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HEART ATTACK: EVALUATION AND MANAGEMENT

Tuesday, 27 May 2014

The usual indication of coronary artery disease / heart attack is chest pain, which is called angina pectoris. Angina is usually the pain felt right in the middle of the chest, behind breastbone, which can spread towards neck, jaw, left arm of wrist. It can feel like handcuffs or tightening of chest. The pain may be prolonged more then 30 minutes and if associated with profuse sweating, nausea, vomiting and palpitations is usually suggestive of heart attack.

The angina pectoris may come with exertion, walking up incline, after a heavy meal, after a strong emotion, fright, and nightmare or smoking a cigarette.

The angina pectoris may be a part of spectrum of acute coronary syndromes, which is heart attack or it may come after exertion, which is usually called chronic stable angina. The treatment options for both are different.

The evaluation for angina pectoris consists of various lab tests. The usually performed tests for evaluation of heart disease are ECG, Treadmill test (TMT), Echocardiography, Nuclear tests and Coronary angiography.

ECG: - This is the basic test for diagnosing heart disease. It is usually normal out side an angina episode or unless patient already had an old heart attack, enlargement of heart chambers or some conduction abnormality. It may signify a major heart attack or other minor forms of heart attack. A normal ECG does not rule out presence of heart disease.

STRESS TEST: - The patient is made to walk on a treadmill and continuous ECG recording is done. The active angina / heart attack should be ruled out before subjecting the patient to treadmill test. The results of this test may be normal or may give clues about presence of blockage in coronary arteries.

ECHOCARDIOGRAPHY: - This is basically ultrasonography of heart. This will tell us about functioning of heart, its contractility, ejection fraction, any valvular blockage or leakage, old or fresh heart attacks.
It may be abridged with a stress test, when it is called stress echocardiography. In this heart functioning is seen at peak exertion, for any areas which are not moving or working properly and signifying blockage in coronary arteries.


NUCLEAR SCINTIGRAPHY: - Nuclear test is done by injecting very small, harmless amount of radioactive substance in blood stream and taking images. Special gamma camera is used to take images of heart at rest and after a stress.

CT CORONARY ANGIOGRAPHY: - This is a newer modality for diagnosing blockage in coronary arteries. This is done by very high end CT scanners like 64 slices or 128 slices. The importance of this test lies in its high negative predictive value which means that if the test is negative showing normal coronary arteries, it is definite and quite reassuring to the patient. But if it is even slightest positive one should go for conventional angiography and diagnosis should be confirmed.

CONVENTIONAL CORONARY ANGIOGRAPHY: - This is the gold standard for diagnosing coronary artery disease. An introducing sheath is inserted through a groin artery or arm artery and a catheter is inserted and guided to coronary arteries, contrast dye is injected and X- Ray films are taken. These will show any blockage in the coronary arteries in form of filling defects, narrowing of lumen or irregularity of lumen.
The coronary angiography is done to decide whether patient needs a coronary angioplasty or coronary artery by-pass surgery or medical management only. The decision is taken only after reviewing the coronary angiography results.
These days it has also become relatively less invasive when it is done through arm i.e. Radial artery route. Radial angiography is devoid of any bleeding complications and is very comfortable for the patient. Patient can be discharged after a short hospital stay and cumbersome leg straightening for six hours is avoided.      

MANAGEMENT: - It is known that heart attack occurs when there is total blockage of coronary arteries with a thrombus or clot. The immediate treatment is addition to taking asprin tablet and other medicines is dissolution of thrombus and opening up of the coronary artery, which is causing heart attack so that damage to the heart muscle which is being deprived of blood and oxygen is avoided well within time. The clot can be tackled by immediate coronary angiography and removal by angioplasty procedure or dissolving the clot by clot busting drugs given intravenously which is called thrombolysis. The results of angiography and angioplasty, which is called primary angioplasty are more favorable if done well in time. The efficacy of clot busting drugs is maximum in first 3 hours. If the clot busting drugs have not worked in a given patient than one should plan for angioplasty procedure and opening of artery which is called rescue angioplasty.  
Actions needed to be taken on suspicion of heart attack : - Chew a tablet of aspirin. Take nitroglycerin as spray or sublingual tablet and repeat after 5 minutes maximum up to 3 doses. Try to call and reach emergency services as soon as possible, do not deceive yourself.
 
Dr TP Singh
Chief Consultant Cardiologist,
SGHS Hospital, Mohali
Mobile No : 09872421946
 

1 comment

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