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“Steps taken today can save from major heart problems,”says Dr Mahboob Alam

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SN: Tell us something about yourself.
I grew up in Multan, Pakistan and received my MBBS degree from The Aga Khan University, Karachi. I completed my post-graduate training at Baylor College of Medicine, Houston, Texas USA.
My practice focuses on management of patients with complex coronary artery disease as well as peripheral arterial disease. I am particularly involved in high risk coronary interventions, limb salvage for limb threatening peripheral arterial disease as well as management of cardiogenic shock in the setting of myocardial infarction (heart attack).

SN: How important is heart health?
Heart health is pivotal to a prolonged healthy life. Our heart works all the time, as long as we are alive. It is an efficient pump and in a healthy individual pumps over five liters of blood per minute. Just imagine how much blood it will pump over an average life span. Just like any machine or equipment, heart also works better if we take care of it. Heart health is all about maintaining a healthy lifestyle that is, having balanced diet, regular exercise and good sleeping habits.
SN: What are the common heart diseases globally?
Most common heart diseases include coronary artery disease (blockages), congestive heart failure, heart blocks and conduction disease. We also like to include stroke, peripheral arterial disease and hypertension in the same broader category “cardiovascular disorders”.
SN: Are they more common in men?
In general, cardiovascular diseases are more common in men. However, certain problems like, congestive heart failure due to diastolic dysfunction, “stiff heart” is more common in older women while coronary artery disease tends to be more prevalent in men.

SN: What causes them?
Traditional risk factors for development of cardiovascular disorders including coronary artery disease are hypertension, diabetes, high cholesterol, cigarette smoking, chronic kidney disease, family history of premature coronary artery disease as well as age (above 45 years in men and 55 years in women).

SN: What is ischemic heart disease?
Ischemic heart disease in particular refers to presence of ischemia – “lack of blood flow to the heart”. If heart develops blockages in the arteries supplying blood to the heart muscle, it results in a “supply – demand mismatch”. In times of increased workload including exercise; heart is not able to get much needed amount of blood to bring in nutrients and oxygen. This results in chest pain or other symptoms of ischemic heart disease.

SN: What is the difference between angina and heart attack?
Angina refers to pain arising from arteries. It is used to describe pain from lack of blood flow due to problems in the arteries. “Angina Pectoris” refers to chest pain in patients with ischemic heart disease. Angina can be classified as stable or unstable. Stable angina is the result of longstanding or chronic blockages with a predictable pattern of chest pain. However, unstable angina is a more serious problem which refers to a change in the stable pattern causing chest discomfort. Heart attack particularly refers to significant blockage that results in damage to the heart muscle. This damage results from either total occlusion or partial occlusion of a major artery due to formation of new plaques or sudden increase in the size of prior plaques or rupture of existing plaques causing blood clot formation in the coronary artery. This is similar to a clogged drain pipe. These patients have unstable angina and need urgent attention.

SN: Heart attacks are becoming common in youngsters nowadays although they apparently seem to be healthy. What can be the reason?
In South Asia we have noticed a sharp increase in the incidence of premature coronary artery disease and younger patients presenting with heart attacks. Most of these heart attacks are due to a sudden rupture of a plaque “area of cholesterol deposition” in the wall of a coronary artery. Once, the plaque ruptures, it causes a sudden total occlusion of a major artery of the heart. In the developed world, these patients are triaged to a hospital where they can undergo urgent coronary angiography and if feasible either angioplasty with stent or bypass surgery. In Pakistan, unfortunately, even in major cities availability of cardiac catheterization facilities are very limited. This results in unfortunate outcomes for many patients with aggressive heart disease presenting with a major heart attack.

SN: How can an individual know he is at risk of heart diseases?
There are certain risk factors that increase risk of heart disease. Most common risk factors include hypertension (elevated blood pressure), hyperlipidemia (increased cholesterol levels), family history of heart disease in a family member at young age (defined as men under 45 years and women under 55 years), diabetes, any vascular disease including peripheral arterial disease or prior history of stroke. In addition, presence of chronic kidney disease also increases the risk. Tobacco use in the form of cigarettes or cigars in particular increases the risk of heart disease. Our diet also plays an important role. So does our physical activity level. A sedentary lifestyle and diet rich in fats will ultimately promote heart disease. Certain risk factors are modifiable with medicines to control them while others are not. Having diabetes, kidney disease or vascular disease is considered risk equivalent. This means that patients with these disorders should be treated like someone with coronary artery disease.

