class) from the time you enlist while most other ratings would take only two to three years. And it got even harder as you move up the ranks. When you reached your 20 years of service as a steward you could expect to retire as an E6 while the non-stewards achieved a much higher pay grade for the same years of service.

I wanted that promotion to Third Class Steward no matter how long it took me. I completed the required correspondence courses in no time; I completed my practical factors and I was almost ready to take the service wide exam for promotion. I still needed to demonstrate to Busabos I could be Steward Third material before I could get his recommendation to take the service wide exam. What this meant was to demonstrate that I could prepare a dish as part of a wardroom dinner menu and the officers would be the ones to judge my cooking.

I was newly married to Louise at that time. I consulted her about what to prepare for my cooking proficiency test. I always enjoyed her cooking and she would make dessert for me even though I wasn’t much of a dessert person. But I always liked her pineapple upside-down cake. I decided I would bake a pineapple upside-down cake for my test and that Louise would be my adviser. I got approval from Busabos about my plan. Louise said I could use her recipe which she had taken from a Betty Crocker Cookbook.

The cook in charge of the galley was CS1 Spencer, a 250-pound black guy that looked like Aunt Jemima. Spencer and I got along well. We shot craps a lot in the storeroom, and we frequently played poker with a bunch of guys after payday. I told Spencer I needed to use his oven for my proficiency test and being such a nice guy, he gave me permission. Now I was all set. On the menu for dinner that day, the main course was Prime Rib Au Jus to be prepared by Busabos, and the dessert was pineapple upside cake.

I examined the Betty Crocker recipe for the pineapple upside down cake and I realized it was a recipe to serve 6 people. We were expecting 20 officers for dinner that day. No problem I thought. With simple math, multiply each ingredient by 3.33 and that should do it. I adjusted the amount of each ingredient to serve 20 people and went on with my baking. Somewhere along the line I must have made a serious error with my calculations. It must have been converting teaspoons to tablespoons and I ended up putting a lot more baking powder than what was required. The oven door popped open and what looked like a lava flow oozed out of the opening down to the floor. It was a big mess and Spencer witnessed the whole thing. He was fuming mad and told me clean up my mess and that I couldn’t leave the galley until he was satisfied the oven was spotless. I had never seen him this mad before.

I fixed up my pineapple upside down cake by getting rid of the excess cake, and served it to the officers anyway. I was too embarrassed to show my face in the wardroom while the officers were having dessert. The officers were aware I made the cake for my proficiency exam. Later I asked Busabos what the officers thought of my pineapple upside down cake. Busabos said that he got feedback from Lt(jg) Bain , our Mess Treasurer, that the officers liked my cake and they unanimously recommended that I should be allowed to take the service wide exam for promotion. That was a big surprise. It could not have been my cake. I think I know what it was. It was the mural in the wardroom walls that I revived and many admired my work including the District Commander! They must have been thinking I had this special talent that the Coast Guard could utilize during my service -- so forget about the cake, give him a chance to advance his career!

I took the service wide exam for Steward Third Class and passed it, but I was so low on the advancement list because there were hundreds of TNs ahead of me that had seniority. Realistically I would have to keep taking the service wide exam for several years to gain seniority before I could get promoted.

After serving three years at the Air Station I was transferred to the USCGC Nemesis across the harbor. The Nemesis was a 165-foot cutter home-ported at the USCG Base, and whose main mission was to patrol the Gulf of Mexico and the Straits of Florida. During the time that I was on the Nemesis, the cutter was very active in rescuing many refugees from Cuba who were trying to reach Miami on their makeshift boats. So we spent a lot of time at sea picking up refugees. This was my first sea duty. I got seasick a lot and it was not pleasant. There were two of us stewards on board. I worked for Steward Third Class Felix Aguilar. I was totally useless when I was seasick and Aguilar didn’t like it one bit because he would have to carry out my duties when I was seasick. He got so fed up with me one time and reprimanded me for being incompetent and told me I should get out of the Coast Guard as I would not make anything out of myself in this outfit. I couldn’t argue with him. I thought he was right. I wasn’t carrying my load. But I couldn’t leave the Coast Guard now. I had a wife and two kids to feed. I told myself I just needed to try harder to be good at my job no matter how much I hated it.

One sunny Sunday afternoon on a routine patrol, the sea was calm like glass and I wasn’t seasick. I had just cleaned up the wardroom after serving lunch. I had heard we picked up about 20 refugees, including women and children drifting on a raft. Our captain had them all on the fantail. They were fed and given blankets to keep them warm and dry. I had about two hours of free time before I would be preparing the wardroom for the evening meal. I went outside on the main deck to get some fresh air strumming my ukulele. I saw the refugees. They were looking at me with curiosity. I approached them and tried to start a conversation in English but nobody seemed to understand me. Two young boys smiled at me pointing at my ukulele. I started strumming, thinking of a song they would know. The only Spanish song I could remember then was “Cielito Lindo” so I started humming the tune and playing the chords on my ukulele, and pretty soon the kids were singing the lyrics and everybody joined in. Then I played and they sang “La Cucuracha”. Some members of the crew came and joined the group. We started singing English songs like “You are My Sunshine” and “When the Saints Go Marching In”. Everybody was having fun. I looked back and saw the captain on the starboard bridge wing witnessing the whole thing. We had eye contact and he gave me the thumbs up of approval. That turned out a very good day for my morale. Even Aguilar was proud of me.

Soon after I married Louise I applied for U.S. citizenship. By virtue of my being married to an American citizen, I was able to acquire my citizenship pretty quickly. I became a citizen in late 1963. While on the Nemesis, I requested to change my rate to Electronics Technician and I received a highly favorable endorsement from the captain. I was given the Electronics Technician entrance exam and passed it. After clearing a background check for Secret security clearance my rating was changed from Stewardsman to Seaman and I was given a set of orders to undergo six months of Electronics Technician ‘A’ school at the Coast Guard Training Center in Groton, Connecticut. It was a great feeling to know my job as a steward had finally come to an end.