Patient Guides

• Heart Attack Symptoms and Warning Signs
• Cholesterol
• Pacemakers and ICDs
• Peripheral Arterial Disease
• Angina
• Cardiac Enlargement

Heart Attack Symptoms and Warning Signs

A blockage in the heart's arteries may reduce or completely cut off the blood supply to a portion of the heart. This can cause a blood clot to form and totally stop blood flow in a coronary artery, resulting in a heart attack (also called an acute myocardial infarction or MI).

Irreversible injury to the heart muscle usually occurs if medical help is not received promptly. Unfortunately, it is common for people to dismiss heart attack symptoms.

The American Heart Association and other medical experts say the body likely will send one or more of these warning signals of a heart attack:

• Uncomfortable pressure, fullness, squeezing or pain in the center of the chest lasting more than a few minutes.
• Pain spreading to the shoulders, neck or arms. The pain may be mild to intense. It may feel like pressure, tightness, burning, or heavy weight. It may be located in the chest, upper abdomen, neck, jaw, or inside the arms or shoulders.
• Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath.
• Anxiety, nervousness and/or cold, sweaty skin.
• Paleness or pallor.
• Increased or irregular heart rate.
• Feeling of impending doom.

Not all of these signs occur in every attack. Sometimes they go away and return. If some occur, get help fast. IF YOU NOTICE ONE OR MORE OF THESE SIGNS IN YOURSELF OR OTHERS, DON'T WAIT. CALL EMERGENCY MEDICAL SERVICES (9-1-1) RIGHT AWAY! In the event of cardiopulmonary arrest (no breathing or pulse), call 9-1-1 and begin cardiopulmonary resuscitation (CPR) immediately.

The actual diagnosis of a heart attack must be made by a doctor who has studied the results of several tests. The doctor may:

• Review the patient's complete medical history.
• Give a physical examination.
• Use an electrocardiogram (or EKG) to discover any abnormalities caused by damage to the heart.
• Use a blood test to detect abnormal levels of certain enzymes in the bloodstream.

What does heart-related chest pain feel like?

By William R. Ladd, M.D., Director of Nuclear Cardiology, Cardiovascular Institute of the South

If you suffer chest pain, particularly while exercising, you will almost certainly wonder whether it might be heart-related - and well you should. Heart muscle pain - angina - is likely to be the first warning of blocked coronary arteries, the cause of most heart attacks.

While there are no infallible guidelines about whether a chest pain is heart-related, it generally takes a particular form. Heart discomfort is rarely a sharp, stabbing pain. The textbook description of angina is a feeling of heaviness, pressure, tightness or aching in the chest, usually accompanied by shortness of breath. The pain generally goes away when you stop exerting yourself, and it frequently isn't especially severe, which is, perhaps, unfortunate.

Even a heart attack may not be unbearably painful at first, permitting its victim to delay seeking treatment for as much as four to six hours after its onset. By then, the heart may have suffered irreversible damage. It is not unknown for patients to drive themselves to emergency rooms with what proved to be very serious and even fatal heart attacks.

Angina is a protest from the heart muscle that it isn't getting enough oxygen because of diminished blood supply. A heart attack is simply the most extreme state of oxygen deprivation, in which whole regions of heart muscle cells begin to die for lack of oxygen. If the blockage in the arteries serving the heart muscle can be cleared quickly enough - within the first few hours of the onset of the attack - the permanent damage can be held to a minimum.

That's why it is so vital to seek medical attention quickly if you feel the sort of pressing pain or heaviness described above. There is a 90 percent probability that pain of this type is angina. And even if it goes away, the artery blockages that caused it are still there and will grow progressively worse.

Ignoring this sort of pain because it is not unbearable or because it goes away is the worst thing you can do. It is the only warning you are likely to get of a potentially lethal condition. Heed it! Consult a cardiologist immediately.

You can have a heart attack without knowing it

By William R. Condos, Jr., M.D., Medical Director, Cardiovascular Institute of the South/Lake Charles

The nation's longest-running heart study suggests that about one heart attack in four produces no symptoms - or at least none that the victim associates with a heart problem.

These so-called "silent heart attacks," however, are only the most extreme case of a still more prevalent condition called "silent ischemia" - a chronic shortage of oxygen - and nutrient-bearing blood to a portion of the heart. Both conditions put their victims at significant risk.

The cause of ischemia, silent or otherwise, is almost always atherosclerosis - the progressive narrowing of the heart's arteries from accumulations of cholesterol plaque. In most instances, this reduction in blood supply generates a protest from the heart - the crushing pain called angina. But in perhaps 25 to 30 percent of heart attack victims, there were no previous symptoms of these gradually developing blockages. The Framingham Heart Study, which followed 4,000 Massachusetts men for more than 40 years, found that 25 percent of their subjects' heart attacks go unnoticed until their annual EKGs detect their after-effects.

The absence of pain, however, doesn't mean an absence of damage. The heart has a built-in reserve capacity, allowing it to suffer a certain amount of scarring and weakening from a heart attack and continue to meet the body's needs. But further ischemia or another heart attack, even a mild to moderate one, may prove fatal because that reserve capacity is no longer there. Even those who survive another heart attack are at increased risk of becoming cardiac cripples, disabled by congestive heart failure or arrhythmias heartbeat irregularities.

There is no way of predicting absolutely who is a candidate for silent ischemia, but statistically, the greater the number of risk factors for coronary artery disease that you have, the more likely you are to be a candidate. Those risk factors include some you can't control - your age, sex and genetic predisposition to atherosclerosis - and those you can influence, like diabetes, high blood pressure, high blood cholesterol, smoking, lack of exercise and obesity.

