The patient may become completely normal, without any symptoms and require only a low dose of aspirin. Some patients and require only a low dose of aspirin. Some patients may have a stable angina after the heart attack, they require only medical treatment.
Some patients may have unstable angina i.e. angina coming at an increasing frequency with increasing severity and sometimes even at rest. Such patients may not respond to medical treatment adequately and may require surgical intervention.
To differentiate between these three categories of patients, we have a battery of tests available. These include :
- Treadmill Test (TMT). This is also known as Stress Test. It is done 3 weeks after heart attack under the supervision of a cardiologist. Some people have a misconception that one may even die after undergoing the test. But on the contrary, this test is absolutely safe. Complications,if any, are only a coincidence and could have occurred otherwise also. This test is not done in patients with unstable angina. Exercise in this test is graded and limited to a particular heart rate or symptoms of the patients. Here person on a fasting state is asked to walk on a moving belt, the speed of which increase gradually. Changes in the ECG, if any, are recorded on to the monitor. If you can walk half to one km without any problem, if you are having normal sex with your partner or if you are climbing stairs, then why be afraid of a treadmill.
- Holter Monitoring. Holter is a small Walkman like machine that you can carry along with yourself. It gives us a continuous 24 hours beat to beat monitoring. It is particularly useful to pick up any disturbance in pulse rhythm and painless or painful episodes of lack of blood supply to the heart.
- Colour Doppler Echocardiography- This is another simple and non-invasive test in which we can pick up the function of various chambers, valves and walls of the heart by placing a transducer on patients chest wall.
- Transesophageal Colour Droppler Echocardiography. This is a few innovative test in which a transducer is placed in the food pipe of the patient where it lies just next to the heart. It gives a much better and clearer view of the heart than the conventional echocardiography. We can also see the main blood vessel supplying blood to the heart, the obstruction of which can lead to sudden death.
- Late Potential. This is a special type of ECG which can predict dangerous irregularity of pulse which otherwise can lead to sudden death if not treated properly and in time. This test is simple and can be done any time just like an ECG.
- Angiography- This is an invasive procedure and is, indicated only in patients who have failed to respond to adequate medical treatment and lead a desirable quality of life.
- MUGA- It gives the same information given by TMT and echocardiography.
Thalium Scan- Thalium gives us the same though better information as given by TMT and echocardiography.
DRUGS AFTER DISCHARGE
If you have suffered a mild heart attack, it is quite possible that you will be discharged without any drugs, and with only advice on diet, exercise and test. On the other hand, there may have been a slight complication that your doctor wants to treat with drugs, in which case, you may be prescribed one of the drugs described on the following pages.
These drugs thin the blood and, at least in theory, prevent further thrombosis either in the veins or in the coronary arteries; they may be given for a few weeks or months. They will normally be given to prevent deep-vein thrombosis in the legs. Unfortunately, however, they do not always succeed in preventing a further heart attack. The disadvantages are that you are required to have frequent blood tests- maybe as often as two or three times a week to start with and then at weekly intervals. If you are on long-term anticoagulants, you will have a blood test once a month after the first few weeks of stabilization. A possible danger is that of serious bruises and internal or external bleeding if the blood is thinned too much.
The most commonly prescribed anti-coagulant is coumarin. If you are prescribed an anti-coagulant, you must not take any other drugs without consulting your doctor.
Aspirin and other drugs, such as persantin, which reduce the stickiness of blood platelets and thus the tendency for the blood to coagulate,may also be prescribed.
The advantages of this kind of treatment for heart attack patients are not, as yet, very clear and there may be problems of gastro-intestinal upsets and, less commonly, the formation of stomach ulcers and internal bleeding. Aspirin is never prescribed with Warfarin because the two drugs can react with each other, causing internal or external bleeding.
The other types of treatment which may be prescribed are those of angina,heart failure, rhythm disturbance, and high blood pressure and those prescribed in the hope of preventing a further heart attack. These medications are all long term, sometimes for the rest of your life and it is essential that you know exactly what their purpose is, how much and how often they have to be taken and in what quantity, and for how long they are to continue. It is important that you raise this last point with your doctor from time to time. Although you must continue to take your drugs exactly as they have been prescribed for you, you must also realize that they are not the be all and end all : what they can do is limited and the self-help measures which are probably just as if not more important.
There is no conclusive evidence The drugs used to control high blood pressure prevent further heart attacks and they may not be without their dangers. In a large trial in the United States called MRFIT, it was shown that among those people with ECG abnormality at the start of the trial, more died in the group who were on drugs for high blood pressure than in the group who were not on such medications.
