Just two months ago a 24 year old male happened to visit his family physician with a vague complaint of chest pain. He was hale and hearty till then. The family physician suspected something amiss and referred the patient to Hospicio Hospital in Margao. This young man, it must be said, had no risk factors for heart disease. "Dr Edward D’Mello, senior physician at Hospicio was stunned when, after painstaking investigations, he arrived at the diagnosis of a recent heart attack. He referred the patient to me for a Dobutamine Stress Echo (DSE) to assess the presence of residual significant blockage and total ischemic burden. DSE was strongly positive for induced ischemia. I referred him to GMC immediately where Dr Manjunath Desai, interventional cardiologist conducted a coronary angiography after which a severe proximal blockage in LAD was detected and a successful angioplasty was done," narrates noted cardiologist Dr Francisco Colaço.
People are dying young “ of all sorts of ailments including heart attacks. The age for getting a heart attack is coming down and one sees so many incidents of young men and women unexpectedly succumbing to heart attacks. Is this our new reality?
Dr Colaço remarks, “The above case shocked us. Why should this young man with no risk factors get a heart attack? He had no underlying valvular disease, no cardiomyopathy, and no congenital abnormal origin of the coronary arteries. What is it that makes young heart attack victims defy conventional norms?"
While Dr Colaço and Dr D’Mello seemed pleased that they were able to help this young man, they do lament the fact that there are tens of people like him who die because patients and doctors hardly ever suspect a heart attack, especially if the patient is too young. Even tell-tale cues are not taken seriously, mistaking the symptoms for gas, indigestion or acidity.
American cardiologist, Dr Eugene Braunwald, in his preface to the premier cardiology textbook ‘Braunwald’s Heart Disease’ wrote 30 years ago “ "It shouldn’t surprise us to see patients suffering from Atherosclerosis (hardening of the arteries that impairs the blood supply to the heart leading to heart attacks) in people in their 80s and 90s. But I am deeply concerned that heart attacks are occurring in the 60s and 70s.” Dr Colaço adds, “What dumbfounds us is that we are witnessing it happen to more and more people in their 20s and 30s.”
Why? Nobody knows all the answers. Heart attacks are known to be associated with a gamut of 'risk factors.' What are risk factors? Risk factors are not the cause of heart attacks. When they are present, singly or in combination, they make you more prone to a heart attack. The more the number of risk factors present the more prone you are for heart attacks. It works in geometric proportion to increase your susceptibility to a heart attack. Among 'risk factors' we have the 'non-modifiable' ones like age, gender and family history about which you can do nothing.
The other risk factors are the 'modifiable' ones which you must endeavour to keep under control: Hypertension (high blood pressure), tobacco use, Raised blood glucose (diabetes), physical inactivity, unhealthy diet, increase of bad cholesterol and lowering of good cholesterol, overweight, 'metabolic syndrome': constellation of high blood pressure, insulin resistance with diabetes mellitus, visceral obesity (apple/pot belly), stress and sedentary lifestyle is very prevalent in Indians.
