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Medical Hand Book -7
From Er.Sulthan
Health Manager

Presentation
From
Er.Sulthan
ஹல ோ டோக்டர்!
குலசை சுல் தான்
வழங் கும்
மருத்துவ சையேடு-7
(ENGLISH)
Prevention is
Better than
Cure

I Love my Heart
 ANGINA
What is the Heart and what does it do?
The heart is an organ that continuously pumps blood that
carries oxygen and nutrients to the body's tissues and
organs. Oxygen and nutrients are then removed from the
blood by muscles and organs to produce energy our
bodies need in order to live. A heart pumps continuously
from before birth to the day of death without stopping. An
adult human heart may between 80,000 to 130,000 times
a day, pumping 2,000-3,000 gallons of blood!
The heart is a muscle and needs its own supply of blood,
oxygen and nutrients for the work it does. This blood flow
is supplied by the coronary
The heart is a muscle and needs its own supply of blood,
oxygen and nutrients for the work it does. This blood flow
is supplied by the coronary arteries.
 What is Coronary Heart Disease (CHD)?

 CHD (also known as coronary artery disease or CAD) occurs when the
coronary arteries become narrowed or blocked. Most of the time such
blockages occur due to the presence of atherosclerosis. Narrowing
along the inner walls of coronary arteries occurs due to the
accumulation of cholesterol, fatty deposits and calcium deposits (called
plaques). This process is called atherosclerosis.

 Myocardial ischemia (is-scheme-e-uh) occurs when certain parts of

the heart do not receive enough blood (oxygen) through blocked or
narrowed arteries. Heart muscle can withstand decreased or absent
blood flow for a period of time before damage to the effected muscle is
no longer reversible.

 Myocardial infarction (Heart Attack) occurs after blood flow to a part

of the heart has been blocked for a prolonged period of time (this can
vary from 30 minutes to several hours) causing permanent damage.
What is angina?

 Angina (say: ann-gi-na) is chest pain or discomfort that

happens when some part of the heart does not get enough
blood (ischemia) to carry the oxygen it needs. It is a common
symptom of coronary heart disease (CHD) , which occurs when
vessels that carry blood to the heart become narrowed and
blocked.
 Angina symptoms may include:
 Pressing or squeezing pain, usually in the chest under the
breast bone, but sometimes in the shoulders, arms, neck, jaws,
or back. Chest pain often steadily builds up over a period of
minutes.
 The pain of angina may make you sweat or make it hard to
catch your breath.
 Angina is usually brought on by exertion. It is usually relieved
within a few minutes by resting or by taking prescribed angina
medicine.
What causes angina?

 Angina usually occurs during physical activities like

walking, sexual intercourse, climbing stairs, exercising or
doing housework. Other triggers include smoking,
alcohol, heavy meals,excessive heat or cold, emotional
stress and stimulant usage.
 It is important to mention that use of cocaine (blow,
crack)or methamphetamines (speed, crank, crystal meth)
can cause angina and even heart attacks in young
healthy people without heart disease. The cause is
thought to be due to severe spasm of the coronary
arteries. Anemia (decreased number of red blood cells to
carry oxygen) and lung disease may also bring on angina.
Figure A shows a normal artery with normal blood flow. Figure B shows an artery containing plaque
buildup
Plaque causes the coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to the
heart muscle is reduced. This causes pain and can lead to a heart attack.
Types of Angina
The three types of angina are stable, unstable, and variant (Prinzmetal's). Knowing
how the types are different is important. This is because they have different
symptoms and require different treatment.
Stable Angina
Stable angina is the most common type. It occurs when the heart is working harder
than usual. Stable angina has a regular pattern. If you know you have stable
angina, you can learn to recognize the pattern and predict when the pain will occur.
The pain usually goes away in a few minutes after you rest or take your angina
medicine.
Stable angina isn't a heart attack, but it makes a heart attack more likely in the
future.
Unstable Angina
Unstable angina doesn't follow a pattern. It can occur with or without physical
exertion and isn't relieved by rest or medicine.
Unstable angina is very dangerous and needs emergency treatment. It's a sign that
a heart attack may happen soon.
Variant (Prinzmetal's) Angina
Variant angina is rare. It usually occurs while you're at rest. The pain can
be severe. It usually happens between midnight and early morning. This
type of angina is relieved by medicine.

