It’s the No. 1 killer of both men and women, and it can begin in many different ways. Here are some of the basics to diagnosing and preventing heart disease.
If you haven’t given a lot of thought to heart disease lately, here’s your wake-up call.
Despite a recent surge in the number of cancer cases, heart disease remains the No. 1 killer of both men and women. The Mayo Clinic reports that about 600,000 Americans will die from it this year; that’s one in every four deaths.
The news gets worse. While more than 90 percent of the American public knows that chest pain is a symptom of an impending heart attack, less than 30 percent know the other symptoms. And because nearly 50 percent of patients die from a heart attack outside the hospital, the Mayo Clinic concludes that too many people don’t recognize or act on those symptoms.
So, here are the facts that everyone needs to know. High blood pressure, high LDL cholesterol and smoking are three key factors in the development of heart disease. Nearly half of all Americans have at least one of these conditions. Diabetes, obesity, poor nutrition, insufficient exercise and excessive use of alcohol also contribute to a person’s likelihood of developing heart disease.
If you’re lucky, and if you see your primary physician for regular check-ups and appropriate tests, you may discover you’ve developed heart disease before it endangers your life. On the other hand, you may be one of far too many people who learn this news the hard way.
Patients experiencing one or more symptoms of impending heart attack arrive at Dixon’s KSB Hospital emergency department (ED) in one of two ways: Either by ambulance or personal transportation. Of these, an ambulance is the best option, since a patient receives care in transit.
Two years ago, KSB underwent a performance improvement project to better enable the ED to identify and assess incoming patients, says Sue Prosch, director of KSB’s emergency department.
“When patients come in from the field by ambulance, we’ve already received a 12-lead EKG,” she explains. “The goal is for all patients who come in with complaints of chest pain and/or heart attack symptoms to have a 12-lead EKG within 10 minutes of arrival.”
She says the 12-lead EKG is an interpretation of the electrical activity of the heart over a period of time. It roughly identifies where any blockage may be, and indicates other cardio conditions such as atrial fibrillation or valve malfunction. When anterior ST elevation myocardial infarction (A-STEMI) is diagnosed, the ED goes into high gear.
According to the Mayo Clinic, A-STEMI is an acute condition that affects the left anterior descending artery. Without fast treatment, A-STEMI results in three to four times more deaths than the other diagnoses.
“We’re all trained to do 12-lead,” Prosch says. “At the same time, nurses draw blood to test for elevated troponin, an indicator that heart muscle is being damaged. They also gain IV access so that medications can be administered quickly. The patient is checked in, helped into a treatment room, undressed and prepared for whatever immediate treatment is determined. Again, this all happens in the first 10 minutes of the patient’s arrival.”
After diagnosis in the ED, a Code STEMI page is sent to the cardiologist on call and the cath lab staff, says Kathy Schafer, director of cardiology services at KSB. As soon as a patient is ready, he or she is taken directly to the cath lab.
“A federal mandate dictates that the patient goes from ED door to balloon (so blood flow is restored) in 90 minutes or less,” Schafer explains. “It’s what we call the ‘golden’ time. The patient has undergone all the tests, IV has been established, the patient has been told what the diagnosis is, and his or her family has been notified.”
The process can be confusing and scary to a patient.
“We take the patient to the cath lab, where he or she is positioned on a cold, hard X-ray table,” says Schafer. “Monitors are hooked up and oxygen continues to be administered. Depending on the patient’s condition, medications may be given by IV. Then the patient is sedated just enough to take the edge off his or her anxiety.”
While the cath procedure is relatively painless, a patient may feel the insertion of a fairly large, sheathed needle into the groin area. It’s guided by X-ray up through the artery and into the area where the heart blockage has occurred.
When the catheter reaches a blocked area, a balloon is placed, relieving the blockage. In some cases, the patient can experience spasms, says Schafer. When the balloon opens up the artery, a stent may be put in place to hold it open and support any weakened spots.
“It’s a delicate procedure because any false move can send the heart into an irregular rhythm,” she says. “Between closely watching the patient’s blood pressure, the progress of the needle and other factors, it’s a finely tuned dance.”
