Why no warning? Direct heart attack?

In the dawn hours, I got a call from our Zydus ER. They have received a gentleman with unusual Acidity like symptoms since midnight. But ER people knew very well that this could be a Heart attack symptom. They did ECG and it showed major heart attack. If not treated, it could be fatal within an hour. We have a robust protocol established which resulted in the completion of the therapeutic procedure just within 40 minutes of the patient’s arrival. The global standard for this is up to 60 min. His main blood vessel was blocked which required angioplasty. The patient became stable and shifted to ICU. Patient’s relative had a difficult time to accept this direct heart attack.

Next morning we had detailed discussion with patient and his relatives and what queries they had?

Doc, Why me ? Why there was no warning signs.

This question baffles many patients and I need to answer this not only to my patient but also my whole community before anyone lands with an unexpected heart attack.

The answer is that we never tested ourself enough.

To understand this you need to understand how Coronary ( blood vessel which supplies oxygen to muscles of the heart ) blockages progress and cause angina.

The heart is a muscle and it pumps the blood. It requires oxygen to keep working. Its oxygen demand is decided by the number of times it pumps in a minute (heart rate ) and the force it generates.

So, higher the heart rate, higher is the oxygen demand.

God has given us excellent blood vessels called coronaries, which can increase the blood supply to almost 3 to 5 times if the demand increases.

That’s why my heart is not having problem at a heart rate of 70 and even when the heart rate reaches to 150. That much demand is met by increasing the blood supply.

So to say at heart rate of 70 to 90 , resting blood supply is much more than adequate.

If the Coronary artery blockage starts and even if reaches to almost 60-70%, resting blood supply to working heart muscle is more than adequate and the patient remains asymptomatic on the day to day work and even this supply can increase if heart rate increases to 110 or up to 130.

If the blockage is 70 to 90 %, then also the resting blood supply remains adequate, and the patient remains symptom-free at the day to day work, he can go to the office, he can go for a garden walk, he can perform almost all his day to day activity without any symptoms. However, if he goes for any exertion, to which he is not accustomed, and heart rate goes to 130 to 150, oxygen demand increases so much and blocked blood vessel can not supply adequate oxygen, which results in angina. Patient slows down and angina goes away.

Here is the catch. We usually do all our activities and so-called exercise at comfortable heart rate, our yoga, our Pranayam, our garden walk with friends and friendly talks, swinging arms forcefully, THIS DO NOT INCREASE HEART RATE and so THIS DO NOT CAUSE ANGINA.

If this patient would have been doing exercise which involved cardio one with heart rate going beyond 130, he would have realised symptoms many months earlier than a so-called sudden heart attack

The usual narrative is – I was able to complete 3 km in 28 min but now just after 8 to 10 min, I will have chest tightness and Chest pain, but, if stop, it will be cleared in a minute or so, and then again I will be able to continue for next round. ( Heart rate reached to 130 and angina started, with rest heart rate came down and angina relieved )

That is why my patient, who was active according to him, going for 20 min colony rounds with his neighbour with 10 hours active office hours, continued to develop blockages over years from 0 to 80% and he didn’t realised as he never checked himself with adequate level of exercise.

What could have prevented this emergency was the addition of regular sessions of meaningful exercise which could check his symptoms on a daily basis.

Remember, angina at rest occurs only when a blood vessel is blocked by more than 90%. And that is a heart attack. We do not want to be that late.

All the health check-ups are checking this only, with Treadmill test and stress tests and abnormal stress tests mean most likely one of the blood vessel is blocked tightly.

There are some special circumstances when the patient does not feel angina, say very elderly patients, advanced diabetics, and Renal failure patients. I have discussed this topic separately and you can search for a silent heart attack for this.


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