 Overview
 It's thought that nearly 7 million people in the United
States suffer from angina. About 400,000 patients go to
their doctors with new cases of angina every year.
 Angina occurs equally in men and women. It can be a
sign of heart disease, even when initial tests don't show
evidence of CAD.
 Not all chest pain or discomfort is angina. A heart attack,
lung problems (such as an infection or a blood clot),
heartburn, or a panic attack also can cause chest pain or
discomfort. All chest pain should be checked by a doctor.
Are there different types of
angina ?
 Some people have angina that comes on with a certain level of
exertion and goes away easily. They may have this kind of
angina for a long time. This is called stable angina.

 When the pattern of angina changes a lot, it's called unstable

angina. This is a sign of danger. Unstable angina includes
angina in someone who hasn't had it before. It also includes
more episodes of angina with less exertion, or any angina that
comes on during rest.

 Another sign of danger is chest pain that doesn't go away with

rest or after taking the medicine nitroglycerin. If you have chest
pain that doesn't go away, go to the emergency room right
away. Emergency Physicians and Nurses are trained to quickly
recognize and treat heart problems with the most effective
therapies available.
 Unstable angina may be the first sign of a heart
attack. If you get angina pain, you should call 108
since this is the fastest and safest way to get to the
Emergency Department. Paramedics can start
treatment before you get to the hospital.

 Do not go to your doctor's office or a clinic because

they will not be able to provide full testing or
treatment for a heart attack.

 If symptoms are mild and you decide to take your

own car, DO NOT DRIVE YOURSELF.
Does every one with CHD get angina ?

 Not all cases of myocardial ischemia cause

angina pain. Persons with diabetes are more likely
to experience "silent ischemia" with no symptoms at
all. Persons over age 70 often experience other
symptoms such as weakness, shortness of breath or
"blacking out spells" instead of angina. In some
cases people may experience heartburn or nausea
due to myocardial ischemia. These symptoms are
sometimes called variant angina.
Is all chest pain "angina?"

 Not all chest pain is from the heart, and not

all pain from the heart is angina. For
example, if the pain lasts for less that 30
seconds or if it goes away during a deep
breath, after drinking a glass of water, or by
changing position, it is NOT likely to be
angina and should not cause concern. But
prolonged pain, unrelieved by rest and
accompanied by other symptoms may
signal a heart attack.
Will angina cause a heart attack?

 An episode of angina is not a heart attack. Angina pain means

that some of the heart muscle in not getting enough blood
temporarily--for example, during exercise, when the heart has
to work harder. The pain does NOT mean that the heart muscle
is suffering irreversible, permanent damage. Episodes of
angina seldom cause permanent damage to heart muscle.

 In contrast, a heart attack occurs when the blood flow to a part

of the heart is suddenly and permanently cut off. This causes
permanent damage to the heart muscle. Typically, the chest
pain is more severe, lasts longer, and does not go away with
rest or with medicine that was previously effective. It may be
accompanied by indigestion, nausea, weakness, and sweating.
However, the symptoms of a heart attack are varied and may
be considerably milder.
When someone has a repeating but stable pattern of angina, an episode
of angina does not mean that a heart attack is about to happen. Angina
means that there is underlying coronary heart disease. Patients with
angina are at an increased risk of heart attack compared with those
who have no symptoms of cardiovascular disease, but the episode of
angina is not a signal that a heart attack is about to happen.

In contrast, when the pattern of angina changes--if episodes become

more frequent, last longer, or occur without exercise--the risk of heart
attack in subsequent days or weeks is much higher. A person who has
angina should learn the pattern of his or her angina--what causes an
angina attack, what it feels like, how long episodes usually last, and
whether medication relieves the attack. If the pattern changes sharply
or if the symptoms are those of a heart attack, one should get medical
help immediately by calling 908.
How is angina or CHD diagnosed?
 The symptoms you describe to your doctor will help your
doctor decide if you need to have your heart tested. Your
doctor will also consider if you have any conditions that
can increase your chance of heart disease. These
conditions include high blood pressure, diabetes,
smoking, or a high cholesterol level, and menopause in
women. If you have family members who have had heart
disease at a young age (under 50), your chance of
developing heart disease is higher.
 An electrocardiogram, sometimes called an EKG, is a
simple test that can show if your heart has been damaged
by a previous heart attack. The EKG can also show if
your angina is caused by your heart, if the EKG is done
while you are having chest pain. This test may be normal,
even in the presence of coronary artery disease, in some
people. This is especially true if pain is not present when
the EKG is done.
The next step after an EKG may be a stress test. Often, this test is done while you
walk on a treadmill. Or it can be done with medicines that put stress on the heart.
Your doctor will look at your EKG to see if it's abnormal when you exercise. This is
analogous to taking a car on a test drive at highway speeds to see how the engine
performs versus testing it in idle (a resting EKG).
Your doctor may also have x-rays of the heart taken before and after you exercise.

