CLINICAL SERVICES > MEDICAL MANAGEMENT    
    

           Coronary Artery Diseases

           Dyslipidemia or high cholosterol

           Systemic Hypertension

           Heart Failure

           Rheumatic Fever and Heart Diseases

           Pulmonary Hypertension

 

MEDICAL MANAGEMENT > CORONARY ARTERY DISEASE

CORONARY ARTERY DISEASE

It involves a spectrum of disorders varying in severity form Angina Pectoris to Myocardial infarction (heart attack). ANGINA:             Angina first described by William Heberden in 1768 is the pain experienced by an individual when the heart muscle does not get enough blood and is usually due to narrowing of the blood vessels that supply the heart.

Diagnosis of angina is largely from the history and manifested by a crushing pressure or heavy gripping pain in the centre of the chest, which may radiate to the jaw, neck, arms, back, and epigastrium. The left arm is affected more frequently than the right arm.

SATBLE ANGINA
Satble angina is by far the safest among the above. It usually follows exercise, but may also be triggered by strong emotions, digesting a heavy meal, or going out in a cold wind and is often a predictable condition which is relieved by rest or nitroglygerine. Stable angina seldom lasts longer than 10 mins.

UNSTABLE ANGINA
It is what the name implies, an unstale condition where the pain is unexpected and usually occurs at rest, it also includes a person having stable angina suddenly experiencing frequent episodes of pain. It usually means there is inflammation and and clot formation inside a heart blood vessel (coronary artery). Unstable angina can also be caused by sudden spasm of the blood vessels supplying the heart even in the absence of any block (vasospastic). Irrespective of the cause unstable angina is an acute coronary syndrome and needs to be treated as a medical emergency usually requiring hospitilization and further intervention. These people are at a great risk of developing life threatning arrhythmias, death due to cardiac arrest and Myocardial Infarction (Heart Attack).

MYOCARDIAL INFARCTION
          Sustained reduction in blood supply to the heart muscle (myocardium) causes myocardial Infarction or Heart Attack. The myocardium cannot tolerate lack of supply of blood for more than twenty minutes. Most heart attacks are caused by a clot that blocks one of the blood vessels that supply blood and oxygen to the heart muscle (the coronary artery). The clot usually forms in a coronary artery over a previously narroewd area due to fat build up (atherosclerosis). This atherosclerotic plaque (buildup) inside the arterial wall sometimes cracks, and triggers the formation of a clot, also called a thrombus. A clot inside the coronary artery blocks it interrupting the flow of blood and oxygen to the heart muscle, leading to the death of heart cells in that area. The damaged heart muscle loses its ability to contract, and the remaining heart muscle needs to compensate for that weakened area.

          The consequences and danger to life due to a heart attack depend on the number of vessels blocked and the location of the blocks in the coronary circulation. This by definition is a true cardiac emergency where minutes and seconds can make the difference between life and death.

          Early hospitalization spells prompt thrombolytic therapy (drugs used to liquefy the clot) and minimal damage to the heart muscle.

          On some occasions this medical treatment may not be adequate, the patient continues to have pain and the blood pressure and cardiac rhythm start destabilizing. Here mechanical methods are adopted to open up the blocked coronary artery by manually entering the vessel and dilating it with a balloon. A metal scaffolding called a stent is deployed to prevent it from collapsing again (Primary Coronary Angioplasty). The culprit vessel is hence opened restoring blood supply to the throttled area of the heart muscle, minimizing muscle damage and avoiding death.

          A Heart Attack is conventionally supposed to produce severe excruciating unbearable pain in the centre of the chest spreading to neck and hand. However in the backdrop of certain conditions like Diabetes the pain is either not perceived or may insignificant enough to be ignored. At times profound weakness, momentary loss of consciousness, intense breathing difficulty are the only symptoms experienced rather than typically described chest pain.

 

 

MEDICAL MANAGEMENT >DYSLIPIDEMIA OR HIGH CHOLESTEROL

DYSLIPIDEMIA OR HIGH CHOLESTEROL
          

          Many people have a wrong notion that Cholesterol per say is bad. On the contrary Cholesterol plays an important role in many bodily functions especially in the brain and hormonal mediation. However any disproportionate increase in the level of these lipid fragments (cholesterol) can be disastrous to an individual especially in the presence of other risk factors like smoking, Diabetes, and sedentary life styles. Cholesterol is the substance which migrates into the walls of the blood vessel wall and triggers a relentless pathological process which produces narrowing (atherosclerosis) and subsequentlyheart attacks.

Cross section of a coronary artery showing the cholesterol build up in the vessel wall narrowing it.

          Total Cholesterol, Low Density Lipoprotein (LDL), High Density Lipoprotein (HDL), Very Low Density Lipoprotein (vLDL) and Triglycerides (TGL) are some of cholesterol fragments that are currently considered valuable in cardiac risk stratification. Cholesterol fractions are always tagged with protein molecules in the circulation and hence called Lipoproteins.

