One in three Irish people have a parent, brother or sister with heart disease, which remains the single biggest cause of death in the Western world. Despite this, great strides have been made in its prevention and treatment in the last two decades that has hugely improved outcomes and reduced mortality.
This is in large part due to better control of risk factors like blood pressure and cholesterol, new cardio-protective medications and access to modern medical interventions.
Coronary artery disease occurs when the blood vessels that supply the heart muscle become coated with plaque. To some extent, this is a normal part of ageing but when excessive plaque builds up it can lead to significant narrowing (50-70%) that compromises blood flow causing angina.
Cardiac pain is usually felt as a heaviness or crushing in the centre of the chest that is often precipitated by exertion and relieved by rest. It can radiate into the arms, jaw and occasionally the back and may be associated with shortness of breath.
Pain that is sharp in nature, affected by breathing or related to indigestion is usually non-cardiac in origin. However, acid reflux can produce pain identical to that of angina and the distinction is not always clear. When chest pain occurs at rest, it may indicate unstable angina or a heart attack particularly if lasting for more than 20-30 minutes.
Coronary disease may be silent particularly in those who are less active. This is because while arteries may be significantly narrowed, blood flow may be sufficient to meet the demands of low level activity. Indeed, it may only come to attention after a heart attack.
In addition, sometimes the symptoms of chest discomfort are vague and ignored or put down to other things. However, it is crucially important in anyone to investigate such symptoms especially if there is a strong family history.
A tracing of the heart (ECG) may show evidence of underlying heart disease but unless done when having pain it is not very sensitive. However, an exercise stress test which involves running on a treadmill with continuous ECG monitoring is a good way of detecting significant coronary disease. When symptoms are reproduced in association with characteristic changes of the heart tracing, it is highly suggestive of angina. In this setting or after a heart attack a coronary angiogram is often performed. This is a minimally invasive test that involves injecting dye under x-ray guidance into the coronary arteries and gives a clear picture of the blood supply to the heart and the extent and location of any arterial narrowing.
With significant two or three vessel disease, a coronary artery bypass is generally recommended. A treatment for single vessel or less severe disease often involves inflating a balloon device to open up the artery (angioplasty) followed by insertion of a stent (coiled hollow tube) to maintain better blood flow. This procedure has also revolutionised the acute treatment of heart attacks enabling the unblocking of occluded arteries, restoring blood flow and reducing heart muscle damage. For this reason, early presentation to hospital with any ongoing acute chest pain is crucial.
So what is the secret to a healthy heart? The build of up plaque in the coronary arteries is accelerated by high cholesterol and blood pressure, diabetes and smoking. When two or more of these factors are combined the risk increases exponentially. Genetic factors also exert a very important influence with disease often presenting earlier and being more severe in those with a strong family history.
Alcohol excess can contribute to higher blood pressure, hardening of the arteries and also directly damage the heart muscle. If you are overweight, extra strain will be put on your heart. Fat tissue is metabolically active and produces inflammatory chemicals that may contribute to coronary disease and plaque inflammation as does smoking. This predisposes to plaque rupture in the arteries that can precipitate blood clots and acute blockages giving rise to a heart attack.
Stress is also a proven risk for heart disease and depression appears to increase the risk of adverse cardiac events. Positive factors include a Mediterranean diet which may reduce the risk of developing heart disease by up to 50% and constitutes fish, fruit and vegetables, poultry, wholegrains, nuts, unsaturated fats and olive oil. In particular, emphasis is on reducing red meat, sugary and processed foods.
Regular exercise can improve several risk factors and also substantially lower cardiac risk with about 30 minutes of moderate physical activity being recommended five times per week.
Remember what’s good for your heart is also good for your brain and is protective against memory loss, dementia and importantly stroke. To summarise, keeping your blood pressure and cholesterol in check and avoiding smoking are the most important medical factors to address. Combining this with regular exercise, alcohol in moderation, a Mediterranean-type diet and a maintaining a normal weight lowers risk to a very low level.
Finally, if you ever get central chest tightness or discomfort even if only on significant exertion make sure to get it checked out.
Dr Kevin McCarroll is a consultant physician in geriatric medicine in St James’s Hospital, Dublin.