Heart Information

• When we commonly refer to "heart disease" we mean "coronary heart disease", which happens when blockages build up in the coronary arteries
• These blockages are called atherosclerotic plaques and the process by which they build up is called atherosclerosis. This is also called "coronary artery disease"
• Other forms of heart disease include, valvular heart disease, heart failure, and disorders of heart rhythm

A heart attack is an injury or death of a part of the heart muscle. It is also called a 'myocardial infarction'. There are 2 major ways in which a heart attack can occur:

• Blockages get worse: As the blockages get larger there is less blood flow to the heart muscle. At one point the heart muscle no longer can get the blood and oxygen it needs. When the blood supply is cut off for more than about 30 minutes, the heart muscle cells begin to die, and a heart attack occurs
• The atherosclerotic plaque cracks: Most heart attacks are caused as a result of 'cracking' or 'rupture' of the plaque (blockage). The plaque becomes unstable and cracks, forming a blood clot which travels and completely blocks the flow of blood through the artery, and causes a heart attack

Angina is a pain or discomfort that is usually felt in the chest, and spreading to other parts of the body, such as the neck, jaw, shoulders or arms. In some cases discomfort is only felt in these areas and not in the chest at all.

Recognize the symptoms of a heart attack

• The typical presentation of a heart attack is an unpleasant squeezing pain which typically occurs in the middle of the chest or the back
• It often radiates to both arms or the throat and jaw, and is accompanied by sweating and / or nausea
• This typical presentation does not always occur. Some may just experience heart burn, or 'stomach upset' not relieved by antacids or not related to food intake, breathlessness at rest, accompanied by a 'run down' feeling
• Some may only experience chest 'pressure' and not 'pain', or pain only in the jaw, teeth or arms

Immediate steps to take

• Chew a tablet of aspirin
• Place a tablet of sorbitrate (nitroglycerin) under your tongue. (if you have a prescription for it)
• Keep the patient calm
• Rush the patient to the hospital

Cardiac Tests

• ECG: This measures the electrical activity of the heart. A change in the ECG pattern can be indicative of the presence of heart disease. The doctor usually looks for two types of changes:
  • Those which indicate a block in the coronary arteries and
  • Those which indicate a problem with the rhythm of the heart beats, such as palpitations
• Stress Test / Stress ECG: The stress ECG provides more information than a rest ECG since the oxygen demand on your heart is greater while exercising. A positive stress test indicates that there are changes on your ECG
• Thallium Stress Test / Nuclear Medicine Stress Test: This stress test is similar to a regular stress test, but in this a dye is injected into the heart and pictures are taken of the heart, before and after the stress test.This can detect areas of the heart muscle that have been damaged by a heart attack and areas that are not getting enough oxygen due to partial blockages of the coronary arteries. Nuclear medicine tests can also provide information on the functioning of the left ventricle

Imagine traveling by road and getting stuck in a traffic jam. To 'bypass' the jam, you take another route and join the same road back again. That's exactly what takes place in a CABG (Coronary Artery Bypass Graft surgery) or commonly known as bypass surgery.

Coronary Artery Bypass Grafting (CABG) is a surgical procedure done to create a 'bypass' around the blocked part of a coronary artery (blood vessels that supply blood to the heart) to restore blood supply to the heart muscle. The bypass is made with the help of blood vessels (known as grafts taken from the other parts of the body (leg, hand, chest wall, etc.)

Why and when is a bypass done? When one or more of the coronary arteries becomes partially or totally blocked, the heart does not get adequate blood supply. This is called an ischemic heart disease or Coronary Artery Disease (CAD). It can cause heart pain (angina) or a heart attack (myocardial infarction).

CABG is one of the treatment options for ischemic heart disease. Bypass surgery is advised for:

• Disease of the left main coronary artery
• Significant, multiple blockages in all three main vessels of the heart
• Failure of angioplasty
• When the efficiency of the left ventricle is reduced to less than adequate.

How is the surgery done?

Before the surgery Once the patient has been diagnosed with a triple vessel disease and has been advised to undergo a bypass surgery he has to plan accordingly.

For a bypass surgery a stay in the hospital of approximately 10 days is expected with a recovery time of a month after the surgery to get back to the normal routine.

The patient is generally put on blood thinners after being diagnosed with a triple vessel disease. So before the surgery the patient is expected to stop blood thinners 5 days prior.

The patient plans with his surgeon or assistant doctors to surgeons and comes for pre-operative investigations. These are important as the surgery would not be carried out unless the patient is found to be fit to undergo surgery.

This is important to avoid complications during surgery and to ensure a smooth recovery. With any deviation in the parameters the patient is treated for the same before being taken for the surgery.

The pre-operative investigations include the following:

• Blood tests: includes CBC, Serological tests, blood grouping, blood sugars
• Urine tests: creatinine, electrolytes
• Chest x-ray
• Ultra sonography
• Carotid and radial Doppler studies
• 2D Echo
• CT angiography of the internal mammary arteries
• Sputum and nasal swabs to check for any active infections in the body
• Lung function tests

Preparing the patient:

• On the day of surgery the patient is given medicines to reduce anxiety and then rolled into the Operation Theatre (OT)
• Electrodes connected to ECG monitor are attached to the patient's back to monitor the heart's activity during the operation
• Intravenous lines are then inserted into the veins of the wrist or arm for administration of medicines and salt solutions
• One IV line is threaded up the vein all the way to the vena cava ( the biggest vessel that carries impure blood from all the parts of the body to the heart) to allow administration of medication directly to the heart.
• A Foley's catheter is inserted into the patient's bladder for collection of the urine. Urine output helps to determine the functioning of the kidney.
• After the initial preparation the patient is anaesthetized by an anesthetist who then carefully monitors the patien'ts vital signs throughout the operation.
• After the patient is anesthetized , a tube is inserted into the windpipe which is connected to a respirator that performs the work of breathing.
• Another naso-gastric ( which goes from nose to the stomach) is inserted through the nose to collect stomach fluids.

Surgery:

• For the surgery, first the chest is cut open at the mid line of the breast bone ( sternum) and the sternum is separated.
• Then the internal mammary artery to be used for the surgery is separated from the chest wall gently.
• Then the surgeon will work on the patients limbs to remove the vein or the artery.
• After this the grafting of the conduits is done.
• After several hours of grafting the chest closure is done in layers.
• The patient is then shifted to the ICU

In a traditional bypass surgery, the heart is stopped after connecting to the heart long machine, which adds oxygen to the blood and circulates it to the other parts of the body during surgery. This is necessary because the heart muscle must be stopped before the grafting can be done.

However, in a beating heart surgery the heart lung machine is not used and the surgery is performed on a beating heart. This method is know as an Off-Pump Coronary Artery Bypass surgery (OPCAB) or beating heart surgery.

It allows the bypass to be created while the heart is still beating by using a device known as 'octopus'. The advantage is a quicker recovery, fewer complications and better long term outcome, especially in elderly patients and in patients with problems like kidney failure, previous brain strokes, etc. Asian Heart Institute is one of the few centers in the world that specializes in this type of surgery, performing nearly 100% of its bypass surgeries on a beating heart with a very significant percentage using total arterial grafting.

Stay in the ICU:

• The patient stays in the ICU for 3-4 days depending upon his clinical condition after which he is shifted to the wards.
• In the ICU the vitals are carefully monitored as it is the most critical stage after surgery.

Redo bypass surgery :A second or redo bypass surgery is needed if blockages develop after the first surgery. It is complex and risky because after surgery, the heart and lungs stick to the breast bone. A beating heart surgery using arterial grafts reduces the risk of a redo bypass surgery. At Asian Heart Institute redo bypass surgery is also performed 'Off-Pump', thereby suggesting the competence of the team.

Re-redo bypass surgery Owing to the complications, a third bypass surgery is very rare. Frequently Asked Questions After Bypass

Surgery

1. When can I drive on my own?

It is wise to wait for 2 months after surgery, before driving on your own. This is the amount of time it takes for the healing of your sternum (breast bone), which was cut open during surgery. Any chance injury, can cause damage if driving is started too early. Please consult with your surgical team before undertaking any activity after a bypass.

2. Can I travel by car?

Yes. You may travel by car as soon as you are discharged. However, for the first few weeks, it is advisable to restrict your travel to less than two hours. If the drive is going to be longer, then take a break every two hours and walk around for a few minutes.

3. Should I speak less?

There is no reason for you to 'speak less' after surgery. However, during the first few days of your recovery, you might feel short of breath while speaking for a long period of time. If so, your body is telling you to rest, and your may keep silent for some time.

4. Will eating curd or watermelon affect the stitches and slow down the healing of the breast bone?

No. Eating curd or watermelon has no effect on your stitches and healing process.

5. When can I start climbing the staircase?

If there is an elevator, there is no need to climb stairs just for the sake of exercising. If you do not have an elevator and have to take the staircase, you can do so as soon as you are discharged. While climbing, pace yourself. Take a minute's rest after climbing 10-12 steps during the first week after discharge. As your walking capacity increases, there is no restriction on climbing steps, as long as you do not run out of breath.

6. When can I go back to work?

It is advisable to wait for at least 2 months after surgery before returning to work. However, depending on the condition of your heart, you may be able to start light work after a month. Please consult with your doctor before returning back to work.

7. What about the blockages in the arteries, will they remain?

The blockages which are present is the arteries remain as they were. The 'graft' which provides the 'new blood supply' is connected below your old blockages, thereby providing adequate blood to the heart muscle.

8. After my surgery, why do I still feel pain in my chest?

To perform your surgery, your chest-bone was cut open and stitched together after surgery. It is quite normal to feel some pain or altered sensations in your chest region for a few months after surgery. However, this pain will be different from the pain of 'angina' which you might have experienced before surgery.

9. What are the restrictions after CABG?

For the first three months avoid swimming, driving, sex, breath holding exercises and yoga. This is because your heart is at time irritable and sensitive. It may lead to irregular heart beat and could be risky for you.

