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Minimising the risks of a heart attack

A major health disaster can be averted if we learn to read the tell-tale signs of coronary heart disease

Coronary angiography and percutaneous coronary intervention in acute myocardial infarction. On the left: Right coronary artery (RCA) was occluded. On the right: RCA was successfully dilated and the blood flow was restored.

CARDIOVASCULAR disease was estimated to result in 17.3 million deaths worldwide on an annual basis. Seventy per cent of sudden cardiac arrests have been attributed to coronary heart disease. In 2016, statistics showed that 16 people die from cardiovascular disease (heart diseases and stroke) in Singapore every day. Cardiovascular disease accounted for 29.5 per cent of all deaths. This means that nearly 1 out of 3 deaths in Singapore is due to heart diseases or stroke.

Can we minimise the risk of heart attack before it is too late? These are some ways:

  • Be familiar with the tell-tale signs The symptoms of heart attack or coronary heart disease include chest pain and it is commonly associated with shortness of breath. Other associated symptoms include dizziness, palpitation (a noticeably rapid, strong, or irregular heartbeat), diaphoresis (unusually heavy sweating), nausea, fatigue, reduced effort tolerance, leg swelling, fainting, intermittent claudication (cramping pain in the legs and especially the calves on walking or exercising that disappears after rest) or even epigastric (upper abdomen) discomfort. A person who has coronary artery disease may also be asymptomatic.
  • Know about your health status by early detection of coronary heart disease and proper evaluation of your heart:  What tests do we do to detect coronary heart disease? A CT coronary angiography is highly recommended as it is very accurate in providing the anatomical information about your coronary arteries. It detects the abnormal narrowing (stenosis) of the coronary arteries ranges from no narrowing (0 per cent) to complete occlusion (100 per cent). It also helps to characterise the types of plaques that a person has in the coronary arteries, such as calcified plaque, soft plaque or mixed plaque.

In addition, it also provides important information about the origin and pathway of the coronary arteries. Some people are born with abnormal origin of the coronary artery. This may result in myocardial ischemia (a condition where the heart muscle is starved of oxygen due to inadequate blood supply) and sudden death.

CT coronary angiography demonstrates severe coronary artery stenosis due to soft plaque. Magnetic Resonance Myocardial Perfusion Imaging (Stress CMR) is frequently used to assess for the presence of myocardial ischemia and myocardial infarction (heart muscle damage due to heart attack) as a result of coronary heart disease. Cardiovascular magnetic resonance is also the gold standard for the assessment myocardial viability.

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Other useful assessments include ECG, treadmill exercise test, radionuclide myocardial perfusion imaging, stress echocardiography and cardiac enzymes. Invasive coronary angiography with the aim of percutaneous coronary intervention can also be carried out if the patient has clear clinical evidence of significant coronary heart disease with a presence of cardiovascular risk factors.

  • Eliminate the cardiovascular risk factors: These are the risk factors for coronary heart disease and sudden cardiac arrest:
  • Hypertension (high blood pressure): People with baseline hypertension had a 63.3 per cent lifetime risk of developing cardiovascular disease at 30 years of age compared with a 46.1 per cent risk for those with normal baseline blood pressure.

According to data from Ministry of Health Singapore, the prevalence of hypertension among Singapore residents aged 18-69 years is around 25 per cent. Recent studies performed in China with total participants of 1.7 million showed that the prevalence of hypertension increases gradually as the age of people increases.

The prevalence of hypertension for both genders is more than 50 per cent among the participants aged 60-64 and it further increases to more than 60 per cent among participants aged 70-74. Essentially, this means that at least one out of two people will have hypertension when they reach the age of 60 and above.

To reduce the risk of developing hypertension, a healthy lifestyle is vital. The following will help to reduce the risk of hypertension: Regular exercise; loss of weight in people who are overweight or obese; avoiding high salt diet; avoiding excessive alcohol consumption; and avoiding exposure to chronic stress.

  • Dyslipidemia: This is defined as elevated total cholesterol (TC), bad cholesterol (LDL-C), triglycerides (TG), non-high-density lipoprotein cholesterol (non-HDL-C) and low level of good cholesterol (HDL-C). The prevalence of dyslipidemia is increased in patients with premature coronary heart disease. Cutting down fatty food is a good dietary approach.
  • Diabetes mellitus: Diabetes mellitus is associated with an approximately two-fold increased risk of coronary heart disease, stroke and cardiovascular disease mortality. To reduce the risk of getting diabetes mellitus, do not eat more than what is required by the body, avoid overweight or obesity.
  • Cigarette smoking: Incidence of a heart attack is increased sixfold in women and threefold in men who smoke at least 20 cigarettes per day compared with subjects who never smoked.
  • Lack of exercise: Men who engaged in moderately vigorous sports activity have been reported to have a 23 per cent lower risk of death than those who were less active. The effects of exercise include elevated good cholesterol level; reduced blood pressure; weight loss and less insulin resistance which means reduced risk of getting diabetes mellitus.
  • Obesity: A National Health Survey of 2010 showed that one in nine Singaporeans aged 18 to 69 is obese - a 57 per cent increase from 2004. Weight loss in overweight and obese adults is associated with a reduction in mortality. Based on body fat equivalence, the recommended Body Mass Index, (BMI) cut-off points for public health action in Asians were 23 kg/m2 and 27.5 kg/m2, respectively. You can check your own BMI using this formula: Body weight in kilograms divided by the square of the height in metres (kg/m2).
  • Chronic Kidney Disease (CKD): Cardiovascular mortality is twice as high in patients with Stage 3 CKD (Glomerular Filtration Rate, GFR 30-59ml/min per 1.73 m2) and three times as high in patients with Stage 4 CKD (GFR 15-29 ml/min per 1.73 m2) compared to people with normal kidney function.
  • Family history of coronary heart disease: First-degree relatives (that is parents or siblings) prior to age 55 for males or 65 for females denote a significant family history. In the presence of positive family history, there is 40-60 per cent increased risk of developing coronary heart disease.
  • Microalbuminuria: Microalbuminuria is defined as persistent albumin excretion in urine between 30 and 300 mg/day. Microalbuminuria has been associated with cardiovascular disease that is additive to conventional risk factors in both non-diabetic and diabetic patients.
  • High sensitivity CRP (hs-CRP): This is high-sensitivity C-Reactive Protein. The baseline level predicts the long-term risk of a first myocardial infarction, ischemic stroke, hypertension, peripheral vascular disease, sudden cardiac death and all-cause mortality among healthy individuals.
  • Lipoprotein(a): Elevated levels may promote atherosclerosis. Lp(a), is a modest, independent risk factor for atherosclerotic cardiovascular disease events, especially myocardial infarction.
  • Treat the problem once identified: Revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) can be performed in patients with severe coronary heart disease. PCI is used primarily to open a blocked coronary artery without the need for open-heart surgery.

If any of the cardiovascular risk factors are identified, please seek medical advice as soon as possible. You may need to be treated with medication.

Healthy lifestyles such as low cholesterol or low fat diet, regular exercise, smoking cessation and maintaining normal weight; adherence to long-term medications, regular review and follow-up with the doctor are all essential in ensuring that the problems are managed properly.

In summary, to minimise the risk of heart attack, let us be familiar with the tell-tale signs of heart attack or coronary heart disease; know about your health status by early detection of coronary heart disease and proper evaluation of your heart; eliminate the cardiovascular risk factors and treat the problem once identified.

This series is produced on alternate Saturdays in collaboration with Singapore Heart, Stroke & Cancer Centre.