Because KSB is a smaller hospital, it has an agreement with larger medical centers in Rockford to handle the more critical cases. “If we encounter major blockage that can’t be treated with a balloon or stents, we contact an interventional cardiologist at one of the Rockford hospitals and confer by phone,” Schafer says. “If the patient needs more treatment than we can do here, you can bet a chopper will be on the way. Meanwhile, we do everything we can to buy time for the patient and the cardiologist.”
Where the patient goes depends on which cardiologist is contacted. “Occasionally, the patient’s family requests a specific hospital,” Schafer explains. “At other times, the patient may not already have a cardiologist of record, or is new to the Dixon community.”
The heart has four chambers: two upper, called the atria, and two lower, called the ventricles, with its own natural pacemaker, or sinus node, in the right atrium. This sinus node emits an electrical signal at regular intervals that’s received by another node located between the upper and lower chambers. These signals coordinate the timing of the blood pumping between them, so that a healthy heart, at rest, beats 60 to 100 times per minute.
During A-fib, or atrial fibrilation, that signal originates somewhere other than the right atrium and spreads through the heart in an erratic manner, sending multiple electrical impulses that disrupt the normal rhythm. With the upper and lower chambers out of sync, the heart rate can jump to 120 to 160 beats per minute, or even higher. This causes the atria to quiver – the “flutter” that many patients experience during A-fib.
When this happens, patients may feel rapid heart rate, chest pressure or pain, shortness of breath and markedly decreased stamina. If the erratic rhythm isn’t brought under control – returned to “sinus rhythm” – the heart muscle may become weak, causing even greater fatigue and shortness of breath, along with leg swelling.
However, the most dangerous problem related to A-fib is a high risk of stroke. Because the atria are not effectively contracting, blood tends to stagnate in them; this leads to the formation of little clots that could travel to the brain. If they lodge in a critical part of the brain, a major or minor stroke may result.
According to Dr. Leela L. Narra, board-certified cardiologist and electrophysiologist with Rockford Health Physicians, there are many reasons why A-fib develops. “We really can’t prevent or predict A-fib,” she explains. “Mainly, we can work to help control it with medications and/or intervention.”
Potential causes of A-fib are heart attack, high blood pressure, heart valve disease, heart defects, overactive thyroid glands, emphysema, viral infections, stress, sleep apnea and stimulants such as caffeine, tobacco and alcohol, says Narra.
“Still, A-fib can occur even when there is no obvious cause,” Narra says. “This is called lone A-fib.”
When a patient is diagnosed with A-fib, a doctor’s first line of treatment is to control the heart rate with drugs and use blood thinners to prevent strokes. Warfarin is the mainstay of anticoagulation drugs for A-fib patients. Also, fairly new oral medications are proving beneficial in treating A-fib patients who don’t have a heart valve dysfunction.
“We now have three new medications that don’t require weekly or monthly blood tests to measure their effectiveness, and also don’t require dietary restrictions, such as greens,” Narra says. “These drugs are not for all patients, though. Elderly patients or those with kidney or valve disease can’t take them.”
For patients who can’t tolerate drug treatment or find it ineffective, two other options exist to control A-fib: electrical cardioversion and radiofrequency catheter ablation.
“In the first, we can use brief, intense electric shocks to try to restore the heart to sinus rhythm,” Narra says. “ Or, in the second, we can go into a vein through the groin with catheters and use radiofrequency or cryo ablation to block the impulses that trigger A-fib.”
During electrical cardioversion, paddles or patches are applied to your chest, similar to the way cardiac arrest is treated. The shock momentarily stops your heart; when it beats again, the hope is that it will be in normal sinus rhythm. Patients are sedated during the treatment, so it isn’t painful.
With ablation, a catheter is threaded through a vein and positioned at the point where the erratic impulses, called hot spots, are located. Radiofrequency ablation (or cryo energy) targets the hot spots and scars the tissue, effectively blocking the signals that cause A-fib and restoring normal rhythm. The success rates of ablation therapy for A-fib are 70 to 80 percent.
