Category Archives: Heart Care

What To Expect Before, During And After Angioplasty?

Dr. Subrat Akhoury

Once a patient has been selected to undergo angioplasty, before the procedure, part preparation (shaving) of groin and wrist are usually done. Depending upon the need and decision by treating cardiologist other parts may also be prepared. Few necessary blood investigations are sent especially complete blood count, kidney function tests and viral biomarkers. Your treating cardiologist will review any risks of the procedure and the anesthesia if needed as well as obtain your informed consent which gives your cardiologist permission to perform the procedure. In case you are not able to give consent – one of your relative will give the consent.

During the procedure you will lie on a table in cardiac catheterization laboratory and be mildly sedated if you are too anxious but you will remain awake throughout the procedure unless indicated otherwise.

The interventional cardiologist will use a small needle to inject local anesthetic idocaine in groin or in the forearm. (This needle prick could be the only pain you will feel throughout the procedure)

Sometimes while balloon is inflated to open the blocked artery you may feel chest pain transiently.

After the procedure, you will have to follow the instructions by cardiologist like immobilization of limbs, when to eat. You should ask your doctor if you have queries.

Associate Director, Cath Lab & Interventional Cardiologist, Asian Institute of Medical Sciences (AIMS), Faridabad

What is Bypass surgery & when is it performed ?

What is heart bypass surgery?

Bypass surgery, or coronary artery bypass surgery, is used to replace damaged arteries in your heart muscle. A surgeon uses blood vessels taken from another area of your body to repair the damaged arteries. It is a surgical procedure that diverts the flow of blood around a section of a blocked or partially blocked artery in your heart. By creating a new pathway to the heart, coronary bypass surgery improves blood flow to your heart muscle.

After coronary bypass surgery, symptoms, such as chest pain and shortness of breath due to poor blood flow to the heart, generally improve. For some people, coronary bypass surgery may improve heart function and reduce the risk of dying of heart disease.

Most coronary bypass surgeries are done through a long incision in the chest while blood flow is diverted through a heart-lung machine (called on-pump coronary bypass surgery). The surgeon cuts down the center of the chest, along the breastbone. The surgeon then spreads open the rib cage to expose the heart. After the chest is opened, the heart is temporarily stopped and a heart-lung machine takes over to circulate blood to the body.

The surgeon takes a section of healthy blood vessel, often from inside the chest wall (the internal mammary artery) or from the lower leg, and attaches the ends above and below the blocked artery so that blood flow is diverted (bypassed) around the narrowed portion of the diseased artery.

What are the different types of heart bypass surgery?

  • single bypass: only one artery is blocked
  • double bypass: two arteries are blocked
  • triple bypass: three arteries are blocked
  • quadruple bypass: four arteries are blocked

When Coronary bypass surgery is done ?

When patient has severe chest pain caused by narrowing of several of the arteries that supply your heart muscle, leaving the muscle short of blood during even light exercise or at rest. Sometimes angioplasty and stenting will help, when more than one diseased coronary artery and the heart’s main pumping chamber — the left ventricle — isn’t functioning well then bypass surgery may be the best option. Your doctor may recommend heart bypass surgery if your coronary arteries become so narrowed or blocked that you run a high risk of a heart attack.

You and your doctor can consider whether coronary bypass surgery or another artery-opening procedure, such as angioplasty or stenting, is right for you.

Coronary bypass surgery is an option if:

  • Patients have severe chest pain caused by narrowing of several of the arteries that supply your heart muscle, leaving the muscle short of blood during even light exercise or at rest. Sometimes angioplasty and stenting will help, but for some types of blockages, coronary bypass surgery may be the best option.
  • Patients have more than one diseased coronary artery and the heart’s main pumping chamber — the left ventricle — isn’t functioning well.
  • Patient’s left main coronary artery is severely narrowed or blocked. This artery supplies most of the blood to the left ventricle.
  • Patients have an artery blockage for which angioplasty isn’t appropriate, you’ve had a previous angioplasty or stent placement that hasn’t been successful, or you’ve had stent placement, but the artery has narrowed again (restenosis).

Coronary bypass surgery may also be performed in emergency situations, such as a heart attack, if your doctor sees that you’re not responding to other treatments.

Some time, patient may not have any symptoms in early coronary artery disease, yet the disease will continue to progress until there’s enough artery blockage to cause symptoms and problems. If the blood supply to your heart muscle continues to decrease as a result of increasing blockage of a coronary artery, you may have a heart attack. In this condition, bypass surgery is done to restore blood flow

How Is Angioplasty Performed And What Is The Recovery Time

Dr. Purshotam Lal

An angioplasty is a common procedure that’s performed to treat people with acute coronary syndrome (ACS). An angioplasty is used to clear blockages in the arteries The angioplasty procedure is similar to that used to perform an angiogram. It is performed with the help of a catheter by an interventional cardiologist in a cath lab. In a cath lab patient lie on a table and be mildly sedated but he remain awake throughout the procedure.