The AHI Advantage :

The latest trend in healthcare is to have lesser invasive surgeries, i.e. surgeries which involve minimal cuts & ensure that patient has a faster recovery. Keyhole or Minimally Invasive Surgery (MIS) is a modern innovative surgical technique that reduces the patient's post surgery distress & allows them to return back to their normal life in just a couple of days. In Minimally Invasive Surgery (MIS) is a modern innovative surgical technique that reduces the patient's post surgery distress & allows them to return back to their normal life in just a couple of days. In Minimally Invasive Surgery, surgeons operate through tiny incisions with the help of long instruments and HD cameras. The AHI team is one of the leading experts in Minimally Invasive Bypass Surgery in India. The team has pioneered the LESS (Lower End Sternum Split) technique which entails only a two – three inch incision in the chest in order to carry out a coronary artery bypass surgery, thereby enabling patients to be discharged within 2-3 days. The LESS is advantageous for patients requiring less number of grafts. Depending on your condition your surgeon will decide whether you can undergo surgery through LESS technique.

Recovery/ Prognosis:

Recovery from the surgery takes time. The patient who has received a CABG can expect considerable relief from symptoms and in many cases, increase life span. It should be remembered however that the graft vessels are subject to fatty blockage at any increased rate, so care must still be taken to reduce the risk factors that cause the original blockage.

You can do many things to reduce the risk factors like:

• Not smoking
• Regular exercising
• Control of vitals like Blood Pressure, sugar levels, cholesterol levels etc
• Rectification of other clinical conditions if any

When we talk about chest pain the first thing that strikes is that it must be related to heart. But not all chest pains are of the heart. But heart ailment being the most serious must be excluded.

Definition

Chest pain is discomfort or pain that you feel anywhere along the front of your body between your neck and upper abdomen.

It typically presents as central or left sided chest pain which radiates to left arm, shoulder, back and jaw. It may begin with shortness of breath followed by pain lasting for a few minutes.

"Ghabrahat" is the most common symptom among Indian population which is also a presentation of Angina. At times there may be discomfort in the chest radiating to the arm, back, neck, jaw or stomach.

How to identify chest pain related to heart?

• Increases with walking with weight like the weight of groceries
• Increases with climbing stairs or walking uphill a slope
• Increases with extremes of emotions like being very excited or being very angry
• Increases with working in extremes of temperatures
• Increases when walking after a heavy or fatty meal
• Increases with during workouts or swimming
• Increases with having sex
• Decreases with rest or stopping the activity which precipitates it
• Decreases after putting Sorbitrate under your tongue

Causes:

Heart or blood vessel problems that can cause chest pain:

• Angina or a heart attack
• Aortic dissection : A tear in the wall of the aorta, the large blood vessel that takes blood from the heart to the rest of the body causes sudden, severe pain in the chest and upper back.
• Pericarditis : Swelling (inflammation) in the sac that surrounds the heart causes pain in the center part of the chest.

Lung problems that can cause chest pain:

• Pulmonary embolism : A blood clot in the lung
• Pneumothorax: Collapse of the lung
• Pneumonia causes a sharp chest pain that often gets worse when you take a deep breath or cough.
• Pleurisy : Swelling of the lining around the lung can cause chest pain that usually feels sharp, and often gets worse when you take a deep breath or cough.

Mind problems:

• Panic attack, which often occurs with fast breathing

Bone and muscle problems:

• Costochondritis: Inflammation where the ribs join the breast bone or sternum
• Shingles, which causes sharp, tingling pain on one side that stretches from the chest to the back, and may cause a rash
• Strain of the muscles and tendons between the ribs

Digestive system problems:

• Heartburn or gastroesophageal reflux (GERD) - Acidity
• Spasms or narrowing of the esophagus (the tube that carries food from the mouth to the stomach)
• Gallstones cause pain that gets worse after a meal (most often a fatty meal).
• Stomach ulcer or gastritis: Burning pain occurs if your stomach is empty and feels better when you eat food

When to Contact a Medical Professional:

• If you have sudden crushing, squeezing, tightening, pressure in your chest.
• If pain spreads (radiates) to your jaw, left arm, or between your shoulder blades.
• If you have nausea, dizziness, sweating, a racing heart, or shortness of breath.
• If you know you have angina and your chest discomfort is suddenly more intense, brought on by exertion and decresases with rest or on taking sorbitrate
• If your angina symptoms occur while you are at rest.
• If you have been diagnosed with a serious condition, such as heart attack or pulmonary embolism.

Your risk of having a heart attack is greater if:

• You have a family history of heart disease
• You smoke, use cocaine, or are overweight
• You have high cholesterol, high blood pressure, or diabetes
• You already have heart disease

Call your doctor if:

• You have chest pain that is severe and does not go away you may call 126-126 immediately

Your doctor may ask questions such as:

• Is the pain between the shoulder blades? Under the breast bone? Does the pain change location? Is it on one side only?
• How would you describe the pain? (severe, tearing or ripping, sharp, stabbing, burning, squeezing, tight, pressure-like, crushing, aching, dull, heavy)
• Does it begin suddenly? Does the pain occur at the same time each day?
• Does the pain get better or worse when you move?
• Can you make the pain happen by pressing on a part of your chest?
• Is the pain getting worse? How long does the pain last?
• Does the pain go from your chest into your shoulder, arm, neck, jaw, or back?
• Is the pain worse when you are breathing deeply, coughing, eating, or bending?
• Is the pain worse when you are exercising? Is it better after you rest? Does it go away completely, or is there just less pain?
• Is the pain better after you take nitroglycerin medicine? After you eat or take antacids? After you belch?
• What other symptoms do you have?

The types of tests that are done depend on the cause of the pain, and what other medical problems or risk factors you have.They include:

• ECG
• Blood tests ( in case of heart attack a CPK-MB and Trop-I are done)
• 2D Echo
• Stress test ( also known as TMT)
• Coronary angiography

What to do if you have chest pain while at home / office and you are alone:

• Immediately stop doing the activity you are doing
• Take rest
• Wait for 5 minutes
• If it does not settle within 5 minutes of rest call 126-126- dial an ambulance and reach the hospital immediately
• On the way to the hospital, you will be given oxygen, Blood Pressure will be checked, a Sorbitrate may be given under the tounge as an emergency measure for chest pain.

A heart bypass surgery is a procedure where a new route is created for blood and oxygen to reach the heart muscles which are deprived of it due to blockages in the existing blood vessels supplying the same.

Alternate names:

• Off-pump coronary artery bypass
• OPCAB
• Beating heart surgery
• Bypass surgery - heart
• CABG
• Coronary artery bypass graft
• Coronary artery bypass surgery
• Coronary bypass surgery

When is the surgery required:

Any patient who has been diagnosed with a triple vessel coronary artery disease is required to undergo a bypass surgery.

A triple vessel surgery is diagnosed in case a patient has symptoms like chest pain ,heaviness, breathlessness, at times associated with perspiration, back pain which may radiate to the jaw etc and undergoes an angiography.

Preparations
Before the surgery:

Once the patient has been diagnosed with a triple vessel disease and has been advised to undergo a bypass surgery he has to plan accordingly. For a bypass surgery a stay in the hospital of approximately 10 days is expected with a recovery time of a month after the surgery to get back to the normal routine.

The patient is generally put on blood thinners after being diagnosed with a triple vessel disease. So before the surgery the patient is expected to stop blood thinners 5 days prior. The patient plans with his surgeon or assistant doctors to surgeons and comes for pre-operative investigations.

These are important as the surgery would not be carried out unless the patient is found to be fit to undergo surgery. This is important to avoid complications during surgery and to ensure a smooth recovery. With any deviation in the parameters the patient is treated for the same before being taken for the surgery.

The pre-operative investigations include the following:

• Blood tests: includes CBC, Serological tests, blood grouping, blood sugars
• Urine tests: creatinine, electrolytes
• Chest x-ray
• Ultra sonography
• Carotid and radial Doppler studies
• 2D Echo
• CT angiography of the internal mammary arteries
• Sputum and nasal swabs to check for any active infections in the body
• Lung function tests

On the day of surgery:

The patient is kept nil by mouth from one night prior to surgery He is given tranquilizers for his anxiety on the day of the surgery before being rolled to the OT He is then rolled in the operation theatre (OT) as per the schedule of the surgery. Inside the OT he is first attended by an anaesthetist who would prepare the patient. Firstly electrodes are connected on his back for ECG monitoring A few IV lines are inserted through which drugs, blood and anaesthetic agents would be injected during the course of the surgery.

A stomach tube is inserted to drain the contents of the stomach so under anaesthesia it doesn't enter the windpipe. A catheter is inserted into the urinary bladder to monitor the urine output and collect urine in a hygienic manner. Once under anaesthesia the surgeon would begin the surgery.

A cut is mid in the midline and the breast bone( sternum) is separated to reach the heart to prepare for the heart surgery.

Under the sternum are the internal mammary arteries that supply the chest wall. As per the plan of conduits to be used the right , left or at times both the internal mammary arteries are harvested from the chest wall by the surgeon.

In the meanwhile another team of surgeons would also harvest conduits from the leg or the hand as per the requirement.Once all the conduits are ready then begins the grafting process.

After the grafting, begins the resuturing of the sternum to close the chest in layers back to normal. There are tubes inserted into the chest to drain the fluids and blood that get collected in the chest cavity after the surgery.

After the surgery:

After the surgery the patient is shifted with all the lines as inserted into the ICU where he stays for 3-4 days depending upon his clinical condition. The ICU stay is highly crucial stage of recovery. Here the patient begins from regaining consciousness and getting oriented. Eventually all the tubes are removed one after the other depending on the monitoring results.

Patient is started on very little fluid followed by sips of water to semi solid to solid diet gradually.Physiotherapy is given to help recovery of the body.

Once the patient is stable enough to be shifted out of the ICU he is then shifted to the wards where he may stay for 5-7 days depending upon his speed of recovery. Patient is mobilized and proper nursing is done so he can be back to his basic routine after being discharged from the hospital.

After being discharged the patient has to follow a rigorous regimen of proper diet and timely medicines as advised by the treating doctors. This will help for a speedy recovery and will help maintain the good result.

