Acute Coronary Syndrome

Lake Louise. (Dr. Noorali Bharwani)
Lake Louise. (Dr. Noorali Bharwani)

Acute coronary syndrome is a medical emergency.

Acute coronary syndrome is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. Part of the heart muscle is unable to function properly or dies. It is critical to make an early diagnosis.

The problem is, not all chest pain patients get investigated because the presentation of symptoms can be short term, intermittent or not very clear. Just like not all patients with headache get a CT scan of the head. Because not every person with a headache has a brain tumour. That is why many brain tumours are diagnosed late.

“Diagnosing a patient presenting with chest discomfort or pain remains a challenge for physicians despite advances in diagnostic testing, clinical practice guidelines, and enhanced understanding of acute coronary syndrome (ACS),” says the Canadian Medical Protective Association (CMPA) in their newsletter (December 2019).

CMPA suggests appropriate triage and testing, as guided by symptoms and patient risk factors. This may help improve the timely diagnosis of ACS. Basically, no chest pain should be ignored irrespective of age or sex of the patient.

What is acute coronary syndrome?

Acute Coronary Syndrome is a name given to three types of coronary artery diseases that are associated with sudden rupture of plaque inside the coronary artery. One such condition is a heart attack (myocardial infarction) — when cell death results in damaged or destroyed heart tissue. Angina and heart attacks are types of acute coronary syndrome.

Acute coronary syndrome often causes severe chest pain or discomfort. It is a medical emergency that requires prompt diagnosis and care. The goals of treatment include improving blood flow to the heart, treating complications and preventing future problems.

Chest pain or discomfort is the most common symptom. However, in some patients’ signs and symptoms may vary significantly depending on patient’s age, sex and other medical conditions.

If you are a woman, older adult or have diabetes then you are more likely to have signs and symptoms without chest pain or discomfort. That is one of the reasons why a correct diagnosis is missed.

CMPA says, “Consistent with the medical literature, risk factors for women also displayed gender-specific characteristics, such as menopause and pregnancy, and women frequently presented with atypical chest pain.”

The signs and symptoms of ACS usually begin abruptly. They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning. Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw.

Early diagnosis is important. When someone is rushed to the emergency room with chest pain, testing must be performed to determine whether or not a person’s signs and symptoms are due to a heart attack or to another cause. The doctor will order a blood test to see if there is evidence that heart cells are dying and order ECG to check for the heart’s electrical activity.

Initially, if the tests are normal then serial testing (ECG and cardiac enzymes) should be done to check for any changes. Mistakes occur if there is failure to consider cardiac risk factors in the diagnosis of unexplained chest discomfort or pain. Especially in female patients.

In conclusion, managing acute coronary syndrome is a relatively common and challenging task, says CMPA. Patient’s risk factors should be considered along with appropriate serial blood testing in the emergency department. This can contribute to safer patient care, says CMPA.

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Stop flirting with your enemies by eating smarter and healthier.

Cruise ship in St. Martin. (Dr. Noorali Bharwani)
Cruise ship in St. Martin. (Dr. Noorali Bharwani)

Let us start with a question – What is the best way to lose weight? Is it intense exercise or less eating? Or both?

You cannot lose weight just by exercising. Regular exercise will make your heart and muscles strong. To lose weight you have to eat less and eat healthy. This has to be a lifelong strategy. Scientific evidence shows most people (who lose weight) will regain their weight over a period of time as they revert to their old eating habits.

There are many challenges faced by people who try to lose weight and maintain the loss. The challenges are to avoid foods containing sugar, salt and fat.

When you start cooking or sit down to eat, ask yourself – am I flirting with my enemies? How grave are the consequences? Let us look at the answers in more detail.

Your enemy number one – sugar.

Today, our diet is packed with huge amounts of added sugars.

Sugar is used as an ingredient in many packaged foods. Statistics from the National Health and Nutrition Examination Survey shows Americans eat about 17 teaspoons of added sugars per day. That’s significantly more than the American Heart Association’s recommendation of not to consume more than nine teaspoons a day. We are consuming twice the amount of sugar than recommended.

