CORONARY HEART DISEASE

Dr R Muthusamy Consultant Cardiologist, Westminster Healthcare, Chennai

Symptoms, Treatments and Costs

Heart disease (CHD) is the number one killer around the world and also in India. In the Western world, CHD incidence and the related mortalities are declining but in India it’s increasing. Literature search confirmed increasing prevalence, and related deaths are more common in the urban than in rural areas. The risk factors contributing to CHD are due to increasing urbanisation, increasing middle class, reduced physical activity, increased work and family related stress and deviation from our ancestral diet. Important modifiable risk factors for CHD are lipids, smoking (22.8%), high blood pressure (BP 25.9%), diabetes mellitus (DM 9.7%), abdominal obesity (6.7%), physical inactivity, low fruit and vegetables consumption and mental stress However, risk factors like sex of person, aging, and genetics cannot be changed and also still many risk factors for vascular disease are unknown to the scientific world. SYMPTOMS: The typical cardiac pain (angina pectoris) happens mainly during physical activities like walking uphill, against wind especially after a heavy meal, while carrying heavy weights. The character of the pain is like crushing in nature or placing a heavy weight on the top of chest. Often these pain travels (radiation) to neck, jaws, left upper limbs especially over the inner aspect towards little finger. Classical angina will be relieved by resting and after using a nitrate spray or tablet under the tongue. However, if this pain persists continuously, then urgent medical help must be sought immediately. Often elderly and diabetics (approximately 25%) may not experience any pain at all. INVESTIGATIONS: It is important that all types of chest pain should be assessed by specialist, especially a cardiologist. Initial investigations are various blood tests, electrocardiogram (12 Lead ECG), treadmill test (TMT) and echocardiogram. If these tests are normal or inconclusive, then further tests are needed at specialist heart centres which are myocardial perfusion scan (MPS) and CT coronary angiogram (CTCA) and selective diagnostic coronary angiogram. These tests help to confirm or exclude CHD and guide the therapy. Normally around 10- 40% of the people do have normal coronary arteries, more often seen in women. TREATMENTS: Aim of the treatment is to relieve the patient’s symptoms and to enable them to live longer. If you take 100 patients after angiogram, need Percutaneous Coronary Intervention (PCI), and Coronary Artery Bypass Surgery (CABG). The rest can be treated with medicine alone due to either normal/minimal coronary artery diseases or diseases which are not amenable for any type of interventional procedures. The initial medical treatment for established CHD is Aspirin (to thin the blood), beta blocker (Atenolol, Bisoprolol, Metoprolol, Nebivolol which reduce the oxygen consumption of the heart, reduce the heart rate, prevent rhythm problems and sudden death), cholesterol lowering drugs (Atorvastatin, Rosuvastatin) and short acting nitrates to be used under the tongue or check. There are other medications to add on to these regimes if the above medications fail to control the anginal symptoms which are long acting Nitrates, Diltiazem, Verapamil, Amlodipine, Isosorbide mono nitrates, Nicorandil, Ranolazine and Ivabradine. Often many people end up in taking several medications due to significant symptoms. However, medications fail to control the symptoms then PCI or CABG will be considered and the PCI vs CABG option depends upon the coronary anatomy. Apart from treating these patients with medications or interventions like PCI and CABG, their modifiable risk factors should be addressed since the disease is still exists and may progress. It is very important that all the patients must adhere to the medications prescribed by the Cardiologist and should not stop or change without consultation with their personnel cardiologist. Also, patients should look after their health by as per their doctors advise including daily 30 minutes long exercise and rehabilitate themselves. The cost of the procedures various depending upon the hospital and the doctor whom he/she consult. Again, the fees structure is different for different type of accommodation patient choose. For example, the cost of cardiac catheterisation in Rs 15,000 – 27,000, PCI 1,10,000 – 1,50,000 plus cost of the stents, permanent pacemaker insertion Rupees 1,10,000 – 1,50,000 plus cost of the pacemaker unit and implantable cardioverter defibrillator Rupees 7,00,000 – 8,00,000. Cost of CABG cost Rupees 4,00,000 – 5,00,000. Also, there may unexpected charges which will be difficult predict. CONCLUSION: In summary, one should aim to prevent the development of heart disease by leading a healthy life style and address their risk factors. However, once developed, then it must be investigated by specialist cardiologist and treatment should be tailored according to the individual’s cardiac disease and needs. Health is our wealth.