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Dr K K Aggarwal

Judicious use of cardiac screening

By Dr K K Aggarwal
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Unnecessary screening can have a considerable cost beyond that of the test itself, warn members of an ad hoc committee convened by the American College of Physicians. Screening tests should be performed judiciously, and the committee has assembled a list of common clinical situations in which more testing is unlikely to be helpful and may be harmful, writes Amir Qaseem, MD, PhD, MHA, from the ACP, Philadelphia, Pennsylvania, and colleagues in the January 17, 2012 issue of the Annals of Internal Medicine. ACP committee has identified 37 clinical scenarios in which screening does not promote patient health, and might even have adverse consequences. Those related to cardiac scenarios: • Performing coronary angiography in patients with chronic stable angina who have well–controlled symptoms on medical therapy, or who lack specific high–risk criteria on exercise testing • Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function • Obtaining ECG to screen for cardiac disease in patients at low to average risk for coronary artery disease. • Obtaining exercise electrocardiogram (ECG) for screening low–risk, asymptomatic adults

How can you explain coronary artery disease to your patients?

By Dr K K Aggarwal
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The following is how I communicate with my patients and explain to them about coronary artery disease.

• There are three coronary arteries, which can be equated to three main roads of the city.

• Any road has shops on each side. The coronary artery has the endothelium on the sides.

• There are pavements in front of the shops. The pavements in coronary arteries are called intima-media.

• When the local municipal corporation does not maintain discipline, shopkeepers start encroaching the pavement. In terms of coronary arteries, this is equivalent to intima media thickness.

• The next to follow are temporary encroachments of the road, which is equivalent to several plaques in the coronary arteries.

• Then comes permanent encroachment, which is equivalent to heart plaques.

• With encroachment, the traffic slows down and heavy honking of horns starts. This denotes angina or chest pain.

• When the traffic congestion is heavy, motorists often blow their horn continuously. This can be equated to unstable angina.

• When the traffic stops, but the car engine is still working, this can be likened to a heart attack.

• When the car stops and the engine also stops, this is a cardiac arrest.

Cynicism is one of the recognized major risk factor for causation of coronary artery disease (blockages in the channels supplying blood to the heart). And anger, jealousy and irritability form the triad responsible for this.

Anger is the enemy of peace, knowledge and devotion. According to Ayurveda, anger is a manifestation of Pitta (metabolism) imbalance and is a pre-disposing risk factor for causation of heart attack, paralysis, gall bladder stone, kidney stone, acidity, ulcer and cancer.

In Bhagavad Gita, Lord Krishna describes the pathway of anger leading to destruction in Chapter 2 Sloka 62 and 63. According to Lord Krishna, when a man’s desires are not fulfilled or expectations are not met one becomes angry. And when one is under the effect of anger he does all types of sinful activities. One loses the distinction between good and bad, loses one’s memory, the understanding becomes clouded, and the intellect gets perverted. Loss of intellect leads to animal-like behavior, and ultimately to destruction of oneself.

Many kinds of repercussions can occur with anger, which are injustice, rashness, persecution, jealousy, taking possession of others property, killing, speaking harsh words and cruelty. The degree of anger may vary from irritation, frowning, resentment, indignation, rage, fury and wrath.

Anger is not always bad. It is only when the anger is an outcome of greed or selfish motives, it is bad.

Righteous or spiritual anger is a type of anger caused with good intentions. This anger passes off the next moment as a wave subsides in the sea. The classical example of righteous anger is when you become angry in a situation where you see a person doing something wrong  to check that person.

The root cause of anger is ignorance, egoism, and passion (strong desires)

with passion being the root cause. To control anger, therefore, passion should be controlled first.

In Vedic language, both anger and passion are Rajo-Vriti disorders and get exaggerated with any Rajas-increasing lifestyle. Living a life with less of Rajas characteristics will reduce the chances of getting into passion and anger.

Rajas-increasing foods are eggs, fish, onion, garlic, fermented foods, etc. Indulging into modern fashion, night clubs, reading novels with stories of violence, living in the company of bad people, indulging in sexual talks, use of tobacco, alcohol and drugs are all Rajas-increasing life styles. A typical Rajasic person is the one indulging in eating, drinking and procreating.

