Diagnosis and treatment of coronary artery disease, valvular heart disease, heart failure, cardiac arrhythmias and congenital heart disease. Risk factors management for primary prevention.

Diagnosis and Treatment of:

-Acute Coronary Syndrome

-Aortic Aneurysm

-Arrhythmia

-Cardiomyopathies

-Carotid Artery Disease

-Chest Pain

-Congenital Heart Disease

-Coronary Artery Disease

-Dyslipidaemia

-Heart Failure

-Heart Murmur

-Hypertension

-Palpitations

-Shortness of Breath

-Stroke/Transient Ischaemic Attack (TIA)

-Syncope/Faint

-Valvular Disease

Tests and Procedures:

-Carotid Triplex

-Computed Tomography (CT) Angiography of Coronary Arteries

-Computed Tomography (CT) of Aorta and Peripheral Arteries, Electrocardiogram (ECG or EKG), Myocardial Perfusion Scan (Thallium Test)

-Exercise Tolerance Test (Stress Test) Dobutamine Stress Echocardiogram (Stress ECHO)

-Transthoracic Echocardiogram (TTE)

-Transesophageal Echocardiogram (TEE)

-24-hour Ambulatory Blood Pressure Monitoring (ABPM), 24-hour Ambulatory Electrocardiogram (Holter) Monitoring

The heart is a powerful muscle with the specific job of pumping blood around the body. It is divided into four hollow areas called chambers that work together as two parallel pumps. The four chambers include two atria and two ventricles. The right atrium and right ventricle comprise one pump that propels blood through the pulmonary circulation to the lungs. The left atrium and left ventricle compose the second pump that moves blood through systemic circulation to all other body tissues.

The heart works in two cycles. Its continuous pumping action keeps the body supplied with oxygen-rich blood. The body's cells take the oxygen they need from the circulating blood. In the first part of the cycle, the blood returns to the right side of the heart, which pumps the blood into the lungs to pick up oxygen. The oxygen-rich blood then enters the left side of the heart, pumping it out to circulate throughout the body.

The heart beats approximately 60-100 times and pumps about 3-5 litres of blood every minute.

Coronary Arteries

-A typical heart is about the size of your clenched fist and is positioned in your chest slightly to the left of your breastbone (sternum). It is made of muscle and continuously pumps blood rich in oxygen and nutrients around the body

-The heart itself requires oxygen and nutrients so that it can carry out its pumping action

-Coronary arteries supply blood that contains oxygen to the heart

-A large artery called the aorta carries oxygen-rich blood from the heart to the rest of your body

-The coronary arteries branch off the aorta

-There are two coronary arteries, which originate from the aorta to supply the heart with oxygen-rich blood

-The right coronary artery divides into two main branches: the posterior descending artery, and the marginal artery

-The left coronary artery also divides into two main branches: the anterior descending artery and the circumflex artery

-These coronary arteries form a network over and through every part of the heart

-This enables every part of the heart to be nourished with oxygen and nutrients

-When the blood supply to the heart muscle is not sufficient to provide enough oxygen for the heart, pain, called angina, occurs.

The pain can occur after exertion (physical exercise or hard work) or at rest.

Heart valves

Valves are essential to your heart’s pumping function. Your heart has four valves, or tissue flaps, that open and close, allowing blood to flow in one direction. There is a valve at the entrance and exit of each ventricle.

The valves at the entrance of the ventricles only allow blood in, and the valves at the exit only allow blood out.

There are four valves in the heart:

1. Tricuspid valve, which lies between the right atrium and right ventricle

2. Pulmonary (pulmonic) valve, between the right ventricle and the pulmonary artery

3. Mitral valve between the left atrium and the left ventricle

4. Aortic valve between the left ventricle and the aorta

Each valve has a set of “flaps” (also called leaflets or cusps). The mitral valve has two flaps; the others have three.

Oxygen-poor blood returns to the heart after circulating through the body. It flows through the veins and enters the right atrium. This chamber empties blood through the tricuspid valve into the right ventricle. The right ventricle pumps blood under low pressure through the pulmonary valve into the pulmonary artery. From there, the blood goes to the lungs, where it gets fresh oxygen. The oxygen-rich blood then returns to the left atrium. From there, it passes through the mitral valve and enters the left ventricle.