Timely checks and routine follow ups should be done regularly.
Prognosis: With timely follow ups, regular intake of medicines and a healthy diet regimen with regular exercise the outlook of the surgery is very good.

Heart valve surgery is used to repair or replace diseased heart valves. Blood that flows between different chambers of your heart must flow through a heart valve. Blood that flows out of your heart into large arteries must also flow through a heart valve.

These valves open up enough so that blood can flow through. They then close, keeping blood from flowing backward.

There are four valves in your heart:

• Aortic valve
• Mitral valve
• Tricuspid valve
• Pulmonic valve

The aortic valve is the most common valve to be replaced because it cannot be repaired. The mitral valve is the most common valve to be repaired. Only rarely is the tricuspid valve or the pulmonic valve repaired or replaced.

Alternative Names

Valve replacement; Valve repair; Heart valve prosthesis; Mechanical valves, Prosthetic valves

Before your surgery you will receive general anesthesia. You will be asleep and unable to feel pain. In open heart surgery, the surgeon makes a large surgical cut in your breastbone to reach the heart and aorta. You are connected to a heart-lung bypass machine or bypass pump. Your heart is stopped while you are connected to this machine. This machine does the work of your heart, providing oxygen and removing carbon dioxide.

Minimally invasive valve surgery is done through much smaller cuts than open surgery, or through a catheter inserted through the skin.

Several different techniques are used:

• Percutaneous surgery (through the skin)
• Robot-assisted surgery

If your surgeon can repair your mitral valve, you may have:

Ring annuloplasty. The surgeon repairs the ring-like part around the valve by sewing a ring of plastic, cloth, or tissue around the valve.

The surgeon trims, shapes, or rebuilds one or more of the leaflets of the valve. The leaflets are flaps that open and close the valve. Valve repair is best for the mitral and tricuspid valves. The aortic valve is usually not repaired.

If your valve is too damaged, you will need a new valve. This is called valve replacement surgery. Your surgeon will remove your valve and put a new one in place. The main types of new valves are:

Mechanical -- made of man-made materials, such as metal (stainless steel or titanium) or ceramic. These valves last the longest, but you will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life.

Biological -- made of human or animal tissue. These valves last 12 - 15 years, but you may not need to take blood thinners for life.

In some cases, surgeons can use your own pulmonic valve to replace the damaged aortic valve. The pulmonic valve is then replaced with an artificial valve (this is called the Ross Procedure). This procedure may be useful for people who do not want to take blood thinners for the rest of their life. However, the new aortic valve does not last very long and may need to be replaced again by either a mechanical or a biologic valve.

Why the Procedure Is Performed

You may need surgery if your valve does not work properly. A valve that does not close all the way will allow blood to leak backwards. This is called regurgitation. A valve that does not open fully will limit forward blood flow. This is called stenosis.

You may need heart valve surgery for these reasons:

• Defects in your heart valve are causing major heart symptoms, such as chest pain (angina), shortness of breath, fainting spells (syncope), or heart failure.
• Tests show that the changes in your heart valve are beginning to seriously affect your heart function.
• Your doctor wants to replace or repair your heart valve at the same time as you are having open heart surgery for another reason, such as a coronary artery bypass graft surgery.
• Your heart valve has been damaged by infection (endocarditis).
• You have received a new heart valve in the past and it is not working well, or you have other problems such as blood clots, infection, or bleeding.

Some of the heart valve problems treated with surgery are:

• Aortic insufficiency
• Aortic stenosis
• Congenital heart valve disease
• Mitral regurgitation - acute
• Mitral regurgitation - chronic
• Mitral stenosis
• Mitral valve prolapse
• Pulmonary valve stenosis
• Tricuspid regurgitation
• Tricuspid valve stenosis

The risks for cardiac surgery include:

• Death
• Heart attack
• Irregular heartbeat (arrhythmia)
• Kidney failure
• Post-pericardiotomy syndrome -- low fever and chest pain that can last for up to 6 months
• Stroke or other temporary or permanent brain injury
• Temporary confusion after surgery due to the heart-lung machine

It is very important to take steps to prevent valve infections. You may need to take antibiotics before dental work and other invasive procedures

Before the Procedure:

Your preparation for the procedure will depend on the type of valve surgery you are having:

• Aortic valve surgery - minimally invasive
• Aortic valve surgery - open
• Mitral valve surgery - minimally invasive
• Mitral valve surgery – open

After the Procedure:

Your recovery after the procedure will depend on the type of valve surgery you are having:

• Aortic valve surgery - minimally invasive
• Aortic valve surgery - open
• Mitral valve surgery - minimally invasive
• Mitral valve surgery - open

The average hospital stay is 5 - 7 days. The nurse will tell you how to care for yourself at home. Complete recovery will take a few weeks to several months, depending on your health before surgery

Outlook (Prognosis):

The success rate of heart valve surgery is high. The operation can relieve your symptoms and prolong your life. Mechanical heart valves do not often fail. Artificial valves last an average of 8 - 20 years, depending on the type of valve. However, blood clots can develop on these valves. If a blood clot forms, you may have a stroke. Bleeding can occur, but this is rare.

There is always a risk of infection. Talk to your doctor before having any type of medical procedure. The clicking of mechanical heart valves may be heard in the chest. This is normal

1 . When do you need a heart valve surgery?

Just as a valve controls the flow of water; we have four valves to control the flow of blood in & out of the heart - Aortic, Mitral, Pulmonary & Tricuspid Valve. Heart valve disease occurs when a valve doesn't work right. A valve may not open all the way. Or, a valve may have problems closing. If this happens, blood doesn't move through the heart's chambers the way it should. For some time and to certain extent this is tolerated by the body & heart but beyond that it needs to be corrected. In such a case, the valve is either repaired or replaced.

2 . What are the problems you could face with your heart valves?

If a valve doesn't open all the way (a condition called Stenosis), less blood moves through to the next chamber. If a valve doesn't close tightly (a condition called Regurgitation), blood may leak backward.

3 . What are the symptoms of a valve disease?

In case of stenosis, since less blood moves through, it could cause breathlessness, swelling in legs or bloating of whole body. In case of regurgitation, the heart has to work harder at pumping the same amount of blood. Sooner or later its capacity gets exhausted & this may cause blood to back up in the lungs or body because it's not moving through the heart as it should. At a later stage things get further complicated & patient may develop rhythm disturbances, heart failure, stroke, etc. A damaged valve (stenosis or regulation) is at risk of valve infection called endocarditis.

4. What happens during a Heart Valve Surgery?

Valve surgery is of two types- repair & replacement (tissue or metallic). Repair means that the valve is mended to help it work better. During valve repair, a valve ring may be sewn around the opening of the valve to support it. Replacement means your diseased valve is removed and a new valve is inserted in its place. Whether a valve will be repaired or replaced can be decided based on certain parameters but final decision can be taken only once surgery has begun. Valve replacement is most often used to treat aortic valves and severely damaged mitral valves.

5. What are the types of valves?

Broadly they can be of two types-mechanical & biological.

• Mechanical (metallic): Made of metal, these generally have a longer durability but require additional precautions. Since blood tends to stick to mechanical valves creating blood clots, patients with these valves need to take blood-thinning medicines (called anticoagulants) for lifetime. Such cases are at a risk of both valve & anticoagulant related complications.
• Biological (tissue): Made from animal or human tissue these function better but wear out over time. They require lesser restrictions on lifestyle. Here the patient is at a risk of only valve related & not anticoagulant related complications.

6. How is the surgery done?

Reaching your heart :

To get to your heart, one or more incisions must be made in your chest.

Stopping Your Heart

During valve surgery, the heart is stopped & connected to the heart lung machine, which does the work of adding oxygen to the blood & circulating it to the other part of the body during surgery. Once the valve surgery has been completed, your heart & lungs take over again.

Repairing or Replacing the Valve

To reach the valve, an incision is made on your heart. If the valve can be mended, the needed repairs are done. If the valve must be replaced, part or the entire damaged valve is removed. The proper-sized replacement valve is positioned and sewn firmly into place. The incision made is closed & the heart is then started again, and the patient is weaned off from the heart & lung machine. The surgery takes between 2 to 4 hours or more, depending on the number of valves that need to be repaired or replaced.

Recovery Time

Hospital stay is about 8-10 days, including at least 1 to 3 days in the Intensive Care Unit (ICU). Recovery after valve surgery may take a long time. You will have to rest and limit your activities. If you have an office job, you can usually go back to work in 4 to 6 weeks. Those who have more physically demanding jobs may need to wait longer.

Life after Valve Replacement

7. How is valve surgery different from bypass surgery?

In brief, valve surgery requires surgeons to work inside the chambers of the heart & therefore the heart needs to be stopped (unlike a beating heart surgery where the heart is not stopped). Valve replacement means a foreign material (valve) is placed inside the chambers of the heart in the blood stream.

8 . What precautions are to be taken after surgery?

Blood thinners (Anticoagulants) - Since artificial valves are foreign bodies they tend to produce clots causing blockages. For this reason, blood thinners (anticoagulants) needs to be given so that chance of clot formation is minimized. The dosage & duration of blood thiner varries from person to person & also depends on type of valve & requires regular blood test (INR test). Blood thinners are required for three months for Bio valves & for life for Mech valve.

Prevention of Infection (Bacterial Endocarditis) - The artificial valves are vulnerable to serious type of infection, so patient needs to take precautions to treat all body infections seriously & cover all surgical procedures (minor or major) properly with antibiotics. Do inform your doctor and dentist that you have had a valve surgery. If you are having a surgical or dental procedure, take an antibiotic before the procedure because bacteria can enter the bloodstream during these procedures. If bacteria get into a repaired or artificial valve, it can lead to a serious condition called bacterial endocarditis. Antibiotics can prevent bacterial endocarditis.

Regular checkup - Valves are subjected to wear & tear. In addition, function of the artificial valve may change over time due to various reasons. Any change in valve function can affect the performance of the heart. Sometimes the patient may not know of the worsening of heart function until its too late. For this reason they should undergo regular checkup preferably once every year. This checkup is usually in the form of 2D Echo & color doppler.

