Age, no bar to heart attacks

by Manjula FERNANDO

Consultant cardiologist at the Colombo National Hospital Dr Vajira Senaratne

The common belief that a heart attack is a disease of the 'middle aged and the old' couldn't be more wrong or outdated with what the recent statistics have proved. Lives of people as young as 20s get suddenly snatched away due to this silent killer and bypass surgeries are becoming a common occurrence among the young.

The Sunday Observer met Consultant cardiologist at the Colombo National Hospital Dr Vajira Senaratne to seek answers to some pressing questions concerning heart disease, including the inescapable question, 'whether bypass surgeries have become a racket in Sri Lanka?'

Excerpts of the interview:

The conditions for bypass surgeries happen in very early stages of childhood. As early as 10-15 years of age, small fatty blocks develop in the coronary arteries. Bad habits such as excessive consumption of animal fat, smoking, no exercise, obesity, stress and those who have a family history develop, very early in life, the conditions for heart diseases.

When the blockade covers 90 percent of the artery, the medicines alone cannot help. Then there comes a stage where the block has to be cleared surgically. You could do that in two ways. One is to perform an angioplasty which is done under local anesthesia.

If the blocks are just one or two, we generally manage with an angioplasty. This is convenient for the patient. There is no surgery under general anesthesia involved. The patient can get back to work very soon.

A bypass surgery is called for when there are many blocks which are long. When you have six or seven blocks, coronary stents cannot be inserted into all these blocks. What you do is create a bypass using a vein from your legs.

There may be an occasional incident where somebody has done a bypass which is unnecessary. So the answer to your question if this has become a racket is 'no'. As a matter of fact, people are highly knowledgeable about heart surgeries now and they can't be easily fooled. When patients come to us, they have a fairly good idea about angiogram, bypass surgery and angioplasty unlike earlier days. The patient himself sometimes suggests an angiogram when we feel it is unnecessary.

There may be different opinions among any two professional, an architech, engineer. The doctors are the same.

The doctor's advice depends on how you look at it, your experience and your knowledge and also the patient's requirements. A person who need not be active, may manage only with medication.

But for someone with responsibilities, in early stages of life, we will recommend a different treatment. A bypass or an angioplasty is recommended if the patient becomes symptomatic in spite of medication. If the patient can manage with medication a surgery will not be recommended.

We go by sceintific data. When there are critical blocks in arteries that is life threatening we recommend surgery.

Q: Some patients claim that they have been recommended bypass, they defied medical advice, but still they are doing fine.

Cardiac surgeries should be done by cardiologists when it is necessary. Usually it is done to patients who come with angina (severe chest pain/discomfort) and with no response to medication, that is if you have chest pain and you are prevented from day to day activities. Following tests, if we find critical blocks we go for a surgery.

The next step is bypass or angioplasty. This is not to prolong life.

The surgery is performed to relieve the patient from symptoms, stop suffering and make the patient comfortable. Some patients who do not undergo surgery may live on but they will have to live in pain and they may have to stop being active. Their quality of life will not be good.

But for patients who come with acute heart attacks, if we don't perform bypass, they will most certainly die. With these patients we prescribe drugs to dissolve the clot, then they are performed a primary angioplasty.

If the patient has an acute blockade of heart vessel, we take him to the angiography lab, under the fluoroscopy machine we visualise the block and pass a wire and a balloon, and open up the artery and then insert a coronary stent and establish the flow back to normal.

The patient is almost back to normal.

If we don't perform the surgery, the restricted blood flow to the heart will cause the particular heart muscle to die and the patient will either die or will be a life long cardiac cripple. I wouldn't deny the fact that some patients could even die on the operating table. If hundred people get saved one could succumb. This is why people should prevent the chances of heart disease developing.

For acute heart attacks, the angioplasty is the best because you give immediate relief and get the patient out of danger. Bypass is usually done for chronic cases of heart disease.

Q: Can a block in an artery clear by itself?

A: These blocks are created due to long-term deposit of fat inside veins and the overgrowth of tissue. We give cholesterol tablets to stabilise the over-growth so that it will not rupture.

If it ruptures the blood and various products can deposits and clog the whole vessel causing a heart attack. By giving aspirin and the cholesterol tablet it will regress the plaque to a certain extent, but it will not disappear.

However, these medications will prevent 'atherosclerotic plaques' (deposit of fat and other substances in the lining of artery wall) from rupturing. Then it will become harder and won't give you a heart attack.

Q: Has the trend of getting heart attacks changed lately?

A: Earlier we thought heart attack is a disease of the middle aged or old. Now it has changed.

We see more and more young people getting heart attacks. The most vulnerable age for heart attacks now is 30-50.

The risk factors for developing the disease is diabetes, high blood pressure, smoking, high cholesterol and lack of exercise. Obesity and family history are also among common causes for heart disease.

