There will be no symptoms till the fourth decade. Initial symptoms may be palpitations due to irregular heart rhythm and breathlessness on exertion. Those symptoms may eventually develop to swelling of legs, cough with frothy blood stained sputum, and even stroke due to clot formation of heart.

Once symptoms occur, it is important to perform imaging on the heart to plan for treatment. If the valve stiff due to deposit of calcium salts, surgery is recommended. Alternatively, PTMC (Percutaneous Transvenous Mitral Commissurotomy) or balloon valvuloplastry, is a semi-invasive procedure where a balloon is used to dilate the narrowed mitral valve.

How is PTMC done?

This procedure can only be carried out through the groin approach. Both the femoral vein and artery will be punctured and one sheath will be inserted through each vessel. A long pigtail catheter will be positioned in the left ventricle the same way as a coronary angiogram. Then a long puncture needle will be placed at the right atrium through the femoral vein. A long coil is then passed to the left atrium through the hole punctured. A balloon-tipped catheter (Inoue balloon) is then guided through the hole created to the left atrium and from there passed through the mitral valve.

The Inoue balloon is inflated several times to stretch the narrow segment of the mitral valve. The entire balloon, catheter, coil and other foreign bodies will be removed. The hole created will usually close off by itself. Even if it is not sealed, such a small hole shouldn’t cause any problem to the heart. Patient will need antibiotics before and after the procedure.

In PART 2 of our look at the symptoms and risks associated with heart attacks, renowned cardiologist Dr Michael Lim Chun-Leng, who is the Medical Director of the Singapore Heart, Stroke & Cancer Centre and Dean of the College of the Asian Pacific Society of Cardiology discusses various ways in which you can minimise the risk of developing heart disease.

Q. What factors can help patients reduce the risk of a heart attack?

Diet: The key is to enjoy a sensible diet and eat in moderation. Eat from a wide variety of food – increase intake of complex carbohydrates (rice, potatoes and whole-grain bread) as well as fruits and vegetables. At the same time, reduce consumption of fats, sugar, salt and alcohol. It is also important to drink a lot of water.

Exercise: Exercise is good for the body in general, but it is important not to over strain yourself, especially if you are in your late 30s or 40s. Personally, I would recommend 30 minutes of brisk walking three to four times a week as a relatively safe form of exercise. This helps to keep the body mobile without placing too much stress on the joints.

Regular Medical Review: Regular medical review by the family doctor can aid in controlling risk factors and maintaining a healthy lifestyle. At the same time, it may also mean quicker detection and earlier treatment of other possible ailments.

Q. What about health supplements? Can they help prevent heart disease?

There are many health supplements which claim to have heart attack prevention properties. However, a study in the New England Journal of Medicine showed that there was no difference between people who took these Vitamin B supplements and those who did not in terms of their chances of developing heart attacks. Hence, it would be wise not to buy into these claims unless they are accompanied by results from proper research trials. The only supplement which has data to show benefit is fish oil.

Q. What drugs are used in the prevention and management of coronary heart disease?

The entire group of statins are the primary drugs used. Study results clearly show that patients who had never suffered from any heart attacks, but had elevated cholesterol levels and were treated with statins had a lowered chance of suffering a heart attack or stroke. As technological advances in medicine gradually allow early detection and prevention, medicine will shift from treating diseases to the prevention of disease. The other major group of drugs are the anti-platelet drugs such as aspirin, ticlopidine and clopidogrel. They are used to prevent clot formation when a cholesterol plaque in the heart artery ruptures. Clot formation in the heart artery can result in occlusion of the heart artery and can cause a heart attack.

Q. What are the side effects of the drugs?

Studies have shown that out of every 1000 people who take statins, only about four would develop some elevation in their liver enzymes. One in 10,000 may develop slight elevation in their muscle enzymes. Severe elevation in enzymes is extremely rare, probably only one in a few million patients would suffer from this.

