Scenario of Heart diseases in India

According to World Health Organization (WHO), Cardiac diseases have nearly doubled in India, an alarming fact, considering that it has almost halved in Europe and the USA. Latest data collected from WHO, suggest that by 2010 there would be close to 100 million cardiac patients in India. It is 30 millions now. As per the WHO findings, men, women and children are at risk. The statistical data given by WHO warns that, women will continue to experience disproportionately high mortality from cardiac diseases. By 2040, women in India will represent a higher proportion of cardio vascular disorder deaths than men. Regarding incidence 1 in 3 individuals age 65 or older has suffered from some form of heart disease or stroke. Studies have found that average annual rates of first major cardiac disease event rose from 7 per 1,000 men at ages 35 to 44 to 68 per 1,000 of ages 85 to 94. The comparable rates occur 10 years later for women but the gap between men and women narrows with advancing age. After age 75, the prevalence of cardio vascular diseases is greater in women than men.

The common accelerators for cardiac diseases are stress, strain, restless ness, work activities and the urbanization. Nowadays, due to the urbanized cultures people are facing more stress and strain at home as well office. The food habits changed, the utilization of vegetables and fruits has been decreased. People are opting fast foods, which may contain some material that harms their heart. The lifestyle of the people making them sensitive to cardiac diseases, as the busy daily life leading them towards stress and restlessness. Because of the modern lifestyle the younger people are also getting the disease in significant rate. Despite the age and gender, the cardiac diseases are evolving as a major threat for human life.

Our Heart :

The heart is a hollow, muscular organ that pumps blood, rich with oxygen and nutrients to all parts of the body. It is the organ which functions incessantly round the clock. Heart lies in the center of the chest, slightly to the left and protected by the breast bone (sternum).
The heart is made up of a powerful muscle called Myocardium. The heart has two separate pumps that continuously send blood through out the body carrying nutrients, oxygen and helping remove harmful wastes. A wall (septum) divides the heart into a right side and left side. The right side heart receives impure blood low in oxygen. The left side heart receives pure blood that has oxygenated by the lungs. This cycle is repeated about 70 times per minute and is counted as a pulse.
The heart is divided into four chambers. Two upper chambers (atria) receive blood from the veins. Two lower chambers (ventricles) pump blood out of the heart through arteries.
The heart has four valves that keep the blood flowing in the correct direction i.e., work as regulators.
The heart muscle is nourished by a system of arteries, which originate from the ‘aorta’: the right and left coronary arteries.

Heart Functions:

The heart functions as interrelated double pumps. One pump (right heart) receives blood, which has just come from the body after delivering nutrients and oxygen to the body tissues. It pumps this dark, bluish red blood to the lungs where the blood gets rid of a waste gas (carbon dioxide) and picks up a fresh supply of oxygen which turns it a bright red again. The second pump (left heart) receives this “reconditioned” blood from the lungs and pumps it out through the great trunk –artery (aorta) to be distributed by smaller arteries to all parts of the body.
Types of Heart disorders :
There are three main diseases of the heart.
1) Coronary artery disease (King’s Disease):
Coronary arteries become narrow or blocked due to the deposition of Cholesterol and other body fats leading to ‘artherosclerosis’, commonly called ‘hardening of the arteries’. Artherosclerosis causes insufficient blood flow to the heart muscles. Angioplasty, intensive medication, life style changes, and in severe cases, a by-pass surgery is recommended to correct the defect.

2) Valvular heart disease:
It is a defect in the valves by birth, infection causing scarring or thickening leading to insufficient opening or closure of valves for blood flow. This disorder can be cured either by medication or by artificial valvular surgery.

3) Congenital heart disease:
Congenital heart defects are problems with the heart’s structure that are present at birth. These defects can involve the interior walls of the heart, valves inside the heart, or the arteries and veins that carry blood to the heart or out to the body. Congenital heart defects change the normal flow of blood through the heart.
There are many different types of congenital heart defects. They range from simple defects with no symptoms to complex defects with severe, life-threatening symptoms. Congenital heart defects are the most common type of birth defect, affecting 8 of every 1,000 newborns. Most of these defects are simple conditions that are easily fixed or need no treatment. A small number of babies are born with complex congenital heart defects that need special medical attention soon after birth. Over the past few decades, the diagnosis and treatment of these complex defects has greatly improved. As a result, almost all children with complex heart defects grow to adulthood and can live active, productive lives because their heart defects have been effectively treated. Most people with complex heart defects continue to need special heart care throughout their lives. They may need to pay special attention to certain issues that their condition could affect, such as health insurance, employment, pregnancy and contraception, and preventing infection during routine health procedures.
Symptoms of heart problems:
1. Angina – and its symptoms

