YOU GOTTA HAVE HEART
BY EVE JACOBS
Suppose you were having a heart attack.
Would you know it? Maybe not.
In a country where medical information is blasted over radio, TV and the Internet every day, how could anyone ignore the thunderous chest ache, radiating arm pain, dripping sweats, the breathlessness and staggering? "Many people dont experience the drama of a TV-style heart attack," says Rohit Arora, MD, professor and director, division of cardiovascular disease at UMDNJ-New Jersey Medical School (NJMS). "So they dont recognize whats happening." And perhaps, like a well-trained mother-to-be, no one wants to appear foolish by rushing to the emergency room, only to be told: "Go home false alarm."
The danger in waiting it out, says Arora, is that "time is muscle."A heart attack is not a single event, a blitz thats over and done in a matter of minutes. The damage often continues for hours after the first symptoms. Delaying treatment means that while the healthy portion of the heart keeps working just fine, more and more heart muscle is damaged as its denied the necessary oxygen-rich blood supply. An hour or two of delay in seeking help might be the difference between life and death.
It may be unfortunate that heart attack pain is often quite bearable at first and frequently indistinguishable from such symptoms as muscle strain and gastrointestinal cramps. Every ER staff tells the story of someone who decides to wait it out at home, then thinks better of it and drives himself to the hospital during a serious, and often ultimately fatal, heart attack. Recognizing the symptoms which can include a feeling of heaviness, shortness of breath, overall tiredness and pain in the neck, jaw and arms is a primary life-saving tool.
Even for those who are ever-watchful for heart problems, the fact remains that about one-quarter of all heart attacks are "silent," meaning that they cause no pain, or none associated with a crisis. So, knowing the warning signals that often precede an actual attack, and, of course, preventing conditions that are known precursors are also tantamount in battling this killer.
KNOWING YOUR RISK FACTORS CAN SAVE YOUR LIFE
So, what if you are that quintessential male baby boomer: 50 years old and somewhat overweight, particularly around the middle; a three-times-a-week tennis player; hard working and non-smoking with slightly elevated LDL (the BAD cholesterol) and blood pressure at the high end of normal; and some family history of heart disease. Are you at risk and what should you do about it?
You probably should be paying attention. Here are the known risk factors for coronary artery disease.
Age. Men who are 45 and up and woman who are 55 and up are more prone.
Sex. Men are more likely candidates. But heart diseases kills more women than any other illness.
Genetic predisposition to atherosclerosis and diabetes. Your risk goes up if you have a family history.
High blood cholesterol. It affects more than half the American population.
High blood pressure. It affects 50 million Americans and only 20 to 25 percent of those affected have the condition adequately controlled.
Smoking; lack of exercise; overweight.
Each of these is potentially a major factor that could lead to heart attack.
And forewarned is forearmed. "For heart disease there is no cure, only repair. And once the damage is done, its not so easy to fix," says Norman Lasser, MD, professor of medicine and director of the preventive cardiology program at NJMS.
ASPIRIN IS NUMBER ONE: CARRY TWO
So now its time to determine your course of action. Lets start with the simple stuff.
Taking aspirin should certainly top your list of dos. "Keep two in your pocket at all times," says Lasser, who has been awarded more than $40 million in grant funding for research in this field. "If you take one of them for that stress headache that wont let up, youll always have one left if you think youre having a heart attack."
He explains that swallowing one aspirin every other day will minimize the ability of platelets to clump together to form a clot that could block blood flow to the heart. Even if your heart attack is in progress, that little white pill can sometimes stop the attack in its tracks and lessen damage to the heart muscle.
"Aspirin is a real phenomenon," Lasser says. "It has a very potent effect that lasts as long as a week."
In addition to stopping a heart attack in progress, it can prevent an attack in those who have heart disease or are at high risk. Participants in the Physicians Health Study who had no symptoms of heart disease and who took one aspirin every other day as a preventative had far fewer heart problems than those who took no aspirin. Lasser, himself, takes one baby aspirin (81 mg) every day, an amount that he says has not yet been proven effective in clinical trials, but is thought to do the trick. Because aspirin causes stomach irritation in many people, the least effective amount should be taken. (The doctor warns against aspirin for those with poorly controlled hypertension or a tendency to bleed, or those facing imminent surgery.)
Youre now armed with two aspirins. What else can you do?
STATINS: THE NEW MIRACLE DRUGS
"Current medical care for heart attacks is really wonderful," says Lasser, "but you have to make it to the hospital or at least into the ambulance first." Consequently, your focus should be on preventing heart disease.
Fat chance, you say. Which may take you right to the point. Is your cholesterol too high? Dont know? You should.