The cardiologist uses a small needle to inject lidocaine, a local anesthetic, to numb an area in the groin, or upper leg, or in the arm.  This needle prick could be the only pain that patient feels throughout the procedure.

How catheter is inserted?

Catheter is a flexible tube that is smaller than the vessels. The femoral artery in the groin – near where your leg bends from the hip – is one of the vessels cardiologists most commonly use to insert a catheter and thread it through the arteries to the heart to perform the angioplasty. Instead of the femoral artery, your doctor may choose to insert the catheter in the brachial or radial artery in the inside of the elbow or wrist.

From this “access” point in leg or arm, a “guiding” catheter is threaded through the arteries to the heart. (Since there are no nerves in your arteries, patient will not feel the catheter.) An x-ray camera and images of your arteries on a TV screen help the physician guide the catheter to the blockage.

When the guiding catheter is properly positioned, the cardiologist injects a contrast dye (radiographic contrast agent) through the catheter into the heart and its arteries. Most people do not feel the dye injection. However, some feel minor discomfort, typically lasting only a few seconds, in their chest. A few feel lightheaded or nauseous.

How blockage is removed?

Next, a balloon catheter – a long, thin flexible tube with a small uninflated balloon at its tip – is threaded through the guiding catheter to where the artery is narrowed. A guide wire – a tiny, thin wire of about .014 inches’ diameter – is then passed across the narrowed segment. It serves as a guide for positioning the tiny balloon across the blockage.

Once in position, the balloon is inflated with water and x-ray dye. (It may be inflated several times.) When fully inflated, the balloon pushes the plaque against the wall of the artery. Some patients feel minor discomfort when it is inflated. If you have more than minor discomfort, medication to relieve it can be given immediately.

As the balloon inflates, plaque that extends into the wall of the artery may tear or crack. This is normal and necessary.

Once the balloon is deflated, x-ray pictures are taken ensure the blockage is gone. When the balloon catheter is removed, final x-ray pictures are made.

What is the recovery time after angioplasty?

Once your cardiologist has completed the procedure, recovery will begin. After the procedure, the artery is closed with a closure device or manual pressure is applied to stop bleeding. Patients are able to walk with assistance in four to six hours and usually stay in the hospital overnight for observation. This is far less time than is required in the case of more invasive procedures, like heart surgery.

Recovery from angioplasty and stenting is typically brief. Discharge from the hospital is usually 12 to 24 hours after the catheter is removed. Each case, of course, is different. In some cases patients were able to go home the same day of their angioplasty without a higher risk of complications. Your doctor will give you specific recovery instructions like no heavy lifting or strenuous exercise for a few weeks after the procedure.

Most people are able to return to work within 1 to 2 weeks after an angioplasty procedure. In case of a heart attack, recovery may be longer.

 Chairman  – Metro Group of Hospitals & Director Interventional Cardiology Cardiology & CTVS in Metro Hospitals & Heart Institute, Noida

Risks Of Cholesterol

What iѕ сhоlеѕtеrоl?

Thоѕе оf уоu who аrе bаttling аgаinѕt high cholesterol and wоrking tоwаrdѕ bringing dоwn the сhоlеѕtеrоl level gеnеrаllу hаvе many inquiries concerning cholesterol iѕѕuеѕ. In the firѕt рlасе, уоu ѕhоuld diѕсоvеr рrесiѕеlу whаt сhоlеѕtеrоl iѕ. Cholesterol iѕ a wаxу, fat-like ѕubѕtаnсе рrоduсеd in thе liver and diffеrеnt cells. It саn bе found in numеrоuѕ food thаt wе еxреnd rеgulаrlу, fоr example, еggѕ, dаirу items, аnd meats.

In any саѕе, сhоlеѕtеrоl iѕ nоt generally awful because оur body needs a ѕресifiс add up tо have thе capacity tо work appropriately. Our bodies’ сеll membranes require this cholesterol tо dеlivеr hormones, vitаmin D, аnd different acids that аѕѕiѕt уоu tо process fat. At the роint when уоur сhоlеѕtеrоl соnѕumрtiоn lеvеl ѕurраѕѕеѕ thе measure of сhоlеѕtеrоl required that is whеn hеаlth concerns ѕtаrt to create.

Whаt is nоrmаl cholesterol rаtiо?

Cоmрuting for уоur сhоlеѕtеrоl ratio саn givе ѕuрроrtivе data аbоut the probability оf cardiovascular diѕеаѕе, however it’ѕ not being utilized аѕ a factor to decide what mеdiсаtiоnѕ tо use tо bring dоwn уоur risk of hеаrt diѕеаѕе. With a ѕресifiс goal to ascertain уоur ratio, divide your aggregate сhоlеѕtеrоl numbеr bу your HDL (High-thiсknеѕѕ lipoprotein) numbеr.