BLOOD-FAT REDUCING DRUGS
Since a raised level of fats in the blood is associated with an increased chance of having a heart attack, it follows that drugs that can reduce fat levels are used in the hope of preventing a recurrence. It should be remembered, though, that the first step is to make every effort to reduce fat levels by changing to a diet low in saturated and high in polyunsaturated fats. The drugs will be given only if the levels remain dangerously high.
One such drug, in fuse for several years, was Clofiabrate; then an international trial was carried out too see if its use could be further extended to healthy people with raised blood cholesterol levels. Fifteen thousand people from Edinburgh, Budapest and Prague took part and after five years, some rather surprising truths were revealed : the drug certainly reduced the risk of having a heart attack, but overall, it killed more people than it saved. Most of these deaths were from disease of the gall bladder, liver and bowel, including cancer. The trail was described in the medical journal The Lancet thus : The treatment was beneficial but the patient died The drug is no longer in use.
There are other drugs which can reduce fat levels in the blood. It is true that they may reduce the chances of future heart attacks, but their benefits are not impressive and are likely to be wiped out by their side-effects. In 1985, two scientists, Doctor Joseph Goldstein and Doctor Micheal Brown, won the Nobel Prize for their research on the structure and function of an enzyme whose activity is vital in the synthesis of cholesterol by the body. This gives new hope that one day soon researchers will find a new drug that will block production of cholesterol by the body.
There has recently been a tendency for some doctors to prescribe long-term beta-blockers to prevent a recurrence. They may be useful for some people but their wholesale use is to be discouraged for the following reasons. In the first place, they can cause a number of side-effects, including wheeziness, fatigue, depression, weight gain, hallucinations, nightmares, insomnia, cold extremities and psoriasis-like skin rashes.
Secondly, they may interfere with your self-healing ability by masking physical warning signs and emotional over-arousal. Thirdly, you may come to rely on them to such an extent that those problems that may have caused the heart attack in the first place are pushed to one side and remain unresolved. In addition, they tend to have an adverse effect on the level of blood fats and so tend to counteract some of their benefits. And finally, their benefits may not last longer than one year.
If you have been prescribed them, however, you must continue to take them regularly as an abrupt stoppage can have serious or even fatal results.
If drug treatment fails to relieve you of angina or if you are believed to be at risk of further heart damage, you may be recommended to have a coronary bypass operation. Other possible surgical treatment includes a heart transplant or the use of an artificial pacemaker.
In the early stages after having a pace-maker fitted, you will attend the pace-maker clinic at frequent intervals say, a month after discharge and again at the end of a further three months. Thereafter a regular six-monthly check is usual. The pacemaker rate is tested electronically and the device is replaced well before the batteries run out.
Obviously, if a major fault develops suddenly, your original symptoms will develop and you must contact your doctor or clinic immediately. It is wise to carry a medical card at all times, giving essential details about yourself, your cardiac condition and your pacemaker so that, in the unlikely event of your needing emergency treatment, the doctor will have all the details he needs to help you.
Fixed-rate pacemakers do not contain any sensing circuits and are influenced neither by biological signals nor by outside electromagnetic interference. A demand pacemaker, however, has to be sensitive to the natural heart rhythm and contains sensing circuits. External electromagnetic signals, some of which closely mimic the heart own signal, may therefore suppress the pacemaker electrical impulse.
In practice this rarely happens, since the pacemakers are well shielded from such signals, but in theory at least, spot-welding machines, anti-theft devices, metal detectors, electromagnets, radio and TV transmitters, metal detectors used in airports and libraries, and faulty microwave opens can all occasionally influence the working of a pacemaker. Manufacturers of pacemakers give detailed instructions as to exactly which sources of electromagnetic interference must be avoided.
CARING FOR THE PATIENT AT HOME
When someone you love has a heart attack, the experience can be alarming, confusing and emotionally draining. Many of the financial, psychological and social problems that both you and the patient are likely to face can be resolved, or at least their burden can be reduced, if you can learn to share them between you and to discuss them openly and constructively with each other. You can also help the patient to recover by maintaining a positive, cheerful and optimistic attitude. Discuss the information you and the patient are given and plan a sensible programme of rehabilitation.
It is particularly important that you appreciate the difference between instructions you are given which are merely intended as guidelines, and those which must be adhered to strictly. Advice regarding medication must be strictly followed, but some of the other recommendations can be given greater latitude. There is nothing more annoying for a patient than your trying to follow every piece of advice you have been given to the letter by throwing away favourite foods, recording every sip of alcohol, or timing every minute exercise with a stopwatch.
Let the patient know his recovery is important to you and that you are there to assist in every possible way. Offer sympathy and understanding but do not take over over his life completely.