The left ventricle pumps this oxygen-rich blood through the aortic valve into a large artery called the aorta. The aorta takes blood from the heart to the rest of the body. The pressure in the left ventricle is high, similar to the blood pressure measured in the arm. When passing through the body, oxygen in the blood is distributed to the tissues. The cycle continuously repeats as the blood flows back to the heart.

Coronary artery disease affects the coronary arteries, supplying the heart with vital oxygen and nutrients required to carry out its pumping action.

The most common cause of coronary artery disease is a build-up of cholesterol, fat and other substances in the blood on the inner surface of these arteries.

This is known as atherosclerosis (pronounced ath-er-o-skler-o-sis). Over a period of time, this atherosclerosis can cause a narrowing of the artery and sometimes block it completely. When this narrowing or blockage occurs, blood flow to the area of the heart supplied by that artery will be reduced or stopped altogether.

This part of the heart then becomes deprived of oxygen, called ischemia (pronounced iss-keem-e-a). During this time, pain may be experienced. This is known as angina.

If this part of the heart continues to be deprived of oxygen, it will die. This could reduce the pumping action of the heart, and it will not be able to supply the body with oxygen. This is very serious.

Several risk factors are known to contribute to coronary artery disease. These are split into two groups; controllable and uncontrollable. The risk factors are summarised in the following table.

Research shows the benefits of reducing the controllable risk factors for atherosclerosis:

-High blood cholesterol (especially LDL or “bad” cholesterol over 100 mg/dL)

-Cigarette smoking and exposure to tobacco smoke

-High blood pressure

-Diabetes mellitus

-Obesity

-Physical inactivity

Research also suggests that inflammation in the circulating blood may play an essential role in triggering heart attacks and strokes. Inflammation is the body’s response to injury, and blood clotting is often part of that response. Blood clots can slow down or stop blood flow in the arteries.

What is a Heart attack?

A heart attack is also called a myocardial infarction (MI) or an acute myocardial infarction (AMI). Many heart attacks are caused by a complete blockage of a vessel in your heart called a coronary artery. A blocked coronary artery prevents oxygen-rich blood and nutrients from reaching a section of the heart. If blood cannot reach the heart muscle, it will die. Treatment within six hours can save heart muscle. You can reduce this damage by getting medical treatment quickly, but once a section of the heart muscle dies, the damage lasts forever.

Warning signs of a Heart attack:

-Pressure, fullness, tightness, or pain in your chest, lasting 5 minutes or longer.

-Constant indigestion-like discomfort.

-Chest pain that moves to your shoulders, arms, neck, jaw, or back.

-Lightheadedness, dizziness, fainting, sweating, or a sick stomach.

-Unexplained shortness of breath.

-Unexplained anxiety, weakness, or tiredness.

-Palpitations, a cold sweat, or pale skin.

Not everyone will have the classic symptoms. For some people, a heart attack feels like a burning sensation, similar to indigestion or heartburn, and the pain may be in only a small area of the chest. Some patients may not feel anything at all.

Heart attack symptoms in women may be different from those experienced by men. Many women who have a heart attack do not know it. Women tend to feel a burning sensation in their upper abdomen and may experience lightheadedness, an upset stomach, and sweating. Because they may not feel the typical pain in the left half of their chest, many women may ignore symptoms that indicate they are having a heart attack. Many people put off getting the care that could save their lives because they think that these signs (also called heart attack symptoms) do not mean a heart attack.

Although chest pain is usually the most common sign, some people have heart attacks without having chest pain.

That is why being aware of the other warning signs is important. Anyone who has any of these signs for 5 minutes or longer should see a doctor right away. Call an ambulance or have someone drive you to the nearest hospital emergency room. Because you could be having a heart attack, do not drive yourself. It could be dangerous to you and others.

What is a stroke?

A stroke is an injury to the brain that may also severely affect the body. A stroke happens when the blood supply to part of the brain is cut off or when there is bleeding into or around the brain. The brain’s nerve cells need a constant supply of oxygen and sugar (glucose), which are carried by the blood. When blood fails to reach brain parts, the oxygen supply to those areas is cut off.

This is called ischemia. Without oxygen, brain cells die. The longer the brain is without blood, the more severe the damage. The area of tissue death that results from ischemia is known as an infarction.

The effects of a stroke may be mild or severe, short-term or permanent. The symptoms of a stroke last for more than twenty-four hours. Some people have strokes and recover completely within a few days, while others may never recover.