Fоr inѕtаnсе, if уоur aggregate cholesterol numbеr iѕ 200 аnd уоur HDL is 50, уоur аggrеgаtе сhоlеѕtеrоl рrороrtiоn is 4:1. Thе реrfесt сhоlеѕtеrоl рrороrtiоn iѕ аrоund 3.5:1. Sо it iѕ ѕuggеѕtеd thаt wе should keep our сhоlеѕtеrоl proportion аt оr below 5:1. Yоu can соореrаtе with уоur specialist to diѕtinguiѕh thе bеѕt роѕѕiblе mеdiсаtiоnѕ fоr уоu аnd for уоu tо achieve уоur optimal рrороrtiоn.

Yоu саn ѕtаrt with bаѕiс wау оf lifestyle modifications оn whаt you еаt, hоw frequently уоu have tо рrасtiсе оr nоt withѕtаnding taking сhоlеѕtеrоl ѕuррlеmеntѕ оr mеdѕ likе statins, if necessary, so уоu саn асhiеvе your орtimаl rаtiо.

Bringing down уоur LDL (Lоw-thiсknеѕѕ liрорrоtеin) аnd expanding thе level оf your HDL, diminiѕhеѕ уоur risk оf hаving саrdiоvаѕсulаr diѕеаѕе. High-thickness liрорrоtеin (HDL) iѕ thе gооd сhоlеѕtеrоl. HDL bеnеfitѕ lie in the way thаt it соnvеуѕ LDL (Bad) Cholesterol bасk tо thе liver whiсh wаѕhеѕ dоwn сhоlеѕtеrоl from thе сirсulаtiоn ѕуѕtеm. Lоw-thiсknеѕѕ liрорrоtеin cholesterol (LDL) iѕ the bаd cholesterol. The higher the LDL is, thе mоrе ѕignifiсаnt are thе chances of heart аttасk.

Thе overabundance cholesterol can dеvеlор аnd аdhеrе to thе mеmbrаnеѕ of your conduits whеn lеvеl of LDL is high. This саuѕеѕ plaque; plaque dеvеlорmеnt саn саuѕе аthеrоѕсlеrоѕiѕ whiсh iѕ thе solidifying оf thе vеinѕ. At the роint whеn the plaque turns оut to bе flimѕу, a blооd coagulation can form, abruptly hindеring an аrtеrу. which саn саuѕе hеаrt attack.

High cholesterol lеvеl саn be a risk factor fоr саrdiоvаѕсulаr diѕеаѕе аnd ѕtrоkе. Blосkаgеѕ that аvоid adequate blood flоw in thе соrоnаrу corridors саn рrоmрt a type оf chest pain саllеd angina. Anginа iѕ a bаѕiс ѕidе еffесt оf coronary supply rоutе diѕеаѕе.

Importance оf сhоlеѕtеrоl

  • Chоlеѕtеrоl iѕ utilizеd by thе bоdу tо сrеаtе ѕtеrоidѕ, оr соrtiѕоnе-likе hоrmоnеѕ, including thе ѕеx hormones. Thеѕе hormones incorporate tеѕtоѕtеrоnе, еѕtrоgеn and соrtiѕоnе. Hence, thеѕе hormones control a bunch оf bоdilу capacities.
  • Cholesterol helps thе livеr to dеlivеr bile асidѕ. Thеѕе асidѕ are еѕѕеntiаl for рrосеѕѕing of fats and frееing the body оf waste.
  • Chоlеѕtеrоl аlѕо асts аѕ a сеll tо interconnect “liрid аtоmѕ”. A lipid аtоm iѕ еxресtеd tо bаlаnсе оut оur сеll mеmbrаnеѕ. Withоut сhоlеѕtеrоl, our bodies will bе ruined.
  • Cholesterol is аn essential рiесе оf thе mуеlin ѕhеаth whiсh is a nеurоn соmрriѕing оf fat-containing сеllѕ that рrоtесt the аxоn frоm electrical mоvеmеnt. It iѕ tо guаrаntее that оur cerebrum functions appropriately by ѕuрроrting соurѕе оf еlесtriсаl imрulѕеѕ. Which helps in mempory power.
  • Finally, chоlеѕtеrоl hаѕ hеарѕ оf uѕеfulnеѕѕ оn the humаn body immunе ѕуѕtеm.

Diabetes In India : Trends

Dr. Subhash K. Wangnoo

Type 1 diabetes (T1DM) is increasing in incidence. Due to the autoimmune destruction of the insulin producing beta cells of the pancreas, treatment of T1DM mandates life-long insulin therapy. Since T1DM is usually detected in childhood or early adulthood, the patient and his family have to cope-up with the diabetes and insulin therapy long term. Patient education is an important part of the management of diabetes. In the routine busy out-patient clinics, there is usually paucity of time to impart detailed in-depth knowledge regarding diabetes, its management, long term complications, etc. To address these issues, the Apollo Centre for Obesity, Diabetes and Endocrinology, has designed a structured diabetes education programme, called 1-STEP, for the patients with type 1 diabetes and their care-givers. This is an interactive educational programme, being conducted in three modules covering the various aspects related to type 1 diabetes and its management. The first module gives an in-depth knowledge about type 1 diabetes- what it is, how it occurs, why do we need to treat diabetes, the associated acute and long term complications, the principles of treating T1DM, need for self monitoring of blood glucose and how to do it, information on frequency of follow up and screening for chronic complications, recognition of diabetic ketoacidosis.