As a rule of thumb, I would urge you to undergo a screening for silent ischemia if you have any three of these factors working against you - a man over age 50 who smokes, or a post-menopausal woman with a ten-year history of diabetes and chronic unfavorable blood cholesterol levels, for instance.

The screening for undetected ischemia is a medical history and physical examination and a cardiac stress test - a workout on a treadmill while your heart function is monitored.

It's a simple, painless and inexpensive way to learn whether the beating of your heart is accompanied by the inaudible ticking of an atherosclerosis time bomb that could kill you.

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Cholesterol

Introduction

Cholesterol – friend or foe? Without it, we couldn’t survive. But too much of this waxy substance in your blood can lead to heart disease, the number one killer of men and women in the United States. The higher your blood cholesterol, the greater your risk for developing heart disease and suffering a heart attack, according to the National Heart, Lung, and Blood Institute (NHLBI).

Every year, more than 1 million Americans suffer a heart attack and about 500,000 people die from heart disease. However, because high blood cholesterol does not cause any symptoms, many people (more than 50 percent by recent estimates) are either inadequately treated or unaware that their cholesterol level is too high. Considering that 41 million estimated American adults have high cholesterol (according to the American Heart Association), the failure to appreciate high cholesterol’s importance places many people at unnecessary risk for developing future heart disease.

What is cholesterol?

Cholesterol is a waxy, fat-like substance that is naturally found in all parts of our bodies. It is present in the walls and membranes of every cell, including cells in the brain, nerves, muscle, skin, liver, intestines, and heart. Without cholesterol, our bodies could not function properly. It acts as the backbone of hormones like estrogen and testosterone, vitamin D, and bile acids that help us to digest fat.

Cholesterol in the body comes from two major sources. The first is from the liver, which is the body’s major cholesterol-producing organ. We also consume foods that contain cholesterol – red meat and eggs have particularly high levels. Because the liver is usually able to make enough cholesterol to satisfy all of our bodily needs, however, too much dietary cholesterol can lead to high bodily levels of cholesterol. (Some liver disorders also lead to excess cholesterol levels.).

These high levels are undesirable because it is difficult for our bodies to appropriately dispose of excess cholesterol. Excess cholesterol has a tendency to deposit into the walls of our arteries, particularly the arteries that lead to our hearts (or coronary arteries). It is these deposits that lead to development of "hardening of the arteries," or atherosclerosis

Left untreated, atherosclerosis is a condition that causes progressive narrowing of the arteries. Narrowing may even occur to the point where the artery becomes either severely or completely blocked. If the blockage occurs in a coronary artery, you may have severe chest pain (called angina) or a heart attack. If the blockage  involves an artery in the brain, you may have a stroke.

The difference between LDL and HDL cholesterol

Cholesterol does not travel freely in the bloodstream. Rather, cholesterol is carried through the blood by particles called lipoproteins. Cholesterol also behaves differently depending on which type of lipoprotein carries it. Low-density lipoproteins (LDL) deposit excess cholesterol on the artery linings (LDL cholesterol is the "bad" cholesterol), and high-density lipoproteins (HDL) remove excess cholesterol from the blood (HDL cholesterol is the "good" cholesterol). Triglycerides  are another type of substance closely related to cholesterol. They are mostly carried throughout the bloodstream by particles called chylomicrons or very low-density lipoproteins (VLDLs). While less is known about triglycerides, in general, there is some evidence to suggest that they are a particularly important cause of coronary artery disease among women and people with other risk factors such as diabetes and obesity.

According to the new guidelines released in May 2001 by the NHLBI's National Cholesterol Education Program (NCEP), everyone age 20 and older should have their cholesterol and triglyceride levels measured at least once every five years. This blood test is done after a nine- to 12-hour fast and provides information about your total cholesterol (TC), LDL and HDL cholesterol, and triglycerides. If your total blood cholesterol is 200 milligrams (mg) per deciliter (dL) or more, or if your HDL level is less than 40 mg/dL, you should talk to your doctor about ways to lower your cholesterol, which may include changing your diet, increasing exercise, or medication.  

HDL cholesterol protects against heart disease. This means that higher numbers of HDL cholesterol are better. A level less than 40 mg/dL is considered low and a major risk factor for the development of coronary artery disease. HDL levels of 60 mg/dL or more help to lower your risk for heart disease.

Triglycerides also can raise heart disease risk. Levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more) may require treatment for some people.

The NHLBI classification of the optimal level of LDL cholesterol is less than 100 mg/dL. Borderline high is 130-159 mg/dL, and very high is 190 mg/dL and above. High LDL cholesterol always requires attention. Your chance of developing coronary artery disease increases if you also have one or more other heart disease risk factors, such as high blood pressure, diabetes, and/or an early family history of heart disease.

Reducing your cholesterol

Lowering cholesterol is important for everyone, including younger, middle-aged, and older adults, and people with or without heart disease and/or stroke. Lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease. This is especially true for people who have already suffered a heart attack.

There are several ways to treat high cholesterol. One option is known as therapeutic lifestyle changes (TLC), which includes a cholesterol-lowering diet (called the TLC diet), physical activity, and weight management. In some cases, it may be necessary to take cholesterol-lowering drugs together with TLC treatment to lower LDL cholesterol levels. Depending on what your LDL level is, your doctor will decide which approach is best for you.