How severe a stroke is depends on:

-What part of your brain is affected

-How much brain cell damage there is

-How quickly your body can restore blood to the injured parts of your brain

-How quickly the healthy parts of your brain can take over for the injured area

Warning Signs for a Stroke. Symptoms typically include:

-Weakness or numbness of your face, arm, and leg on one side of your body.

-Sudden blindness or dimming of eyesight, especially in only one eye.

-Loss of speech, slurred speech, or trouble understanding speech.

-A recent change in your personality or mental ability.

-Trouble swallowing.

-Headache (usually severe and comes on quickly) or changes in the pattern of headaches, including migraines.

-Unexplained dizziness, staggering or impaired balance, unsteadiness or sudden falls, especially if you have the above warning signs.

*If you notice one or more of these symptoms, don’t wait… get medical attention immediately!

Blood is pumped through your heart in only one direction. Heart valves play critical roles in this one-way blood flow, opening and closing with each heartbeat. Pressure changes behind and in front of the valves allow them to open their flap-like “doors” (called cusps or leaflets) at just the right time, then close them tightly to prevent a backflow of blood.

There are four valves in the heart:

1. Tricuspid valve, which lies between the right atrium and right ventricle

2. Pulmonary (pulmonic) valve, between the right ventricle and the pulmonary artery

3. Mitral valve between the left atrium and left ventricle

4. Aortic valve between the left ventricle and the aorta

Two problems can disrupt blood flow through the valves: regurgitation or stenosis.

Regurgitation is also called insufficiency or incompetence. Regurgitation happens when a valve doesn’t close properly, and blood leaks backwards instead of moving in the proper one-way flow. If too much blood flows backward, only a small amount can travel forward to your body’s organs. Your heart tries to compensate for this by working harder, but with time your heart will become enlarged (dilated) and less able to pump blood through your body.

Stenosis happens when the leaflets do not open wide enough, and only a small amount of blood can flow through the valve. Stenosis occurs when the leaflets thicken, stiffen, or fuse together. Because of the narrowed valve, your heart must work harder to move blood through your body.

In both circumstances, the heart must work harder to pump blood. In valvular stenosis, the heart’s pumping ability decreases when the valve narrows, leading to several problems. For example, less blood can fill the ventricle if the mitral valve is narrow when the left atrium contracts. This limits the amount of blood that is then pumped out to the body.

When a valve fails to close completely, blood can flow back into the chamber that it was coming from. This valve condition also impairs the heart’s ability to pump the necessary blood volume to the rest of the body. So, for example, if the mitral valve does not close completely when the left ventricle contracts, blood passes back into the left atrium and forward through the aorta. The blood “regurgitating’ or being forced back into the atrium can cause pressure to build in the atrium and even back into the lungs. The excess pressure in the lungs limits their efficiency.

What causes valve disease?

There are three leading causes of valvular heart disease. These are birth defects known as congenital heart disease, rheumatic fever and age.

Congenital heart disease

Some people are born with an abnormal heart valve, and for many of these people, they never cause a problem. However, in some cases, as people get older, these valves can no longer function as well as before. Stenosis and/or regurgitation can then occur.

Abnormal valves are also more likely to become infected than healthy valves. This can cause a condition known as endocarditis, leading to valve function problems.

Rheumatic fever

This is the most common cause of valve disease. Rheumatic fever itself is not very common today; however, 20-30 years ago, it affected many people.

People, who contracted rheumatic fever as a child, can experience problems with the valves in their hearts as adults.

Rheumatic fever can affect more than one valve and can cause both stenosis and regurgitation.

Age

In older people, the most common cause of valve disease is a thickening of the valve. This means the valve cannot open and close as easily as before. This restricts the blood flow.

Medications for Cardiovascular Disease: ACE Inhibitors. ACE stands for Angiotensin Converting Enzyme. This enzyme constricts or narrows blood vessels causing blood vessels to narrow, raising blood pressure. The ACE inhibitor prevents this constriction; blood vessels are relaxed, lowering blood pressure and allowing more oxygen-rich blood to reach your heart. ACE inhibitors include Captopril, Enalapril, Vasotec, Istopril, Lisinopril, and Zestoril.