9. Why do anticoagulants require repeated blood tests?

To prevent clot formations blood is required to be maintained at a certain level. If anticoagulation is higher, patients experience spontaneous bleeding from body parts (e.g. gums, in stools, in sputum, or in vomiting). lf less, blood may clot in the valve. You are therefore advised to get a regular blood test called PT/INR (International Normalized Ratio) done as per your Doctors advice. These PT/INR numbers tells you exactly how fast your blood is clotting, information that is absolutely necessary to decide whether your dosage of anticoagulant needs to change.

10. Why is the anticoagulant dosage changed often?

The effect of anticoagulants varies from person to person and also from time to time depending on the state of the body (illness, pregnancy), medications or diet changes. So a regular check of INR level is necessary, after which the dosage is adjusted accordingly.

11. Anticoagulants have to be taken for how long?

For mechanical valves, it is for a lifetime. For biological valves, it is usually discontinued after 3 months, but if the heartbeats are irregular it may be continued for lifetime.

12. Are there any diet restrictions while on an anticoagulant?

A normal balanced diet is always advisable. Avoid too much of green leafy vegetables and certain vegetable oils. These substances contain large amounts of Vitamin K which can lower the effect of your anti coagulant medicine.

Other foods that need to be avoided include:

• Cauliflower, Broccoli, Cabbage
• Tomato
• Fruits like guava, papaya, jackfruit
• Red meats & egg

The following information is important for your Doctor:

• Date of surgery
• Present INR & date of testing
• Last INR & date of testing
• Present dose of anticoagulant
• Dose of anticoagulant when INR was last tested
• Range of INR recommended by your Doctor

The Asian Heart Institute (AHI) Advantage

The latest trend in healthcare is to have lesser invasive surgeries, i.e. surgeries which involve minimal cuts & ensure that patient has a faster recovery. Keyhole or Minimally Invasive Surgery (MIS) is a modern innovative surgical technique that reduces the patient's post surgery distress & allows them to return back to their normal life in just a couple of days. In Minimally Invasive Surgery, surgeons operate through tiny incisions with the help of long instruments and HD cameras. Valve surgeries are regularly performed at AHI using the Minimally Invasive Surgery approach. Depending on your conditions, your surgeon will decide whether you can undergo valve surgery through Minimally Invasive Technique.

Hypertension is a disorder characterized by consistently high blood pressure. Generally, high blood pressure consists of systolic blood pressure (the "top" number, which represents the pressure generated when the heart beats) higher than 140 or diastolic blood pressure (the "bottom" number, which represents the pressure in the vessels when the heart is at rest) over 90.

India:

Hypertensive heart disease is the leading cause of illness and death from high blood pressure The prevalence of hypertension has increased from 2% to 25% in the last 6 decades among urban residents and from 2% to 15% in rural residents.

Hypertension awareness, treatment and control status is low in India

Types of high blood pressure:

Primary (essential) hypertension:

For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called essential hypertension or primary hypertension, tends to develop gradually over many years.

Secondary hypertension:

Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Kidney problems ( diabetic nephropathy, polycystic kidney disease, glomerular disease, renal artery stenosis)
• Adrenal gland tumors (Cushing's syndrome, aldosteronism, pheochromocytoma)
• Thyroid problems ( Hyperthyroidism, hypothyroidism)
• Certain defects in blood vessels you're born with (congenital) ( co-arctation of the aorta)
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines
• Alcohol abuse or chronic alcohol use
• Obstructive sleep apnea
• Obesity
• Pregnancy

Resistant hypertension: When your blood pressure is difficult to control

• If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which should be a diuretic, you may have resistant hypertension.
• Having resistant hypertension doesn't mean your blood pressure will never get lower. You may have to fine-tune your medications to come up with the most effective combination and doses.

White coat hypertension:

The term white coat hypertension refers to when a person's blood pressure rises in the presence of a doctor and returns to normal once he is home or away from the doctor.

Risk factors: Some are modifiable and some are non modifiable.

1) Non- modifiable:

• Age: The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Family history: High blood pressure tends to run in families

2) Modifiable:

• Being overweight or obese: The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls
• Using tobacco: Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the in tobacco can damage the lining of your artery walls ( endothelium). This can cause your arteries to narrow, increasing your blood pressure. Passive smoking also can increase your blood pressure.
• Too much salt (sodium) in your diet: Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet: Potassium helps balance the amount of sodium in your cells. If you don't get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• Drinking too much alcohol: Over time, heavy drinking can damage your heart ( alcoholic cardiomyopathy ) Having more than two drinks a day for men and more than one drink a day for women is considered healthy by some, but what is the point in destroying the liver, kidneys and other organs eventually?

Mechanism

High blood pressure means the pressure inside the blood vessels (called arteries) is too high. As the heart pumps against this pressure, it must work harder. Over time, this causes the heart muscle to thicken( hypertrophy) Sometimes, the muscle can be so thick that it does not get enough oxygen relative to the amount of heart muscle. This can cause angina (chest pain). Uncontrolled blood pressure can lead to breathlessness due to increase pressure on the walls of the heart which may precipitate a hypertensive urgency/ emergency and heart failure. High blood pressure also leads to thickening of the blood vessel walls ( arteriosclerosis).

Symptoms:
In about 50% of the population the disease is asymptomatic.
A few people with early-stage high blood pressure may have:

• Dull headaches
• Dizzy spells
• Nosebleeds than normal

These signs and symptoms usually don't occur until high blood pressure has reached a severe or life-threatening stage.

Problems that occur because of high blood pressure (complications):

• Coronary artery disease and angina
• Heart failure
• Thickening of the heart muscle (called hypertrophy)
• Eye blood vessel damage ( retinopathy)
• Fluid build up under the retina ( choroidopathy)
• Optic nerve damage ( optic neuropathy)
• Problems with your brain ( encephalopathy)
• Stroke
• Severe damage to the body's main artery ( aortic dissection)
• Unstable chest pain ( unstable angina)
• Fluid back up in the lungs due to impaired pumping of heart ( pulmonary oedema)
• Sudden loss of kidney function ( acute renal failure)

Investigations:

• Routine blood pressure monitoring with a physician
• Blood investigations to find the underlying cause if any
• Urine analysis to rule out kidney disease
• ECG and 2D Echo to assess the condition of the heart

Treatment:

1) Preventive Treatment:

• Eat healthy foods
• Decrease the salt in your diet.
• Maintain a healthy weight
• Increase physical activity
• Limit alcohol
• Don't smoke
• Manage stress
• Monitor your blood pressure at home
• Practice relaxation or slow, deep breathing
• Yoga

2) Medical:

• ACE inhibitors
• Angiotensin receptor blockers
• Calcium channel blockers
• Beta blockers
• Diuretics

3) Surgical:

• Renal artery stenting
• Renal artery- radio frequency ablation
• Nephrectomy of the failed kidney
• Removal of adrenal tumors
• Extensive sympathectomy

Dietary Approaches to Stop hypertension (DASH) :

• Foods low in saturated fats, cholesterol and total fat
• More fruits, vegetables and low-fat dairy products
• More whole grain foods, fish, chicken and nuts
• 3500 mf of dietary potassium each day. Foods rich in potassium include green leafy vegetables, oranges, potatoes, brown rice, avocados and bananas
• LESS red meat, sweets and drinks high in sugar
• No more than 3000mg of sodium per day.

When to Contact a Medical Professional:

At your every visit with a healthcare professional you may insist on checking your blood pressure as high blood pressure is usually asymptomatic.

However if you are known to have high blood pressure and if you develop any symptoms you must visit the closest hospital immediately.

What to expect at your visit with a physician?

• Firstly a thorough physical check up will be done by your physician to detect any sign of heart disease or other damage due to high blood pressure
• Lab tests may be advised which include urine analysis, blood cell count, potassium sodium and creatinine levels in blood, blood glucose levels, cholesterol and triglycerides in blood, ECG
• The doctor would inquire about family history as blood pressure runs in the family
• You may be asked to give information about any changes in the diet or intake of tobacco in any form, intake of alcohol in any form
• Your doctor may also inquire about any social or emotional factor that could influence blood pressure ( family situation, job status, work conditions)
• A dietary assessment will be done to check the intake of sodium, fat, caffeine etc.

What to expect by your physician on subsequent visits:

• You will be expected to carry the blood pressure monitoring chart along for assessment by the physician
• Investigation reports as advised by the physician for evaluation of the physical condition and to assess any damage due to high blood pressure
• Changes in medications depending upon the condition after the evaluation.

How to measure blood pressure at home:

• There are devices available in market that use a digital readout with a cuff that can be electronically inflated and deflated
• Certain devices also monitor pressure from the finger but they are not considered very accurate
• In some cases the doctor may fit a patient with a portable unit that record blood pressure during a full day's activity known as ambulatory monitoring.

Obesity is a disorder involving an excessive amount of body fat to an extent that it may have a negative impact on the body.

Causes : Obesity is generally caused by eating too much and moving too little. If you consume high amounts of energy from your diet, particularly from fat and sugars, but do not burn off the energy through exercise and physical activity, much of the surplus energy is then stored by the body as fat.

Other factors:

• Genetics
• Overeating
• A diet high in simple carbohydrates
• Frequency of eating
• Slow metabolism
• Physical inactivity
• Medications
• Pregnancy
• Lack of sleep

How to measure: Obesity is likely when an individual BMI is 30 or higher.

BMI: calculated by dividing your weight in kilograms (kg) by your height in meters (m) squared.