The second module covers diet and lifestyle management in detail, including the components of diet, meal patterns, food exchange lists, knowledge on glycemic index, role of functional foods, addressing dietary issues during school, and how to make healthy choices while socialising and going out. It also includes education on hypoglycaemia in detail- what it is, how to recognise and corrective measures; as well as information regarding physical activity.

The third module covers all aspects about insulin- types of insulin, types of insulin delivery devices available, practical tips on storage of insulin, insulin administration technique including site rotation and needle changing. It also empowers the patients with knowledge on how to adjust insulin doses on a day to day basis using the blood sugar readings. Information regarding insulin pumps in detail, as well as carbohydrate counting is also included.

Structured education programmes for type 1 diabetes are already prevalent in the western world, but are lagging behind in our country. There still exist many myths and misconceptions related to type 1 diabetes and insulin therapy amongst the general population, which influences the patients and their families, thus hampering the optimal management of T1DM. This 1-STEP is an effort to clear these prevailing myths, empower the patients with knowledge about their disease, involve them actively in managing their diabetes, interact with other patients and learn from their experiences, and bridge the gap between the patients and their healthcare providers.

 Senior Consultant Endocrinologist and Diabetologist at Apollo Centre for Obesity, Diabetes and Endocrinology of Indraprastha Apollo Hospitals, New Delhi. He is also Honorary Physician Endocrinologist to the President of India. Dr. Wangnoo is a member of over a dozen scientific bodies and medical associations, and has served on the executive committees of several of them. He is frequently invited as a speaker or faculty member at national and international conferences. 

Hypertension An Epidemic In Waiting

Dr. Jitendra Kumar

Our body needs oxygen and other nutrients for proper functioning. This is achieved through circulation of blood. To achieve this purpose, our heart pumps blood through blood vessels to each and every cell of the body. Because of this pumping activity, blood flows under some pressure.

This is similar to the water supply of our houses. Water flows because of pressure. Normally the pressure should be just adequate to achieve flow to even distant taps but at the same time it should not be that high that pipe gets damaged or there is some leakage. But some times the balance is disturbed and blood pressure increases from a normal acceptable level, this condition is known as hypertension.

During heart contraction (systole) pressure inside the blood vessel becomes maximum. This pressure is known as systolic pressure and is normally 120 mm of mercury. Whereas when heart relaxes (diastole) pressure normally decreases to 80 mm of mercury and is called diastolic pressure. So a normal BP is expressed as 120/80 (Systolic BP/Diastolic BP). Millimeter of mercury (Hg) is a method to measure pressure. It means that pressure of blood is enough to lift a mercury column to the said height.

How to measure your blood pressure?

If we put one tube inside the artery of a patient, through a pressure-measuring device, blood pressure can be directly estimated. This is the method applied in intensive care unit where exact measurement is required in presence of various variables.

A balloon cuff (1) is wrapped around arm. Then through a balloon pump (2) the cuff is inflated to a pressure above the blood pressure. When pressure in the cuff becomes more than that of blood pressure, blood to forearm ceases to flow. Now seeing the mercury column (3), cuff is gradually deflated and blood flow is listened through a stethoscope (4). When pressure in (3) is similar to systolic pressure, blood starts flowing and a sound is heard at (4). After some time sound disappears and this corresponds to the diastolic pressure.

Instead of mercury column, pressure can be measured by a dial manometer also. There are some more simple electronic versions for home use. Ambulatory Blood Pressure monitors have been developed to monitor BP continuously for 12 to 24 hours as patient is sleeping or performing normal activity.

Normal and high blood pressure

It is very difficult to define normal blood pressure. When a group of healthy people will be examined, all of them will have different values. Not only this, a same person may have different value at different times. If you are angry or tense, blood will flow more rapidly and your blood pressure will increase. There is a term called white-collar hypertension. Here blood pressure is high when in a doctor’s clinic but at home blood pressure is normal. Similarly when you are calm and quiet, after a good night sleep, your blood pressure will be lower. These are normal fluctuations. So, to define hypertension BP should be persistently high. And it should have been measured at least twice during two separate examinations after the initial screening.

At normal blood pressure, a person should lead a normal life. This BP is less than 120/80. As per the Seventh US joint national Committee on Prevention, Detection and evaluation of High Blood Pressure (JNC-7), if BP is more than 140/90, it is termed as hypertension. Values in between (120-139/80-89) are pre-hypertension.

In children and pregnant women blood pressure should be lower.

Why does one develop hypertension?

This occurs due to a combination of genetic and environment factors. In more than ninety percent people there is strong family history of hypertension and the cause cannot be pinpointed. This is called essential hypertension and occurs most commonly between the ages of 35 and 55 years. In rest of the patients there may be a specific cause most important being diseases of kidney or hormone. Contraction of main abdominal artery and intake of steroid drugs are among other causes.

Every effort should me made to exclude the presence of underlying offending condition especially when onset of disease is in extremes of age and there is no family history. Plan of treatment may be totally different in these patients.

