Friday, June 03, 2011


There is a very simple, and yet important paper reported in the European Heart Journal, on the influence of fear following a heart attack and the outcomes. Otherwise seen as the influence of the emotions on the biological. This paper by the group of workers from Imperial college, studied 208 subjects ( I am sure that they can get more if they have more funds or time ) with a heart attack, assess their level of fear by questionaire ( this is the weak part of their study ), and measured their response, biochemically ( inflammatory markers ) and also physically, heart rate and BP variability. They found that intense fear was associated with increase levels of certain inflammatory markers and stress hormones, which usually correlates with more cardiac events and worse outcomes. That's simple.
What is important about this paper is the fact that we have now documented the association between an emotion ( fear ), and biological functions and responses. My interest in the area, started when we were trying to understand the effects of "vodoo" on sudden cardiac death? How did vodoo witches, make their subjects so afraid, that they died ( self fulfilling). In fact, one of the pioneer workers in this area in the 1980s was a certain doctor, called Regis de Silva. He is a graduate of the University of Malaya medical school ( first batch ), who migrated to USA, and landed with a job at Mass General, Boston. His interest was sudden cardiac death. He was trying to understand arrhythmic cardiac deaths from intense fear.
I remember seeing a patient in the 80's, when I was a lecturer in University Hospital, who was so afraid, when he was diagnosed with heart valve disease, that he passed away. Once diagnosed, he was so afraid, that he could not sleep, and literally panicked over every small feeling of unwell ( whether related to his heart or not ). One day, he just collapsed and died.
I suppose the lesson that we learn is, to remain calm and confident, when you suffer a cardiac event. Choose your cardiologist well. Trust him, if not get a second opinion. Rest assured that cardiology is very advanced, and most cardiac conditions have good modalities of treatment, albeit at a cost. In Malaysia, even the government hospitals have a good average standard of cardiac care. Angioplasty is widely available. Many young cardiologist are out there. Our role as seniors, is to help them shorten their learning curve, and their skill in decision making. They are doing a good job.
Should you or your love ones suffer an unplanned cardiac event, find a good practitioner. Discuss things with him / her calmly. Discuss all the pros and cons ( of course having learned from the internet - helps for the discussion to be more meaningful ), with him. Be satisfied with the explanations, and allow him to proceed as per discussed. If you are not happy, get a second opinion. Being fearful, always distressed and unhappy, does not help. It may worsen the situation.
In a few simple words, if you have suffered a heart attack, and should you reach a tertiary heart center within 4 hours ( some stretch to 8 hours ), it is an acute emergency, an immediate angioplasty is the treatment of choice. You have to trust your cardiologist there, and trust that he will do a good job. If you survive 8 hours and only see a practitioner after 8 hours, he will probably wait and stabilise you. Going for immediate angioplasty then carries more risk, and does not confer enough benefit to justify those risks. You have plenty of time for opinions and discussion, and pre-discharge angiogram or submaximal stress ECG, would be reasonable ( assuming that your heart attack is uncomplicated. A complicated heart attack, should always merit a pre-discharge angiogram. Some centers who cannot carry out immediate angioplasty in the first 4 hours, amy just treat you medically with thrombolytic agents ( clot busters ), and aspirin, in the immediate period, and then arrange for you to be transfered to a tertiary care center, when you are recovered and stabilised. That is also acceptable treatment.

Maybe, one day, we should write on treatment standard of care for various cardiac conditions.

In the meantime, should you have an acute cardiac problem. see a medical practitioner, stay calm, do some reading and trust him, or find another. Fear is damaging to your heart.

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