Editor’s Note: The Kyiv Post is happy to announce the start of an occasional column on health and medical issues from Dr. Richard Styles, a family physician working at American Medical Centers in Kyiv.
Perhaps nowhere in medicine is such attention and funding evident than in the diagnosis, treatment and prevention of heart disease. It is perhaps because of that attention that I have chosen it as the subject of my first article. The heart has always been a very special organ, even recognized as such by the early Greek and Chinese doctors. It has always been attributed with special powers and some spiritual sense.
Indeed, it is a remarkable organ, beating some 30 million times in an average Western life. It is awesome to think of any mechanical equivalent that supports such technological brilliance. Yet, at a basic level, it is a very simple four-chambered muscular pump with four valves and an electric circuit that maintains its operation.
We have perhaps been seduced into believing that modern medicine and technology are absolutely necessary for us to survive heart disease. It is easy to forget that, 30 years ago, most people survived their heart attacks at home and went on to live a healthy life afterwards. A few did not survive. But the survival rate in the years since has not been as great as we perceive. The falling mortality rate from heart disease in Western European countries and America may have more to do with decreased tobacco consumption and better nutrition than with high technology.
Heart attack, also called coronary (artery) thrombosis or myocardial infarction, is the most common and worrying condition to affect the heart. It is a sudden obstruction to the blood flow of an area of the muscular pump with death of the muscle and subsequent scarring. Most patients recover as the dead piece of muscle scars. Unless the affected area is huge or supports some of the heart’s vital circuitry, death does not occur. Usually, the process is very painful. But often, especially as we get older, it can be a painless experience often picked up on later screening.
The obstruction is caused by the buildup of fatty deposits in the arteries supplying the heart, a process called atherosclerosis. More often, deposits partially block arteries, causing a cramping chest pain on exercise called angina. This process may well be natural in Western society. Many young soldiers killed in Vietnam had coronary artery occlusions that were evident at post-mortem. Sometimes decreased blood flow to the heart solely produces the symptom of exercise intolerance.
There is a genetic form of high cholesterol (fat) levels that puts its family members at huge risk of coronary atherosclerosis. In these families, heart attacks and deaths often occur in the third and fourth decades. All members of such families should be screened and treated for high cholesterol levels. Some people and families handle cholesterol well and have no history of heart disease others less well. Smokers and those with high blood pressure are more at risk, while diabetics have a ten-fold increase in the risk of heart attack. Lowering cholesterol across a whole population will reduce the risk of heart attacks.
Heart attack is now treated with aspirin to thin the blood and by a “clot-busting” drug – streptokinase, if the heart is unstable in any way or is failing to beat well. then a long tube is inserted into an artery in the leg and directed to the coronary arteries where the injection of dye can demonstrate the blockage and a small metal tube or stent is used to push the clot aside. Some stents even exude drugs to prevent further blockage.
Medical worker checks men‘s blood pressure at the “Healthy Heart” event in Kyiv on Sept. 28, 2008. The aim of the event was to attract people’s attention to the risk of heart disease and its prevention. (UNIAN)
There is now irrefutable evidence that decreasing cholesterol in those who have heart disease or who have had a heart attack brings considerable benefits as does the use of aspirin and a drug to lower pulse rate.
The prevention of coronary artery disease and its diagnosis at treatable stages have now reached the art of perfection, but not without some considerable intervention and not risk-free. Prevention revolves around lifestyle issues of diet, exercise, no smoking and low blood pressure.
Diagnosis should always begin with a skilled physician taking a history and assessing risk factors and determining to what extent the individual wishes to undergo tests. Resting cardiographs give little accurate information about blood flow to the heart but may indicate poor blood flow or past heart attacks. A cardiograph on a treadmill will give more accurate information an may indicate that further tests are required. Angiography will give an accurate picture of the heart’s blood supply and can be supplemented by the simultaneous insertion of stents where appropriate.
It is, however, not without risk of heart attack itself. If a clot is dislodged, it can also cause a stroke. More modern tests, some of which are now available in Ukraine, include CT imaging and the use of nuclear and echo stress tests, all of which now provide accurate results in specialist centers and have no serious risks.
Coronary artery bypass surgery has to a great extent been superseded by the use of stents. But, after both procedures, fatty clots have a tendency to re-form over a 10-year period. So follow up diagnostics are important.
While modern medicine has gone a long way to minimize the risks of heart disease and treat it effectively, progress has posed new problems. Today’s dilemma demonstrating the fragility of medicine is posed by this situation: a patient who has had a diagnostic procedure in the absence of any risk factors or symptoms, but yet is shown to have incomplete occlusion of his coronary arteries.
Is this a natural process that will reverse, as it probably would have done in the young Vietnam soldiers? Or should the patient have immediate intervention? It wouldn’t have been an issue 40 years ago. Hopefully one day soon we will have the answer.
Dr. Richard Styles is a British family physician at American Medical Centers, a full-service clinic, in Kyiv.