Pacemakers and ICDs: A Patient Guide

These electronic medical devices monitor heart rhythm and deliver appropriate electrical therapy when the heart rate is irregular (a condition called arrhythmia). Pacemakers and ICDs can be effective in extending and improving the lives of heart patients. Millions of people are affected by arrhythmias, which contribute to about 500,000 deaths each year in the US.

What are artificial pacemakers?

As the name implies, an artificial pacemaker "paces" the heartbeat in patients who have a slow heart rate. It is a device equipped with a battery-powered pulse generator and one or more wires. A pacemaker detect a heartbeat that is too slow or irregular and provides electrical signals that tell the heart to beat at a proper rate by delivering signals to the appropriate chambers of the heart.

Many pacemakers are programmed to lie dormant for as long as the heart is beating at a steady rate of 60-70 pulses per minute. When the heartbeat is too slow, a pacemaker sends an electrical impulse to pace the heart back to an appropriate rate.

What is an implantable cardioverter defibrillator (ICD)?

ICDs represent a major revolution in the field of cardiology for patients at high risk for suffering serious, potentially life-threatening arrhythmias. More sophisticated than pacemakers, ICDs are small electric generators that monitor the heart constantly, but only initiate an electrical signal when it detects an incorrect heart rhythm. ICDs not only function as pacemakers for slow heart rates, but may also deliver high-energy electrical therapy for fast heart rates, called defibrillation shocks. Surgically implanted like a pacemaker, an ICD is a miniature version of the shock paddles used by paramedics and emergency room doctors.

Who needs an artificial pacemaker?

Normal heartbeat is controlled by a natural pacemaker in the heart called the sinus node. An electrical signal is generated by the sinus node, a group of special cells in one of the upper chambers of the heart, called the atria. The signal spreads through the heart to the lower chambers, called the ventricles, and causes the heart to beat.

A pacemaker is needed when the function of the sinus node becomes too slow from age, heart disease, or heart medications. Another leading cause for pacemaker implantation is heart block-the failure of the electrical signal to reach the main pumping chambers of the heart, which in turn causes a slow heart rate.

When the heart beats too slowly, the brain and body do not get enough blood flow, leading to fainting, dizziness, lack of energy, fatigue, shortness of breath, and low tolerance for exercise and physical activity. Extreme slowing or complete stopping of the heartbeat can be fatal.

Who needs an ICD?

ICDs have been proven to prolong survival in patients with abnormal heart rhythms, usually those who have damaged hearts. Patients may be survivors of cardiac arrest caused by ventricular tachycardia (VT), a heart rhythm disorder that originates in the ventricles . VT is a rapid rhythm during which patients may feel faint or dizzy, or even pass out. During VT, the heart does not pump blood as efficiently as it does during a normal rhythm because rapid contractions prevent it from filling adequately with blood between beats. VT can be dangerous, even life threatening, if not properly treated.

Patients may also have atrial fibrillation (AF) or ventricular fibrillation (VF), heart rhythm disorders that originate in the ventricles. AF and VF are abnormally rapid heart rhythms that are highly unstable and irregular.

During fibrillation, electrical signals move chaotically through the heart, preventing it from pumping blood and beating properly. This often results in loss of consciousness. If left untreated, it may result in sudden cardiac death.

An ICD can deliver several types of therapies. These therapies include defibrillation, which delivers a brief, high-energy electric shock, and cardioversion, which consists of synchronized shock impulses that may progress from low-energy to high-energy levels, depending on what is needed to stop the rapid rhythm.

An ICD can act like a pacemaker by stimulating your heart if the rhythm is too slow. This requires little energy, so you may not feel anything. If an ICD detects a rapid beat, it can emit a series of pulses, which may feel like a fluttering in your chest. If this fails, the ICD can deliver one or more mild shocks, which may feel like thumps, to put you back into normal rhythm.

If your heart begins to beat dangerously with a very fast, irregular rhythm, the ICD provides a high-energy shock to give your heart's natural pacemaker time to get control of the rhythm again. The defibrillating shock is a strong one that feels like a kick in the chest and may even knock you out. But it may also save your life.

Implantation

An artificial pacemaker or ICD is implanted by a minor surgical procedure performed under local anesthesia. The surgery usually takes 1 to 2 hours and the risk of complications is approximately 1 to 2 percent. A pacemaker, which is about as large as 3 silver dollars, is placed beneath the skin just below the right or left collarbone. The wire or wires are threaded through a large vein into the heart. Using an X-ray, a physician attaches the electrodes at the end of the wires to the inner wall of the heart. The other end of the wire is attached to the device.

An ICD is larger than a pacemaker-about as big as a pager-and is implanted in a similar manner.

Pacemaker and ICD precautions

These devices generally will not prevent you from performing everyday activities, but certain precautions should be considered. First, remember to tell your doctor and dentist that you have the device before having any test or procedure. It is also wise to carry a medical ID card in your wallet because medical equipment that uses electromagnetic and radio wave technology may interfere with how your device performs. For example, magnetic resonance imaging (MRI), which uses a magnet to produce images of organs, may interrupt your device’s operation.

Other medical equipment used to dissolve kidney stones, treat irregular heart rhythms, treat acute or chronic pain, and deliver radiation for treatment of cancerous tumors may interfere with your device’s performance or require reprogramming of the device.

Home appliances do not pose a threat to your device’s operations, but large motors, high-voltage and radar machinery, such as transmitters and arc welding equipment, could temporarily affect your device.

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Peripheral Arterial Disease: A Patient Guide

What is Peripheral Arterial Disease?