Now, here’s the million dollar question “ why are heart attacks in India more common than in the West? Dr Colaço says, “A true pioneer, Dr Enas A Enas was the first cardiologist to sound the alarm on the strikingly high rates and malignant nature of heart disease among Indians. He is also the first cardiologist to sound the alarm on the epidemic of coronary artery disease among Indians worldwide. We can attribute this to factors like, 'Indians have faulty genes.' One of which is the 'starvation gene' which would prime us for long periods of famine. However, exposed to bad food like cheese burgers, hamburgers, French fries, sweetened drinks plus roadside food prepared in vanaspati ghee or dalda, it makes us easy prey to coronary disease. Biscuits, crackers, cakes are exceedingly noxious to lining of our coronaries. Roadside eateries add another blow to our health: the shamelessly use the same oil again and again to cater to different customers which makes it all the more toxic to the delicate arteries"
Thanks to this unwholesome food we are seeing an increase in obesity, diabetes and high blood pressure even in young kids. Once you have a clumping of these risk factors, your risk for heart diseases “ no matter your age “ becomes 4-6 times higher. “Fortunately, smoking is on the wane in the last few years,” points out Dr Colaço. Scientists are now busy researching on genes which are responsible factors for causing heart attacks, in an effort to nip young heart attack epidemic in the bud. "But, it is worthy to mention, that Dr Enas found one very important thing “ that Indians have high levels of Lp(a) which is a killer Lypoprotein. Lypoproteins are carriers of fat in the blood and are associated with an increased risk of heart attack. Unfortunately there is no agent to decrease the level of Lp(a). Indians also have high levels of Homocysteine. It is a sort of chemical which accumulates because of depletion of Folic acid. Hyperhomocysteinemia is a possible risk factor for coronary heart disease. The vegetarianism in Indians also leads to vitamin B12 deficiency, another risk factor.
It is known that women somehow are protected from heart attacks during the reproductive period because of estrogen. Why are heart attacks in women increasing even during the reproductive period? One can attribute this to the increased levels of stress. Stress is common now in all ages and genders. It is seen in young and old, males and females, in equal proportions. Sadly, young women have taken to smoking. Today working women are subject to additional stress because of demanding jobs and domestic chores. Working women’s life has been thrown totally out of gear.There are various opinions regarding consumption of alcohol and its relation to heart attacks. All western studies have demonstrated that alcohol in moderation protects against heart attacks. One peg a day for men and half a peg a day for women (because their body mass is less) protects against heart attacks whereas if one exceeds these amounts or resorts to binge drinking, on the contrary, the heart dilates and the heart muscles are weakened. One develops a condition called 'dilated cardiomyopathy' which eventually leads to heart failure.
"Indian studies, however, come as a disappointment to tipplers like me. There are two studies," says Dr Colaço, which seem to say that as far as heart attacks are concerned Indians would better keep totally away from the cup that cheers. "What a disappointment to all of us but not many are ready to take these studies with the seriousness they deserve. Frank Sinatra after all said with much aplomb, "Alcohol is men’s worst enemy but the Bible says love your enemy". I do that," smiles Dr Colaco asking, "What is the 'French paradox'? The French are known as gourmands and 'bon-vivants', yet the incidence of heart attacks is lower than in other Western countries. The secret lies in the fact that they consume large amounts of red wine which contains the protective anti-oxidant known as 'Resveratrol'.
Stress is the greatest factor in triggering heart attacks. Stress has been increasing globally from womb to tomb. In young people there is a mad rat-race which leads to stress. Acute stress is worse than chronic stress. It triggers heart attacks and sudden 'plaque' rupture which blocks blood-supply to the heart. Undoubtedly physical stress is good and monitored physical activity is salubrious. Doctors recommend that it is best to exercise is 20 minutes a day on most days of the week so as to raise the pulse at least 20 beats from the basal heart rate. This can also be achieved in '10 minute blocks' from morning to evening. Exercise is salutary even when it does not lead to weight loss, So the weighing machine shouldn’t discourage us from exercising. There are two views about yoga’s beneficial effect on the heart. Most doctors say, the evidence at hand, that yoga prevents heart attacks is anecdotal. Never the less, yoga has its own benefits “ it promotes a healthy style of life, brings in discipline, makes one more methodical regarding diet and helps in relaxing the body mentally and physically.
Box
Fact File
Acute stress is more dangerous than chronic stress for heart patients
Risk factors are not the cause of heart attack, but plaque deposits in the arteries and hardened arteries are
The more the number of risk factors the more prone one is for heart attack
Indians have faulty genes that make them prone to heart attacks
Best exercise is 20 minutes a day or two 10-10 minutes blocks between a long or short break No protective action is found of alcohol on controlling heart attacks
Yoga offers a healthy, disciplined, methodical and relaxed life style
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