Very recently [ February 2010 ] during a bridge tournament at The Madras Gymkhana Club , an elderly gentleman complained of chest pain and requested the tournament director to announce for tablet Sorbitrate. I heard the announcement . As a coronary care physician i have often witnessed people neglecting and ignoring warning signals of heart attack . It is often assumed to be "gas ", acidity , muscle catch etc. I considered it necessary to discontinue my play and attend to this gentleman. Apart from chest pain at rest he also had breathlessness [ considered to be an anginal equivalent ]. he did not have any sweating . The chest pain occured at rest and was of about ten minutes duration , at which point he requested for medicine . It was of new onset and was distinctly more severe and prolonged than the one he had about a year back. He gave a history of established coronary artery disease by angiography [ and also angioplasty five years back ] . Associated Factors such as AGE more than 70 years old , MALE gender and diabetes mellitus suggested an intermediate likelihood of heart attack in this gentleman. Clinical examination revealed a rapid but regular pulse. He was given 5mg of substrate under the tongue. Same was repeated after five minutes . In the meantime I had managed to procure Tablet Aspirin , 300 mg of which was given with instruction to chew the same. Simultaneously arrangements were made to rush him to a hospital with the best cardiac facility , good ICCU and a good coronary care team. Since the patient was feeling better after medication , he was unwilling to go to the hospital. I had to impress upon him the importance of immediate evaluation and also the necessity of admission for observation . In the event of a heart attack any delay would result in lesser chance of survival and active life. Medical science has limits. In about 60 minutes time he was hospitalized and believe me ,we were just in time. He recovered well enough to participate in the Gymkhana monthly open in less than three weeks time. The expression on his face said it all !!! The earlier the treatment , the lesser the damage to the heart. Time is of essence in heart attack care.
Even in developed countries , one in five heart attack victim dies before he reaches the hospital . Hence SUDDEN DEATH is among the most common presentation [ symptom ] of heart attack. The challenge for a good coronary care team is not only to save lives but also the heart muscle . Lesser the damage to heart muscle , higher the chance of long and active life. The difference between mediocrity and excellence in coronary care is the difference between life and death and between active life and restricted life. Given the varying severity of heart attacks , the daunting task is to optimise outcomes within a short period .Time is of essence in heart attack management. The biggest delay usually occurs not during transportation to the hospital but rather between the onset of pain and the patient’s decision to call for help.This delay can be reduced by creating community awareness about the significance of chest discomfort and the importance of early medical evaluation and treatment. It is important to reach the hospital within the ‘golden hour ‘ as this will help keep total ischaemic [ insufficient blood supply ] time within 120 minutes.
In our country patients come really late . It is also important for all coronary care centres to treat patients at affordable cost and without charging an advance .We have to make it affordable for everybody , since heartattacks can happen to anyone. It is possible to provide excellent treatment at low-cost .
Diagnostic evaluation and treatment approach for patients presenting with suspected heart attack :
1, Those with clearly atypical chest pain , normal E.C.G. and no clinical history suggestive of likelihood of coronary artery disease are sent home.
2, Those patients with a low likelihood of myocardial ischaemia are observed in Emergency Room . Serial ECGs and cardiac markers [e.g., Troponin and CK-MB ] are performed at baseline , 4-6 and 12 hours after presentation.
If new elevations in cardiac markers or ECG changes are noted , the patient is admitted to the hospital.
If the patient remains pain free , the cardiac markers are negative and there are no ECG changes, the patient may go on to stress testing . This may be performed as early as 6 hours after presentation in the emergency room or on an outpatient basis within 72 hours.
3, Those with clear evidence of heart attack are promptly administered 300 mg of Tablet Aspirin [ to be chewed ] . They are hospitalised . Supplemental oxygen is given where necessary . For control of discomfort sublingual [ under the tongue ] Nitroglycerin is given . Intravenous Morphine is used for pain relief . Intavenous beta blockers are also useful in control of the pain .
If no contraindications are present , CLOT DISSOLVING DRUGS [ Fibrinolytic therapy ] is ideally to be initiated within 30 minutes of presentation [i.e., door – to – needle time less than 30 minutes ]. The aim here is to PROMPTLY AND FULLY open up the blocked coronary artery. When administered within the " GOLDEN HOUR " of the onset of symptoms it can reduce the relative risk of in-hospital death by upto 50%. It also reduces the damage to heart muscle and also the incidence of other serious complications.
Since heart muscle can be saved only before it has been irreversibly damaged , it is clear that " EVERY MINUTE COUNTS ".
Patients treated within 1 – 3 hours of the onset of symptoms generally benefit most.
Although less, the therapy remains of benefit for many patients seen 3 – 6 hours after the onset of heart attack .
Some benefit is possible up to 12 hours , especially if chest discomfort is still present .
PREVENTION DELAYED IS WELLNESS DENIED – Welcome To Better Health Foundation .
A big issue for the health-care profession is the quality of advice on offer and whether it is sufficiently impartial. Many feel that a lot of private medicare is not about advice but about pushing products and procedures. Experts are worried that the health-management system may end up becoming a distribution channel for products and procedures. There is also a degree of complacency and laxness about how people choose health-care.
The patients also lack the expertise to evaluate the service they are getting and also don’t know enough about the disease to be able to demand what they need.
You are WELCOME TO FORWARD THIS INFORMATION to your friends and family members.
Better Health Foundation [Live Longer, Live Healthier ], A Not- FOR -Profit Health Initiative by Dr. Rajeshkumar Shah M.D. brings to you,
Early Disease Program- For early detection of lifestyle (Hurry, Worry & Curry) Triggered conditions such as:
Overweight and Obesity,
Coronary Heart Disease,
High blood pressure,
Cervical,Colon, Breast and Prostate Cancer,
Any other Medical problems.
Followed by advice on effective intervention (Aimed at Control or Cure) by way of lifestyle changes and Medical treatment and information on monitoring (Aimed at avoiding
complications and need for interventional and surgical treatment).
o Annual Health status Analysis and advice accordingly
o Individual counseling for lifestyle – Triggered Diseases
o Interactive group counseling for lifestyle Triggered Diseases Aimed at raising awareness about lifestyle Triggered Diseases.
o Health education and updated Medical information for all Medical conditions.
Evidence based medicine: As a patient you want to be well informed about the effectiveness and/or side effects of each and every medicine that has been prescribed or treatment procedure that has been recommended. Better Health Foundation is committed to provide updated information to patients and their families and friends and thus hopes not only to ease the healthcare decision making process but also aims at improving healthcare decision making through systematic reviews of the effects and/or side-effects of healthcare intervention. A systematic Risk Benefit and Cost Benefit Analysis of treatment option helps. The aim is to get the patient to understand all aspects of the treatment and hand out treatment plans that are effective and with the least side effects.
Providing explanation of the problem and reassurance about the ability to formulate a treatment plan that is effective in ensuring that a long and productive life is possible goes a long way in achieving patient comfort. The decision to use a particular treatment intervention should also factor in patient preferences and situation. Presently, only doctors call the shots. In the long run, with knowledge, people can change the existing profit based System of Medicine !
Dr. RajeshKumar H. Shah M.D.
Consulting Physician and Cardiologist
Chairman and Medical Director
Better Health FOUNDATION
(A Not For Profit Health Initiative)
MEMBER: INDIAN SOCIETY OF CARDIOLOGY MEMBER: The Association of Physicians of India.
Formerly: Hony. Consultant Physician and Cardiologist,
Shri Sindhi Medical Relief Society (Regd.)
Apollo visiting Interactive Physician.