If you are a 50-year-old man and your cholesterol readings are above 200 (LDL cholesterol over 160) then bringing them down will most likely increase your life span. The first study to show that lowering cholesterol reduces the number of heart attacks was released in 1984, but it didnt actually demonstrate that people live longer. And that would seem to be the whole point. Lasser says that the 4S or Scandinavian Simvastatin Survival Study, which recruited 4,444 men, was the first to show that decreasing cholesterol levels in those with known heart disease saves lives. That was in 1994.
At this point we all know that limiting dietary sources of animal fats has health benefits. But we also know that maintaining a low fat diet is hard, and cholesterol problems can be hereditary, so that getting cholesterol low enough may not be possible.
The real news is that a class of drugs called statins really work to lower cholesterol quickly and can actually prevent heart attacks. Lipitor, Mevacor, Pravachol and Zocor (their generic names all end in statin) are the three most commonly prescribed. Newer studies have shown that these drugs also reduce the risk of stroke, may help to avert osteoporosis and may even stave off dementia.
"Statins are proving to be miracle drugs," Lasser says. They sometimes lower cholesterol levels so quickly and so dramatically that they can actually ward off heart attacks in situations like acute coronary syndrome.
Lipitor is the most potent and biggest seller of the statins, which not only lower LDL rapidly, but stabilize unstable atherosclerotic plaques. Plaques that line artery walls can come loose, lodging in the artery and seriously reducing the flow of oxygen-carrying blood to a part of the heart. This can cause a blood clot to form. When a clot totally blocks blood flow in that artery, a heart attack (also called myocardial infarction) can result.
Statins are taken once a day and have few side effects. Specialists agree that their use should not be limited to those at very high risk for or who have already been diagnosed with coronary artery disease. In fact, they have been shown to prevent heart attacks even in those with average cholesterol and no heart symptoms, so the challenge is to identify who among these "average" people is at greatest risk.
The big question now is determining how low cholesterol should go, says Lasser. "Is lower than the current recommendations actually better? If you lower the goal to 130, or 100 or 80, is that beneficial? What is the stopping point?" Lasser also points out that another strategy in fighting cholesterol is to raise HDL (the GOOD cholesterol). A study completed in 1998 showed that raising HDL without lowering LDL was capable of preventing heart attacks. Tricor and a new long-acting niacin are new drugs which are available to lower triglycerides and raise HDL.
HIGH BLOOD PRESSURE: WAY OUT OF CONTROL
Although the condition is easy to diagnose and medications generally work, high blood pressure kills more than 40,000 yearly. Uncontrolled hypertension is a major and most often preventable risk factor for heart attack, heart failure and stroke.
How crucial is salt intake in controlling blood pressure? Do roasted peanuts, chips and pretzels, and the tasty soups you have for lunch, actually make a difference?
Minimizing salt intake has been a major prevention strategy for two decades. But the news is that some specialists say the jury is still out. That doesnt stop Arora who repairs damaged hearts every day from eating salt-free nuts during our interview. Does he dislike the salted variety or is he listening to his own heart?
He is. The average American eats 9 grams of sodium each day, when all thats needed to maintain normal blood pressure is 400 mg. Although the majority of specialists are adamant that cutting salt reduces blood pressure, others say that strategy only works for people who are salt-sensitive (somewhere between 30 and 70 percent of the population). And sometimes salt restriction lowers blood pressure, but not nearly enough. Optimal blood pressure is 120 over 80 mm Hg or below. The systolic (first number) measures pressure during a heartbeat. The diastolic (second number) measures after the heartbeat.
But while specialists continue analyzing the effects of that shaker of salt, what do they agree on? The consensus is: It probably will help, and certainly wont hurt, if you cut down on your salt.
Even if you take all nutrition headlines with a grain of salt, you may still want to look into the DASH (Dietary Approaches to Stop Hypertension) diet. The first DASH study was completed in 1997. The second published in the New England Journal of Medicine in January 2001 added sodium reduction to the original diet. The findings show that emphasizing fruits, vegetables and low-fat dairy products, including some whole grains, poultry, fish and nuts, and eating very little red meat and sweets, lowers blood pressure in those who have hypertension and those who dont. The results are even better when salt intake is greatly reduced. The diet cuts saturated fat, total fat and cholesterol intake way down. Data show that a decrease of 8.9 mm Hg in systolic pressure and 4.5 mm Hg in diastolic pressure can be achieved by combining DASH with lowered sodium.
The diet works for almost everyone, but seems more effective for blacks than whites, women than men, and those who have hypertension as compared with those in the high normal range. It can either reduce the amount of medication required to lower blood pressure or completely eliminate the need for drugs.