“Some patients need these treatments to be repeated,” says Narra. “Others do very well and don’t need re-treatment.”
Even when faulty valves are the culprit and are repaired or replaced, A-fib may continue because the heart’s atrium has enlarged.
Blood thinners and rate-control medications help to deal with the problem and avoid strokes.
Aortic Valve Disease
Aortic valve disease is a common cause of serious heart problems. Because it can be congenital or acquired, the age range of those affected is wide.
The aortic valve allows oxygen-rich blood to flow from the heart to the aorta, and prevents blood from flowing back into the heart (called regurgitation or backflow). A healthy aortic valve, or tricuspid, has three leaflets that control this ebb and flow.
With congenital valve disease, a person is born with a bicuspid valve that has only two leaflets. As a result, the valve may not open or close properly, causing the heart to pump harder to send blood, or allowing for backflow. It may go undiagnosed in infants and children because it often causes no symptoms.
“A pediatrician or primary care physician may detect a heart murmur at any age, but we also see patients come in with congenital heart disease in middle age,” says Dr. Madhusudan R. Malladi, a board-certified cardiologist at FHN Memorial Hospital in Freeport. “Acquired valve disease usually starts later in life, generally between the ages of 60 to 80.”
A number of things can cause acquired valve disease, including suffering rheumatic fever in childhood. Another is endocarditis, an infection of the inner lining of the heart, caused when bacteria or other germs from another part of the body get into the bloodstream and attach to the surface of the heart valve. They attack the valve, causing holes, lesions, scarring and narrowing.
“More commonly, we see aortic valve stenosis or obstruction of the valve,” Malladi says. “This can be the result of atherosclerosis in the elderly. Calcium builds up in the valve, preventing it from working properly. Obstruction or backflow can force blood back into the proximal chamber of the heart and into the lungs, which then become congested.”
A patient may experience symptoms such as fatigue, dizziness, lightheadedness, chest pain/angina and shortness of breath, and may even pass out.
“Valve disease is diagnosed first by listening to the heart to find any murmurs,” Malladi explains. “Then, we get an echocardiogram that helps us to determine the valve abnormality and heart function. The problem can be within the valve itself, abnormal membranes or muscle adjacent to the valve.”
Since the problem is structural or mechanical, medications seldom help. Surgery to repair or replace the existing valve is the go-to treatment.
“In elderly patients, we consider using tissue valves [for replacement], but for younger patients, we prefer mechanical ones because they last longer,” Malladi says. “With mechanical valves, patients need to take blood thinners for the rest of their lives.”
Valve replacement involves open-heart surgery. In high-risk patients, a relatively new procedure called transcatheter aortic valve replacement (TAVR) can be used to replace the damaged or diseased valve. In this minimally invasive procedure, a valve mounted on a catheter is inserted through the groin blood vessel and advanced to the damaged valve area, where it is implanted. This is accomplished under local anesthesia, along with some sedatives, without stopping the heart or using a heart-lung machine.
“Freeport Hospital doesn’t offer TAVR but medical centers in Madison and Chicago, as well as the Mayo Clinic, can provide TAVR,” Malladi says. “Also, OSF Saint Anthony Medical Center in Rockford has recently begun to do the procedure.”
Yet another valve problem is mitral valve regurgitation, often caused by mitral valve malfunction.
“In mitral valve prolapse, mitral regurgitation occurs when the valve between the heart’s left atrium (upper chamber) and ventricle (lower chamber) doesn’t close properly,” explains Malladi. “The mitral valve bulges and prolapses into the atrium, causing blood to leak backwards into the left atrium. In a significant number of cases, the mitral regurgitation occurs with heart attacks, resulting in damaged heart muscle, damaged supporting structures of mitral valve apparatus and from dilated cardiomyopathy.”
All of this may sound overwhelming, but in order to be proactive, it’s important to know the signs of impending heart attack and have a basic understanding of the underlying conditions that cause them. Most important of all is to schedule regular exams with your primary physician and to be aware of all the symptoms of heart disease, beyond just chest pain. Knowing the warning signs of heart attack could save lives – including your own.