Peripheral arterial disease (PAD) affects millions of people in the United States, most of whom are not aware that they have the disease. PAD interferes with one's lifestyle by decreasing walking ability (it affects the limbs) and affecting cardiovascular health. Left untreated, PAD increases the risk of heart attack, stroke, amputation of lower extremity limbs, and death. A patient with PAD has about five times the risk of dying of a heart attack or stroke over the next ten years as the patient who does not have peripheral arterial disease.

Like coronary artery disease (CAD), peripheral arterial disease is a form of atherosclerosis – a progressive disease that involves the hardening and narrowing of the arteries due to a gradual buildup of plaque (fatty deposits). Whereas CAD involves the coronary arteries, PAD occurs in the hundreds of arteries outside of the heart (called peripheral arteries).

Which arteries are most affected by PAD?

The major areas where atherosclerosis produces symptoms in the peripheral artery beds are:

• Cerebrovascular, or brain arteries (e.g., carotid and vertebral arteries) – Cerebrovascular disease (including carotid artery disease) is the leading cause of stroke and disability in the United States. 
• Renal, or kidney arteries – Renal artery stenosis (PAD of the renal arteries) is a major cause of high blood pressure and renal failure requiring dialysis or transplant. 
• Lower extremity, or leg arteries – Lower extremity PAD is a major cause of diminished ability to walk. Advanced cases lead to gangrene, ulcers and amputation of the legs. 
• Mesenteric, or intestinal arteries – Mesenteric arterial disease (PAD of the mesenteric arteries) is less common but can cause severe pain, weight loss, and even death from intestinal gangrene.

What are the symptoms of PAD?

PAD is underdiagnosed and undertreated in the United States, and rarely offers warning signs to its estimated 8 to 12 million victims, who are generally older adults. Probably only a third of the afflicted, about 4 million people, have leg pain from PAD, which means that two-thirds of them really don't have symptoms. Symptoms, however, can include: pain, ache, cramp or severe fatigue in one or both legs when walking (pain will subside upon resting) – so that those affected slacken their walking pace, or stop altogether. In later stages of progression, leg circulation may be so poor that pain occurs in the toes and feet during periods of inactivity, especially at night. This is known as rest pain, which usually worsens when the legs are elevated and is often relieved by lowering the legs (due to the effects of gravity on the leg circulation).

In later stages of the disease, the blockage can get so bad that it can lead to gangrene and ulcers and loss of the foot or limb.

Isn’t PAD part of the normal aging process and, therefore, not preventable?

The likelihood of acquiring PAD increases with age. Nearly 20 percent of Americans over the age of 70 have PAD, as compared to less than 8 percent of those 69 years of age or younger. Despite widely held beliefs in the general population, the symptoms of PAD are not inevitable results of the normal aging process. The vast majority of diagnosed patients are able to control this progressive condition with proper medical treatment.

What are the risk factors for PAD?

Individuals who are at risk of PAD are anyone over the age of 70, or individuals 50 years and older who either smoke or have a history of smoking or have diabetes mellitus. African Americans have an increased risk – probably a two- to three-fold risk of PAD.

Risk factors for PAD are much the same as for cardiovascular or cerebrovascular disease. They are age, smoking, hypertension, hyperlipidaemia, diabetes, obesity, physical inactivity, and family history. Of these, by far the most important is cigarette smoking – especially for those smoking more than 15 cigarettes a day.

How is PAD diagnosed?

The standard definition of PAD is created by an abnormal value of the ankle-brachial index (ABI). The ABI is a measurement performed with an electronic stethoscope and a simple office blood pressure cuff. This test measures the blood pressure at the ankle and at the arm, and the physician can easily compare the pressure at these two sites. A blood pressure that is lower in the ankle than the arm implies a blockage in the artery between the heart and the leg. Such a blockage represents peripheral arterial disease. A recent study shows that the ABI test is not performed as often as it should be.

Several tests may be required to diagnose PAD and determine the extent of the disease: 

• Medical history and physical exam 
• Ankle-brachial test 
• Treadmill exercise test 
• Reactive hyperemia test 
• Segmental pressure measurements 
• PVR waveform analysis 
• Duplex arterial imaging or ultrasound imaging 
• Photoplethysmography (PPG) 
• Anteriogram

How can PAD be prevented?

Strategies to prevent PAD are similar to those that prevent coronary artery disease. They include:

• Learn your family medical history. A patient’s family medical history can greatly increase (or decrease) the risk of the patient developing certain medical conditions, including PAD. 
• Eat a heart-healthy diet. While certain vitamins and minerals have been shown to be helpful to heart health, fats and oils such as saturated fat and tropical oils (palm and coconut oil) have been shown to be particularly harmful, because they can speed up the development of PAD, atherosclerosis, and obesity. 
• Improve cholesterol level. A person's total cholesterol ratio (which includes LDL cholesterol, HDL cholesterol, and triglycerides) should be no more than 200 milligrams per deciliter and no more than five times the HDL level. Key strategies to improve cholesterol ratios include a heart-healthy diet, regular exercise, limited alcohol use, and prescription cholesterol-reducing drugs (if needed). 
• Have blood tested. Researchers recently identified factors found in blood that can help to predict an individual's risk of developing PAD. The factors include the ratio between total blood cholesterol and HDL cholesterol and C-reactive protein levels. 
• Control homocysteine levels. High homocysteine levels have been linked to damage of the arteries, which can increase the risk of heart attack, stroke or other cardiovascular problems. Homocysteine can be kept at moderate, healthy levels if the body has adequate levels of three important B-vitamins: vitamin B-6, vitamin B-12, and folic acid. 
• Exercise regularly. Exercise can be an excellent tool in the prevention of heart disease. Physically, it can slow or even reverse the process of atherosclerosis, as well as lower blood pressure and reduce cholesterol levels (consult with your physician before beginning any exercise program). 
• Control diabetes. Persons with diabetes are more likely to develop heart-related diseases. Preventative care is crucial to the overall health and heart function of diabetic patients. 
• Control high blood pressure (hypertension). Individuals with high blood pressure are at greater risk of developing vascular problems. Hypertension can be controlled through blood pressure-lowering medications, self-monitoring, eating a heart-healthy and low-salt diet, and engaging in regular exercise. 
• Control weight. Obesity and being overweight are major risk factors for a host of serious health conditions, including PAD, high blood pressure, diabetes, heart attack, and stroke. 
• Manage stress. Stress may be a direct contributor to poor heart health because it produces increases in blood pressure that could become permanent. 
• Quit smoking (or don’t start to smoke). Tobacco smoking is a major cause of PAD and stroke. A study by the Centers for Disease Control and Prevention (CDC) shows heart disease as the leading smoking-related cause of death in the United States among men and women. 
• Control chronic depression. Depression has been linked with a higher risk of developing high blood pressure, heart disease, and having a heart attack.

How is PAD treated?

Early intervention is very important. If patients stop smoking, if their diabetes is well controlled, if their blood pressure is normalized with either diet or medication, if their cholesterol is normalized with diet or medication – these things can help to greatly change the progression of the disease and significantly reduce the likelihood that the patient will have a heart attack or stroke.

What are the current drug therapies for PAD?

For every PAD patient, reducing risk should be the primary goal of treatment, and healthy lifestyle changes are the first step. Medications also play a key role in treatment, with several types of drugs working together to reduce stroke and heart attack risk. One class of drugs called antiplatelet agents includes a common household medication – aspirin – that prevent platelets from sticking together and forming clots in the artery. There is also a prescription antiplatelet called clopidogrel (Plavix).

Everyone who has atherosclerosis – including patients with PAD – should be on a cholesterol lowering medication. Most patients should be on a statin. Statins lower both total cholesterol and LDL cholesterol (bad cholesterol).

Blood pressure also needs to be monitored in PAD patients and, in many cases, lowered. A recent study, called the HOPE study, used an ACE (angiotensin converting enzyme) inhibitor, called ramipril. The study showed that patients who were randomized to ramipril had lower heart attack, stroke, and cardiovascular death rates than patients who were randomized to a placebo drug.

Also, patients with high blood sugar should be put on antidiabetic drugs, since this condition can also lead to heart attack and stroke.

What treatments are used to specifically address leg pain?

The aforementioned types of medications, combined with the right lifestyle changes, can reduce a patient’s stroke and heart attack risk. But none of these therapies address the leg pain of PAD called claudication, which requires its own treatment strategy. Pain from intermittent claudicating is caused when leg muscles do not receive the oxygen rich blood required during exercise. The pain can be severe enough to hinder a person from walking.

There are three major options available:

1) Discontinue cigarette smoking completely and permanently. This not only prevents the progression of the atherosclerosis, but also may improve walking tolerance.

2) Begin a structured exercise program that includes walking on a treadmill or walking outside for about 30 to 40 minutes a day (rest when leg pain begins and resume walking when pain subsides).

3) Begin medication. There are two drugs available in the United States: Pentoxifylline (Trental), which has been available for several years, and a drug called cilostazol (Pletal), which was approved in 1999. Cilostazol has been shown to be very effective in increasing the walking distance in patients who have intermittent claudication. Your physician can tell you if either medication is right for you or in combination with exercise therapy or other treatments.

What other treatment options are available?

PAD can be treated with angioplasty alone or in combination with stenting, and with bypass surgery. In the 20-30% of patients who experience progressive deterioration, surgical treatments may include arterial grafts to remove the blockage in the peripheral arteries. Blockages tend to occur in large arteries with a high pressure, and at the bifurcation of arteries. In extreme cases (3-6%) amputation of the affected limb may be necessary.

How common is continued leg pain after a bypass?

It is quite common for claudication to persist after surgery but ideally this symptom should be less severe. This is because it is usually not possible for the surgeon to bypass all of the many blockages that exist in patients with PAD. The ABI (ankle-brachial index) does not predict functional ability to walk since individuals with the same ABI may have very different walking limitations. Recommended care and management is to embark on an exercise rehabilitation program in a supervised setting. Such a program usually involves treadmill walking at least three times a week. These programs are often administered by vascular specialists, or at the Vascular or Cardiac Rehab centers usually located in nearby hospitals. A vascular internist or cardiologist should supervise the care.

What treatment options are in development for PAD?

Photoangioplasty is a new combination drug and laser therapy currently being tested for use in the treatment of peripheral arterial disease. The procedure is no more invasive than standard balloon angioplasty, but may be much more effective, according to a report published in the journal Science Notes (2001). A drug called texaphyrin (TEX-a-frin) is injected directly into the patient's veins about 24 hours before the procedure. Once in the bloodstream, the drug attaches itself to areas of fatty plaque buildup. For the procedure, a fiber-optic laser is threaded through the body via a catheter and into the affected areas. Once in the target area, the laser is activated and its light triggers a reaction in the drug that dissolves the plaque.

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Angina: A Patient Guide

What is angina?

Angina is short for “angina pectoris,” which in Latin means “pain of the chest.” More specifically, angina is pain originating from the heart when it doesn’t get enough blood flow.