Special chemicals (radioisotopes such as thallium) are injected into a vein during
maximal exercise and taken up by normal heart muscle. A radioactivity counter and
computer measure the radioisotope distribution to different parts of the heart (a
"picture" is taken). Differences in radioisotope concentration and in the rates at
which the radioisotopes disappear indicate unequal blood flow. These pictures can
show if an area of the heart is short of blood during exercise. If this is so, it may
mean that the arteries supplying blood to your heart are blocked.
The most accurate (as well as most invasive) way to assess the presence and
severity of coronary disease is a coronary angiogram, an x-ray of the coronary
artery. A long thin flexible tube (a "catheter") is threaded into an artery in the
groin or forearm and guided to the heart. Dye is injected into the arteries around
the heart. X-rays are taken. If any of the arteries that supply the heart are
blocked, the x-rays will show it. These blockages can cause angina and put you at
risk of a heart attack.
What are the treatments for heart
disease?

 Prevention is the best treatment. The best way to prevent

coronary artery disease is to control high blood pressure,
diabetes or a high cholesterol level and, if you smoke, to stop
smoking. Whether you have these conditions or not,
maintaining a healthy diet, a healthy weight and a regular
exercise program can help you avoid coronary artery disease.
Hormone replacement therapy with a medicine called estrogen
also may help prevent coronary artery disease in women after
menopause.

 If you already have coronary artery disease, controlling blood

pressure, diabetes and cholesterol and quitting smoking are
important to keep the problem from getting worse. A healthy
diet, a healthy weight and a moderate, regular exercise
program are also important in people with coronary artery
disease.
Medication - Most people with heart disease need to take medicine. This
medicine may include one aspirin every day. This treatment has been shown to
reduce the chance of having a second heart attack in people who have already
had one. Medicines called beta blockers, **calcium channel blockers and nitrates
also help relieve angina.

Angina is often controlled by drugs. The most commonly prescribed drug for
angina is nitroglycerin, which relieves pain by widening blood vessels. This allows
more blood to flow to the heart muscle and also decreases the work load of the
heart. Nitroglycerin is taken when discomfort occurs or is expected. Doctors
frequently prescribe other drugs, to be taken regularly, that reduce the heart's
workload. Beta blockers slow the heart rate and lessen the force of the heart
muscle contraction.
**Calcium channel blockers, although effective in reducing the frequency and
severity of angina attacks may result in a higher overall death rate in patients with
underlying coronary artery disease (especially in people with a prior heart attack).
This is documented in shorter acting calcium channel blockers (those taken more
than once a day). Not enough information is currently available for longer acting
calcium channel blockers. The use of calcium channel blockers, particularly ones
that must be taken more than once a day have been discouraged in patients with
coronary artery disease .

Calcium channel blockers may still indicated for persons having high blood pressure
without coronary artery disease or certain heart arrhythmias. If you are taking a
calcium channel blocker and have had a prior heart attack or have been diagnosed
with angina please consult your doctor!
 Angioplasty is a treatment for heart disease. Angioplasty uses a tiny balloon to
push open the blocked arteries around the heart. The balloon is inserted the same
way that a cardiac catheterization is done, through a long thin tube inserted in an
artery in the arm or leg. A stent, which is a small metal tube, might be put into
the artery, where the blockage was, to keep the artery open longer.

Surgery - Another treatment for angina is bypass surgery. Veins or arteries from
the legs or breast bone are sewn into the arteries of the heart to bring blood past
a blockage and increase the blood flow to the heart. Bypass is usually done when
angioplasty isn't possible or when your doctor feels that the results would be
better with bypass surgery than with angioplasty.
Heart Angioplasty

Angioplasty Baloon
What are side effects of heart disease
treatment ?

 Each of the medicines prescribed for heart disease, just like most
medicines, may have side effects. Aspirin may cause upset stomach.
The nitrates may cause hot flushes and headaches. Beta blockers
cause fatigue and sexual dysfunction in some patients. Calcium
channel blockers may cause constipation and leg swelling. These are
some of the more common side effects of these medicines. Most
patients don't have side effects from these medicines. If you have side
effects after taking a medicine, tell your doctor.