Controlling anger and passion is a procedure involving effort. As a fish swims upstream against the current in a river to breathe, a person has to work against the disturbed thoughts. To balance and stabilize the mind, consuming ‘satvik’ foods like fresh food, vegetables, milk, and barley bread will help. Many exercises can/help also to control anger.

A few suggested ones are observing silence for 20 to 30 minutes in a day, walking regularly, practicing speaking kind words; doing regular meditation, practicing non violent communication daily and learning to think differently.

During an episode of anger one can try left nostril pranayama, a short deep breathing exercise, taking a walk, drinking cold or simple water or chanting AUM or I AM. With inspiration one chants “I” and with expiration “AM” reminding one who I AM. That I am the expression of pure spirit and my purpose of life is not to become angry. Remember the person who gets angry will have high blood pressure. On whom you are angry may have no change in blood pressure.

One should realise that during anger, one loses the power of discrimination and suffers from intellectual impairment. Therefore, anger has to be controlled much before it becomes full blown. The initial stage of anger is irritability, and therefore, with the onset of irritability, one should try to control it at the earliest.

One should never judge an individual with his own level of perception. One should realise that if a servant starts working with your level of expectations, he or she will not be working with you as a servant.

One should also make sure that one is not hungry at the time of feeling angry or irritable. Regular meals prevent development of anger.

Anger can be expressive or suppressive. Expressive anger presents with aggressive behavior and the outbursts of anger can cause social unhealthiness. It can cause sudden rise in upper blood pressure or cause rupture of a plaque in the artery supplying blood to the heart precipitating a heart attack.

Suppressive anger can lead to acidity, asthma, formation of plaques in the heart arteries etc. In long run suppressed anger if not expressed may end up with depression, despondency, guilt etc.

Therefore anger should neither be passed on to others (expressive) nor taken within (suppressed or repressed). Anger, therefore, should be altered, neutralized, or modified. This can be done by temporarily holding it for some time and than taking timely action. Temporary holding can be achieved by using the above exercises. Remember both passion and anger are energies which should be conserved and not wasted.

The mythological explanation of Shiva the Neelkanth is also the same. One should neither throw the poison (anger), nor drink it but keep it in the throat for some time and take the right action after the anger manifestations are over.

From Vedic text point of view every thought arises from the silent potential web of energized information or consciousness. This thought from the mind is then analysed by the intellect and the modified by the ego. At this stage it leads to an action. An action lead so memory and memory leads to desire for the action again,.

If this desire if fulfilled it leads to action again and then desire again. Repeated fulfillment of desires leads to habits formation, addictions and development of a particular personality.

If the desire is not fulfilled it leads to irritability and irritability leads to anger which then can be expressive or suppressive.

The answer therefore lies in changing the perception at the level of the thought or controlling the desires and or the expectation.

Sometimes back Late Shri K. R. Narayanan the Vice President of India went to Chennai to have his wife’s medical check-up and came back with his own bypass surgery. Many at that time were surprised after reading it. But is it not common?

A large number of cases with heart disease for the first time present with heart attack, sudden death or cardiomyopathy – a condition where the heart gets dilated. Many of these situations may need emergency therapeutic procedures including bypass surgery or balloon therapy.

Coronary artery disease (CAD) in which there is deposition of fat in the channels supplying blood to the heart is not a one day process. It takes on an average 10-50 years for the blockage to become significant to cause cardiac symptoms.

The process of fat deposition called atherosclerosis is multi factorial. Active or passive smoking, uncontrolled blood pressure or diabetes, stress, high cholesterol, stress (especially negative), obesity and lack of exercise are a few of the known risk factors. These risk factors must be present for long enough to cause the blockage.

In simple words it is said “you cannot gift, or accept as a gift, a heart attack”. You have to earn it i.e. you cannot get heart attack by smoking 100 cigarettes or not exercising or having you blood pressure or diabetes uncontrolled for a day.

Ten years to produce blockage of coronary arteries is long enough period for a person to get it checked up or for a doctor to detect it by way of investigations. But few are in the habit of getting a regular medical check up. We are very particular about our car, fridge, computer or cooler and will have it checked and serviced at regular intervals but not our body.