High salt intake, excessive weight, lack of exercise, mental stress, alcohol intake, crowding are the environmental factors, which increase blood pressure.

Why one should treat hypertension?

Treatment of hypertension is simple. But many people do not take treatment because of ignorance. If left untreated, hypertension can decrease the life span by 10 to 20 years. So cost of this ignorance is heavy.

Hypertension can damage various organs. Because heart has to pump against pressure, its size gradually increases. This further leads to heart attack and cardiac failure. Delicate blood vessels of eyes get damaged due to high pressure leading to disturbance of vision. In brain, damage of vessels can cause formation of blood clots or bleeding causing stroke (paralysis). Sudden rise of BP can cause blindness and coma. 10 % of patients die of kidney failure. Bleeding from various sites such as nose, lungs and menstruation is also common.

Do you have hypertension? What are the symptoms?

Anger and headache are not reliable symptoms. Hypertension may be found in children and sanyasis also. Early morning headache at back of the head may be found in severe hypertension but normally there is no direct correlation between headache and presence or degree of hypertension. So periodic measurement of BP is the only solution.

Other symptoms are- Dizziness, palpitation, easy fatigue, nasal bleeding, blurring of vision, chest pain, breathlessness and fits.

If there is underlying kidney disease then there may be swelling of face and feet, urinary difficulty in form of frequency, difficult voiding, inadequate voiding or decreased urine output. Presence of obesity, rounding of face, muscle weakness, episodic headache, palpitation and perspiration are found if there is underlying hormonal disease.

When high BP is detected for the first time

First, presence of hypertension is confirmed by repeated measurements. Person should be calm and quiet and should have taken some rest before BP measurement. If presence of hypertension is confirmed, then initial evaluation is done to

    Determine cause of hypertension

    Determine extent of damage especially on heart, kidneys and eyes

    Determine presence of other disease, which help in deciding best treatment plan.

A competent doctor should make a thorogh examination at presentation. He should measure BP in both arms in, sitting and standing position. He should make note of all the pulses. Following basic tests must be done- urine examination, kidney function test, hemoglobin level, sodium and potassium level, blood glucose and cholesterol level, eye check up for retina and ECG. Depending on requirement, the doctor may prescribe, chest X-ray, ultrasound abdomen, Doppler study, Nuclear scan, other blood tests including assessment of hormonal diseases.

If there is no family history, if onset is abrupt or if hypertension has started before 35 years of age or after 55 years of age or if BP is difficult to control, there is high probability of underlying disease. In two persons with same level of high BP, the hypertension may be twenty times severe if there are underlying risk factors such as-onset in young age, male sex, persistent diastolic pressure above 115 mm Hg., obesity, smoking, alcoholism, diabetes, high cholesterol and presence of damage to heart, kidney, eyes and brain. These people need more aggressive treatment.

Lifestyle and dietary management

Lifestyle has a major bearing on BP management and all patients, even if they are on medicines, must be encouraged to follow general non-pharmacological methods.

Relief of stress is important. One may have to change his job or his attitude towards job and life. Relaxation techniques and Yoga will be of help.

Smoking and alcohol intake should be minimized.

Weight reduction of 4.4 kg over 6 months is proven to decrease BP by 2.5 mm Hg. Caloric reduction is important.

Exercise as per physical limitation of a person should be encouraged. It helps in Bp control directly and through weight reduction. Exercises like jogging, swimming are better than weight lifting and push-ups.

Role of diet has been proven in several clinical trials. In this regard, important aspects are- calorie, salt, potassium, calcium and fat. Calorie should be restricted to achieve normal weight. Salt restriction is beneficial in lowering BP and it also increases the efficacy of medicines. Some types of patient are particularly salt sensitive such as- kidney patient, elderly and diabetics. Up to 5 gram of common salt per day is desirable. There is no need and use of completely stopping salt. Increased intake of potassium has same effect as that of salt restriction. Potassium is found in fruits and vegetables. But kidney patients should better be avoiding potassium. High calcium intake has also been found to be beneficial for BP control. Fat restriction helps in reducing weight and in limiting damage to blood vessels.

Drugs for high blood pressure

Although lifestyle and diet is definitely important, they may not alone be sufficient. Then a person should not feel disheartened. Requirement of medicine is not a sign of failure of patient’s effort on lifestyle modification. There are many groups of anti-hypertensives from which the best can be chosen for a particular patient. Various groups of medicines with examples are as under-

    Diuretics- Furosemide, Hydrochlorothiazide.

    ACE-inhibitors- Enalapril, Ramipril, Lisinopril

    Angiotensin receptor blockers. (ARB)- Losartan, telmisartan, Irbesartan.

    Antiadrenergic- Clonidine, methyldopa, Doxazocin, Prazocin, atenolol, propranolol, labetalol.