Classification:

Overweight (not obese), if BMI is 25.0 - 29.9

Class 1 (low-risk) obesity, if BMI is 30.0 - 34.9

Class 2 (moderate-risk) obesity, if BMI is 35.0 - 39.9

Class 3 (high-risk) obesity, if BMI is equal to or greater than 40.0

Complications:

If you're obese, you're more likely to develop a number of potentially serious health problems, including:

• High triglycerides and low high-density lipoprotein (HDL) cholesterol
• Type 2 diabetes
• High blood pressure
• Metabolic syndrome — a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol
• Heart disease
• Stroke
• Cancer, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate
• Breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts
• Gallbladder disease
• Gynecologic problems, such as infertility and irregular periods
• Erectile dysfunction and sexual health issues
• Nonalcoholic fatty liver disease, a condition in which fat builds up in the liver and can cause inflammation or scarring
• Osteoarthritis
• Skin conditions, including poor wound healing

How to manage obesity:

• Starting to make healthy changes in your diet, such as eating more fruits, vegetables and whole grains and reducing portion sizes.
• Focus on achievable, enjoyable changes.
• Eat breakfast.
• Tracking how much you're eating or drinking each day so that you get a sense of how many calories you're taking in. It's easy to underestimate how many calories you actually take in every day.
• Beginning to increase your activity level. Try to get up and move around your home more frequently. Start gradually if you aren't in good shape or aren't used to exercising. Even a 10-minute daily walk can help.

Definition :

A heart attack is a serious medical emergency in which the supply of blood to the heart is suddenly blocked, usually by a blood clot or deposits of cholesterol called plaques.

Risk factors or causes for developing Heart Attack

• Smoking
• High-fat diet
• Diabetes
• High cholesterol
• High blood pressure
• Being overweight or obese

Mechanism:

Before a heart attack, one of the plaques ruptures (bursts), causing a blood clot to develop at the site of the rupture. The clot may then block the supply of blood running through the coronary artery, triggering a heart attack. Lack of blood to the heart can damage the heart muscle.

A heart attack is known medically as a "Myocardial infarction or MI or ACS-Acute coronary syndrome".

*CAD- Coronary artery disease is a condition in which coronary arteries (the major blood vessels that supply blood to the heart) get clogged up with deposits of cholesterol.

Symptoms OF ACS/Heart attack can include:

• Chest pain – a sensation of pressure, tightness or squeezing in the centre of your chest
• Pain in other parts of the body – it can feel as if the pain is traveling from your chest to your arms (usually the left arm is affected, but it can affect both arms), jaw, throat/ neck, back and abdomen
• Feeling lightheaded or dizzy
• Sweating
• Shortness of breath
• Feeling sick (nausea) or being sick (vomiting)
• An overwhelming sense of anxiety
• Coughing or wheezing
• Upper abdominal discomfort or feeling of gas

Although the chest pain is often severe, some people may only experience minor pain, similar to indigestion. In some cases, there may not be any chest pain at all, especially in women, the elderly and people with diabetes. These patients present with atypical symptoms.

DIAGNOSIS :

All patients with chest discomfort, back discomfort or stomach upset must undergo an ECG to rule out any heart problem, as a heart attack can present with any of the symptoms. If a heart attack is suspected, you should be admitted to hospital immediately. You will usually be admitted to emergency department/ ward or ICU for evaluation with non -invasive test, or in case of strong suspicion of heart attack directly shifted to the cardiac catheterization unit to confirm the diagnosis and begin treatment.

Tests helpful in diagnosis include :

• ECG: It determines the electrical activity of the heart. It tells us whether there is a heart attack or any other rhythmic disturbances ( tachycardia or bradycardia)
• Cardiac enzymes: A blood test to detect damage to the heart muscle
• 2D Echo: An ultrasound based test to detect the motion of the heart muscles and the flow of blood through the valves
• Stress test: A treadmill or bicycle or medication based test which increases your heart rate and detects changes in the ECG
• Stress echo: A test in which a 2D Echo is done followed by a stress test and again followed by a 2D echo to correlate changes in the ECG with 2D Echo. It can also be done with the help of medicines to increase the heart rate (Dobutamine stress Echo)
• Coronary angiography- (CAG): It can help determine presence & then exact location of blockage in coronary arteries. The test involves inserting a thin tube, known as a catheter, into one of the blood vessels in your groin or arm. The catheter is guided into your coronary arteries using X-rays. A special fluid, known as a contrast agent, is pumped through the catheter. This fluid shows up on X-rays & can help locate the site of any blockage or narrowing. This contrast agent can cause allergic reaction or damage to your kidney specially in diabetics and patients with renal failure.

TREATMENT

The treatment options for a heart attack depend on :

• Whether you have had an ST segment elevation myocardial infarction (STEMI) which is a major heart attack affecting a large area of heart or full thickness of the heart muscle (CALL 126-126)
• Or another type of heart attack (Non ST segment elevation MI) which is a smaller heart attack not affecting a large area of the heart muscle or the full thickness of the heart muscle.

If your heart attack is treated within 6 hours of onset of heart attack (GOLDEN HOUR) the recovery of the heart function is far better and risk of heart attack is less. So it is important to go to the hospital with facility of angioplasty at the earliest from the onset of heart attack. The best treatment option is emergency angioplasty. In the absence of facility of angioplasty in any hospital, blood thinning injection (thrombolysis) can be done.

• PCI (primary percutaneous coronary intervention) - Opening clogged blood vessels of heart with a balloon & deploying a stent to maintain blood flow in a vessel.
• If your symptoms started within the past 6 hours but you cannot access PCI quickly – you will be offered medication to break down blood clots. (Thrombolytics/Anticoagulants)
• If your symptoms started more than 12 hours ago – usually treatment is done with blood thinner drugs or injections

PREVENTION OF HEART ATTACK

Making lifestyle changes is the most effective way to prevent having a heart attack (or having another heart attack).

These are the main steps you can take to help prevent a heart attack:

• Eat a healthy, balanced diet (avoid excess fat/ oil/ meat ; include more of green veggies, fruits, nuts, fish)
• Avoid smoking/ alcohol
• Try to keep your blood pressure in normal limits
• Exercise daily
• Manage stress in a healthy manner
• Yearly health check ups with a physician.

In NSTEMI (small heart attack with minimal muscle damage) - usually treatment is done with blood thinner drugs or injections. The best course of treatment will be decided after an angiogram and may include medication, emergency angioplasty or bypass surgery.

SECONDARY PREVENTION OF CAD
Patients of heart attack will require to:

• Take blood thinners ( aspirin, clopidogrel, prasugrel, ticagrelor)
• Cholesterol lowering medicines ( statins)
• Other cardio-protective medicines
• After an angioplasty and stent it is compulsory to continue blood thinning medicines for at least a year and preferably life long.
• Regular follow –up once in every 3-6 months for first 2 years may be advised.
• Regular physical activity/exercise for one hour on daily basis is advisable.
• Before undergoing any invasive procedure like dental extraction/ any major or minor surgery it is advisable to discuss discontinuation of blood thinner medicines with cardiologist beforehand.

Complications:

The complications of sudden heart attack due to acute blockage depend on how much, how long, and where a coronary artery is blocked. If the blockage affects a large amount of heart muscle, the heart will not pump effectively. If the blockage shuts off blood flow to the electrical system of the heart, the heart rhythm may be affected.

Pumping problems:

In a heart attack, part of the heart muscle dies. Dead tissue, and the scar tissue that eventually replaces it, does not contract. The scar tissue sometimes even expands or bulges when the rest of the heart contracts. Consequently, there is less muscle to pump blood. If enough muscle dies, the heart's pumping ability may be so reduced that the heart cannot meet the body's need for blood and oxygen. Heart failure, low blood pressure, or both develop. If more than half of the heart tissue is damaged or dies, the heart generally cannot function, and severe disability or death is likely.

The damaged heart may enlarge, partly to compensate for the decrease in pumping ability (a larger heart beats more forcefully). Enlargement of the heart makes abnormal heart rhythms more likely.

Rhythm problems:

Abnormal heart rhythms (arrhythmias) occur in more than 90% of people who have had a heart attack. These abnormal rhythms may occur because the heart attack damaged part of the heart's electrical system. Sometimes there is a problem with the part of the heart that triggers the heartbeat, so heart rate may be too slow. Other problems can cause the heart to beat rapidly or irregularly. Sometimes the signal to beat is not conducted from one part of the heart to the other, and the heartbeat may slow or stop. In addition, areas of heart muscle that have poor blood flow but that have not died can be very irritable. This irritability can cause heart rhythm problems, such as ventricular tachycardia or ventricular fibrillation. These rhythm problems greatly interfere with the heart's pumping ability and may cause the heart to stop beating (cardiac arrest). A loss of consciousness or death can result. These rhythm disturbances are a particular problem in people who have an imbalance in blood chemicals, such as a low potassium level.

Other problems:

Pericarditis (inflammation of the membranes enveloping the heart) may develop in the first day or two after a heart attack or about 10 days to 2 months later. Pericarditis is more common in people who have not had the blocked artery opened by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). People seldom notice symptoms of early developing pericarditis because their heart attack symptoms are more prominent. However, pericarditis produces a scratchy rhythmic sound that can sometimes be heard through a stethoscope 2 to 3 days after a heart attack. Sometimes, the inflammation causes a small amount of fluid to collect in the space between the two layers of the pericardium (pericardial effusion). Later developing pericarditis is usually called Dressler (post-myocardial infarction) syndrome. This syndrome causes fever, pericardial effusion (extra fluid filling up in the sac around the heart), inflammation of the membranes covering the lungs, pleural effusion (extra fluid in the space between the two layers of the pleura), and joint pain.

Other complications after a heart attack include malfunction of the mitral valve, rupture of the heart muscle, a bulge in the wall of the ventricle (ventricular aneurysm), blood clots (emboli), and low blood pressure (hypotension). Nervousness and depression are common after a heart attack. Depression after a heart attack may be significant and may persist.

Definition:

It is a non surgical treatment used to open narrowed coronary arteries to improve blood flow to the heart. It is an interventional procedure and it starts out the same way as an angiography.

Types:

1) Balloon angioplasty: A procedure in which a small balloon at the tip of the catheter is inserted near the blocked or narrowed area of the coronary artery. The technical name for balloon angioplasty is Percutaneous Transluminal coronary Angioplasty (PTCA) or percutaneous Coronary Intervention (PCI).

When the balloon is inflated, the fatty plaque or blockage is compressed against the wall of the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart.