How does angina occur? What causes it?

At different times, the heart has a varying need for blood flow and the oxygen it carries. The heart receives this blood flow through its own set of blood vessels called the coronary arteries. Normal coronary arteries can open up and the heart can pump itself more blood during times of increased need. Unfortunately, over time, these arteries can develop internal blockages that slow the flow of blood through them. When these blockages reach a certain degree – usually when the internal size of the artery is narrowed by about 70% or more – it becomes impossible for the heart to get enough blood during the times it needs more. These times of increased need include:

• During exercise
• When performing physical work
• After eating
• When experiencing emotional stress or a sudden increase in blood pressure

With the relatively decreased blood flow and oxygen, the heart muscle produces chemicals that cause the pain and other symptoms of angina. Stopping the exertion or work and placing nitroglycerine under the tongue helps restore the blood flow balance – symptoms are usually resolved in 5-10 minutes.

How and why do these blockages in the coronary arteries develop?

The coronary arteries start off, as do all arteries, with a smooth inner lining. Over time, material becomes imbedded in plaques, or deposits, under the inner lining. This process is called coronary artery disease (CAD) or cardiovascular disease (CVD). Plaques are a mixture of cholesterol, fatty acids, and scar tissue. Ongoing inflammation seems to be an active part of the process. Though CAD seems to be part of the natural aging process of the arteries, it develops at widely differing rates in different individuals, based on a variety of factors:

• High blood pressure
• Abnormal blood cholesterol levels (high LDL cholesterol and/or low HDL cholesterol)
• Smoking
• Diabetes
• Male gender
• Heredity
• Eating increasing amounts of saturated fat and cholesterol (whether the blood cholesterol levels are abnormal or not)
• Being overweight
• Sedentary lifestyle
• Cocaine use
• High levels of certain chemicals in the blood, like homocysteine

Each of these factors causes damage to the arterial lining and/or causes plaques to develop more rapidly.

What are “hereditary factors”?

Though the chance of developing CAD and angina increases for everyone with increasing age, it seems that an increased chance of developing it earlier in life tends to “run in families.” If someone in an individual’s immediate family – a parent, brother, or sister – has had a heart attack or angina before age 50, then that individual has an increased risk of developing CAD at an earlier age. This hereditary effect is in addition to having high blood pressure, diabetes, or a high cholesterol level running in one’s family.

Is chest pain the only symptom of angina?

Not entirely. While angina means literally “pain,” the term is used to describe any of the symptoms that can result from decreased blood flow to the heart. For many people this includes some type of chest discomfort, either as the main symptom or one of a combination of symptoms. Some describe pressure or tightness in the chest rather than pain, per se. People may also experience any of a variety of symptoms, including:

• Sensation of indigestion or discomfort in the abdomen
• Dizziness
• Breathing difficulty
• Excessive sweatiness
• Nausea or vomiting
• Pain, pressure, or numbness in the neck, jaw, upper or mid back, or arms.

Symptoms unrelated to chest discomfort are referred to by doctors as “anginal equivalents.”

Can someone ever be sure that chest pain is not angina?

This is a difficult question, but chest pain that occurs once or twice and is brief, lasting only a few seconds, is unlikely to be related to the heart or any other significant problem. However, people with a wide variety of chest sensations – for example, burning, tingling, “electrical feeling,” sharp pain, dull pain, pain worse when moving the arms or neck or worse when swallowing or breathing – as well as those with the anginal equivalents described above, could be having angina, a heart attack, or another life-threatening problem. In short, the chest contains several vital organs and any recurring or prolonged abnormal feeling is a cause for concern. Seeing a doctor promptly is the best course of action. In many cases, this may mean calling an ambulance for transportation to the emergency department of the nearest hospital.

Is angina the same thing as a heart attack?

Angina is not the same as a heart attack, but the difference is only one of degree. CAD causes both conditions, but while angina is the result of the gradual development of partial blockages in the coronary arteries, a heart attack is caused by very sudden, total or near-total blockages in these vessels. Because CAD underlies both processes, those with angina are at increased risk for a heart attack, though about 50% of heart attacks occur in individuals who have had no prior angina or symptoms of heart disease.

Are there different degrees or severities of angina?

Yes. A stable pattern of symptoms to which a person has become accustomed over time is called stable angina. With stable angina, a particular level of activity – for example walking up three or more flights of stairs – may predictably bring on a person’s symptoms. When he or she rests or takes a nitroglycerine tablet, the symptoms are relieved over a few minutes. There is no immediate need to treat stable angina (other than resting or using nitroglycerine when symptoms result), and patients with stable angina have been treated with medications only for many years. Increasingly, however, angioplasty on a non-urgent basis is being used to help reduce symptoms for those with stable angina.

If the amount of coronary artery blockage increases rapidly, then angina symptoms may be brought on by lower and lower levels of exertion, or symptoms may be stronger, last longer, or take more time to resolve. When this progression happens over a matter of a few hours or days, or when a person experiences symptoms at rest, it is called unstable angina. Those with unstable angina are at very high risk for a heart attack require immediate treatment. Most commonly, the rapid progression of symptoms occurs because one of the coronary artery plaques or blockages “ruptures” or breaks through the inner artery lining. When the material in the plaque is exposed to the bloodstream, a clot can rapidly form, quickly reducing blood-flow further and causing worsening symptoms. When the blockage is total or near-total, a heart attack begins. Alternately, a person with long-term stable angina may gradually worsen over time, to the point of having unstable angina just on the basis of gradually worsening CAD.