Beta-blockers stop certain cells in the body from being stimulated by hormones such as adrenaline. Adrenaline usually makes the heart beat quicker and more forceful, so that a beta-blocker would prevent this. You may take a beta-blocker to help control your heart rate and blood pressure.Examples of beta-blockers are Atenolol, Bisoprolol, Labetolol, Metoprolol, Propanolol and Sotolol.

Blood thinners are part of a class of medicines called anticoagulants. Although they are called blood thinners, they do not thin your blood. Instead, they decrease the blood’s ability to clot. Decreased clotting keeps fewer harmful clots from forming and from blocking blood vessels. An example is Warfarin (Coumadin).

While taking blood thinner medications, you should also avoid smoking and drinking alcohol. Also, watch your diet. Large doses of vitamin K (found in liver, green leafy vegetables such as spinach, broccoli, cabbage, cauliflower, and brussels sprouts) can decrease the effects of the medicine. This does not mean that you should stop eating these foods; just be careful not to eat too much of them. Aspirin is an “antiplatelet,” which means that it stops blood cells (called platelets) from sticking together and forming a blood clot. That is why some patients recovering from a heart attack are given aspirin to prevent further blood clots from forming in the coronary arteries. Aspirin also reduces the substances in the body that cause pain and inflammation.

Plavix is also an “antiplatelet,” used for patients after a recent heart attack or after PTCA with stent placement to reduce the risk of clot forming.

Calcium-channel blockers slow the rate at which calcium passes into the heart muscle and into the vessel walls. This relaxes the vessels. The relaxed vessels let blood flow more easily, lowering blood pressure. This helps to reduce the workload of the heart. Examples of Calcium-channel blockers are Diltiazem, Dilzem, Norvasc, Nifedipine and Verapamil.

Cholesterol Lowering Drugs are also known as lipid-lowering drugs. They reduce the amount of cholesterol in your bloodstream. Your doctor may give you a cholesterol-lowering medicine if you have high levels of total cholesterol or LDL cholesterol (“the bad cholesterol”) that cannot be reduced with a diet and exercise program.

Examples are: Lipitor, Pravachol, Zocor

Diuretics are sometimes called “water pills”. They lower the amount of salt and water in your body, removing excess fluid from the body, which helps to lower your blood pressure.

Examples are: Lasix, Frumil

Nitrates are drugs that widen or vasodilate blood vessels. This improves blood flow and allows more oxygen-rich blood to reach the heart muscle. Nitrates also relax your veins. If less blood is returning to the heart from your arms and legs, it eases your heart's workload.

Examples are Nitroglycerin (GTN), Nitroderm, Monocard, Imdur and Isosorbide Mononitrate.

Warfarin is a medication that prevents blood clots from forming or growing larger. In cardiology, it is most often prescribed for people with certain types of irregular heartbeats (atrial fibrillation, atrial flutter), after a large heart attack and after metallic heart valve replacement surgery. It is also taken after blood clots in the legs and lungs.

How should I take Warfarin? Warfarin is a tablet and is taken orally, usually once daily. Follow the directions of your doctor carefully. Do not take more or less than your doctor prescribes; continue taking it even if you feel well. Do not stop taking it without talking to your doctor.

Are there any risks in taking Warfarin? The main risk when taking Warfarin is bleeding. However, it is a very safe medication, provided it is taken with your doctor's instructions, regular blood tests are done to check its effect, and a steady diet is followed.

Does Warfarin have any side effects? Side effects with Warfarin are quite unusual, but they can occur. Warfarin may turn your urine orange. Other potential side effects of Warfarin include headache, upset stomach, diarrhoea, fever and skin rash. Call your doctor immediately if you experience any of the following: Unusual bleeding or bruising, black or bloody stools, blood in the urine, tiredness, unexplained fever, chills, sore throat, or stomach pain.

What special dietary instructions should I follow? Certain foods contain high amounts of vitamin K. Do not ingest large quantities of these foods, as they will decrease the effectiveness of Warfarin. These foods include liver, green leafy vegetables, broccoli, cauliflower, etc. The American Heart Institute will provide a special booklet to our patients taking Warfarin.

Should I avoid any medications while taking Warfarin? Certain medications interact with Warfarin and may increase or decrease its effect. Please let your doctor know what prescription and non-prescription medication you are taking, and do not add or remove any medicines before consulting with your physician.

How should I store this medicine? Keep it in a tightly closed container, out of reach of children, and at room temperature, away from excess heat and moisture.