Angina develops when the blood flow to the heart is less than the demand. Angina is the heart muscle’s complaint of inadequate oxygen, occurs when the work of the heart is increased by:
• Excitement
• Exercise
• Walking fast
• Eating a large meal
Angina may also occur when you are at rest. The feelings that go with poor circulation are passed along the spinal column to the brain and may trigger any nerve along the path. Therefore, the feelings of angina vary greatly from person to person. They may be described as:
• Indigestion.
• Tightness.
• Fullness.
• Numbness / tingling in any part of the arm.
• Choking.
• Pains in the jaw, teeth, ear lobes.
• Discomfort in the neck or between the shoulder blades.
Many people have angina that is well controlled by medications and modifications of certain activities, if not controlled by them coronary by-pass surgery may be recommended.

2. Chest discomfort
3. Chest pain
4. Brief pain episodes – often 2-5 minutes
5. Pain worsens on exercise
6. Shortness of breath
7. Indigestion
8. Palpitations

Risk factors:

Most of these heart problems develop due to the risk factors.
1) Smoking:
The habit to smoke may increase the chance of getting heart disease of coronary arteries. Smoke may interrupt the blood circulation or creates a vacuum type of state in a part of blood vessel. Chain smokers are very prone to cardiac diseases.
2) Hypertension:
The cause of hypertension is unknown and its symptoms do not appear until it has reaches an advanced state. In persons with cardiac disorders it increases the heart’s workload and may contribute in hardening of the arteries.
3) High Cholesterol and high triglyceride level in the blood:
It is not known exactly how high cholesterol and triglyceride levels in blood contribute to the development of heart disease. These are produced by the body for normal body functions. The excessive fatty material deposits along the arteries and forms ‘plaques’ or ‘atheromas’, which lead to the blockages of arteries.
4) Tension / Stress:
Stress alone probably does not cause cardiac disease. However, it may weaken the body’s defense mechanisms against disease. We cannot do very much to alter the stress in our lives but we can improve the ways in which we react to a stress. Some helpful ways to reduce stress and related illnesses are:
1. Breathing exercises
2. Meditation techniques
3. Regular exercises or participation in sports
5) Lack of exercises:
Lack of exercises slows down the rate of blood circulation and blood pressure by which disorders may occur gradually. The person suffering from Obesity may need the exercise most.
6) Obesity:
Obesity leads to high cholesterol and other body fats content. Cholesterol gets deposited in arteries and causes blockages in arteries. To lower the risk of progression of cardiac diseases you should achieve and then maintain a body weight normal.
7) Diabetes:
In general your food habits cause diabetes. Diabetic body contains high sugar,
which may create a viscosity in blood vessels, leads to improper blood flow and blood pressure.
Diagnosis of heart disorders:
Combination of several methods and procedures are used to diagnose the heart disorders.

1) ECG (Electro Cardiogram):
Electrocardiogram is a test measures the electrical activity of the heart. This signals that makes the heart’s muscle fibres contract come from the sinoatrial node, which is the natural pace maker of the heart. In an ECG test, the electrical impulses made while the heart is beating are recorded and shown on a piece of paper. This is known as an electrocardiogram and records any problems with the heart’s rhythm, and the conduction of the heart beat through the heart, which may be affected by underlying heart disease.
2) Echocardiography:
Echocardiography is a procedure that uses ultrasonic waves directed over the chest wall to obtain a graphic record of the heart’s position, motion of the walls, or internal parts such as the valves.
3) Angiogram:
An angiogram is an x-ray exam that allows a doctor to see your blood vessels and the flow of blood to your heart. It shows the degree of blockage in your arteries, how well your heart is pumping and whether or not your heart valves open and close properly. During an angiogram procedure, a special dye is injected into the blood vessels so they can be seen on x-ray film. An angiogram can help your doctor make a proper diagnosis and suggest treatment for heart disease
4) Coronary 64- slice CT scan:
A CT scan is a safe and effective procedure.
A CT scan technologist will escort you into the CT scanning room in your Radiology department, where you will see a table and a large, doughnut- shaped device called a gantry. The technologist will have you lie down on the padded table and make sure that you are comfortable. You will be asked to lie very still during the scan and hold your breath for a brief time to minimize any body movement. You will receive an injection of fluid contrast to outline the coronary arteries and structures so the physicians can better view your heart and coronary system. During the scan you may hear a humming noise but you will not feel anything unusual. You may feel the table move while images are being taken at certain locations of your body. The technologist will be monitoring you during the entire exam through a window and can communicate with you via an intercom. The actual scan portion of the exam will take just a few seconds.
The 64-slice CT scanner, in a fraction of second, produces 64 images per rotation, a speed at which an accurate scan of your heart may be performed in approximately 5 seconds. This means new diagnostic power in diagnosing patients with chest pain and ruling out blockages. This CT scanner offers the ability to provide a compressive view of the coronary arteries in 5 heartbeats.
After diagnosis:
Depending on the type & intensity of the disorder the patient will be advised a plan of
management by the cardiologist.