          As a general rule it is the LDL that enters the arterial wall. This entry is mediated by a dynamic process that is enhanced by high LDL and/or low HDL levels. These LDL molecules attach to the receptors in the arterial wall and then migrate into the tissues. After aiding metabolism they are picked up by circulating HDL Cholesterol and taken back to the Liver. If LDL Cholesterol is altered or oxidized and continues to stay in the vessels instead of getting extruded it triggers off a chain of activity which ultimately results in the narrowing of the blood vessels. Even high Triglyceride levels are damaging to the vessels. Hence it is prudent to observe a meticulous dietary pattern which consists of low amount of saturated fat, engage in regular brisk exercise to keep the cholesterol at optimally required levels. The ideal level of Total Cholesterol should be less than 200, LDL Cholesterol < 110, HDL>45, Triglycerides <175. If a person is Diabetic and a Hypertensive already symptoms of heart disease, then his Triglycerides should be less than 150, LDL Cholesterol < 100, and Total Cholesterol < 150.

MEDICAL MANAGEMENT >HYPERTENSION

HYPERTENSION

          The human heart acts as a pump which contracts and generates a pressure which is then transmitted to the blood vessels ultimately resulting in the flow of blood within them. This pressure inside the blood vessels is called Blood Pressure, which is vital for uniform supply of blood to the tissues.

          When the blood pressure is higher than normal it is called high blood pressure or hypertension. The pressure generated inside the vessels when our heart ejects blood is called the systolic blood pressure and the pressure inherent in the blood vessels even during the heart’s relaxed state is called Diastolic Blood Pressure. These values are expressed as readings one upon the other i.e. 120 / 80 mmHg or 160 / 90 mmHg etc.

          Blood pressure values within 130/80 mmHg are normal. Readings above 130 / 80 mmHg but below 140 / 90 mmHg are categorized as Pre-Hypertension. The condition may run in the family or may be seen in highly tense individuals, diabetics, smokers and obese people. Elevated systolic or diastolic pressure or both stresses the vessel walls and causes them to change. This change is poorly tolerated by the heart, the kidneys and the eyes leading to complications.

          Generally high blood pressure or hypertension is a fairly symptom less disorder with the individuals not having any suggestion of his disease worsening until the Brain, Kidney, Heart, eyes or Peripheral blood vessels are adversely affected (target organ damage).

Uncontrolled Blood Pressure leads to :

Thickening of blood vessel walls & narrowing of vessels supplying the brain and/or the heart (causing stroke, heart attack respectively)
Slow Kidneys damage and subsequent kidney failure
Heart muscle thickening as it works harder to pump blood against the greater pressure and later it dilatation and dysfunction
Damage of the blood vessels in the eye affecting vision and causing blindness
Narrowing or occlusion of the blood vessels supplying the limbs causing intense pain on activity

          In the vast majority there is no obvious cause for high pressure. It can be hereditary wherein they may have a tendency to retain salt. About 10 % of them may have hypertension secondary to other conditions like Kidney or Adrenal Disease.

ADVICE :

Please check your Blood Pressure once a year, after 30 years of age
Reduce salt and saturated fat intake
Practice regular dynamic exercise and meditation
If your Blood Pressure is still high take medication under the supervision of your Doctors
Prevail on your Doctor to asses you for other risk factors including Diabetes, high cholesterol and kidney function periodically.
Make sure you achieve and maintain adequate hypertensive control for your age.

MEDICAL MANAGEMENT >HEART FAILURE HEART FAILURE Inability of the heart to pump adequate blood to the body is called heart failure. Though it can be sudden, as following a massive heart attack and sudden loss of significant heart muscle; it usually is a long drawn out process that progresses over years. A variety of underlying conditions can lead to heart failure. Almost all the congenital heart diseases can at some point of time cause heart failure if neglected. Acquired disorders like Coronary Artery Disease, Hypertension and Diabetes are particularly important. Also Valvular Heart Diseases, Anemia, Thyroid Dysfunction, Chronic Lung Diseases and some idiopathic conditions like Cardiomyopathies can all lead to heart failure. By far the commonest symptom is shortness of breadth. However patients may manifest with easy fatigability, palpitations, swelling of the feet and rather sudden weight gain due to water retention, loss of appetite, low urine output, inability to lie flat and sleep interruption. Treatment largely depends on the underlying cause. Structural defects causing heart failure can be surgically treated (Surgical Correction). Anemia and thyrotoxicosis (Increase thyroid function) can be promptly corrected reversing the failure. Revascularization (PTCA, CABG) in coronary artery disease can improve heart function. Finally in those whom failure cannot be reversed it can be managed with rest, diet restriction and medications like Digitalis, Frusimideand ACE inhibitors to reduce symptoms and improve quality of life.