2) Balloon angioplasty with stenting: In most cases, balloon angioplasty is performed in combination with the stenting procedure. A stent is a small metal mesh tube that acts as a scaffold to provide support inside the coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently. During a period of several weeks, the artery heals around the stent. In this way restenosis is diminished.

Angioplasty with stenting is recommended in patients having one or two blockages in the coronary arteries. For multiple blockages it is suggested to undergo a bypass surgery.

Are these procedures considered surgical procedures?

No. they are not considered as surgical procedures because there is no large incision used to open the chest. There is access made to the coronary arteries through femoral artery (from the groin) or the radial artery (from the hand).

Will I be awake during the procedure?

Yes, you will be given a mild sedative to relax you but you will be awake and conscious during the entire procedure. The doctor will use a local anesthesia to numb the catheter insertion site.

Where is the procedure performed?

The procedure is performed in the Cath lab.

Who performs the procedure?

A specially trained interventional cardiologist and a team of fellow physicians, nurses and technicians perform the procedure.

How long does the procedure take to perform?

The procedure may take anywhere between half an hour to one hour. The preparation and recovery time may add several hours in the cathlab.

What are the possible risks of the procedure?

If you need to have an angioplasty your cardiologist may discuss the following risks with you:

• Bleeding at the catheter insertion site
• Infection
• Mild to moderate skin reaction from x ray exposure
• Continued chest pain or angina
• Irregular heart rhythm
• Kidney failure
• Blood clots
• Stroke
• Acute closure of coronary artery

Does an interventional procedure cure coronary artery disease? For most people, these procedures increase blood flow to the heart, diminished chest pain and decrease the risk of a heart attack.

But it does not cure a coronary artery disease.

To achieve the best result you must be committed to leading a heart healthy life style as follows:

• Take your medications as prescribed
• Make dietary changes
• Quit smoking
• Exercise regularly
• Keep your follow up appointments
• Be an active member of the rehabilitation for a healthy heart.

Preparing for the procedure:
Allergies: Please discuss all your allergies with your cardiologist specially the ones mentioned below

• Iodine allergy
• Dye allergy
• Contract agent allergy
• Latex or rubber products allergy

Medications: discuss the medications that you take with your cardiologist as he may want to add or alter a few, the major ones being:

• Anti-coagulants
• Aspirin
• Diabetes medicines

Pre-procedure tests: you need to undergo the following before the procedure:

• Blood tests which include serology, sugar levels and creatinine levels
• ECG
• Chest x-ray

What happens during he procedure?

Angioplasty is done in a cathlab as follows:

• The patient is rolled into the cathlab after the initial preparations are done after admission
• In the cathlab the patient is given a few medications and IV line is inserted for administration of medicines if required during the procedure
• In the procedure room the cardiologist begins by giving local anaesthesia at the catheter insertion site
• Using x-ray imaging, a guide wire is passed from the insertion site after it is punctured and over the wire a catheter is threaded all the way to the coronary arteries
• Through this catheter another tube with an inflatable balloon is passed such that it reaches the blocked artery and it is positioned such that the deflated balloon is right at the level of the lesion
• The balloon is then inflated till the fatty blockage is compressed against the wall of the artery. Most balloons are mounted with a stent so after the balloon is inflated the stent expands and takes its place and the balloon can be pulled out after deflating it
• The stent remains in place and the catheter is pulled out slowly and the procedure is completed.

What to expect after the procedure?

After the procedure you will be expected to stay in the ICU for one day for observation and monitoring of vitals as the first 24 hours is the time when complications if any may throw up.

After the first 24 hours in case of no complications you may be shifted to the wards where you may stay for another 24 hours till you are made stable and then you may be discharged.

A responsible adult must drive you home after discharge. You may not be allowed to drive for a few weeks. You may consult your doctor about when to start driving.

What is an Arrhythmia

An arrhythmia is a disorder of the heart rate (pulse) / heart rhythm. The heart can beat too fast (tachycardia), too slow (bradycardia), or irregularly.

How does a normal heart beat :

Normally, your heart works as a pump that brings blood to the lungs for purification and the rest of the body for supply of oxygen to the tissues.

To help this happen, your heart has an electrical system that makes sure it contracts (squeezes) in an orderly way.

The electrical impulse that signals your heart to contract begins in the sinoatrial node (also called the sinus node or SA node- the upper signal station). This is your heart's natural pacemaker.

The signal leaves the SA node and travels through the heart along a set electrical pathway.

From here it reaches the AV node- lower signal station from where the signal spreads over the ventricular muscles which contracts them thus making the heart pump blood.

Different nerve messages signal your heart to beat slower or faster.

Any trouble with the SA or AV node can cause the heart to loose the synchronous rhythm.

Types of Arrhythmias

There are two major types of arrhythmias:
In tachycardia, the heart beats too quickly: over 100 beats per minute.
In bradycardia, the heart beats too slowly: less than 60 beats per minute.

Tachycardia are classified by their location:

Supraventricular tachycardia (SVT) is the most common type of arrhythmia. It can affect the top chambers of the heart, including the atria (upper chambers that fill with blood) and the AV node. Electrical signals in the atria fire abnormally, interfering with signals coming from the SA node. A rapid, regular heartbeat of 150 to 200 beats per minute may result.

In ventricular tachycardia, electrical signals originate in the ventricles (lower chambers of the heart), and do not travel through the heart as they normally should. In effect, the SA node no longer controls how the ventricles contract and pump blood and can cause death. The heart beats so quickly that it cannot effectively pump blood. A serious, but uncommon condition, ventricular tachycardia may be a warning sign of underlying heart disease.

Bradycardia:
Bradycardia most commonly happens when :

• Sinus node ( upper signal station) transmits electrical impulses more slowly or,
• Fails to fire impulse.
• Nearby tissue may block the sinus node's signals before they reach the atria and ventricles through the proper channels. This is called heart block
• Sinus node is damaged, due to heart disease, aging, inherited or congenital defects, or medications, including those used to control arrhythmias and high blood pressure.

Bradycardia commonly affects the elderly Arrhythmias are caused by problems with the heart's electrical conduction system like:

• Abnormal (extra) signals may occur.
• Electrical signals may be blocked or slowed.
• Electrical signals travel in new or different pathways through the heart.

Some common causes of abnormal heartbeats are:

• Abnormal levels of potassium or other substances in the body
• Heart attack, or a damaged heart muscle from a past heart attack
• Heart disease that is present at birth (congenital)
• Heart failure or an enlarged heart
• Overactive thyroid gland
• Some infections

Arrhythmias may also be caused by some substances or drugs, including:

• Alcohol, caffeine, or stimulant drugs
• Heart or blood pressure medicines
• Cigarette smoking (nicotine)
• Drugs that mimic the activity of your nervous system
• Medicines used for depression or psychosis

Symptoms
An arrhythmia may be present all of the time or it may come and go. You may or may not feel symptoms when the arrhythmia is present. Or, you may only notice symptoms when you are more active.

• Palpitations (awareness of the heartbeat)
• Fainting
• Light-headedness, dizziness
• Paleness
• Shortness of breath
• Sweating

Exams and Tests
Taking a Pulse (Heart Rate) by yourself :

You can easily check your pulse on the inside of your wrist, below your thumb. Gently place 2 fingers of your other hand on this artery. Do not use your thumb, because it has its own pulse that you may feel. Count the beats for 30 seconds, and then double the result to get the number of beats per minute. You can check the rate and the regularity of the pulse.

• The doctor will listen to your heart with a stethoscope and feel your pulse. Your blood pressure may be low or normal.
• ECG is generally the first investigation done.

Heart monitoring devices are often used to identify the rhythm problem, such as a:

• Holter monitor (used for 24 hours)
• Event monitor or loop recorder (worn for 2 weeks or longer)

Other tests may be done to look at heart function:

• Coronary angiography
• Echocardiogram
• A special test, called an electrophysiology study (EPS), is done to take a closer look at the heart's electrical system
• Sometimes genetic study is needed to identify some hereditary causes.

Treatment :
It depends on the cause of the arrhythmia. Few of them are

• Medications to control the heart rate and rhythm.
• Radiofrequency Ablation -This is conducted along with EP study and the abnormal electrical pathways are destroyed with the help of catheters put in the heart. This is commonly used for supraventricular tachycardia having an abnormal pathway.
• Pacemakers- A pacemaker is a device that has a battery placed in the chest and wires going to the heart. It sends electrical impulses and makes the heart contract at regular intervals as required. Pacemakers are required for bradycardias.
• Implantable Cardioverter defibrillators - These are used in ventricular tachycardias and ventricular fibrillations to prevent sudden cardiac death. It gives a shock when the heart rhythm reaches a dangerous life threatening state.
• Cardiac resynchronisation therapy - These are specialised pacemakers used in heart failure patients whose heart pumping is not synchronous and is too low. It improves the cardiac output and decreases the heart failure hospitalisations.

Definition: A pacemaker is a small device, about the size of a half dollar piece, that's placed under the skin near your heart to help control your heartbeat. A pacemaker is implanted as part of what's often referred to as "cardiac resynchronization therapy."

Why is a pace maker needed?
People may need a pacemaker for a variety of reasons — mostly due to one of a group of conditions called arrhythmias, in which the heart's rhythm is abnormal.

Reasons for abnormal heart rhythm may be as follows:

• Normal aging of the heart may disrupt your heart rate, making it beat too slowly.
• Heart muscle damage resulting from a heart attack is another common cause of disruptions of your heartbeat.
• Some medications can affect your heart rate as well. For some, genetic conditions cause an abnormal heart rate.

Regardless of the underlying cause of an abnormal heart rate, a pacemaker may fix it.

A pacemaker can often be implanted in your chest with a minor surgery. You may need to take some precautions in your daily life after your pacemaker is installed.

Why is it done?

• Pacemakers are implanted to help control your heartbeat.
• They can be implanted temporarily to treat a slow heartbeat after a heart attack, surgery or overdose of medication.
• Pacemakers can also be implanted permanently to correct a slow heartbeat (bradycardia) or, in some cases, to help treat heart failure

How your heart beats ( hyperlink to the arrhythmias subtitle "how does a normal heart beat")? What does a pacemaker do?