We know added sugars are bad for us. It is associated with an increased risk of overweight and obesity. That is directly linked to the development of type 2 diabetes. Studies have shown odds of being overweight or obese were 54 percent greater among individuals with the highest intake of sugars compared with those with the lowest intake.

Those who like to eat sweet stuff also increase the risk of heart disease. Several studies have shown a higher sugar intake also meant higher levels of total cholesterol, LDL (bad) cholesterol, and triglycerides irrespective of your weight.

Your enemy number two – salt.

We know too much sodium (salt) is bad for your heart. And yet, most North Americans consume about 50 per cent more than the maximum of 2,300 mg per day of salt. Reducing salt intake reduces the risk of heart disease.

Sodium is present in all types of food as a preservative or to improve the taste. It is lurking in some foods you wouldn’t necessarily suspect.

According to the Centers for Disease Control and Prevention, 10 categories of food (breads, pizza, sandwiches, cold cuts and cured meats, soups, burritos and tacos, savory snacks, chicken, cheese, eggs and omelets) account for 44 per cent of our overall sodium intake.

Best thing is to cook at home. Restaurant foods are heavily loaded with salt. Eating at home is always healthier and safer.

Your enemy number three – fat.

If you eat the right kind of fat then fat is good for you. Studies show different types of fats -monounsaturated, polyunsaturated, and saturated – had varied effects on health.

Saturated fat is the bad one. Instead of consuming saturated fat, eat unsaturated fats (fish, nuts, olive oil) or healthy carbs (grains, legumes). This way you can protect your heart. You want your heart to pump forever!

Avoid trans fats. American Heart Association says, “Doughnuts, cookies, crackers, muffins, pies and cakes are examples of foods that may contain trans fat. Limit how frequently you eat them. Limit commercially fried foods and baked goods made with shortening or partially hydrogenated vegetable oils.” Trans fat is really bad fat.

Eat more foods that contain unsaturated fat. Avocados, nuts, olive oil, and fatty fish should all appear regularly on your plate. Keep an eye on the calorie intake. Otherwise these foods are good.

My favourite diet: heart-healthy Mediterranean diet with a four-point plan.

According to Mayo Clinic website, if you’re looking for a heart-healthy eating plan, the Mediterranean diet might be right for you.

The main components of Mediterranean diet include:

  1. Daily consumption of vegetables, fruits, whole grains and healthy fats
  2. Weekly intake of fish, poultry, beans and eggs
  3. Moderate portions of dairy products
  4. Limited intake of red meat

Sounds pretty simple! Enjoy!

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What can we learn about our heart from a cardiac stress test?

Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)
Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)

Let us start by understanding the difference between cardiac stress test and cardiac Holter monitor.

What is cardiac stress test?

Robert Arthur Bruce (1916-2004) was an American cardiologist who invented the treadmill cardiac stress test used to diagnose heart disease. Patient’s heart signals are monitored on a treadmill set at successive stages of difficulty. Bruce also created the Bruce Protocol in the early 1960s, monitoring the heart signals of a patient on a treadmill.

Why is cardiac stress test important? Some heart problems only appear when your heart needs to work harder. Cardiac stress test helps to show how your heart copes under stress.

A cardiac stress test is done in a controlled clinical environment. It measures the heart’s ability to respond to external stress.  The stress response is induced by exercise or by intravenous injection of a medication.

What is cardiac Holter monitor?

Norman “Jeff” Holter (1914 – 1983) was an American biophysicist who invented the Holter monitor, a portable device for continuously monitoring the electrical activity (ECG) of the heart for 24 hours or more. Holter donated the rights to his invention to medicine.

The test is used to identify any heart rhythm problems. The device is the size of a small camera. It has wires with silver dollar-sized electrodes that attach to your skin.

Who needs cardiac stress test?