But we see people getting heart attacks without having any one of the above risk factors. We still don't know exactly why these people get heart attacks.

A study is needed to establish the reasons behind this new trend and we have decided to do a research.

It could be due to wrong dietary habits or lack of exercise or stress due to lifestyle. The unfortunate thing is that heart attacks are becoming a disease of the young.

I had a patient who was just 24 years undergoing bypass surgery recently. It was a very pathetic situation since the patient has to take a costly life-long medication after the surgery.

An angiography costs about Rs. 35,000, a bypass about 500,000 and an angioplasty about Rs. 500,000. Even patients in richer countries find it difficult to afford bypass surgery.There are certain risk factors we can completely eliminate. Smoking can be stopped, make daily exercising a habit, we can control obesity and stress. Except hypertension and diabetes, the other factors can be completely controlled.

Take Away food has a very high content of cholesterol, because they mostly involve animal fat, they add a lot of oil to make it tastier and heavy smoking is another factor. A proper lifestyle and reducing stress are key in fighting the disease.The surgeries can only relieve the suffering. Heart disease is incurable. A bypass cannot buy time. What we do is make his condition better so that he could live a near normal life. This fact has to be highlighted. Preventing the disease must start at a very young age because heart disease is developed over a period of decades sometimes.

The message must be communicated to the children. It should be incorporated in the school curriculum. In spite of so much of health education by doctors via media I think still this issue has not penetrated to the masses.

Understanding medicines better:

Modern Clinical Pharmacology

by Nilma DOLE

Clinical pharmacy needs to be understood by the public and it is gaining considerable awareness in Sri Lanka now.

The Sunday Observer spoke to Dhineli Perera, a Sri Lankan Australian qualified Clinical Pharmacist with regard to latest technologies pertaining to this specialised area in Medicine. Here are excerpts from the interview:

Q. Explain a little about yourself, your background and what you do.

A: I'm a Clinical Pharmacist from Melbourne. I was born and raised in Australia, but my parents are from Sri Lanka. I did my Bachelor of Pharmacy and Bachelor of Commerce at Monash University. In Melbourne, I work on the hospital ward as a Clinical Pharmacist and member of the health care team at a major tertiary hospital. However, I have taken 12 months leave to volunteer in Sri Lanka in this up and coming area of practice

Q. What is Clinical Pharmacy?

A: Clinical pharmacy is the practice of pharmacy as part of a multidisciplinary healthcare team in a hospital ward setting. It is directed at achieving safe, judicious, effective and appropriate use of medicines. This is known as quality use of medicines.

Q. Why are Clinical Pharmacists important?

A: Clinical Pharmacists work to support the other members of the healthcare team.

They help:

.* Prescribers assess if patients have been compliant with their medicines and thereby tailor drug therapy for individual patient needs

. *Nurses prepare for any special requirements related to specific medicines (eg. how fast the intravenous medicine should be given or if the medicine should be given with or without food)

. *Patients understand the changes that have occurred to their medicines in hospital, the importance of adherence to prescribed medicines and advise them on medicine related problems that may occur with strategies to resolve them

Q. How can Sri Lankans understand their medicines better?

A: Sri Lankans can ask what their medicine is for, what it is called, what the dose is and how long they should continue to be on it. They can also ask their doctors or pharmacists if there are any side effects that they should look out for. In my time in Sri Lanka, I have noticed that many patients have limited knowledge about their medicines - despite having taken them for years.

Q. What work have you done to increase awareness in this field?

A: I have been volunteering in Sri Lanka for nine months in a few different parts of this field. Firstly, teaching the Clinical Pharmacy module in the Bachelor of Pharmacy program at Peradeniya University, and partly at University of Sri Jayewardenepura.

However, in the past five months, my main focus has been on initiating a research project at the Colombo North Teaching Hospital which aims to see if a clinical pharmacist could have some positive impact on how medicines are used and understood by health professionals and patients alike. We hope to show that Sri Lanka is already producing clinical pharmacists that are capable of adding value to the current healthcare team.

Q. What advice would you give Sri Lankans about the role of a Clinical Pharmacist?

A: Sri Lankans are not likely to see Clinical Pharmacists in the hospitals any time soon. We are still at the start of our research project, and there is a long way to go before this will actually get implemented into the health system.

But, if there was one piece of advice I would share, it would be to take responsibility understanding your medicines and ask your doctor or other healthcare professionals more questions about your medicines. Don't be scared of becoming more informed about your health, after all - you have a right to know what you are taking and why.

Q. As for the future, where do you see this area of clinical practice going?

A: After teaching a small portion of the future pharmacists of Sri Lanka I have confidence that there is great potential for this field in the future.

However, a lot will depend on acceptance of the specialty by patients and other health professionals as well as government leaders recognising the potential contribution that the profession could have to the health and well-being of Sri Lankans nationwide.