    Vasodilator- Minoxidil. Hydralazine

    Mineralocorticoid receptor antagonist- Spironolactone

    Calcium Channel blocker- Amlodipine, Nifedipine, Diltiazem

Treatment has to be individualized. A doctor should start with the best possible medicine as per patient need. For example, diuretics are better for elderly and patients of heart failure but may precipitate gout.. ACE-I and ARB are better for patients of diabetes and of heart attack but ACEI can cause dry cough and foetal damage in pregnancy. Drugs like propranolol reduces anxiety but is harmful in asthma. Drugs like Prazocin may be beneficial in prostate enlargement. Calcium antagonist can better control BP but may cause swelling of feet. Proper choice of medicine along with a change in life style and diet will be able to achieve target BP.

Target blood pressure

Treatment should be started when BP is more than 140/90. If diastolic BP is less than 89 and systolic is more than 160 then again treatment should be started in patients above 65 years of age. Patients who have fluctuating BP and those who are not receiving treatment, should be followed six monthly so that treatment may be started at proper time.

In patients of diabetes and evidence of organ damage, target BP should be 130/85. Lower is better and in some patients especially those with kidney diseases, it is advocated to achieve a target of 120/75. In patients in whom target is not being achieved, there are several possibilities. Prescription might be faulty with inclusion of inadequate and inappropriate drugs. Or patient may not be taking medicines as prescribed. Excessive salt intake makes BP control difficult. Some times BP remains high due to concomitant use of medicines such as steroids, contraceptive pill or even nasal drops for cough and cold.

Summary

Hypertension is a very common disease. But many people are not aware about their disease due to absence of clear-cut symptoms. This ignorance can reduce the life span of a person by up to 20 years and can lead to serious complications such as heart failure, kidney failure and brain hemorrhage. So regular BP measurement even in absence of symptom is desirable. When hypertension is detected, one should not jump with BP lowering drug but a complete evaluation of patient is mandatory. Lifestyle and dietary management has an important role in treatment but along with this, medicines may be required. There are numerous medicines from various groups to choose from. An aware and motivated patient with the help of a competent doctor can lead a normal healthy life.

 Director of Nephrology and Transplant Medicine at Asian Institute of Medical Sciences (AIMS), Faridabad. He is an expert in many procedures such as CRRT, hemoperfusion, CAPD, and kidney transplant.

Coronary Artery Bypass Graft (CABG)

  1. What is Bypass surgery & when is it performed?

Heart bypass surgery, also known as coronary artery bypass surgery, is performed to replace damaged arteries in the heart muscle. The damaged arteries are repaired by taking blood vessels from another area of the body. These arteries supply oxygenated blood to the heart. The heart doesn’t work properly if these arteries are blocked, or if blood flow is restricted. This can lead to heart failure. A certain type of bypass surgery is recommended basis the number of blocked arteries.

  • Single bypass: only one artery is blocked
  • Double bypass: two arteries are blocked
  • Triple bypass: three arteries are blocked
  • Quadruple bypass: four arteries are blocked

Risk of getting a heart attack, heart failure, or another cardiac issue depends on the number of arteries blocked. Surgery may take longer or become more complex if there is blockage in more arteries.

When a material in blood (plaque) builds up on arterial walls, less blood flows to the heart muscle. The muscle is more likely to become exhausted and fails if it is not receiving enough blood. This mostly affects or damages the left ventricle, the heart’s primary pump. Doctorsgenerally recommend a heart bypass surgery when coronary arteries become so narrowed or blocked leading to a high risk of a heart attack.

This condition is known as coronary artery disease, or atherosclerosis. Doctorsgenerally recommend a bypass surgery when the blockage is too severe to manage with medication or other treatments. The operation can save your life if you are having a heart attack or are at a high risk of having one. If you have ongoing angina and shortness of breath from diseased heart arteries, elective coronary bypass surgery is highly effective at eliminating or reducing discomfort. You can get your life back with a coronary bypass surgery.

  1. Bypass or Angioplasty- which one should be performed?

During cardiac catheterization, images of the inside of the coronary arteries are examined by the doctor. If plaques in these arteries (coronary artery disease) are causing areas of narrowing, you may need treatment. Treatment options depend on various factors including:

  • Severity and extent of coronary artery disease
  • Symptoms, such as chest pain and shortness of breath
  • Overall heart function
  • Other medical conditions, such as peripheral artery disease, diabetes or prior stroke or heart attack

Medications and lifestyle changes may be the treatment of choice for some people.

In other cases, angioplasty or Percutaneous coronary intervention may be recommended for opening the clogged arteries. Angioplasty may especially be recommended when you experience chest discomfort (angina) due to reduced blood flow that has not responded to medication and lifestyle changes.

During angioplasty, a tiny balloon at the site of the blockage is inserted and then expanded to widen the narrowed artery. Your doctor may then implant a stent (small metal coil) in the clogged artery to keep the artery open and hence reduce the risk of it narrowing again. It is possible to even have angioplasty during cardiac catheterization, if your doctor thinks it is the most feasible treatment option for you.

In a case where arteries are narrowed or blocked in multiple areas, or the left main coronary artery is narrowed, your doctor may recommend coronary bypass surgery. Some studies and researches show coronary bypass surgery may also be an appropriate treatment if you have diabetes and have multiple blocked or narrowed arteries.

