CARDIAC DISEASE
Heart Of The Matter

By RAJGOPAL NIDAMBOOR

Do you know that in the US, 500 people die of cardiovascular disease every day? Or, do you know two out of six, in India, for example, die from heart disease? That almost half of all the deaths that have occurred, in the US alone, are due to heart disease? That every 30 seconds someone dies from a heart, or blood vessel, ailment? And, six out of ten males over the age of 30 have signs of heart disease? Probably, yes. And, maybe you care, or you don’t -- so long as it doesn’t affect you, or someone close to you.

What emerges clearly by way of such startling paradigms is quite obvious: heart disease is a top threat to health for many of us. Yet, our traditional approach to the danger is passé: most of us have a stoical tendency to ignoring our body signals. This would only call for trouble -- sooner than later.

So, what would be most useful, and handy, in such a context? A belief in common sense pathways: of getting to know where you stand vis-à-vis your cardiac health. Something that could save your life.

Take Heart

First, the basics. The heart, as all of us know, is a four-chambered pump -- a little larger, perhaps, than your fist. It weighs just less than a pound; yet, it pumps about 2,000 gallons of blood through your body in a day. That’s not all. The heart also carries waste products from the cells to the liver, kidneys, and lungs, where they are processed and disposed off. In simple terms, the amount of pumping your heart has to do depends on the amount of activity, and stress you may put it through. To choose but just one example: running requires much more blood and pumping action than sleeping.

The heart’s muscle -- myocardium -- is essential to our heart’s pumping action. It must have oxygen and nutrients to work -- “elements” which it receives through the three coronary arteries, and their branches, outside of the heart. Heart disease occurs when plaque, composed of fats and scar tissue, thickens the inner walls of blood vessels. It most often affects the vital coronary arteries. What’s more, plaque eventually crowds and narrows them, choking off easy passage for blood and its components. Called atherosclerosis, the condition develops silently, sometimes without symptoms. Atherosclerosis, put simply, is a slow progressive disease that may start very early in life.

Control Risk Factors

A host of risk factors plays a major role in the development of heart disease. For example: cigarette smoking, physical inactivity, stress, obesity, high blood pressure, high blood cholesterol, diabetes etc., The risk factors are two-fold: controllable, and not controllable. Also, if you have any two of any of the following risk factors -- high blood pressure, high blood cholesterol, and cigarette smoking -- the chance that you will have a heart attack is four times greater than if you have none. However, if you have all the three major controllable risk factors -- high blood cholesterol, high blood pressure, and smoking -- the chance is eight times greater.

However, it is quite possible to “control” the three major risk factors, as also other risks -- viz., diabetes, obesity, a sedentary lifestyle, type “A” personality -- aggression, certain medications/medical conditions. But, there are also risks you cannot control: male susceptibility, heredity, and increased age. So, if you have increased risk of heart disease, you should try to minimise the risk factors. As for those with genetic related phenomenon, or a strong family history of premature coronary disease, they’d better take all steps possible. For one primal reason -- they are definitely at high risk… Yes, you will also have to promptly undertake the following measures -- quit smoking, avoid alcohol, restrict salt usage, limit calorie intake, exercise regularly, reduce your emotional stress levels through meditation or yoga, get tested for hypertension, and elevated fat etc.,

It's a very complex process, doubtless. All the same, it is extremely important for each of us to get a complete lipid profile, and look at cholesterol levels, and other factors. You should try to have a total cholesterol level of 180, or less. It is also imperative that you lower your blood pressure -- the higher your blood pressure, the greater is your risk of heart attack, strokes, and kidney disease.

High blood pressure, or hypertension, tends to often run in families. The caveat? If any of your close relatives have had high blood pressure, heart attack, or stroke, at an early age, you should have your blood pressure monitored regularly… Forewarned, after all, is forearmed.

Atherosclerosis

The explosion of dietary fads and changes, together with the boom in cigarette smoking and alcohol consumption, has led to an increased number of people in a given population presenting with clinical manifestations of arterial disease. It is, of course, a known fact that arterial disease is due to atheromatous [lipid deposit] degeneration of the arterial wall.

