Is there any form of treatment, diet or exercise which will prevent recurrence, cause regression of atheroma, encourage development of collaterals or reopen clogged arteries? These aspects remain controversial and will therefore be discussed in some detail.
Restriction of caloric intake to treat or prevent obesity is essential. Diet should be constructed out of what the patient eats normally and what is usually cooked in his home. He can simply reduce the quantity eaten and avoid rich fatty foods. Crash diets and special diets do not usually work out as the problem is life-long. There is some controversy about the use of saturated and unsaturated fats.
Those consuming a lot of saturated fats usually have higher blood cholesterol levels and these in turn are related to higher incidence of atheroma. Whether consumption of unsaturated fats after myocardial infarction will prevent further infarction is doubtful. However, a change to unsaturated fats (which do not solidify at room temperature) seems prudent. If this change does not help the patient, it may at least help his children, as atheromatous deposits commence at a fairly young age.
There are similar doubts about cholesterol intake. The endogenous production of cholesterol is approximately 2,000 to 3,000 mg/day and the endogenous production is said to be cut down by the amount one consumes in one’s food. Yet, the standard advice is to reduce daily intake of cholesterol to below 300 mg/day. Eggs (cholesterol content approximately 250 mg each yolk) should be avoided. An egg without its yolk does not taste like an egg, but like slime.
There is nothing sacrosanct about egg for breakfast; one can get the same amount of protein from a cup of skimmed milk. One hears about white meat being superior to red meat after a heart attack, but there is little difference between the cholesterol content of chicken (60 mg/100 g edible protein), fish (70 mg) and mutton (65 mg). Fish has more unsaturated fats and may therefore be preferable. Red meat, pork and lard should be avoided.
A word about social eating may not be out of place. At times one sees patients who have withdrawn from this pleasant pastime because the food might have been cooked in “dalda or that the custard may have yolk of egg in it. This seems like carrying things too far, and doing without an evening out to avoid such “poisonous” stuff may be too high a price to pay for the doubtful gains.
One does not need to bore one’s friends and hosts with one’s heart attack. One should pick up from the table a little bit of everything, avoiding what one considers too rich in calories, fat or cholesterol. An occasional indiscretion is not likely to make any significant difference to the atheroma which has collected over the previous few decades.
The evidence against smoking is too strong to be ignored. Not only are heart attacks more common among smokers, the incidence of reinfarction is higher in those who continue to smoke and lower in those who give up smoking after the episode. One’s advice should therefore be quite unambiguous, consistent and repeated.
Missionary zeal should however be kept out of one’s advice, as there are patients who are genuinely unable to give up smoking and they will either tell lies or go to another doctor. If the doctor smokes himself, his advice is not likely to be of any use.
If anyone thinks that a bit of brandy in the evening will make his heart stronger, he is fooling himself The vast majority of our patients do not drink to an extent which would be directly toxic to the heart muscle (approximately half a bottle of spirit per day), but even social drinking would add its quota of calories (approximately 150 cal/large peg) and may make one eat a little more than one would otherwise and this creates problems in weight control.
The patient must count these extra calories/The recent news that small amounts of alcohol (3-4 small pegs) may increase the high density lipoproteins and protect the heart against future heart attacks has gladdened those who enjoy a “chhota” in the evening. A prudent doctor should await more evidence before advising his patients to start drinking for this purpose.
The amount of exercise must be individualized and essential work must get the first priority. This seems like starting the obvious, but every now and again one sees a patient with cardiac failure or frequent ectopics going out for his prescribed 3-5 km walk and coming back exhausted, because the doctor said that he must. This does not make sense as there is no proof that physical exercise opens up the clogged arteries or prevents recurrence of heart attacks.
Physical training does make the body more efficient, reducing the oxygen requirement of work improves morale and confidence and helps return to normal life-style and work. Gains in terms of improvement of underlying disease are questionable. Physical work and exercise within limits of anginal pain, excess breathlessness, faintness and exhaustion should be encouraged and may be essential for the patient to earn his living.
He should avoid sudden severe physical exertion for which he is not conditioned e.g. running after a bus or carrying loads upstairs. Exercise with breath held, e.g. pushing a car, weight lifting or underwater swimming are known to cause marked rise of blood pressure and should therefore be avoided.
Free-breathing exercises like jogging specially walking are good, but one should not overlook the risk of getting run over in the traffic conditions of our cities. Golf is an expensive way of walking in a safe area. Yoga is a good relaxation technique. The exercise is insufficient to increase mechanical efficiency or to open up coronary collaterals.
Sex is a topic which most of our patients do not bring up although it is always in their mind. A mature physician should discuss it freely and frankly with his patient, perhaps not in the very first interview. The amount of exercise involved in a sexual intercourse has been measured and amounts to about the exertion involved in going up two flights of stairs. If the patient can undertake this much exertion, he can return to his normal sexual activity.
Whether the man or the woman plays the active role makes little difference in the oxygen consumption. “Will I die during the sex act?” Very few such incidents have been recorded, the usual setting being partner other than wife and place other than home and usually after excessive eating and drinking. “But doctor, you said I should avoid sudden, severe exertion”. Yes, but most of out patients are 50 years plus and married for 20 years plus and usually living with their own wives. Sex is neither sudden nor severe under these circumstances.