During bypass surgery, surgeons take a sample of healthy blood vessels usually from inside the chest wall or the lower leg and attach it above and below the blocked artery. This permits blood to bypass the blocked area and flow to the heart muscle.

While angioplasty is a minimally invasive scheme, of widening a coronary artery where a balloon catheter is used to widen the artery from within and a stent is placed inside the artery to keep it open. Anaesthetic is not needed (although the patient may be suggested sedation), and patients can go home same day or the next day.

The recovery time for angioplasty is quicker than heart bypass, but patients having CHG are not advised to go for angioplasty. People who have triple-vessel disease are suggested to have heart bypass, and if one has diabetes, heart bypass gives better survival outcomes. Angioplasty is usually used for people having less-severe coronary artery disease.

  1. What to expect before, during & after bypass surgery

Before the procedure:

  • One should not take any drugs having aspirin for three days before the surgery. These drugs can cause bleeding more than usual.
  • One should quit smoking. People who have a habit of smoking have more mucous in their lungs and is hard to remove after surgery.
  • One needs to have someone to stay with them after getting home from the hospital.
  • One can also hire a home health aide but these services can prove to be costly.
  • One may require blood while in the hospital. Anyone can donate their own blood, after telling the doctor.
  • One may not be allowed to eat or drink anything after midnight before the surgery. Take your normal pills with a small sip of water. If diabetic, check with the doctor about your diabetic medicines.
  • One needs a chest X-ray, a urine test, and ECG of your heart and blood tests before surgery. These tests may be done at an outside facility or in the hospital the day before surgery.
  • The day before surgery, one needs to scrub the abdomen and legs with a soap to kill germs.
  • One needs to bring all the pills to be taken with and show them to the nurse.
  • Do not bring any valuables, such as jewellery or money to the hospital.
  • The doctor would explain the surgery to you and give u a consent form for signatures.
  • One should meet other members of the team involved in the surgery, such as the anaesthesiologist, etc.

During the procedure:

  • If one is in the hospital, day before the surgery, one would have the time to see their loved ones before the surgery.
  • One is asked to remove dentures and non-permanent bridgework, hair clips, jewellery and nail polish before going in to surgery.
  • In the morning of the surgery, your chest, groin and legs will be shaved.
  • Nurse will start an IV in the arm to give you fluids.
  • One might also receive drugs to help you relax and have a facemask to breathe oxygen.
  • One will be asked to go to the washroom five to ten minutes before the surgery as during and immediately after the surgery, a small tube is inside the bladder to drain urine.
  • The room for operation might be cool and you may have a blanket if you wish.
  • One will receive drugs to put to sleep and to block pain so that one is not be awake during the surgery.
  • The surgeon divides the breastbone and spread the ribs to get to the heart. The heart-lung machine will take over the work of your heart and lungs.
  • The surgeon then removes a small length of blood vessel from your leg or chest and he will begin sewing it to your heart vessels.
  • Once this is done, the surgeon will start your heart and turn off the heart-lung machine.
  • Your breastbone is wired shut and the wound is closed with stitches or staples.
  • One may have two or more small pacing wires on the chest. These wires will be used to help control your heart beat if needed. They will be removed before going home.
  • One will have two or three tubes in your chest which will be hooked to a machine to drain the extra air and blood. These tubes will be taken out in about a day.

After the procedure:

  • One is taken to the Cardiac Surgery Intensive Care Unit.
  • One will have a breathing tube inside your windpipe. The nurse uses a small tube to remove mucous from the lungs and mouth to prevent any build-up in your lungs.
  • This procedure can cause pain, make one cough and hard to breathe, but drugs may be given to treat these symptoms.
  • On waking up, one will be weaned from the machine that is helping to breathe. Once this happens, the tube in your windpipe is taken out.
  • One will have a mask on their face to give oxygen after the breathing tube is removed,.
  • The facemask is taken off and will have a small tube under your nose to provide oxygen.
  • When in pain, tell the nurse, who can give you drugs to ease the pain.
  • One should take deep breaths and cough for 10 to 20 times per hour to prevent any fluid build-up in the lungs. (You will learn to use a small gauge, called an incentive spirometer, to see how depth of your breath and to train to breathe deeply.)
  • After the surgery, one should get up as soon as you can and talk with family and friends. This might speed up your healing and helps family and friends feel less worried.
  • One can walk, with help, the day after surgery.
  • If vessel for the bypass surgery was taken from your leg, onhee may have some swelling in the legs.
  • After a day or two, one will be moved to the Cardiac Progressive Care Unit, where one will be kept for three to five days.
  • One will have an IV, oxygen and a monitor to check your heart.
  • One may have a chest X-ray, blood work, or other tests, as needed.
  • One may have anaemia after the surgery, which is normal but will make you feel tired.
  • The dressings over your chest and leg wounds will be taken off after a day or two.
  • Most stitches are inside and will dissolve over time while the staples would be taken out in about five to seven days after the surgery.
  • One may also have small paper strips on your chest and legs, which will slowly peel and should be taken off after one week you get home.
  • One can talk to a dietician about the kinds of food need to be eaten and avoided.
  • One can slowly start walking more, begin exercises to help heal and learn what to do when you get home.
  • One also needs to see the surgeon about four weeks after going home.
  • One should arrange a follow-up visit with one’s own doctor.

