Thursday, January 19, 2006

Managing an Incident

This article was published in The Star (Malaysia) on the 18th of December 2005. Please note our standard disclaimer.

At the offset, a few points must be understood and followed when dealing with a patient suffering from a heart attack:

1. Allow the patient as much rest as possible.

2. Get help as soon as possible. Try not to do it alone.

3. Get medical help as soon as possible. More time loss, more heart damage.

If you experience chest pains, which you think could be due to a heart attack, especially if you have two or more cardiac risk factors, call a relative, friend or colleague to send you to the nearest medical clinic where an ECG can be done, and where you can be attended to quickly.

Once a diagnosis of heart attack is established, the attending physician or cardiologist can re-establish blood flow quickly with the use of IV thrombolytic (commomly called “clot buster”) drugs like streptokinase. Other clot-busters are now available. The cause of the acute heart attack is very likely a blood clot in a major artery.

IV clot busters are a good treatment for acute heart attacks. It is easily available. It can be administered by physicians and general cardiologists, and it is relatively cheap.

Eating the clot away (that’s how clot-buster drug works) is an effective way to restore blood flow. However, it is important to note that some patients cannot receive these clot buster drugs. For example, patients who have recently undergone major surgery, patients with bleeding tendencies, patients with a history of internal bleeding like bleeding peptic ulcer, patients who are allergic to the drug, patients who have a recent stroke, and patients with uncontrolled hypertension.

There are some drugs that work alongside the IV clot busters, like aspirin and plavix. They assist and enhance the good results obtained with the clot busters.

The other very good means of re-establishing blood flow is direct, or primary angioplasty (clearing the artery with the balloon).

Angiograms and angioplasty can now be safely performed in patients who have just suffered a heart attack by interventional cardiologists and their team.

In fact many clinical studies have shown that direct or primary angioplasty, when performed by a good interventional cardiology team, yield very good results. The procedure directly addresses the cholesterol plaque narrowing the artery as well as clears the blood clot in the artery.

It restores blood flow immediately. It is invariably associated with implantation of a coronary stent. The successful results or failures are immediately known.

However the disadvantage is that, results are only good in centres that do them regularly. It has to be done by specially trained “interventional cardiologists” and their teams. When done by teams not conversant with the technique, deaths can occur. Training and skill of the angioplasty operator and the team is important to get good results.

Also, to get good results, the angioplasty has to be done as soon as possible after the heart attack, before the heart muscle cell damage becomes permanent. Remember, time is heart muscle. Restoring blood flow with angioplasty after four hours or longer of chest pains only allow minimal recovery of the heart muscle and is of minimal help to the patient.

Not only does angioplasty provide complete clearance of the blockage, the accompanying angiogram allows detailed examination of the whole heart circulation, providing a complete check for other potential culprit blockages waiting to cause another heart attack. Of course, besides the need for skilled personnel, direct angioplasty’s other disadvantage is cost.

Other medications important in the management of a heart attack include, cholesterol lowering agents like “statins”, agents to smoothen the artery wall like ACE-inhibitors (for example, captopril ) and angiotensin receptor blocking agents (for example Valsartan), vasodilators of the artery (for example nitrates), and beta-blockers (for example metoprolol). These drugs are in addition to the medications for hypertension and diabetes (commonly associated conditions).

As you can see, the patient may indeed be loaded with a whole fistful of drugs even after successful direct angioplasty.

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