Any person who has a worrisome symptom like chest pain – especially in older men with risk factors for heart disease. An exercise stress test is not 100 per cent accurate. But it helps decide what the next step should be.

When to get a cardiac stress test?

The U.S. Preventive Services Task Force, an independent panel that makes recommendations to doctors, urges physicians not to routinely offer exercise stress testing to people without symptoms or strong risk factors for coronary artery disease.

Main indication for ordering stress test is when a person complaints of chest pain. Chest pain is not an uncommon complaint. Chest pain can have many possible causes besides heart disease.

For example, chest pain can be due to indigestion, anxiety, or muscle injury. If your doctor finds that you probably don’t have a heart problem, you may not need a stress test at all, says Choosing Wisely (2017 Consumer Reports. Developed in cooperation with the American Society of Nuclear Cardiology).

If you do have a heart problem, your first choice should often be a simple stress test without imaging. This test has little risk and is inexpensive. It is usually accurate for people with a low risk of heart problems.

Imaging stress tests are usually safe and can use little or no radiation. But for people at low risk, the tests may produce false alarms. This can lead to follow-up tests that you don’t really need. The extra tests can expose you to more radiation. Inappropriate testing can also lead to unnecessary treatment, says Choosing Wisely.

An imaging stress test can cost 10 times more than a regular stress test. You should only get an imaging stress test when it will help your doctor manage your disease or lead you to a better treatment. Discuss your symptoms with your family doctor. We can learn a lot from cardiac stress test if appropriately ordered.

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High-Rise Buildings Present Challenge in Cardiac Arrest

Disneyland. (Dr. Noorali Bharwani)
Disneyland. (Dr. Noorali Bharwani)

If there is a life-threatening emergency in a high-rise building then it is longer to rescue the people trapped in the building. In case of fire there are problems related to evacuation, accessibility, smoke movement and fire control.

What happens if you have a heart attack (cardiac arrest) in a high-rise building?

A study shows patients residing on higher floors of high-rise buildings in Toronto had lower survival after out-of-hospital cardiac arrest. Most out-of-hospital cardiac arrests occur in residential areas, and these cases are associated with poorer outcomes than nonresidential cardiac arrests, says an article in the Canadian Medical Association Journal (CMAJ).

Studies have shown that the mean time from ambulance arrival on scene to patient contact was 2.8 minutes for people on the first two floors but 3.1 minutes for those on the 3rd to 9th floors and 3.3 minutes for those on the 10th floor or higher.

Cardiac arrests on higher floors had longer rescue times, which contributed to poorer outcomes.

There are a number of issues which affect access in a high-rise building. For example:

  • Lack of witnesses to provide immediate help, CPR (Cardio Pulmonary Resuscitation) or call to paramedics.
  • There are barriers to elevator access. Studies have shown additional elevator stops happened in 18.6 per cent of high-rise residential calls. Elevators were not easily accessible in 33.9 per cent of all paramedic calls to apartment buildings.
  • Requirement for an entry code to a building (67.6 per cent of all access barriers), lack of directional signs (82.6 per cent) and inability to fit the ambulance stretcher into the elevator (67.9 per cent).
  • CPR in elevators is challenging.

What would help?

  • Train the family members of those at risk to do CPR.
  • Place automated external defibrillators strategically in certain residential locations.
  • Smartphone technology can link residents who are trained first responders to defibrillators in their neighbourhoods and to victims of cardiac arrest in apartments.

Recently another article in CMAJ (January 18, 2016) discussed this subject. During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria. Of these 76.5 per cent of patients had cardiac arrest below the third floor and 23.5 per cent of the patients had cardiac arrest on the third floor or higher.

The authors found survival was greater on the lower floors (4.2 per cent v. 2.6 per cent). They also found survival was 0.9 per cent above floor 16, and there were no survivors above the 25th floor. Wow, that can make you nervous!

Their conclusion: “In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise building may increase survival.” This kind of action can alleviate other disasters like fire.

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