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Paging Dr. Frischer - Heart Attack
Dr. Alan Frischer

You think that you are having a heart attack! What are the symptoms? How do they show themselves? What brings them on?
It’s actually not at all unusual in my daily practice for a patient to come in with some type of chest pain, believing that they are experiencing a heart attack. Sometimes, they are!
This remarkably common killer is the leading cause of death for both men and women. Approximately 1.1 million Americans suffer heart attacks each year, and close to half of them die. While heart attacks can occur at any time, 4:00 to 10:00 in the morning is the peak time, most likely due to higher levels of adrenaline in the blood.
What is a heart attack, also known as a myocardial infarction? It usually begins with the rupture of an atherosclerotic, cholesterol plaque on the inner wall of a coronary artery. A blood clot forms there and completely obstructs the artery, which should be supplying blood to the heart muscle. Because of the resulting lack of oxygen, the heart muscle is injured, and it is this injury that may lead to chest pain or pressure.
If the blood flow is not restored within 20 to 40 minutes, irreversible death of the heart muscle will begin. Muscle continues to die for the next six to eight hours, at which time the heart attack is usually complete.This dead heart muscle is eventually replaced by scar tissue.
Who gets heart attacks? This discussion needs to be all about risk factors. Just as it is extremely rare to hear about a drive-by shooting in Beverly Hills, it is extremely uncommon to hear about a heart attack in a 35-year-old woman without risk factors. Both scenarios are possible, of course, but not likely. If you are having symptoms, your doctor will evaluate these symptoms in the context of your own unique risk factors.
There are essentially six major risk factors for getting a heart attack, and many other “softer” risk factors. You do not need to have all of the major risk factors to experience a heart attack, but the more you have, the more likely a candidate you become.
High Blood Cholesterol (Hyperlipidemia): Cholesterol is the major component of the plaque deposited in arterial walls, so elevated cholesterol levels are associated with higher risk. Cholesterol can only dissolve in the blood if combined with the proper lipoproteins. Otherwise, it turns into a solid substance and clogs the arteries.
Note, however, that the cholesterol that is combined with low-density lipoproteins (LDL cholesterol) is the “bad” cholesterol. The cholesterol that is combined with high-density lipoproteins (HDL cholesterol) is the “good” cholesterol, which actually removes cholesterol from arterial plaques. Therefore, both elevated levels of LDL cholesterol as well as low levels of HDL cholesterol are associated with an increased risk of heart attack.
High Blood Pressure (Hypertension): High blood pressure, both systolic and diastolic, is a major risk factor for developing atherosclerosis and heart attack. Controlling hypertension with medications and the proper lifestyle can reduce this risk.
Tobacco Use: Tobacco (including second-hand smoke) contains chemicals that cause damage to blood vessel walls, accelerate the development of atherosclerosis, and consequently increase the risk of heart attack.
Diabetes: Diabetes Mellitus is associated with accelerated atherosclerosis throughout the body, regardless of whether insulin or pills are being used to treat it. Therefore, diabetics are at risk for reduced blood flow to all arteries, including the heart (coronary artery disease), legs (peripheral vascular disease), brain (cerebral vascular disease leading to stroke), and genitals (erectile dysfunction) at an earlier age. Diabetics can lower their risk through rigorous control of blood sugar levels.
Being Male: At any age, men are more likely than women to develop atherosclerosis and coronary heart disease. There is much speculation and the reason is not completely clear. Women do have higher HDL (“good”) cholesterol levels than men.
A number of secondary risk factors for heart disease are observed more often in men than in women, including stress, inactivity and obesity.
Family History of Heart Disease: Individuals with a family history of coronary heart disease have an increased risk of heart attack, especially if there is a heart attack or sudden death before age 55 in a male first-degree relative (father or brother), or before age 65 in a female first-degree relative (mother or sister).
The classic symptoms of a heart attack typical for men are listed below. They are generally (but not always) related to exertion, and often subside with rest.
•Chest pain, fullness, and/or squeezing sensation
•Jaw pain, tooth pain or headaches
•Shortness of breath
•Sweating
•Dizziness
•Heartburn and/or indigestion
•Arm pain (more commonly the left arm)
•Upper back pain
•General malaise (vague feeling of illness)
Despite knowing the warning symptoms listed above, note that between 40% and 60% of all heart attacks are unrecognized! In other words, a heart attack may show either no symptoms at all (a “silent” heart attack) or vague symptoms that can easily be mistaken for a different problem. Women and diabetics are more likely to have unusual presenting symptoms, and therefore take longer to be accurately diagnosed. These symptoms seen more often in women and diabetics include neck and shoulder pain, abdominal pain, nausea, vomiting, fatigue, coughing, and restlessness. To further complicate matters, women are more likely to have chest pains that are not due to the heart, such as spasms of the esophagus; are less likely to have typical findings on an EKG; and are more likely to have misleading, or falsely positive stress tests.
How is a heart attack diagnosed? Accurate tests can be performed quickly. An electrocardiogram (ECG) records the heart’s electrical activity. ECG abnormalities can (but not always) appear when a heart attack is occurring and heart muscle is deprived of oxygen. Blood tests measure levels of cardiac enzymes, which are elevated in the blood several hours after the onset of a heart attack. Their levels correlate with the amount of heart muscle that has died.
Time is of the essence. Prompt medical attention allows for early treatment, and the more rapidly the blood vessels are re-opened, the more heart muscle is saved. Interestingly, the most common actual cause of death from a heart attack is ventricular fibrillation, which occurs when the heart’s electrical system malfunctions, causing a fatal heart rhythm.
Prevention is key to avoiding a first heart attack, as well as for subsequent heart attacks. There are so many heart-healthy measures you can take! Get your blood pressure under control, and if you are a diabetic, get your blood sugar under control.
You can lower your LDL and raise your HDL by losing excess weight, exercising, and taking medication for cholesterol. Most patients at high risk for a heart attack should be on cholesterol medication (statins), no matter what their cholesterol levels. Your doctor may recommend that you take aspirin, beta-blockers, or ACE inhibitors, and multivitamins high in folic acid and omega-3 fatty acids. Quit smoking!!!
Remember, everything you did leading up to the heart attack earned you that heart attack, so it is high time for major change. Good heart health to you all!
Dr. Alan Frischer is former chief of staff and former chief of medicine at Downey Regional Medical Center. Write to him in care of this newspaper at 8301 E. Florence Ave., Suite 100, Downey, CA 90240.

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Published: July 8, 2010 – Volume 9 – Issue 12



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