 Every medical procedure, such as angioplasty or bypass surgery, has

a potential risk. The major risks can include heart attack, stroke or
even death. These possibilities are rare. Most patients do very well
with these procedures. After an angioplasty, you can expect to return
to your previous activity level, or even a better activity level, within a
few days. It takes longer to recover from bypass surgery.
Which treatment is right for me?
First you need to understand how serious your heart disease is and the
treatment choices you have. For less serious heart disease, you and your
doctor may consider medicine with or without angioplasty. As heart
disease becomes more serious, the choice of treatment includes bypass
surgery. If you have a more severe case of heart disease, you and your
doctor will consider which procedure will help you live a longer and better
quality life. The factors that affect this decision differ with each patient.

Once you have heart disease, does it ever go away?

If you have heart disease, you need to work with your doctor to
manage your risk factors and to monitor your condition. Heart disease
doesn't go away, but with proper treatment you can live longer and feel
better.
 Structure of the Heart

External view of a Mammalian Heart

The heart is a 4 chambered muscular pump located inside the chest or the
thoracic cavity. It is a mesodermal derivative and is a myogenic heart. The heart
is surrounded externally by a thin, transparent 2 layered serous sac called
pericardium. The narrow cavity between the 2 layers is called the pericardial
cavity which is filled with a watery fluid called the pericardial fluid. The fluid
performs 2 functions
a) it allows frictionless movements of the heart and
b) it protects the heart from mechanical shocks. The wall of the heart is primarily
made up of cardiac muscles called myocardium.
The heart is formed of 4 chambers, namely 2 auricles and 2 ventricles. The
auricles are named as right and left auricles and the ventricles are right and left
ventricles.
A groove is present externally between the auricles and the ventricles called the
coronary sulcus.
The ventricles also home two grooves present on them called anterior
interventricular sulcus and posterior interventricular sulcus. These sulci
receive coronary arteries through which the heart receives the blood.
Auricles
The right and the left auricles are separated by a fibrous partition called
interauricular septum. Both the auricles have very thin walls because they have
to push the blood only into the ventricles. The inner surface of the auricles is
very smooth except for a network of low ridges called the musculi pectinati
Diagram of Heart cut open
The right auricle receives deoxygenated blood through the 2 major veins, namely
the inferior vena cava, superior vena cava and the coronary vein. The left auricle
receives oxygenated blood from the lungs through the pulmonary veins.
An oval depression is present on the interatrial septum called the fossa ovalis. It is
actually the remnant of foramen ovale, which is an opening in the interatrial
septum of the foetal heart, which closes at the time of birth.
Ventricles
The auricles are separated from the ventricles by an auriculo ventricular septum.
The right auricle opens into the right ventricle by a right auriculo ventricular
aperture. The left auricle opens into the left ventricle by a left auriculo ventricular
aperture. The left auriculo ventricular aperture is guarded by a valve called
bicuspid valve. It has two cusps (flaps) and hence the name bicuspid. The right
auriculo ventricular aperture is guarded by a tricuspid valve containing 3 flaps.
Both the tricuspid and the bicuspid valves are fastened to small conical muscles
called the papillary muscles on the ventricular wall through several tendinous
strands called the chordae tendinae.
Section through Mammalian Heart
The ventricles have thicker walls than the auricles. The walls of the left ventricle is
about 3 times as thick as that of the right ventricle. This is because the left
ventricle has to pump the blood to the farthest end of the body, while the right
ventricle has to send the blood only to the nearby lungs.

Two main blood vessels carry blood from the ventricles. One large aortic arch
(aorta) carries blood from the left ventricle to the various parts of the body except
the lungs. The pulmonary artery takes blood from the right ventricle to the lungs.
The base of the aortic arch and the pulmonary artery are guarded by semi lunar
valves. Each semi lunar valve is made up of 3 half moon cusps (flaps), attached to
the wall of the aorta by one border with the curved edge free inside the lumen of
the aorta. They open during ventricular systole and close during ventricular
diastole. They allow the blood to flow into the aorta from the ventricles and the
reverse flow is prevented.

On the right wall of the right auricle is the sino-auricular node or SA node. It
represents the sinus venosus which has completely merged into the wall of the
right auricle. It is called as the pacemaker as the cardiac impulse originates from
here and it determines the rate of heart beat.
 Action is the proper fruit of knowledge.

The best of all medicines is resting and fasting

Health is a blessing that money cannot buy.

From Er.Sulthan
E Mail:er_sulthan@yahoo.com
Next Release…..

 Kidney Stones
 Medical Hand Book -8

From
Health Manager