In the first few days after a person experiences angina for the first time, it cannot be determined whether a person will have a stable pattern or will quickly develop an unstable one. For this reason, those with a new onset of angina, no matter how mild, are usually treated as though they have unstable angina.

There is another less common form of angina called “variant angina,” “atypical angina” or “Prinzmetal’s angina” (named for one of the doctors who first described it). It is caused by the spasming of an area of a coronary artery. The symptoms are similar to those of the other forms of angina, but usually occur at rest and may occur in younger persons and those felt to be at low risk for CAD (though cigarette smoking is associated with this form of angina, too). Nitroglycerine and other medications that relax the blood vessel spasm help relieve the problem. Though it sounds like unstable angina, the risk of heart attack is lower with variant angina because underlying rigid blood vessel blockage is not the problem and the spasm is reversible. Because they seem so similar in terms of symptoms, the definitive diagnosis of atypical angina often requires an angiogram or cardiac catheterization to look for underlying CAD. Sometimes patients with variant angina will also have underlying CAD that may or may not give them a different pattern of symptoms.

How is angina diagnosed and evaluated?

Angina is first suspected based on a person’s symptoms – the more typical the symptoms, the easier it is to diagnose. Patients with neck or arm pain, dizziness, or nausea present more of a challenge for the patient and physician because these symptoms are linked to many other problems besides heart disease. In any case, once angina is suspected, several tests help to evaluate things further – including confirming the diagnosis and determining the severity of the underlying CAD, which will help to determine the optimal treatment. In each case, deciding which test is best depends on the level of suspicion for CAD and angina and the suspected severity of the underlying problem.

A first step is an electrocardiogram or ECG (or EKG, an abbreviation for the German word for the same). When the heart is not getting enough blood, the electrical waveforms of the ECG can show characteristic changes from normal that may help make a diagnosis. The limitations of ECG are that heart problems other than CAD can cause changes in the waveforms, and that even when a person is having angina or a heart attack, the ECG may be completely normal. Timing is also important. If the ECG is done at a time when a person feels no symptoms and the blood flow is adequate, it may not reflect what happens when decreased blood flow occurs.

This last limitation is reduced when an ECG is done during exertion or exercise. This is the basis for an exercise treadmill test (ETT) , sometimes called a “stress test.” With this, a person has a continuous ECG during a period of exercise. If the exercise causes an increased need for blood that the diseased vessels cannot provide, the ECG may become abnormal. Also, a person may experience angina symptoms during exercise. Unfortunately, the ETT is not perfect and, for a variety of reasons, may be incorrectly positive or negative up to 35% of the time.

The limitations of the ETT can be further reduced, however, by adding an echocardiogram to the process. This is called a stress echocardiogram study, or “stress echo.” Using a sophisticated computer and monitor and a plastic probe and some gel on the chest, the echocardiogram can look directly at the movements of the heart with each beat. It has been shown that when the heart isn’t getting enough blood, the walls of the heart begin to beat irregularly. There are several patterns of irregularity of varying severity. This “wall motion abnormality,” as it is called, can happen before the ECG is abnormal and before a person develops chest pain or other angina symptoms. Though it provides increased accuracy for the diagnosis of CAD and angina, it, too, is not 100% accurate.

Another exercise study, using the radioactive element thallium, is more accurate than the stress echo. This test is also done during exertion and is usually referred to as a “stress thallium study” or a “stress thal.” Thallium is injected through an IV line during a period of exercise. By comparing pictures of the heart (created by radiation emitted from the thallium) during and after exercise, areas of decreased blood flow or prior heart damage can be identified. Though it is more accurate, the stress thallium study takes more time than the other stress tests, is more expensive, and involves an IV and some radiation (though not much).

In addition to the various stress tests showing what happens with exercise, monitoring what happens in the “recovery period” after exercise can be important as well. During this period, irregular heart rhythms or a slower than expected return to normal heart rate can indicate a poorer prognosis. With any of the stress tests, an adequate level of exercise is extremely important for the accuracy of the study. This is calculated based on the person’s heart rate and blood pressure with exertion. If a person cannot exercise adequately – due to age, arthritis, poor conditioning, or lung problems, for example – then exercise can be simulated by a continuous IV injection of a medication called dobutamine. This causes the heart rate and blood pressure to increase without the person having to exercise and is used mostly in conjunction with the stress echo. An alternative to dobutamine for the thallium study is a continuous injection of a medication called persantine that causes unblocked coronary arteries to widen while those that have significant blockages cannot. The differences between the areas of the heart supplied by the blocked and unblocked vessels can then be seen on the thallium pictures.

The most accurate test for the evaluation of CAD and angina is an angiogram or cardiac catheterization.. This is, however, the most expensive and invasive of the tests and is therefore used only when absolutely necessary. An angiogram involves the use of a significant, though safe, amount of radiation (x-rays), and is the most difficult to perform and most risky of the tests addressed in this article. In trained hands, however, the risk of complications is less than 1-2%. The angiogram procedure involves threading a catheter, or thin plastic tube, from a blood vessel in the groin up into the aorta, the major blood vessel going from the heart to the body. The openings for the coronary arteries are in this location and contrast dye is injected through the catheter into them. X-rays are used to show the arteries and any blockages. Laying out the pattern and extent of diseased vessels with an angiogram is necessary prior to angioplasty or bypass surgery.

A developing technology for evaluating some patients with CAD is magnetic resonance angiography, or MRA. By using the same MRI technology that’s used more commonly to look at the brain, spine, or joints, some significant coronary artery blockages can be seen. There are limitations to this study, but it may be an alternative in some cases.