Plan of management:
1) Medical management:
If the disease is curable by medicines and drugs, the patient is kept under medication.
2) Angioplasty:
If the disorder is unable to be cured by medication, the patient undergoes Angioplasty. Percutaneous transluminal coronary angioplasty (PTCA) or angioplasty, is an invasive procedure performed to reduce or eliminate blockages in coronary arteries. The goal of PTCA is to restore blood flow to blood-deprived heart tissue, reduce the need for medication, and eliminate or reduce the number of episodes of angina (chest pain). Opening a blockage or a plaque in a coronary artery typically involves the use of an angioplasty balloon. When the blockage is calcified or so dense that a balloon cannot be placed, other devices are used. Plaque cannot be cut out, ablated with a laser, or bored out using a surgical drill bit. Often, a stent is implanted after angioplasty to keep the artery open and present restenosis (regrowth of plaque).
The arteries are accessed through a needle puncture made in the groin (femoral artery) or arm (brachial artery). Usually the femoral artery is used. More than one blockage can be treated during a single session, depending on the location of the blockages and patient’s condition. The procedure can take 30 minutes to several hours, depending on the number of blockages being treated.
Angioplasty patients often are given Aspirin at least 2 hours before the procedure. Aspirin –sensitive patients may be given another antiplatelet drug, such as Ticlopidine or Clopidogrel. Angioplasty is performed in a catheterization laboratory equipped with x-ray equipment and monitors. Before going into the catheterization lab, a mild sedative is given to the patient and the insertion area may be shaved.
3 ) A.Coronary artery surgery:
The Coronary artery ‘by pass’ surgery is done in severe cases, which allows the blood to go around a blocked artery. During this surgery, part of a saphenous vein in the leg is removed. This does not change the blood flow into the leg or ability to walk. One end of this vein is sewn (grafted) to the aorta. The other end is sewn to the coronary artery below the blockage. This lets oxygen-rich blood flow directly from the aorta through the by-pass graft to the coronary artery feeding the heart muscle. Sometimes, a part of an artery from the chest (internal mammary) is used for the by-pass graft.
One or more coronary artery by-pass grafts may be used to improve circulation to the heart muscle to relieve the symptoms of angina or to improve the function of the heart.
3 ) B. Valvular heart surgery :
In Valvular heart surgery, when possible your own valve is repaired. More often, it is done with an artificial or tissue valve. Some people feel better right after surgery since their symptoms are relieved. For most, however, it is several months before they feel the benefits of valve surgery. It takes time for the heart to recover from the extra work it was doing before surgery. For this reason, your doctor may ask you to keep taking medications, follow a special diet and limit your activity. Have your nurse or physician fill in the type of valve used in your surgery and circle its placement in the heart.

Anti Coagulation in Cardiac surgery:
The human blood has a fantastic quality of keeping in fluid state when it is flowing uninterrupted in a blood vessel, but it starts to form a clot from the time when it comes in contact with injured tissue or a foreign material. To get rid of this phenomenon, when an artificial valve inserted, an anti coagulant also be given to avoid the clotting in blood.

Other surgery in a patient who has already undergone Valvular heart surgery:
The patient, who is already given with anticoagulants, if she/he has to undergo any other surgical procedure, will experience more bleeding at the time of surgery. Such patient will have to get admitted a few days before surgery and his anti coagulant drugs will have to be changed so that he/she does not bleed excessively at the time of surgery.

