Myocardial Infarction (Heart Attack)

By: BigFudge

Breast cancer organizations in the United States receive more funding than any other disease,
despite the fact that Heart Disease is the number one killer in the United States. Heart Disease
kills more than ten times as many people as breast cancer, while breast cancer organizations
receive about 5 times the amount of funding compared to heart disease (6). One fatal result of
heart disease is a heart attack, which the medical community calls a myocardial infarction (MI).
Many have heard of a heart attack, but a large proportion of them do not know exactly what they
are.

To understand what is going on in a heart attack, we need to understand the basics of the heart in normal situation. The heart pumps the blood around the body, bringing nutrients and oxygen to
all the cells in your body. Because the cells can’t use any nutrients from the blood on the inside
being pumped, the heart has very specific blood vessels that receive the freshest blood. These
blood vessels go around the heart, making sure it is always supplied with oxygen.

The way the heart pumps blood is very similar to the way one pushes toothpaste out of the tube:
from the bottom of the tube. The only difference is the mechanical action pushes the blood in
the heart from the top to bottom, and then out. As for the actual contraction, the cells use tiny
electrical currents to contract. As the electricity travels top to bottom, the heart contracts, forcing
blood to get pushed out. It is important to know that this electrical current is very organized and
travels and a very specific pattern in healthy individuals. Thus, the blood circulates and the body
and heart is happy.

Understanding a myocardial infarction goes back to the blood vessels surrounding the heart,
because the heart cells cannot receive oxygen from the blood inside being pumped. Before a
heart attack even happens, the blood throughout the body has plaque and fat naturally circulating.  If there is too much plaque and fat in the blood, it will deposit on the walls of the vessels, limiting the blood flow through it. Fat and plaque can also stick together and form little balls which can become lodged and cut off blood flow as vessels become narrow, which is called ischemia. An MI is where these fat and plaque deposits cut off blood flow to the blood vessels surrounding the heart, preventing blood from oxygenating the heart tissue. Without the oxygen from the blood, the heart tissue begins to die in the area affected. In severe heart attacks, damage to the heart from ischemia progresses and the electrical conduction, which is normally extremely organized, becomes extremely chaotic. This causes the heart to quiver, rather than rhythmically pumping. Blood stops moving, and the body runs out of oxygen, including more heart tissue. Net result: death.

Signs and symptoms are provided in textbooks, but in reality, they are very diverse and vary
person to person. Most commonly, patients express the following complaints: chest pain which
radiates to other parts of the body, profuse sweating, nausea, vomiting, shortness of breath or
difficulty breathing, and/or abdominal pain. Some show none of these signs, and an MI is
diagnosed by an electrocardiogram or levels of troponin in the blood.

As for treatments, there are anticoagulants like heparin and coumadin, and platelet aggregation
inhibitors like aspirin. Nitroglycerin is commonly prescribed to patients who have a history of
heart problems, and makes the blood vessels bigger which can alleviate the chest pain associated. Antihypertensives like Lisinopril and Amlodipine are showing limited long term benefits (5). Improvements to diet and activity level are important, both to prevent initial and future MI’s. Once an MI is discovered within the hospital, it is critical to get the patient to a catheterization lab, where there are a few options. One option is using blood vessels from elsewhere in the body to replace or redirect the blood flow around the blockage. Another way is to put a stent in, a metal object which forces the vessel wide enough for blood flow. Lastly, they can pass a wire through the blood vessels and destroy the clot mechanically or with chemicals.

According to the American Heart Association, Mayo Clinic, and the National Heart, Lung, and
Blood Association, the best way to prevent an MI is through diet and exercise (1) (3) (4). A
healthy lifestyle may not completely prevent it, especially with a family history of heart disease,
but use of blood thinners is more common to prevent it. Avoiding other risk factors is important
as well, including but not limited to smoking, drinking, stress, and lack of sleep,

Here are some numbers to scare you into making healthier choices. According to the CDC, heart
disease claims over 610,000 victims every year in the United States alone, attributing to over a
quarter of all the deaths in the country. Furthermore, “Every year about 735,000 Americans have
a heart attack. Of these, 525,000 are a first heart attack and 210,000 happen in people who have
already had a heart attack” (2). They go on to note that almost half of the country has at least
one high risk factor for heart disease, such as high blood pressure, high cholesterol, or smoking.

Hopefully by now you get a sense of what a myocardial infarction is, some common signs, and
some treatments. If the numbers of how prevalent didn’t scare you, millions of americans share
the same disposition. Now I recognize that not all have access to the information or the financial
means to necessarily act on this, but that doesn’t mean you can’t use this information to help
your loved ones. I should also note that I am not saying breast cancer shouldn’t receive less, but
merely pointing out the discrepancy in how common the diseases are.

Bibliography

1) American Heart Association. (2014, April). How to Help Prevent Heart Disease At
Any Age. Retrieved February 01, 2016, from http://www.heart.org/HEARTORG/HealthyLiving/HowtoHelpPreventHeartDiseaseAtAnyAge_
UCM_442925_Article.jsp#.VqoFLIrLIU

2) Center for Disease Control. (2015, August 10). Heart Disease Facts. Retrieved February
01, 2016, from http://www.cdc.gov/heartdisease/facts.htm

3) Mayo Clinic. (2014, November 15). Heart attack. Retrieved February 01, 2016, from
http://www.mayoclinic.org/diseasesconditions/heartattack/basics/prevention/con20019520

4) National Heart, Lung, and Blood Institute. (2015, November 6). How Can a Heart Attack
Be Prevented? Retrieved February 01, 2016, from http://www.nhlbi.nih.gov/health/healthtopics/topics/heartattack/prevention