Another CAD test getting increased attention is the electron beam CT scan (EBCT). This type of “heart scan” is often offered in a shopping mall setting, either by itself or as part of a “total body scan.” This technology uses some radiation, but is appealing to many because does not involve needles, exercise, or risky procedure. It works by detecting tiny calcium deposits in the lining of the coronary arteries. In some situations, this has allowed people to know they have potentially significant CAD before they have symptoms. In other situations, there are calcium deposits but no significant narrowing of the arteries, and the abnormal EBCT results have led to further testing which has proven to be unnecessary. In other situations, there may be significant artery narrowing without calcium deposits and so the EBCT results may be falsely reassuring. Given these limitations, the exact usefulness of EBCT has yet to be determined, though research is ongoing. At the current time, EBCT is not part of the typical evaluation of CAD and angina.

Laboratory blood tests have a use in the evaluation of patients with angina, but only in certain instances. Patients with possible unstable angina and heart attack are evaluated with blood tests in the emergency department or hospital. Heart enzymes (like creatine phosphokinase or CPK) and proteins (like myoglobin and troponins) can be measured in the blood in situations of prolonged or unstable symptoms, to determine whether a heart attack has occurred. Blood tests are also useful in determining or monitoring a person’s risk factors for CAD, like cholesterol, diabetes, or homocysteine. Unfortunately, unless someone is having a heart attack, no blood tests can tell definitely whether or not a person has CAD.

How is angina treated?

Those with risk factors for CAD and angina like diabetes, high blood pressure, and high blood cholesterol levels should control them with lifestyle modifications (exercise, controlling body weight, and an appropriate diet) and medications (there are many).

Even for those without these risk factors, everyone with angina or at risk for CAD should make lifestyle modifications to reduce and sometimes reverse the development of CAD. This includes quitting any smoking or drug use, eating a diet low in cholesterol and saturated fat, exercising regularly, and maintaining a lean body weight.

Many medications can help reduce the symptoms of angina. Medications used for stable angina include nitroglycerine (short- and long-acting), beta blockers, and calcium channel blockers, all of which help to balance the heart’s supply and demand for blood. ACE-inhibitors reduce the risk of heart attack in those with CAD. Aspirin is very helpful in reducing the chance of clot formation and heart attack, and it and several other medications may help by reducing inflammation within the plaques.

A supervised exercise program, cardiac rehabilitation, can help increase exercise tolerance in those with CAD, especially after a heart attack or heart procedure like angioplasty or bypass surgery.

Beyond medications, there are three procedures that directly improve blood flow to the heart:

• Angioplasty
• Coronary artery bypass grafting (abbreviated CAB or CABG)
• Enhanced external counter-pulsation (EECP)

Choosing which procedure is best depends on a particular patient’s overall condition as well as the severity and distribution of coronary artery blockages. Angioplasty (also known by the abbreviation PTCA, for Percutaneous Transluminal Coronary Angioplasty) can be done immediately following an angiogram or at a later date. The procedure involves passing a small balloon catheter across the artery blockage and inflating it; most of the time the blockage will then stay open. In addition, a small wire-mesh tube, called a stent, may be left behind within the blockage to minimize the chance of it reclosing.

Coronary artery bypass surgery is a major surgical procedure involving stitching vein or artery sections from the aorta onto the coronary arteries, beyond the blockages. This restores blood-flow to previously deprived areas of the heart. The original technique is performed with the heart completely stopped and the blood flow to the brain and body maintained by a cardiopulmonary bypass machine. The newer off-pump coronary artery bypass method (OP-CAB) is possible for some patients. With OP-CAB, the cardiopulmonary bypass machine is not needed and the risk of stroke may therefore be reduced. As a result, the heart can recover faster because its beating was not stopped for the surgery. For those with limited blockages in certain locations on the heart, a minimally invasive procedure (MIDCAB) may be possible.

Angioplasty, angioplasty with stenting, or any method of bypass surgery may also be performed electively in those with stable angina who are determined to be in need of surgery. For those with unstable angina, any of these may need to be performed on an emergency basis.

Enhanced external counter-pulsation (EECP) is a technique for improving blood flow to the heart without involving surgery. It involves 35 hour-long sessions once or twice a day in which cuffs (like large blood pressure cuffs) are inflated and deflated on both legs in synchronization with the heartbeat. Over the course of treatment, the pattern of blood flow to the heart may change, providing benefit and decreasing angina symptoms even for many months after the treatment has ended.

Where can I learn more about angina?

You can learn more about the causes, symptoms, and treatment of angina and coronary artery disease by using these as search terms on Heartinfo.org. As well, the American Heart Association (www.americanheart.org) and National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov) have information available on their websites.

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Cardiac Enlargement: A Patient Guide

By Dr. Joseph Toscano

What is cardiac enlargement?

Cardiac enlargement refers to an increase in the size of the heart. There are two types of cardiac enlargement: hypertrophy and dilation. (Though usually occurring separately, they may occur at the same time.) Hypertrophy involves an increase in the thickness of the heart muscle. Dilation involves an increase in the size of the inside cavity of a chamber of the heart. Hypertrophy usually occurs in only one chamber while dilation may occur in one, two, three, or all of the chambers, based on its cause. In most cases, cardiac enlargement is abnormal and accompanied by additional cardiovascular problems. The one exception is regular aerobic exercise, which produces a beneficial enlargement involving both hypertrophy and dilation of the heart.