WHEN DASH IS NOT ENOUGH
There are a lot of pills on the market for high blood pressure at least 50 plus 25 combination therapies. Most are not new. In fact, diuretics which rid the body of excess fluids and salt, and are often combined with another medication have been at work since the 1950s. Fifty percent of those treated for hypertension are prescribed either an ACE (angiotensin converting enzyme) inhibitor or a calcium channel blocker, which reduces heart rate and relaxes blood vessels. ACE inhibitors interfere with the bodys production of angiotensin, a chemical that causes blood vessels to constrict. Other major categories of hypertension drugs include: beta blockers, that reduce the heart rate and the hearts output of blood; sympathetic nerve inhibitors, that inhibit particular nerves that cause arteries to constrict; vasodilators, drugs that cause muscles in the walls of certain blood vessels to relax, allowing the vessels to dilate; and angiotensin II receptor blockers, which block the effects of angiotensin. A trial period may be necessary when first starting the drugs because responses to these medications vary widely.
CLOT BUSTERS SHOULD BE GIVEN SOONER
Heart attack kills one-third of its victims, with 50 percent of deaths occurring in the first hour after symptoms begin. Most patients wait two or more hours before going to the hospital, and many wait 12 hours or more. "Sometimes there is a lot of pain, sometimes there is no chest pain, and sometimes there is no pain at all," says Arora. "You have a greater risk of dying if you have no warning symptoms."
For those whose symptoms send them racing to the hospital, aggressive therapy saves lives. Clot busters (thrombolytics) should be given as soon as possible, preferably within 30 minutes after a heart attack to avert potentially irreversible damage, states Arora. They work to penetrate and open clotted arteries quickly.
Whats revolutionary is the recommendation that these drugs be given in the ambulance. "Current trials show that administering thrombolytics to heart attack patients in the ambulance before arrival at the ER reduces morbidity and mortality an added 10 to 20 percent," he says.
CHEMO COCKTAILS FOR UNSTABLE ANGINA
Unstable angina causes periods in which the heart muscle is starved for oxygen, a condition referred to as ischemia. This condition usually results when the coronary arteries are partially obstructed. The episodes generally do not cause permanent damage, and so are not considered heart attacks, but they are potentially serious, cause debilitating chest pain and do require treatment.
"Chemo cocktails" a combination of several drugs to treat unstable angina and some heart attacks are revolutionizing therapy, says Arora. The chemo cocktail concept is similar to that used to treat AIDS and cancer. Studies combining aspirin with potent clot-busters like retavase, anti-platelet drugs like Plavix and/or a potent glycoprotein IIlb/IIIa inhibitor that helps prevent platelet clumping are pushing drug-therapy success rates for these conditions way up. The drugs all help to prevent blood clot formation, but they work in different ways. "Combination therapy may be the wave of the future," says Arora.
THE $3 MILLION QUESTION: DRUG THERAPY VS ANGIOPLASTY
Which saves more heart attack patients, drugs or angioplasty? "That is the grist of discussion right now in our specialty," says Arora. The American College of Cardiology says both approaches save lives.
Arora explains that only hospitals meeting the following criteria should do angioplasties to treat heart attacks: The hospital must perform more than 200 per year; the physician must do more than 75 each year; and the patient must be able to get angioplasty within 90 minutes of the heart attack. Angioplasty refers to an intervention in which there is reconstruction of a blood vessel. Balloon angioplasty is a procedure in which a catheter with a tiny uninflated balloon on its tip is inserted into a clogged artery. When the balloon is inflated at the site of the obstruction, it widens the artery, restoring blood flow.
"Roughly 90 percent of hospitals in the U.S. do not have a cardiac catheterization lab, so they cant perform angioplasty," he says. UMDNJs University Hospital in Newark meets all the criteria. Needless to say, if you end up at a community hospital thats not equipped with this kind of lab in which cardiac specialists perform sophisticated diagnostic procedures drugs are the way to go.
Recent studies indicate a 95 percent success rate for aggressive, primary angioplasty, an average 60 percent success rate for treatment with a thrombolytic and an 80 percent success for chemo cocktails, according to Arora. But in this area, too, the research continues.
NEWER OPTIONS FOR SICK HEARTS
New strategies using traditional therapies and the development of several very powerful drugs are keeping many more heart attack patients alive. But sometimes even the most potent drugs dont do the job. Since so few hearts are available for transplant, its fortunate that new technologies are providing options for some very sick patients. (See sidebar.)
The magazine of the University of Medicine and Dentistry of New Jersey