Now you will know all about the surgery, as how you will be treated on the day of admission, pre operative day, on the day of surgery and after the surgery etc.

1 ) Your Admission :
On admission you will meet some of the health care team who will care for you during your stay at KIMS.
There is a considerable amount of information we need from you, to help us plan the care necessary for your recovery. The questions related to family and personal medical history, allergies, symptoms, medication, lifestyle changes due to disease, diet and other matters will be asked by the nursing staff. They will measure height, weight, blood pressure, pulse and temperature.
It is also a time when you can ask questions and express any worries or problems. You will undergo some tests include chest x-ray, blood tests, ECG.
Apart from the nurse seeing you, other staff such as your cardiologist, anaesthetist, surgeon, the intensive care doctor and physiotherapist will also visit. The visit from the physiotherapist is an important one, as you will be shown deep breathing and coughing excercises, which will assist your recovery.
Your chest and legs will be clipped of body hair to prepare the skin for surgery. Skin tests will be performed by the nurse to check you are not allergic to solutions and tapes used in hospital ( eg : Iodine, Elastoplast).
In the evening you will have a shower using an antiseptic soap solution. Belongings will be packed in the evening before surgery and stored on the cardiac unit while you are in the Intensive care unit.
You are encouraged to send all valuables home.
You will be told the time at which your surgery is planned.
You and your nearest ralative will have to sign a CONSENT FORM in which the name of the surgical procedure will be clearly mentioned along with its inherent risks and complications. Make sure that you read the consent form clearly and have all your queries solved before signing it.

2 ) Day of Surgery :
You will be taken to the operation theater in a wheel chair or a trolley during the scheduled time of your operation.
The anaesthetist will meet you in operation theatre and explain to you the basic steps of anaesthesia.
During the surgery monitors are placed on your body to show blood pressure, breathing rate and heart rate.
You will be covered with sterile drapes. Ask for blanket if you’re cold.
If you’re not asleep, you may notice much noise and activity.
You may notice bright lights or if a video screen is used, lights may be dim.
3)Cardio-thoracic ICU:
Upon waking up in the Cardio thoracic ICU, you will find that there will be a tube in your mouth, which will be attached to ventilator. This will ensure your optional breathing status.
Various lines will be attached to your forearms and neck. This is for administration of fluids and various drugs as well as constant monitoring of your blood pressure and other parameters.
Two or three tubes will be coming of your chest. This aids the draining of any blood or fluid.
A urinary catheter will already have been inserted for constant drainage of urine.
You will be unable to speak or move initially as a result of the various apparatus attached to you.
“ DO NOT PANIC “
Our staff nurses are thoroughly framed and very experienced in post-operative cardiac care and understand your every need. Please cooperate with them and follow their instructions to ensure a safe recovery.
One of our senior doctor monitors you round the clock.
The first tube to remove will be your breathing tube.
After a few hours you will be given sips of water to drink.
One by one the monitoring lines attached to your body will be removed. Your diet will be gradually advanced from liquids to semi solids and then solids.
The chest tubes and urinary catheters will be removed on 2nd day, you will be made to sit in a chair and after a few hours, transferred to your room.

4) Post operative course :
You are likely to experience some symptoms in the first few post operative days.
• Pain:
You will be experiencing some pain at the operative site. This is a perfectly natural course, which will slowly subside day by day. The staff nurse will administer pain medication to you for alleviation of the symptom.
• Fatigue:
This is very commonly experienced during the recovery process. Physical activity is good for your heart, your circulation and your general well being. You should therefore, increase your activity gradually to avoid becoming too tired. You will also find a definite need for more rest/ sleep during the first few weeks at home (ex: a nap after lunch). This fatigue resolves and you will notice a steady improvement
• Loss of appetite:
You may loss appetite because of medication and antibiotics given in the surgical procedure and lack of activity. In initial post-operative days this is a very common symptom, which will be gradually decreased as days go by and you become stronger.
• Decreased sleep, decreased concentration and memory:
These are very common side effects. Do not worry. They will gradually subside as your health progress towards the better.
• Palpitations (fast / irregular heart beats), Sweating:
About one third patients experience palpitations in the early stages after heart surgery. If this occurs to you, it is readily treated with medication. During your recovery at home if palpitations recur, and last longer than 10 minutes, contact your cardiologist.
You may experience episodes of sweating. In winter particularly, you may feel the cold more than usual.