An implanted electronic pacemaker mimics the action of your natural pacemaker. An implanted pacemaker consists of two parts:

The pulse generator: This small metal container houses a battery and the electrical circuitry that regulates the rate of electrical pulses sent to your heart.

Leads (electrodes): One to three flexible, insulated wires are each placed in a chamber, or chambers, of your heart and deliver the electrical pulses to adjust your heart rate. Pacemakers monitor your heartbeat and, if it's too slow, the pacemaker will speed up your heart rate by sending electrical signals to your heart. In addition, most pacemakers have sensors that detect body motion or breathing rate, which signals the pacemaker to increase your heart rate during exercise to meet your body's increased need for blood and oxygen.
Types of pacemakers:

• Single-chamber pacemakers : These types of pacemakers usually carry electrical impulses from the pulse generator to the right ventricle of your heart.
• Dual-chamber pacemakers : carry electrical impulses from the pulse generator to both the right ventricle and the right atrium of your heart. The impulses help control the timing of contractions between the two chambers.
• Biventricular pacemakers: Biventricular pacemakers are a treatment option for people with heart failure whose hearts' electrical systems have been damaged. Unlike a regular pacemaker, a biventricular pacemaker stimulates both of the lower chambers of your heart (the right and left ventricles so that all or most of the ventricular muscle pumps together. This allows your heart to pump blood more effectively. Because this treatment resets the ventricles' pumping mechanism, it's also referred to as cardiac resynchronization therapy (CRT).

Risks

Complications from having surgery to implant your pacemaker are uncommon, but could include:

• Infection where the pacemaker was implanted
• Allergic reaction to the dye or anesthesia used during your procedure
• Swelling, bruising or bleeding at the insertion site, especially if you are taking blood thinners
• Damage to your blood vessels or nerves near the pacemaker
• Collapsed lung
• Puncture of your heart muscle, which can lead to bleeding into the lining (pericardium) of your heart and may require emergency medical care
• Life-threatening complications of pacemaker implantation are rare.

Risks
Before your doctor decides if you need a pacemaker, you'll have several tests done to find out the cause of your irregular heartbeat. These could include:

• Electrocardiogram
• Holter monitoring
• 2D Echo
• Stress test

How is the procedure carried out?
During the procedure :

• Surgery to implant the pacemaker is usually performed while you're awake and typically takes a few hours.
• You'll be given a sedative to relax, and the area where your pacemaker is inserted will be numbed by giving you a local anaesthesia
• During surgery, one or more flexible, insulated wires (leads or electrodes) are inserted into a major vein under or near your collarbone(clavicle) and guided to your heart with the help of X-ray images.
• One end of each wire is secured to the appropriate position in your heart, while the other end is attached to the pulse generator, which is usually implanted under the skin beneath your collarbone.

After the procedure

• You'll usually stay in the hospital for one day after having a pacemaker implanted.
• Before you leave, your pacemaker is programmed to fit your particular pacing needs. A return visit is often scheduled to make sure your pacemaker's settings are correct.

After that, most pacemakers can be checked remotely using wireless technology. Using your cellphone or radiofrequency signals, your pacemaker transmits and receives information between you and your doctor's office, where your doctor can access the data — including your heart rate and rhythm, how your pacemaker is functioning, and remaining battery life. Remote technology means fewer trips to the doctor's office, but you'll still need to be seen by your doctor in person for scheduled checkups.
After your procedure to implant your pacemaker, your doctor may recommend :

• You avoid vigorous exercise or heavy lifting for about a month.
• You may have some aches and pains near the area where your pacemaker was implanted. These pains can be relieved with over-the-counter medicines, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin IB, Advil, others), but talk to your doctor before taking any pain relievers.

Special precautions:
It's unlikely that your pacemaker would stop working properly because of electrical interference. Still, you'll need to take a few precautions:

• Cellphones: It's safe to talk on a cellphone, but avoid placing your cell phone directly over your pacemaker implantation site when the phone is turned on. Although unlikely, your pacemaker could misinterpret the cellphone signal as a heartbeat and withhold pacing, producing symptoms, such as sudden fatigue.
• Security systems. Passing through an airport metal detector won't interfere with your pacemaker, although the metal in it may sound the alarm. But avoid lingering near or leaning against a metal-detection system. If security personnel insist on using a hand-held metal detector, ask them not to hold the device near your pacemaker any longer than necessary or ask for an alternative form of personal search. To avoid potential problems, carry an ID card stating that you have a pacemaker.
• Medical equipment. If a doctor is considering any medical procedure that involves intensive exposure to electromagnetic energy like am MRI, tell him or her that you have a pacemaker.
• Power-generating equipment. Stand at least 2 feet (60 centimeters) from welding equipment, high-voltage transformers or motor-generator systems. If you work around such equipment, your doctor can arrange a test in your workplace to determine whether it affects your pacemaker.

Devices that are unlikely to interfere with your pacemaker include:

• microwave ovens
• televisions and remote controls
• radios
• toasters
• electric blankets
• electric shavers
• electric drills

Results :

Once your pacemaker is implanted, the battery should last five to 10 years, which is the average battery life. When a pacemaker's battery wears out, the entire pacemaker's pulse generator is replaced, and you'll need another procedure to fix your device. The leads of your pacemaker can be left in place — though they may need to be replaced eventually — and the procedure to change your pacemaker's battery is often quicker and requires less recovery time than the procedure to first implant your pacemaker.

Pacemakers are a standard treatment for many conditions affecting your heart's electrical system. By preventing a slow heart rate, pacemakers can treat symptoms, such as fatigue, lightheadedness and fainting. Because most of today's pacemakers automatically adjust your heart rate to match your level of physical activity, they can allow you to resume a more active lifestyle.

Though the term may sound like the failure of heart to pump, but to understand correctly it means that the heart is not pumping as well as it should. The main function of the heart is to pump blood so that ht e oxygen in the blood can reach the body cells and the body can function properly.

With heart failure, the heart becomes weak due to which the blood flow to the cells decreases due to which there is fatigue (feeling of tiredness) and shortness of breath. Everyday activities become difficult.

How does a normal heart pump blood?
The normal healthy heart is strong muscular pump which measures a little larger than the wrist. It pumps blood continuously through the circulatory system without a break.

It has 4 chambers:

• 2 above which are called as atria, divided into the right and left
• 2 below which are called as the ventricles, divided into right and left

The blood flows through these 4 chambers in the following manner:

• Oxygen rich blood travels from the lungs to the left atrium
• From the left atrium it travels to the left ventricle
• From the left ventricle it is pumped to the rest of the body to deliver oxygen.
• Once the cells take up oxygen from the blood, deoxygenated blood from the rest of the body is brought to the right atrium
• From here it travels to the right ventricle
• From the left ventricle it is sent to the lungs for oxygenation again

What is heart failure:
It is a chronic, progressive condition in which the heart muscle cannot pump the blood adequately to meet the needs of the body for oxygen.

Causes of heart failure:

• Coronary artery disease (blockages in the arteries of the heart)
• Past history of a heart attack ( myocardial infarction)
• High blood pressure (hypertension)
• Abnormal heart valves
• Heart muscle diseases
• Congenital heart defects ( heart defects present from birth)
• Severe lung diseases
• Diabetes
• Sleep apnoea (inability to breathe on lying down)

How does the body make up for this problem?

• Enlarging the heart: the chambers of the heart enlarge, as enlargement makes the chamber stretch more and makes it strong so it can pump more blood.
• Thickening of the heart: The muscles of the heart begin to thicken thus making it strong and helping it pump more blood.
• Pumping faster: This helps the output to increase thus some demands of the body for oxygen can be met.
• Narrowing of blood vessels: The blood vessels of the body start narrowing which keeps the blood pressure up thus making up for the heart's loss of power
• Diverting blood: The body constricts the blood vessels of lesser important parts of the body so important organs like liver brain and kidneys receive the adequate blood supply and the required oxygen.

These measures mask the problem of heart failure but cannot solve it.
Eventually the body cannot keep up and thus the person experiences fatigue, breathlessness and other such symptoms.

Types of heart failure:
A) Left Sided heart failure: As mentioned earlier the function of the left side of the heart is to pump oxygenated blood to the body. Hence, the left side is larger and stronger than the other chambers

So when the left side fails it has to work harder than normal to pump the same amount of blood.

There are 2 types of left sided heart failures:
1) Systolic failure: systole means contraction phase of the heart. So in a systolic failure the left ventricle loses its ability to contract normally. Hence it cannot push enough blood in the circulation.

2) Diastolic failure: Diastole means relaxation phase of the heart. So in diastolic failure the left ventricle loses its ability to relax sufficiently hence it cannot fill properly with blood which happens during the resting phase between each heart beat.

B) Right sided heart failure: The function of the right side is to receive deoxygenated (impure blood) from the body and further pump it back into the lungs for purification.
The right sided heart failure occurs as a result of the left sided heart failure. The process is as follows:

• First the left ventricle fails; hence it is not able to pump blood efficiently to the body
• The residual blood remains in the left ventricle hence the left atrium also cannot push all its blood to the left ventricle.
• There is back pressure on the left atrium hence pure blood coming from the lungs to the left atrium is also not able to flow sufficiently thus creating a back pressure in the lungs
• The lungs are under pressure hence they cannot take further impure blood coming from the right side of the heart
• Thus there is pooling of blood in the right side and due to this its pumping capacity is affected leading to failure
• As the right side fails to pump blood ahead there is pooling of blood from where it comes, which presents as edema of the lower limbs as it pools in the limbs due to gravity.

C) Congestive cardiac failure:This situation is a medical emergency and requires immediate medical attention.

As there is heart failure, the blood does not circulate properly, thus there is pooling of blood through out the body. When it pools in the lower limbs there is oedema of the ankles and legs.

Due to the back pressure in the lungs it can cause fluid to collect leading to pulmonary oedema. This can cause breathlessness, especially on lying down. It has to be treated immediately or it can lead to pulmonary distress.