SN: Can stress cause heart problems?
Stress plays a significant role in progression of coronary artery disease. While stress directly does not promote blockages, but creates an environment that is stressful for the heart. Stress releases corticosteroids as well as epinephrine in the body. In addition, stress results in lifestyle that is not conducive to healthy living. It promotes hypertension which also increases risk of heart disease. Acute sudden onset of very high stress can also result in a form of heart failure called “Takotsubo Cardiomyopathy”. It is also known as “Broken Heart Syndrome”. It is usually seen in women in their middle age and is provoked by a sudden emotional stress. Most of the times, heart failure resolves over time, and initially can mimic a heart attack.

SN: How important is maintaining blood pressure in preventing a heart attack?
Management of blood pressure in patients with hypertension is one of the most important aspects of primary prevention of heart disease. The risk of heart disease as well as stroke and kidney failure drastically reduces in patients who control their blood pressure with diet, exercise, weight loss and medicines.
SN: Are symptoms of heart attack different in women?
Women in particular can present with atypical features of heart attack. Not all heart attacks present with a crushing chest pain on the left side. It can also mimic heart burn and may present with nausea, upper abdominal discomfort, left arm numbness or heaviness or even with sudden passing out due to heart rhythm problems.

SN: Can congenital heart defect be detected during pregnancy? Can they be prevented?
Certain congenital heart defects can be detected during pregnancy. Easiest way is screening during second trimester of pregnancy with fetal ultrasound. Ultrasound can be used to evaluate the unborn baby’s heart at an early stage. It can be used to look at heart function, heart chambers as well as heart valves. Certain congenital heart defects including atrial or ventricular septal defect (hole in the heart) can be treated and managed after birth. There are however, certain serious defects including Tetralogy of Fallot that require extensive surgical corrections after birth. With the availability of new surgical techniques, these patients are now living much longer. Prevention of congenital heart defects include adequate prenatal supplementation of the expectant mother. In addition, if there is a family history of congenital heart disease in the immediate family members, the couple should seek advice from a genetic counselor prior to conception.

SN: When is a stent and bypass required?
In patients with multiple vessel “triple vessel” coronary artery blockages or blockages involving the left main coronary artery referred to as “Widow Maker”; we usually recommend bypass surgery. Stents can be used to treat a wide majority of blockages when not involving the main artery. In certain high risk patients where bypass is not an option due to high surgical risk, we can consider stents for multiple vessels as well as for main artery (however, a lot of circulatory support is needed).

SN: Is cholesterol always bad?
Certain forms of cholesterol are bad. Low Density Lipoprotein (LDL) and Triglycerides (TG) are associated with increased risk of coronary artery disease. Good cholesterol HDL or High Density Lipoprotein is associated with protection against heart disease. Therefore, a high HDL and lower LDL will provide protection against development of coronary artery disease and will also reduce risk of further events in patients who have already had a heart attack. Therefore, not all cholesterol is bad. An aerobic exercise schedule, weight loss, high protein and low carbohydrate and low fat diet can help promote good cholesterol. Use of nuts in particular walnuts or pecans and increased fiber intake can also help with it.

SN: Some people experience increased heart rate and shortness of breath while exercising or climbing stairs. What does it indicate?
This shortness of breath on exertion can be due to multiple reasons. Most common cause will be heart disease. In addition, it can be related to lung disorders due to smoking. Certain patients are obese and physically deconditioned and that can also result in similar symptoms. However, if one has symptoms of shortness of breath with exertion, he or she should seek an opinion from a physician and may need cardiac work-up including an electrocardiogram, echocardiogram and a stress test amongst others.

SN: What should one do to keep heart healthy?
Keeping one’s weight under check is extremely important. Goal is to keep Body Mass Index less than 25.0 kg/m2. A routine aerobic exercise (a brisk walk or light jogging, swimming, sports) will help maintain a healthy metabolic environment in the body. In addition, watching diet to reduce fried food, fats and excess carbohydrates will help reduce worsening of plaques. Addition of fibers in the form of salads or whole grains and nuts can increase good cholesterol. Most importantly, a healthy sleep cycle as well as stress management plays an important role. Individuals with risk factors need to be vigilant about their medications and lifestyle to mitigate the long term effects on heart.

SN: Well, that was really enlightening. Anything left that you would like to add at the end?
A healthy heart is associated with a healthy life. Please take care of your heart. Simple steps taken towards heart health today will save you from major problems in later life. Consult a physician if you are having trouble controlling your risk factors.

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