Sunday, 24 July 2011

Heart Attack in Women

Published in Panorama

Heart Attack and Women

Rita was feeling nauseous and experienced discomfort in her upper abdomen. She swallowed a couple of antacids attributing her state to indigestion brought on by the previous day’s partying. The antacids seemed to provide no relief and the uncomfortable sensations continued. Feeling a trifle irritated at the persisting symptoms, Rita decided to consult her physician. Following complete history taking, the physician ordered an ECG which showed evidence of an infarction! Rita was all of 42 years!

Various research studies point to at least one in five women having some form of cardiovascular disease. There is increased risk of heart attack in women who’ve attained menopause. More women than men will suffer a second heart attack within four years after the first attack. The probability of women with diabetes developing heart disease is higher than men with diabetes developing it. Diabetes doubles the risk of a second heart attack in women.

Says Dr.K.G.Balakrishnan, Cardiologist, Zulekha Hospital, Sharjah, “Risk of heart attack in women before menopause is less, is true to some extent. But now, with the changing lifestyle, this trend has also changed. Generally premenopausal women are protected by the oestrogen circulation and then progressively, five years past menopause, the are almost on par with men as far as the risk of heart attack is concerned. But the things are changing because of factors like stress, high blood pressure, diabetes and obesity which contribute to premenopausal women also being susceptible to heart attacks. Also, globally there an increasing number of women smokers, adding to the risk.”

Explaining the factors leading to a myocardial infarction or heart attack, Dr.Ramachandran, Cardiologist, Prime Medical Centre says, “A network of coronary arteries supplies our heart oxygen-rich blood which is needed for its efficient functioning. In some people, over time, cholesterol and other substances form a plaque in these blood vessels causing the arteries to narrow and hinder the smooth passage of blood to the heart muscles. Parts of the plaque can break away or get dislodged and block the artery, stopping the flow of blood to certain areas of the heart. When this happens, that area of muscle is damaged or dies, leading to infarction. So it is imperative that we prevent a heart attack by preventing the buildup of plaque or clotting of the arteries.”

Which of course, may not be an entirely easy task, particularly in those who are predisposed to the risk, genetically. Dr.Ramachandran explains, “Obesity, diabetes and hypercholesterolaemia are predominantly genetic and runs in the family. So even younger ages of women with such family history, say between 35-45, are at risk of getting heart attacks. Here again we differentiate between modifiable and non modifiable risks. The genetic factors are non modifiable. So are racial factors, like certain race of people are at a higher risk like African Americans, some Asian ethnic groups have higher risk of hypertension, etc. As opposed to these, there are risk factors which can and need to be controlled. Smoking, hypertension, excess cholesterol, excessive alcohol, are all preventable factors.”

Citing other instances where younger women face the risk of heart attacks, Dr.Ramachandran reveals, “There is yet another group of women who have chest pain which appears to be due to the reduced circulation of blood into the working muscles of the heart. When we study them, we find their coronary artery appears normal, yet they have pain which is from the heart because the smaller vessels are diseased rather than the larger ones. These again are younger overweight or obese women with a tendency to hypertension and diabetes.”

Younger women could be suffering from other systemic disease which affect the coronary arteries, leading to heart disease and attacks. “Especially in the Asian population we see women with rheumatic heart disease, various types of arthritis which can be risk factors for heart disease,” explains Dr.Ramachandran. “These women will have a history, having suffered from fever and joint pains in their childhood which they may have even forgotten! By the time they are 25 years, they get symptoms for heart disease, like breathlessness or palpitation. Alternatively, at times we come across young women in their twenties who’ve had arthritis in their teens and not had any manifestation of the symptoms, or a mild attack which got on to the heart.”

What are the symptoms of an impending heart attack? Dr.Balakrishnan explains, “The commonest symptoms is pain which is usually in the center of the chest, behind the breastbone. It is not superficial and doesn’t get alleviated by pressing over the region, nor aggravated by deep breathing or cough. The pain is of a compressing and squeezing nature, lasting for 15-20 minutes or even more and it does not normally respond to the use of nitroglycerine tablets kept under the tongue. Feeling fatigued and breathless are other symptoms.”

Continuing on the warning signs, Dr.Balakrishnan says, “Sometimes it presents as upper abdominal discomfort which people tend to pass off as gas, take some antacids, find no relief and so come to the doctor. Sometimes they take the antacids for a couple of days and then come to the hospital but by this time the infarction would have completed and it’s too late to use the clot dissolving medicines. Sometimes it can be pain, not in the chest but in the hands, jaw, neck, back – between the shoulder blades alone. Sometimes, it’s very difficult even for doctors to make an inference that it is related to the heart! So a lay person can easily miss the sign which is what happens very often!”

What about nausea, dizziness and sweating as indications of an impending attack? Dr.Balakrishnan clarifies, “Mere nausea alone may not indicate heart attack. The upper abdominal discomfort followed by vomiting can be a presentation in some of the heart attack cases. Dizziness can happen sometimes due to the irregular heart beat due to insufficient blood supply to the heart. Sweating is some sort of the body’s reaction to the pain. Cold sweat is one of the body’s mechanism of reacting to pain but isolated cold sweat alone is not interpretative of heart problem. In fact even fear and panic can bring on a cold sweat!”

Symptoms of heart attack can mimic other conditions which makes it difficult for the layperson to heed warning signals. What about the silent heart attack which diabetics, particularly women diabetics are known to get? Says Dr.Balakrishnan, “Unfortunately in these people, there are no forerunners or indicators. At the most they may be experiencing shortness of breath when walking or climbing stairs. When this happens, it is better for these people to seek medical attention. But a silent heart attack occurring is not recognized till it’s complete!”

So how does diagnosis happen? Dr.Balakrishnan explains, “Normally when we suspect heart condition in such patients, we put them to a treadmill test, followed by an angiogram where necessary. There are cases where patients come to the hospital for some other reason and in the course of routine investigation we get an ECG done. This could show evidence of an old infarction. But here again there is nothing more to be done except continue the medication and start treatment as for a patient with coronary artery disease. But when somebody comes with some acute changes in the ECG without pain, then we should look at it from the perspective of doing the blood test to see whether there is any evidence of an infarction or not, to decide the course of treatment.”

Speaking on prevention of heart attacks and related problems or minimizing risk factors through diet, Dr.Balakrishnan clarifies, “The emphasis here is on two things. (1) Dieting only for the elevated cholesterol (2) Dieting to tackle obesity as well as elevated cholesterol. The approach is totally different for these two entities. Someone who has normal weight but has high cholesterol, then the advice is only to lower the cholesterol by avoiding animal fat, red meat, organ meat, yellow of egg, oils which solidify in winter – the saturated fats like butter, ghee, coconut oil and all vanaspathi. The Mediterranean diet is now considered the best and includes olive oil and dry fruits.”

Dr.Balakrishnan continues, “If, however, you are eating to reduce obesity, fat contributes 8 calories/gm as against proteins and carbohydrates which contributed 4 cals/gm. So totally avoid fat to the extent possible; sweets and refined sugar too must be avoided. Take fibre rich foods comprising green leafy vegetables which do not add calories but at the same time fill the stomach. This can be accompanied by diluted low fat laban.”

Dr.Ramachandran further advocates regular exercise, cessation of smoking, diabetes and hypertension control through appropriate diet and medication.


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