One must have a routine ECG done as a baseline at the age of 20. ECG may or may not diagnose underlying blockage and may be abnormal only at a time when the person is actually having cardiac pain. But the comparison with the base line ECG often helps in doubtful cases. In some cases the ECG abnormalities may be present even at rest.

The heart for its nutrition is dependent on oxygen and nutrients from the coronary arteries. The work the heart has to do on DEMAND is related to the oxygen and nutrition it will get on SUPPLY.

If the demand is more i.e. in situations like running, jogging, walking etc. the supply needed is more. And if the arteries are not being able to supply the required nutrition, as they are blocked, the heart will cry at the time of increased demand – called angina.

It takes at least 70% blockage of one or more of the arteries to cause symptoms of chest pain. Therefore the conditions may remain silent for a long period of time.

Before the person becomes symptomatic the evidence of blockage can easily be found by creating a situation of demand vs. supply imbalance – a test called as stress test or treadmill test (TMT). The person is subjected to graded exercise on a machine, while changes in heart rate, BP and the ECG is recorded, and also constantly monitored. The level of exercise when the person becomes symptomatic or the abnormal ECG changes suggestive of lack of blood supply appear indicates the severity of blockage, and further mode of treatment.

Normally a person without blockage should be able to do 12-14 minutes of graded exercises on the machine, achieving an exercise of about 10-12 METS i.e. about 10 times the basal energy expenditure, without causing any symptoms or ECG changes.

The TMT may be positive in the first 3 minutes of exercise, called severely positive, or in the 3-6 minutes of exercise, called moderately positive, or after 6 minutes or exercise called mildly positive TMT test.

Persons with moderately or severely positive TMT are often symptomatic, but the group with mildly positive TMT may be symptomatic or asymptomatic.

Silent heart disease is very common. The persons may have severe blockage of the coronary arteries and may suffer from episodes of damage to the heart muscles without experiencing any symptoms. Painless episodes are common amongst diabetics and patients with thyroid disorders.

Symptoms also depend on the duration of disease, age of the patient and the development of collaterals in the heart. If the person is old, there is enough time for the collaterals to develop and the person may do well on medicines. On the other hand if the person is young, the collaterals may not be adequate and he may end up with a heart attack.

Bypass surgery is necessary when there is failure of adequate medical treatment to provide the desired quality of life. Normally when the patient becomes symptomatic or for the first time he is detected to have underlying coronary disease, he is put on medical treatment first and if he does not respond he is considered for balloon or bypass surgery.

There are occasions when at the first detection of disease the patient may be subjected for surgery, for instance if  the TMT test shows positive test (lack of blood supply)  at 0-3 minutes of exercise or if angina occurs at low levels of heart rate or at rest or recurrent pain (3-4 times/day).

Angiography is often considered if the patient is young, has survived a recent cardiac arrest, has unstable angina or post heart attack angina or TMT is positive in the first stage.

If the angio shows disease of the main channel supplying blood to the heart it becomes an emergency surgery. Presence of 2 or 3 artery blockage in otherwise asymptomatic patient is not an indication for surgery. One has to correlate with the symptoms and response to the treatment.

Also a patient asymptomatic on drug with 2 or 3 vessel disease may not be subjected for surgery. Many a time an angina may temporarily become unstable due to some precipitating factors like blood loss, thyroid disorder, stress, fever etc. In such cases treating the precipitating factor may control the angina.

Indians have more severe heart disease. The blockage is more common, more severe and more diffuse. They also report late to the doctors. It is therefore expected that if we do not change our life style we may have the largest number of bypass surgeries in the world in time to come.

Bypass is not a cure. It only bypasses on already blocked artery. If the defective life style or risk factors continue either new blockage will appear in the non-bypassed vessels or in the grafts. The only answer is early detection of blockage and change in the life style.

Every person should have his TMT done once in 5 years after the age of 30 and annually if he has 1 or 2 risk factors, viz. family history of heart disease, high blood pressure, diabetes, smoking, obesity, stress, high cholesterol or a history of sudden death in the family.