Mystery of the missing breast cancer genes

Researchers from the University of Adelaide are hoping to better understand why the mutated genes for breast and ovarian cancer are not passed on more frequently from one generation of women to the next.

That's despite a documented link between breast cancer genes and increased fertility in women.

Dr. Jack da Silva from the University's School of Molecular Biomedical Science says that because women who carry breast cancer genes are more fertile, in theory they have a greater chance of passing these genes on to future generations.

Mutations

"A recent study in the United States found that mutations in the breast cancer genes BRCA1 and BRCA2 were directly linked with a 50 pc increase in the fertility of women, which is a huge number," Dr. da Silva said.

"With such an increased fertility rate, you would expect to see a high frequency of these cancer-causing genes in modern populations, but in fact that is not the case - the frequencies are relatively low."

In a paper published in the Proceedings of the Royal Society B, he argues that the so-called "grandmother effect" may in part be the reason behind this phenomenon.

Reverse

"In an earlier study, researchers found that post-menopausal women create a 'grandmother effect' - that is, the longer they live, the more they are able to support their daughters and their grandchildren, thereby creating an environment in which more grandchildren are born.

"The reverse of this is that women who die earlier - such as from breast or ovarian cancer, which are usually post-menopausal - will no longer be able to support their daughters and grandchildren.

This has the effect of limiting the number of grandchildren born, and therefore the chances of passing on the mutated genes from one generation to the next is also limited," Dr. da Silva said.

However, the "grandmother effect" does not entirely negate the increased fertility caused by breast cancer genes, he says.

Change

"Our change to today's industrial and technological age has been relatively rapid in human history. For most of our existence, we have been hunter-gatherers.

During this time, female fertility was limited, and this may have reduced the increase in fertility caused by mutations of these genes."

Dr. da Silva said further studies examining modern-day hunter-gatherer societies might shed more light on how and why the spread of these genetic mutations occurs across generations.

- MNT

'Good' cholesterol may not protect against heart disease

A new study by Harvard School of Public Health (HSPH) researchers has found that a subclass of high-density lipoprotein (HDL) cholesterol, the so-called "good" cholesterol, may not protect against coronary heart disease (CHD) and in fact may be harmful.

This is the first study to show that a small protein, apolipoprotein C-III (apoC-III), that sometimes resides on the surface of HDL cholesterol may increase the risk of heart disease and that HDL cholesterol without this protein may be especially heart protective.

"This finding, if confirmed in ongoing studies, could lead to better evaluation of risk of heart disease in individuals and to more precise targeting of treatments to raise the protective HDL or lower the unfavourable HDL with apoC-III," said Frank Sacks, professor of cardiovascular disease prevention at HSPH and senior author of the study.

A high level of HDL cholesterol is strongly predictive of a low incidence of coronary heart disease (CHD). But trials of drugs that increase HDL cholesterol have not consistently shown decreases in CHD, leading to the hypothesis that HDL cholesterol may contain both protective and non-protective components.

ApoC-III, a proinflammatory protein, resides on the surface of some lipoproteins - both HDL and low-density lipoproteins, or LDL ("bad") cholesterol.

The researchers, led by Sacks and Majken Jensen, research associate in the Department of Nutrition at HSPH, examined whether the existence or absence of apoC-III on HDL cholesterol affected the "good" cholesterol's heart-protective qualities, and whether its existence could differentiate HDL cholesterol into two subclasses - those which protect against the risk of future heart disease and those which do not.

Blood samples collected in 1989 and 1990 from 32,826 women in the Brigham and Women's Hospital-based Nurses' Health Study were examined, along with blood samples collected from 1993 to 1995 from 18,225 men in the Health Professionals Follow-up Study.

During 10 to 14 years of follow-up, 634 cases of coronary heart disease were documented and matched with controls for age, smoking, and date of blood drawing.

The researchers compared plasma concentrations of total HDL, HDL that has apoC-III, and HDL without apoC-III as predictors of the risk of CHD.

After adjusting for age, smoking status and other dietary and lifestyle cardiovascular risk factors, the researchers found that two different subclasses of HDL have opposite associations with the risk of CHD in apparently healthy men and women.

The major HDL type, which lacks apoC-III, had the expected heart-protective association with CHD. But the small fraction (13 pc) of HDL cholesterol that has apoC-III present on its surface was paradoxically associated with a higher, not lower, risk of future CHD.

Those men and women who had HDL apoC-III in the highest 20 pc of the population had a 60% increased risk of CHD.

The results suggest that measuring HDL apoC-III and HDL without apoC-III rather than the simpler measure of total HDL may be a better gauge of heart disease risk (or of HDL's protective capacity). "Reduction in HDL-apoC-III by diet or drug treatments may become an indicator of efficacy," said Jensen.

- MNT