Again due to the improper circulation of the blood the kidneys are not able to dispose of sodium and water. Hence there are chances of water retention that can make the body tissues swell.

Classes of heart failure:
The table below describes the most commonly used classification system, the New York Heart Association (NYHA) Functional Classification.

For Example:

• A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction of the left main coronary artery is classified:
  Function Capacity I, Objective Assessment D
• A patient with severe anginal syndrome but angiographically normal coronary arteries is classified:
  Functional Capacity IV, Objective Assessment A

Signs and symptoms:

Prevention and treatment of heart failure:

1) Lifestyle changes:

• Quit smoking
• Losing excessive weight and then maintaining a stable weight
• Tracking daily fluid intake
• Avoiding alcohol
• Avoiding or limiting caffeine
• Eating a healthy heart diet
• Being physically active
• Managing stress
• Keeping track of blood pressure
• Avoiding flu and pneumonia by taking timely vaccines

2) Medications:

• Anticoagulants
• Antiplatelet agents
• ACE inhibitors
• Beta blockers
• Calcium channel blockers
• Cholesterol lowering medications
• Diuretics
• Digitalis preparations
• Vasodilators

3) Surgery:

• Angioplasty in case the cause is coronary artery disease
• By pass surgery if there are multiple blockages
• Heart transplant

4) Implantable Medical devices for heart failure:

• Valve replacement if there is defect in the heart valves causing the failure
• Left ventricular assist device (LVAD)

What is a left ventricular assist device (LVAD)?

The left ventricle is the large, muscular chamber of the heart that pumps blood out to the body. A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own.

When is an LVAD used?

This device is sometimes called a "bridge to transplant," but is now used in long-term therapy. People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. During this wait, the patient's already-weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can help a weak heart and "buy time" for the patient or eliminate the need for a heart transplant. Most recently, LVADs are being used longer-term as "destination therapy" in end-stage heart failure patients when heart transplantation is not an option.

How does an LVAD work?

A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump's battery and control system. LVADs are now portable and are often used for weeks to months. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.

Complications:

If you have heart failure, your outlook depends on the cause and the severity, your overall health, and other factors such as your age. Complications can include:

4) Implantable Medical devices for heart failure:

• Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment.
• Heart valve problems. The valves of your heart, which keep blood flowing in the proper direction through your heart, may not function properly if your heart is enlarged or if the pressure in your heart is very high due to heart failure.
• Heart rhythm problems. Heart rhythm problems (arrhythmias) can be a potential complication of heart failure.
• Liver damage. Heart failure can lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly.

Some people's symptoms and heart function will improve with proper treatment. However, heart failure can be life-threatening. People with heart failure may have severe symptoms, and some may require heart transplantation or support with a ventricular assist device.

10 steps to prevent heart disease
Although you might know that eating certain foods can increase your heart disease risk, it's often tough to change your eating habits. Whether you have years of unhealthy eating under your belt or you simply want to fine-tune your diet, here are eight heart-healthy diet tips. Once you know which foods to eat more of and which foods to limit, you'll be on your way toward a heart-healthy diet.

1. Control your portion size

How much you eat is just as important as what you eat. Overloading your plate, taking seconds and eating until you feel stuffed can lead to eating more calories than you should. Portions served in restaurants are often more than anyone needs.

Use a small plate or bowl to help control your portions. Eat larger portions of low-calorie, nutrient-rich foods, such as fruits and vegetables, and smaller portions of high-calorie, high-sodium foods, such as refined, processed or fast foods. This strategy can shape up your diet as well as your heart and waistline.
Keep track of the number of servings you eat. A serving size is a specific amount of food, defined by common measurements such as cups, ounces or pieces.

2. Eat more vegetables and fruits

Vegetables and fruits are good sources of vitamins and minerals. Vegetables and fruits are also low in calories and rich in dietary fiber. Vegetables and fruits contain substances found in plants that may help prevent cardiovascular disease. Eating more fruits and vegetables may help you eat less high-fat foods, such as meat, cheese and snack foods.

Featuring vegetables and fruits in your diet can be easy. Keep vegetables washed and cut in your refrigerator for quick snacks. Keep fruit in a bowl in your kitchen so that you'll remember to eat it. Choose recipes that have vegetables or fruits as the main ingredients, such as salads or fresh fruit mixed into salads.

It is advisable to eat a serving of fruits or salads BEFORE meals. This will reduce your meal intake and also give good satiety. This simple means helps in quick weight loss.

3. Select whole grains

Whole grains are good sources of fiber and other nutrients that play a role in regulating blood pressure and heart health.

4. Limit unhealthy fats

Limiting how much saturated and trans fats you eat is an important step to reduce your blood cholesterol and lower your risk of coronary artery disease. A high blood cholesterol level can lead to a buildup of plaques in your arteries, called atherosclerosis, which can increase your risk of heart attack and stroke.

The American Heart Association 2007 offers these guidelines for how much fat to include in a heart-healthy diet:

The best way to reduce saturated and trans fats in your diet is to limit the amount of solid fats — butter, margarine and shortening — you add to food when cooking and serving. You can also reduce the amount of saturated fat in your diet by trimming fat off your meat or choosing meats with less than 10 percent fat.

You can also use low-fat substitutions when possible for a heart-healthy diet. For example, boiled potato chaat contains low fat.

low-fat dahi rather than butter, or use sliced whole fruit or low-sugar jam on your toast instead of butter or cheese spreads. You may also want to check the food labels of some cookies, crackers and chips. Many of these snacks — even those labeled "reduced fat".

may be made with oils containing trans fats. One clue that a food has some trans fat in it is the phrase "partially hydrogenated" in the ingredient list.

When you do use fats, choose monounsaturated fats, such as olive oil or canola oil. Polyunsaturated fats, found in certain fish, avocados, nuts and seeds, also are good choices for a heart-healthy diet. When used in place of saturated fat, monounsaturated and polyunsaturated fats may help lower your total blood cholesterol. But moderation is essential. All types of fat are high in calories.

An easy way to add healthy fat (and fiber) to your diet is ground flaxseed.
Flaxseeds are small brown seeds that are high in fiber and omega-3 fatty acids. Studies have found that flaxseeds may help lower cholesterol in some people. You can grind the seeds in a coffee grinder or food processor and stir a teaspoon of them into yogurt, applesauce or hot cereal.

Quinoa : In comparison to cereal grasses like wheat, quinoa is higher in fat content and can provide valuable amounts of heart-healthy fats like monounsaturated fat (in the form of oleic acid). Quinoa can also provide small amounts of the omega-3 fatty acid, alpha-linolenic acid (ALA)

5. Choose low-fat protein sources

Lean meat, poultry and fish, low-fat dairy products, and eggs are some of your best sources of protein. But the yellow of the egg is to be avoided as it has high cholesterol content.

But be careful to choose lower fat options, such as skim milk rather than whole milk and skinless chicken breasts rather than fried chicken patties.

Fish is another good alternative to high-fat meats. And certain types of fish are rich in omega-3 fatty acids, which can lower blood fats called triglycerides. You'll find the highest amounts of omega-3 fatty acids in cold-water fish, such as salmon, mackerel and herring. Though one should avoid frying fish.

Other sources are flaxseed, walnuts, soybeans and canola oil. Legumes — beans, peas and lentils — also are good sources of protein and contain less fat and no cholesterol, making them good substitutes for meat. Substituting plant protein for animal reduces fat and cholesterol intake.

6. Reduce the sodium in your food

Eating a lot of sodium can contribute to high blood pressure, a risk factor for cardiovascular disease. Reducing sodium is an important part of a heart-healthy diet. The Department of Health and Human Services recommends:

Healthy adults have no more than 2,300 milligrams (mg) or 23 grams per day of sodium a day (about a teaspoon of salt).

People age 51 or older, African-Americans, and people who have been diagnosed with high blood pressure, diabetes or chronic kidney disease have no more than 1,500 mg of sodium a day

Although reducing the amount of salt you add to food at the table or while cooking is a good first step, much of the salt you eat comes from foods such as papads, pickles, chiwdas(salted mixtures) and packed processed foods. Eating fresh foods and making your own soups and stews can reduce the amount of salt you eat.

If you like the convenience of ready-made prepared meals, look for ones with reduced sodium. Be wary of foods that claim to be lower in sodium because they are seasoned with sea salt instead of regular table salt — sea salt has the same nutritional value as regular salt.

Another way to reduce the amount of salt you eat is to choose your condiments carefully. Many condiments are available in reduced-sodium versions, and salt substitutes can add flavor to your food with less sodium.

7. Plan ahead: Create daily menus

You know what foods to feature in your heart-healthy diet and which ones to limit. Now it's time to put your plans into action.

Create daily menus using the six strategies listed above. When selecting foods for each meal and snack, emphasize vegetables, fruits and whole grains. Choose lean protein sources and healthy fats, and limit salty foods. Watch your portion sizes and add variety to your menu choices.

For example, if you have grilled salmon one evening, try a black-bean patties the next night. This helps ensure that you'll get all of the nutrients your body needs. Variety also makes your meals and snacks more interesting.

8. Allow yourself an occasional treat

Allow yourself an indulgence every now and then. A candy bar or handful of potato chips won't derail your heart-healthy diet. But don't let it turn into an excuse for giving up on your healthy-eating plan. If overindulgence is the exception, rather than the rule, you'll balance things out over the long term. What's important is that you eat healthy foods most of the time.

Incorporate these eight tips into your life, and you'll find that heart-healthy eating is both doable and enjoyable. With planning and a few simple substitutions, you can eat with your heart in mind.

9. Eating at regular intervals

Avoid staying hungry for long times. Prolonged hunger makes you hog calories and put on weight faster than ever. It is hence advisable to eat at regular intervals and plan a diet where all the vital substances required by the body are included in proper proportions.(Make an appointment with our dieticians today)

10. Track your Diet

With all the inputs from the dietician and nutritionist about a planned diet, it is equally our responsibility to maintain the same.
Below is a diet chart which will help you with the same.