Atherosclerosis [pronounced, ath-er-o-skleh-ro-sis] comes from two Greek words, athero, meaning gruel or paste; and, sclerosis meaning hardness. Atherosclerosis is a process in which deposits of fatty substances -- cholesterol, cellular waste products, calcium [not dietary, or supplement] and other substances -- build up in the inner lining of an artery. This build up, as you already know, is called plaque. Plaque usually affects large- and medium-sized arteries. Some hardening of the arteries often occurs when people grow older.

A generalised degenerative disease, atherosclerosis is often found in all major arteries beyond middle age -- however, the fatty streak, which represents the disorder, is a reversible lesion. Yet, it may expand on to the next stage of the condition -- the fibrous plaque.

Plaques can grow large enough to considerably reduce the blood flow through an artery.

The coronary arteries, as you know, bring blood to the heart muscle. The aorta is the large vessel that the heart pumps blood through to the body. However, most of the damage occurs when the arteries become brittle and rupture. Plaques that rupture cause blood clots to form. Clots can block blood flow, or break off, and travel to another part of the body. Either event can obstruct a blood vessel that feeds the heart. When this happens, it causes a heart attack. Likewise, if a blood clot blocks a blood vessel that feeds the brain, it can cause a stroke. Also, if blood supply to the arms, or legs, is compacted, it can cause difficulty in walking and ultimately gangrene. Gangrene is necrosis [pathologic death of one or more cells, or tissue, or organ] due to obstruction, loss, or reduction of blood supply.

Beginning & Progression

Atherosclerosis is a slow, complex disease that typically starts in childhood and progresses when people grow older. In some people, it progresses rapidly, even in their third decade. Researchers say the process begins with damage to the innermost layer of the artery -- the endothelium. Other causes that are implicated in the process are --

• Elevated levels of cholesterol and triglycerides in the blood.
• High blood pressure.
• Tobacco/cigarette smoke; also, alcohol use. Tobacco smoke greatly worsens atherosclerosis and speeds up its growth in the coronary arteries, the aorta, and the arteries in the legs.
• Diabetes.

Genetics

Research and clinical studies suggest that men -- and, most people -- with a family history of premature cardiovascular disease have an increased risk of atherosclerosis. It goes without saying that the two risk factors cannot be controlled. But, the silver-lining is -- research demonstrates the benefits of reducing the controllable risk factors for atherosclerosis:

• High blood cholesterol [especially, LDL or “bad” cholesterol over 100 mg/dL].
• Cigarette smoking and exposure to tobacco smoke.
• High blood pressure.
• Diabetes.
• Obesity.
• Physical inactivity; and, lack of exercise.

Research also suggests that inflammation in the circulating blood may play an important role in triggering heart attacks and strokes. Inflammation is the body’s response to injury, and blood clot is often a part of that response. Blood clots, as described earlier, can slow down, or stop blood flow in the arteries.

Blood [Plasma] Lipoproteins

There are two important elements which need to be specially looked into. They are --

• Chylomicrons.
• The cholesterols: low-density lipoproteins [“bad;”LDL]; high-density lipoproteins [“good;” HDL].

Chylomicrons are involved in the transportation of dietary “lard” from the gut to adipose [fat] tissue, including the liver and muscle cells. While they possess the heaviest mass of any lipid-containing particle, they seem to be rich in triglycerides. Generally, fat absorption is completed within a few hours of ingesting food. During the process, the chylomicron concentration is subject to fluctuation. In fit, healthy people chylomicrons account for a modest post-food intake rise in triglycerides. However, in individuals where the clearance of chylomicrons from the circulation is delayed, there may be a marked rise in triglycerides following food ingestion. This denotes a pathological condition, or disease.

Cholesterol can be both “good” [HDL] and “bad” [LDL]. So, you may well ask the question -- why is LDL cholesterol considered “bad?” When excess LDL cholesterol circulates in the blood, it can leisurely build up in the inner walls of the arteries that feed the heart and also brain. Slowly enough, and in association with other substances, LDL can form plaques that can clog the arteries. This condition, as you know, is called atherosclerosis. The consequential effect may be a heart attack or stroke.