5) Psaty, B. M. (2003). Major outcomes in high-risk hypertensive patients randomized to
angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT). American College of Physicians Journal Club, 139 , 7. Retrieved February
11, 2016, from acpjc.acponline.org/Content/139/1/issue/ACPJC20031391007.htm

6) Vox. (2014, August 20). The truth about the Ice Bucket Challenge: Viral memes
shouldn't dictate our charitable giving. Retrieved February 01, 2016, from
http://www.vox.com/2014/8/20/6040435/alsicebucketchallengeandwhywegivetocharitydonate

Raynaud's Disease

By: TheGreenLabCoat

Working in Family Medicine, you see several chronic diseases on a daily basis: diabetes mellitus 2, hypertension, and osteoporosis - Or as one of our elderly patients jokingly refers to them, “all these old people diseases.” Recently during a new patient visit, I noticed that this patient’s fingers were a different color from the rest of her hand; fleshy, pink hands but with almost paper white fingers. At first I thought it might have been a skin discoloration that naturally occurs in some people, but through the course of the visit her hand gradually turned blue, and then a bright shade of red. I couldn’t help but to ask the patient, “Are you aware that your fingers have been changing colors since you sat down in here?” The patient waved her unusually colorful hand in the air, stating “Oh honey, I have Raynaud’s, it's fine. I was just holding my soda.” Not knowing exactly what she meant at the time, I decided to educate myself on the subject: What is Raynaud’s?

Raynaud’s Disease, named after Maurice Raynaud in 1862, is a disorder of the blood vessels that causes them to overreact, predominantly in the hands and feet. Our body has an internal thermostat with many locations of thermometers. When we are cold, the sensors in our body tell us “Hey, we need to keep the heat up so that all of our organs continue to function.” It sends out a signal that binds to receptors on our blood vessels, instructing them to secrete vasoconstriction hormones. When this happens, our blood vessels constrict, kind of like shutting all the windows around the house to keep the heat in. In this situation there is less blood going to our extremities, keeping the core of our bodies warmer. People who have Raynaud’s disease are unable to regulate the appropriate blood flow when exposed to cold temperatures. Their blood vessels spasm, which can cause pain, numbness, and tingling. Color changes in fingers are the most observable symptoms when an attack is happening. Emotional distress may also be a trigger of this phenomenon.

Though the exact cause of Raynaud’s is still unknown, scientists have been able to separate this disease into two major classifications: Primary Raynaud’s Phenomenon (PRP) and Secondary Raynaud’s (SR). PRP is the most common type in most people. Development can occur at any age but happens most frequently between the ages of 15 - 30, and it typically affects women more often than men. If a family member has PRP, there is a 33% chance that their offspring will develop the disease as well.

Secondary Raynaud’s (SR) has been associated with rheumatic disorders such as Lupus and scleroderma. Depending on severity of SR, it could be life threatening due to the hardening of blood vessels which down the road could be a contributing factor of heart issues such as ischemia or plaque buildup in the arteries.

Neural abnormalities, hormonal and genetic factors, and smoking all have been noted as potential causes of this disease. A few blood tests and observing capillaries of the fingernails under a microscope are the common methods of diagnosing Raynaud’s Disease. There currently are no medications to cure Raynaud’s. Outcomes for patients with PRP are usually very good. No reported mortality and little morbidity. In very rare cases, ischemia of the affected body part can result in necrosis.

Following the guidelines below can help prevent an attack:

●        Keep warm - Manually regulating body temperature can help to prevent an attack. For instance, avoid moving from a hot summer day to a cold air conditioned room. Wearing mittens and socks to bed during winter, or changing out of wet clothing items a rainy day are both good preventative measures.

●        Do not smoke - Nicotine in cigarettes causes the body temperature to lower, which may trigger an attack.

●        Control stress - Emotional well being can prevent an attack. Relaxation methods such as meditation has been reported useful.

●        Avoid stimulating medications, foods - Vasoconstrictor medications such as narcotics, beta blockers (blood pressure medication) OTC cold medication, and caffeine.

As for SR, there is no FDA-approved medication specifically, but this type of Raynaud’s is usually treated with calcium channel blockers such as amlodipine (norvasc) and felodipine which work by relaxing the smooth muscle and dilating the small blood vessels.

When my patient returns to the clinic, hopefully just for a routine check up, I will be able to have a conversation with her about this disease and not look like a deer caught in headlights. I might be able to learn a few pointers from her to potentially offer future patients with this disease some information.

References

Peer-Reviewed

Herrick, A. L. (2005, May 01). Pathogenesis of Raynaud’s phenomenon. Retrieved February 12, 2016, from http://rheumatology.oxfordjournals.org/content/44/5/587.full.pdf html

Wigley, F. M., MD. (2002, September 26). Raynaud's Phenomenon. Retrieved February 12, 2016, from http://www.nejm.org/doi/full/10.1056/nejmcp013013

Non-Peer-Reviewed

Hansen-Dispenza, H., MD, & Lisse, J. R., MD,FACP. (2015, November 17). Raynaud Phenomenon. Retrieved February 12, 2016, from http://emedicine.medscape.com/article/331197-overview

Mayo Clinic Staff. (2015, March 04). Diseases and Conditions Raynaud's disease. Retrieved February 12, 2016, from http://www.mayoclinic.org/diseases-conditions/raynauds-disease/basics/definition/con-20022916

Raynaud’s Phenomenon by Dr. Nicolas Gumpert is licensed under CC BY 2.0