 

  1. What are the risks involved in Bypass surgery & complications

They may include the following:

  • There is a huge risk of bleeding from the graft and other sources and near about 30 percent of patients require blood transfusions after surgery. Very rarely the bleeding would be severe enough to do any additional surgery.
  • Another risk is that of Heart rhythm problems where Atrial fibrillation (a condition where the upper chambers of the heart quivers rather than beating properly) is a frequent complication of coronary bypass surgery and can lead to blood clots that forms in the heart and which can travel to the other parts of the body. Some other forms of heart rhythm problems are also possible though less common.
  • Also there may be chances of Blood clots, if formed, they can lead to a heart attack, stroke, or lung problems.
  • Infection at the site where the chest gets opened for surgery can also happen. This complication is also rare, but can occur in only about 1 percent patients.
  • Post-Pericardiotomy syndrome is a condition occurring in near about 30 percent of the patients starting from a few days to 6 months after the surgery. Common symptoms are fever and chest pain.
  • Kidney failure or renal, failure is another risk that may damage the functioning of a patient’s kidneys, though often temporary.
  • Many patients report difficulty in thinking after the surgery. This problem improves in about 6 months to an year. Researchers are finding its cause, though one theory says that use of the heart-lung machine dislodges tiny bits of fatty build-up in an artery that travels up to the brain.
  • People can have adverse reactions to anaesthesia including difficulty in breathing while asleep.
  • Death is a very rare risk but can happen after the bypass surgery caused by heart attack or stroke.

Surgical Risks of Bypass

Every surgery has risks and holds the potential for small to serious complications. Some of the possible surgical risks involved for bypass surgery include:

  • Spiking high fever
  • Developing a bad infection
  • Bleeding from the site or some infection at the incision
  • Having adverse reaction to anaesthesia
  • Loss of a lot of blood
  • Developing blood clot affecting the lungs

Some more risks likely to occur during bypass surgery include:

  • Having a sudden heart attack or stroke
  • Dying during the bypass surgery
  • Infection in the chest
  • Abnormalities of heart rhythm; this is called arrhythmia
  • Chronic pain of breastbone towards the wound site
  • Severe Pneumonia
  • Difficulty in breathing
  • Kidney or Renal failure
  • Difficulty with cognitive function and thinking
  • Chest pain with fever that may live up to six months

 

WHAT ARE THE RISKS INVOLVED IN ANGIOPLASTY AND COMPLICATIONS

What is Angioplasty?

The arteries in the heart tend do get blocked by plaque when a person is suffering from coronary heart disease, which prevents oxygen rich blood from reaching the heart. Angioplasty is the medical process used to restore the blood flow in the arteries.

It is a minimally invasive procedure in which a small tube with a balloon at one end is inserted into the artery. The balloon causes the plaque to be pressed outward towards the walls of the artery, widening it enough to restore regular flow of the blood.

Things to keep in mind before an Angioplasty

It is usually required of the people about to go through an Angioplasty to first go for routine blood tests and electrocardiogram. Hearing aids, spectacles or similar aids should be carried along for ease of communication.

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HOW IS ANGIOPLASTY PERFORMED AND WHAT IS THE RECOVERY TIME

What is Angioplasty?

The arteries in the heart tend do get blocked by plaque when a person is suffering from coronary heart disease, which prevents oxygen rich blood from reaching the heart. Angioplasty is the medical process used to restore the blood flow in the arteries.

It is a minimally invasive procedure in which a small tube with a balloon at one end is inserted into the artery. The balloon causes the plaque to be pressed outward towards the walls of the artery, widening it enough to restore regular flow of the blood.

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Heart Attack Warning Signs

A lot of people tend to ignore symptoms or signs that might be indicative of a heart attack, while it may happen suddenly, it is important to pay close attention in case you experience any of these signs. More so, if you are diabetic, overweight, have high cholesterol or high blood pressure. The symptoms may be quite subtle and less obvious unlike what is typically shown in movies where a person clutches his heart dramatically and falls. A heart attack may or may not be that intense. So, when in doubt, always have it checked. The faster you get help, the less damaging it would be for the heart muscle.

Chest discomfort

It is the most common symptom of a heart attack and may feel like a discomfort in the center of the chest lasting for a couple of minutes. Some might feel intense pressure or pain – the feeling can be different for different people. Some people, especially women, may not feel chest pain at all.

 

Upper Body Discomfort

Some people may experience pain or discomfort in upper body, such as in arms, back, jaw, neck or the stomach. They may even report feeling nauseous or experience heartburn. These symptoms are more likely to be reported by women than men. These symptoms could happen because of other reasons as well but it is important to note that they may likely happen in a heart attack as well.

 

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