The levels of HDL cholesterol and LDL cholesterol in the blood are measured to evaluate the risk of having a heart attack. The optimal level for LDL cholesterol is less than 100 mg/dL; experts suggest that a level of 130 mg/dL is quite preferable for most people. A high LDL level -- more than 160 mg/dL or 130 mg/dL, or above, especially if one has two or more risk factors for cardiovascular disease -- mirrors an amplified risk of heart disease. It is primarily for this reason that LDL cholesterol is habitually called “bad” cholesterol.

On the other hand, approximately one-third to one-fourth of blood cholesterol is carried by HDL. Labelled "good" cholesterol, a high level of HDL seems to shield us from heart attack. As a matter of fact, experts reckon, low HDL cholesterol levels -- less than 40 mg/dL -- enhance the risk of heart disease. Clinicians also think that HDL is likely to carry cholesterol away from the arteries and back to the liver, from where it’s expelled from the body. It is also suggested that HDL removes excess cholesterol from the plaque in the arteries, and slows down their build-up.

There is also another type of cholesterol, lipoprotein-[a] -- Lp[a] -- which is a genetic variation of plasma LDL. A high level of Lp[a] is an important risk factor; it is said to establish premature elevation of fatty deposits in the arteries. Although the exact mechanism of such a process is not very well understood yet, it’s, in effect, known that lesions in the artery walls contain substances that may possibly interact with Lp[a]), and lead to the fatty build-up.

Cholesterol

The test for cholesterol is simple. All your laboratory technician needs to do is take a blood sample from a vein and identify the levels of HDL and LDL. There is no need for you to change your diet, or fast, before you undergo the test. It depends in the light of your family history as to how often you need to have your cholesterol levels measured. It is recommended that you could have the test done once every year; or, once every two years -- or, on the advise of your family physician. Cholesterol is measured in millimoles per litre. The recommended, or ideal, total cholesterol level is less than 5.2 mmol/l.

How To Lower “Bad-LDL” Cholesterol & Increase “Good-HDL” Cholesterol

• You need to monitor your cholesterol intake watchfully. All the cholesterol you require is produced by your body. Extra intake by way of food is superfluous to the amount of cholesterol required by your body.
• Avoid, or reduce, animal fats, especially eggs, full-fat cheese, milk, ice-cream, and butter.
• Increase your fibre intake -- e.g., bran, brown rice, leafy greens.
• Increase your intake of rice and pulses -- in other words, complex carbohydrates.
• If you are overweight, you ought to shed those bulges. In simple terms, reduce weight.
• Stick to a 20-minute work-out, or exercise, at least 4-5 times a week; or, walk for 30-35 minutes, four times, during the same period.
• Stop smoking -- this is a must.
• It is said that moderate consumption of red wine can increase HDL cholesterol [However, it must be emphasised that most people do not use alcohol as “medication” -- which is a fallacy. Most important: one needs to balance the benefits against the increased risk of alcoholism, cirrhosis of the liver, and breast cancer -- not to speak of accidents due to drunken driving].

Hyperlipidaemia

Hyperlipidaemia is an elevation of lipids [fats] in the bloodstream. Lipids include cholesterol, cholesterol esters, or compounds, phospholipids and triglycerides. They are transported in the blood as part of large molecules called lipoproteins.

In simple terms, hyperlipidaemia is a condition where there’s an excessive amount of cholesterol in the blood. The state is also called hypercholesterolaemia.

Types

When hyperlipidaemia is defined in terms of a class or classes of elevated lipoproteins in the blood, the term hyperlipoproteinaemia is used. Hypercholesterolaemia is the term for high cholesterol levels in the blood. Hypertriglyceridaemia refers to high triglyceride levels in the blood. They, singly, or jointly, undermine cardiac health.

Triglyceride is a form of fat. It is derived from food and is also made in your body. People with high triglycerides often have a high level of total cholesterol, a high level of LDL cholesterol, and a low HDL cholesterol level. Many people with heart disease also have high triglyceride levels. People with diabetes, and obese individuals, are also likely to have high triglycerides. Triglyceride levels of less than 150 mg/dL are normal; levels from 150-199 are borderline high. Levels that are borderline high, or high [200 mg/dL to 499 mg/dL], would need treatment. Triglyceride levels of 500 mg/dL or above are very high, and not safe. Patients with high triglycerides, who also have high LDL cholesterol levels, need to be treated promptly and effectively.

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