Q. What kind of symptoms indicate an imminent heart attack?

Shortness of breath on exertion, chest tightness or chest pains often precede a heart attack but in reality, many of these patients present with these symptoms only when they are about to have a heart attack. Such symptoms occur when more than 70% of your arteries are clogged up. However, studies have shown that the majority (two thirds) of heart attack patients have only a 40% to 60% diameter narrowing of the heart arteries and do not feel any chest pains until they get a heart attack.

Q. How does advanced technology help with heart disease?

In the last few years, technological advances have made it possible to take X-ray pictures of the heart arteries in three dimensions without the need to put a tube into your body. In the past, the usual non-invasive tests such as treadmill testing, stress echocardiography and nuclear perfusion scans have been used to screen for blockage of the heart arteries. But they can only detect patients with severe blockage, and even then, for those with severe blockage these tests can only pick up 70% to 90% of these patients. Today, CT angiogram of the heart arteries allows us to visualise the arteries within seconds in a safe and non-invasive manner. This test is a painless outpatient X-ray scan. Its greatest advantage is that it will allow doctors to make a more accurate diagnosis and begin earlier treatment of heart disease.

Q. Who is at risk of a heart attack?

The main risk factors are high cholesterol, high blood pressure, diabetes mellitus and smoking. Men, older people, and people with a family history of stroke and heart disease, tend to face a higher risk of cardiovascular disease.

Q. How often should a screening test be taken?

Patients should see their family doctors for annual assessment and to control risk factors. For those who have had a CT angiogram of the heart arteries, it is usually unnecessary to repeat it for at least another five years.

To be continued…

What is Stroke?

Strokes occur when a part of the brain does not get sufficient blood supply.  This may be the result of a blood vessel blockage (ischaemic stroke) or rupture (haemorrhage stroke) in the brain.  Blood vessel blockages may occur with blood clots forming directly in blood vessels in the brain (thrombotic stroke), around regions of blood vessel walls with fatty deposit build-up.

Blood clots could also travel from the heart (formed in the heart from abnormal stasis of blood due to impaired heart function) or arteries in the next to block blood vessels in the brain (embolic stroke).  Blood vessel rupture may occur due to a region of blood vessel wall thinning or weakness (eg. aneurysm)

What are the symptoms of Stroke?

• sudden hemi-body numbness/weakness/clumsiness
• swallowing difficulties, slurring of speech or comprehension difficulties
• double vision or sudden loss of vision in one eye
• sudden loss of balance, unsteadiness of gait or dizziness
• sudden alteration  of conciousness
• sudden, most severe headache of your life

Transient ischaemic attack (TIA) refers to symptoms that usually last under an hour (up to 24 hours) and are regarded as ‘mini strokes’ or ‘warning of impending strokes’.  These occur when the blood supply to the affected brain is transiently cut off.  If left untreated, up to a third of patients with TIA may go on to have a full-blown strokes.

Relatively small strokes are termed lacunar strokes with larger ones may affect the circulation of the anterior (front 2/3 of the brain) or posterior (rear 1/3 of the brain including the brainstem) regions of the brain either partially or totally.

How to identify the risk factors of stroke?

Age, smoking, hypertension, hypercholesterolaemia, diabetes mellitus, and heart disease all increases the risk of stroke.  Severly narrowed blood vessels in the neck and brain also increase the risk for stroke.  There is an increasing evidence that high homocysteine (an amino acid) levels in the blood and obstructive sleep apnoea (presenting with snoring and excessive daytime sleepiness) may also be independent risk factors for stroke.

In Part 2, we will explore on the examinations and diagnosis of stroke, treatments, early complications of strokes etc.

P.S. Thanks to Dr Andrew Pan (MBBS, MRCP, FAMS)

Most of us will be indulging in a little more alcohol this festive season and studies have shown that a little alcohol may actually be good for the heart health – but only in moderation.

Drinking too much alcohol can raise the level of some fats in the blood (triglycerides) and can also lead to high blood pressure, heart failure and an increased calorie intake.  In addition to the dangers such as alcoholism and accidents, excessive alcohol intake has also been linked to liver disease, ………………..to read more about it, get your own copy of Healthy Times Magazine from your nearest bookstands, MPH, Borders, 7-Eleven or order Online Here.