• Blurred vision:
Temporary blurred vision is common after cardiac surgery. It is advisable to wait up to 12 weeks before having your spectacles checked.
Graded Exercise training:
Our physiotherapists, who are experts in cardiac rehabilitation, will guide you through out your post-operative course. The key words in this training will be Gradual, Steady Progress. The physiotherapist at KIMS will formulate a very detailed plan for your graded exercise training at home, so that the return to active lifestyle is ensured rapidly and safely.
Preparations for Discharge:
Before you are discharged from the KIMS you will have to undergo some blood tests, chest x-ray, ECG and ECHOcardiography to monitor your progress in the initial post operative period.
Your sutures on the chest wall will be removed before discharge. In some cases where the patient’s recovery is exceptionally fast and he/she is discharged early, then the patient is called back to hospital after a few days for removal of stitches.
Make a clear idea from the dietician regarding your diet
In case of diabetic patients, your Insulin dosages or drug dosage will be adjusted by our diabetologist before discharge.
You will be given a detailed discharge summary from the KIMS, which will include your diagnosis, investigation reports, Operation reports as well as drug treatment and also your detailed dietary and physiotherapy plan.
Make sure you understand your drugs, their dosage and their timings of administration clearly from the doctors or the staff nurses before discharge.

Valvular heart surgery – Pregnancy:
The anti coagulant drugs given to a pregnant patient may affect the baby. So if a female patient desires to have a child after valvular heart surgery, she should be under close observation of her physician so as to ensure a safe delivery and a healthy baby.

Lifestyle after discharge:
Your lifestyle after discharge from the hospital may different from your lifestyle before surgery.
1) Regular medication & Check ups:
You have to follow the guidelines given by the doctors, and should maintain regular medication as well the check up, which ensure your longer and safe life. Most patients need medication while they are recovering from open- heart surgery. Some times it is helpful to continue, for an indefinite time, the same medication used before surgery. This:
• Keeps the heart pumping at its beat.
• Relieve the workload on the heart.
2) Food habits:
It is normal for your appetite to be down after surgery. It will pick up as you begin to recover. If a special diet has been recommended by your doctor talk to your dietician before you go home. Not everyone is placed on a special diet after open-heart surgery. If no special diet has been ordered for you, the information here can guide you to balanced eating which speeds healing and lessens fatigue. In addition, the practice of weight control is important in reducing the work of your heart after recovery.
Balanced eating: No one food provides all the nutrients needed by the body; therefore, each day you should eat a variety of fruits, vegetables, whole grains, breads, meats, and dairy products.
Eat more: Fresh fruits Eat less: Saturated fats
Vegetables Salt and sodium
Whole grains Sugar
Low-fat foods Alcohol
3) Exercise:
Regular aerobic exercise keeps your body fit and controls your body weight. Follow the physiotherapist’s instructions before you start exercise. The breathing and meditation are normal exercises and apart from those some more exercises are good for cardiac patients.
4) Smoking & Alcohol:
If you find it difficult remaining a non-smoker, do seek advise and support from the cardiologist.
Upon returning home it is acceptable for females to drink 1 to 2 standard drinks of alcohol and males, 3 to 4 standard drinks of alcohol per day. Feel free to discuss this with your cardiologist and family doctor, particularly if you have diabetes.
5) Sexual Activities:
Sexual activities may be resumed when you, the patient, wish. There are no physical restrictions on sexual activity, resume according to your own physical comfort. Assuming the passive role may be helpful, both in terms of wound healing discomfort and also fatigue. Energy demands can be equated with climbing two flights of stairs.

ACTIVITY GUIDELINES AFTER DISCHARGE :

Walking in the garden during 1st week
Sewing 2 weeks
Kitchen tidy / washing dishes 2 weeks
Ironing 4 weeks
Playing cards 4 weeks
Making the bed 4-6 weeks
House work - Sweeping 6 weeks
Vacuuming
Cleaning shower
Darts and comparable arm games 6 weeks
Driving 6 weeks
Office work 6 weeks
Exercise bike 6 weeks
Cycling (consult with your surgeon) 6-12 weeks
Swimming (consult with your surgeon) 8-10 weeks
Car washing 8-12 weeks
Heavy lifting 12 weeks
Wood chopping 12 weeks