Angina pectoris, cardiac failure, hypertension, cardiac arrhythmias, diabetes and any other associated disease will require appropriate treatment. Nitrates, including transdermal nitroglycerine, beta blockers and calcium channel blockers are the drugs commonly required.
Lipid lowering drugs like clofibrate have been out of favour lately because there is no evidence that they reduce the frequency of heart attacks or the mortality rate. Advantage, if any, is counteracted by the increased incidence of gall-stones and small intestinal disease including malignancy. Anti-coagulants are now rarely used for long-term prevention.
Low dose heparin has not quite caught on. Antiplatelet drugs have been more fashionable recently. The subject was reviewed by Mitchell (1983) and the evidence for aspirin, sulphinpyrazone and (Dipyridamol) was carefully weighed. The verdict was “not proven” for all three drugs in spite of their widespread usage and “pushing” by their manufactures and protagonists.
Evidence in favour of beta blockers preventing recurrence of heart attacks is fairly strong now and many centres are using these drugs as a routine, starting about a week after the acute infarct and continuing for 1-2 years (Pratt and Roberts, 1983). Propranolol (80 mg t.d.s) and metroprolol are probably as effective as timolol which was used in the best known trial.
The author has no first-hand knowledge of the use of these drugs for the specific purpose of preventing recurrence of infarction. These drugs are commonly indicated for the treatment of post-infarction angina, arrhythmias or hypertension. Patients on these drugs may be deriving the additional benefit of their protective action. Calcium channel blockers have also been used for the same purpose, but there is not enough evidence in their favour at present.
Some patients will require tranquilizers, although a sympathetic physician who has time to listen to and answer the patient’s questions is often an effective tranquilizer. A few patients may require anti-depressant therapy. One should be aware of the possibility of these drugs causing cardiac arrhythmias.
6. Return of Work:
The patient should generally return to his previous job except if specifically disabled for it, e.g. jobs involving hard physical work or airline pilots. Return to the same organization generally ensures a more sympathetic attitude and return to shorter hours and less strenuous work initially.
During this phase the patient should be called up for review more frequently, possibly every week or 10 days, to check his response to work, to answer the many questions which arise in the patients mind and generally to encourage him to get back to his normal life-style, possibly full stream ahead in about six months after the acute infarction. The frequency of reviews can then be reduced to once in 3 to 6 months or once a year, with the assurance that he is welcome anytime that he has any problem.
The question of surgery will be raised by most patients as more and more people are learning about coronary artery bypass grafting from the lay press. The expected gains from surgery are relief of angina and probable improvement of myocardial function and longevity. On the negative side is the operative, mortality rate of about 5% in India, perioperative infarction (2-3%) and the cost.
In India the operation will cost Rs.60,000 to one lac. This amount includes cost of initial investigations, including coronary arteriography, drugs, hospitalization, surgeon’s fees, travel expenses and cost of a close relation staying with the patient. One must consider all these overheads because this is what the family finally ends up paying and not just the surgeon’s fees.
Getting operated in USA will similarly cost not less than Rs. 250,000. Not many families are able to afford these amounts and if in one’s opinion the financial condition of the family does not permit such expense, it may be more kind not to mention surgery if the patient does not ask about it.
Patients may ask if they can travel abroad. All aircrafts are pressurized; air travel is therefore no problem. But falling ill abroad can be very expensive; therefore it is better to be covered by adequate insurance or financial backing. Air travel also may involve carrying hand baggage over long distances in cold weather. Customs clearance delays and formalities are bad enough to give a heart attack to a perfectly normal person. One should therefore advise these patients not to carry back gifts and things from abroad.
Driving is also known to cause rise of blood pressure and to cause ectopic beats. One should advise against driving in the early stages of convalescence, especially in case of people who want to reform the habits of all other drivers, cyclists and pedestrians. Some people are, however, more tense in the rear seat than in the driver’s seat.
In the organization of day-to-day activity one should advise relaxation and avoidance of impatience, hurry and temper. Getting ready a few minutes before the time of departure can help.
Interpersonal relations in the family need adjustment. The wife often takes up the attitude, “He never listens, I told him to give up smoking 20 years ago”, or “I should have looked after him better”. The children, who are often grown up by now, take on a more protective attitude.
“Daddy doesn’t pick up that bucket of water” which the daddy resents because he likes to retain his position as the strong and dependable head of the family. The physician is able to help only if he knows the family well and has a good rapport with them. If the wife is understanding and educated enough, it helps if she can accompany the patient during the reviews.
The fact that the patient has greater chance of getting another attack, especially within the first year post-infarction, should not be emphasized. One should however advise about settling one’s financial affairs and making out a proper will on the basis of “anyone of your age should”.
In the Armed Forced we have the experience of rehabilitating cases of acute myocardial infarction after very stringent resting. Many of them are back on fully duty and are holding positions of responsibility. This experience shows that the outlook of a “heart-case” may not be that bleak after all. Functional recovery is excellent in many patients with good motivation.
Finally, a bit of philosophy. One must put the heart-attack in its proper perspective. Above the age of 65 to 70 years the remaining longevity may not differ significantly with or without dont’s. One can thus be less stringent in this group of patients. Heart attack is after all only one of the numerous- causes that people die of. If we busied ourselves with precautions against all known causes of death, we would be left with little time to live. Let us not forget that life is for living.