Heart Attack

Dr. Steven Reisman, a New York City Cardiologist and Director of The New York Cardiac Diagnostic Center announces the recent implementation in his office of a device to measure “endothelial dysfunction” which is a measurement useful in the early detection of risk for heart attack and stroke. The device is call EndoPat and it is a fifteen minute test  with the patient lying down and probes put on one finger in each hand to measure the ability of blood vessels to dilate after the inflation of a blood pressure cuff for several  minutes.

EndoPat measures reactive hyperemia. Reactive hyperemia is calculated automatically by the device and shows the degree of vascular reactivity. Several recent studies have shown an abnormal test reveals dysfunction which can be an early risk factor for the development of atherosclerosis and “hardening of the arteries” and may also be a contributor to the progression of atherosclerosis.

The measurement of endothelial dysfunction is important in the early determination of risk for atherosclerosis; endothelial dysfunction may even be present before the occurrence of obstructive blockages on other imaging modalities. It is known that the process of atherosclerosis begins early in life and endothelial dysfunction contributes to this disease state and in fact precedes the development of plaque in the blood vessels.

Thus the use of this device to measure endothelial dysfunction or flexibility verses stiffness of the blood vessel is important in individuals early on to identify those who need aggressive life style changes along with risk factor modification in the prevention of both heart attack and stroke. Many interventions such as exercise, weight reduction, a healthy diet, and occasionally medications have been demonstrated to be beneficial in improving endothelial function. EndoPat can also be used to follow the individual’s response to these interventions over time.

EndoPat has been shown to be useful in many groups of patients including those with a family history of coronary artery disease, individuals with chest pain, those with elevated levels of cholesterol or triglycerides, diabetics, those with hypertension, women with chest pain, and also men with erectile dysfunction.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center, recommends that EndoPat can also be used in younger and middle age individuals as an early indicator of the need for aggressive attention to life style modification in those who are at increased risk for heart attack and stroke.

Dr. Steven Reisman, a New York City cardiologist, will discuss the relationship between acute risk factors or acute triggers and the development of a heart attack or stroke. It is well known that there are chronic risk factors for heart disease such as hypertension, hyperlipidemia, diabetes mellitus, smoking, and other factors. There are also acute risk factors that can precipitate a cardiac event. Acute risk factors may result in a rapid increase in blood pressure, vasoconstriction, or even increase in coagulability.

There are several psychological triggers that are known to play a role. These include anger, emotional upset, anxiety, stress in the work place, bereavement, and sexual activity.

An interesting phenomenon has been observed that showed a significant increase in heart attacks at 9 am in the morning. It appears that the act of waking up, when a person who is vulnerable to a heart attack, goes from a supine to an upright position increases the catecholamines in the body. These particular individuals most likely have an underlying plaque that is vulnerable and is more likely to clot in the morning.

There are physical triggers that can include vigorous physical activity along with sexual activity. These factors play a bigger role in those who are sedentary and a lesser role in those who have the habit of exercising on a regular basis.

There are psychological stresses which include an outburst of anger which elevates the risk of heart attack. Also, episodes of anxiety can increase the risk of a heart attack. In addition, depression and frustration may also be associated with increasing the risk of a heart attack.

There are also population stresses that can increase the risk of a heart attack such as earthquakes, war, and even elevated pollution levels and respiratory infection and also floods.

Dr. Steven Reisman, a New York City cardiologist and director of the New York Cardiac Diagnostic Center feels that an initial evaluation with a cardiologist in consultation to evaluate risk of a heart attack along with proper exercise and treatment of psychological stress and prevention of psychological stress is key to helping diminish the risk of heart attack and stroke in these individuals.

Sudden Cardiac Death (SCD) refers to an unexpected death from a cardiovascular cause in an individual with or without pre-existing heart disease according to Dr. Steven Reisman, a Manhattan Cardiologist. This usually is a death occurring within one hour of an acute change in clinical status or an unexpected death that occurred within the previous 24 hours.

In the United States the incidence of sudden cardiac death varies between an 180,000 to 450,000 deaths per year. SCD still accounts for greater than 50 percent of all coronary heart disease (CHD) deaths, and approximately 15-20 percent of all deaths in the United States.

The incidents of SCD increases with age regardless of race or sex. Women, at any age have a lower incidence in SCD than men. Approximately two-thirds of women who present with SCD have no known history of heart disease compared with 50 percent of men.

A variety of risk factors have been proposed for the pathophysiology of SCD. CHD is the most common underlying disease associated with SCD in the western world being responsible for approximately 75 percent of SCD. Cardiomyopathies such as dilated and hypertrophic along with primary electrical disorders are responsible for the remainder. CHD in relation to SCD occurs in three settings including acute myocardial infarction, ischemia without infarction, and structural alteration such as scar formation with ventricular dilatation.  The mechanism of SCD in cases without acute myocardial infarction is likely an electrical event due to a ventricular arrhythmia which is a caused by ischemia or other arrhythmogenic stimuli in a chronically diseased heart. It is suggested that approximately 90 percent of deaths that occur within one hour of symptom onset are arrhythmic in nature.

Coronary heart disease or congestive heart failure significantly increases SCD risk of the population. SCD risk factors may be similar to CHD risk factors. Risk factors for sudden cardiac death include smoking, diabetes mellitus, and hypertension. There are certain measurements on the standard resting electrocardiogram that may serve as risk factors for SCD including an elevated resting heart rate, prolonged QT interval and prolonged QRS duration. Some studies have suggested early repolarization as a risk factor for sudden cardiac death.

Certain nutritional patterns may provide protection for the risk of SCD. In some studies consuming fish one to two times per week was associated with approximately a 50 percent reduction in SCD risk. Light to moderate levels of alcohol consumption may be associated with reduced risk of SCD. In some studies it is suggested that an increase in plasma magnesium levels may provide protection for SCD. In addition, a mediterranean diet appears to provide some protection for SCD.

There are certain triggers that may be associated with SCD. There may be a certain diurnal variation to SCD with the greatest incidence occurring in the morning hours from 6am to noon. Certain studies have suggested the highest risk of out of hospital arrest may be on Mondays. These patterns may suggest activity with psychological exposure playing a role in triggering SCD. Although there are long term benefits of exercise, it is also suggested that SCD occurs with a higher than average frequency during or shortly after vigorous exertion. Chronic habitual exertion may result in increase cardiac electrical stability but transient vigorous exercise may have an increased risk for SCD. Both depression and acute mental stress may trigger SCD and acute increases have been seen in situations such as populations experiencing disaster such as earthquake along with life stresses such as the death of a spouse or loss of a job.

The New York Cardiac Diagnostic Center along with Dr. Steven Reisman, a Manhattan Cardiologist, promotes early diagnosis of heart disease and strategies to increase both awareness and prevention of triggers and risk factors related to both coronary heart disease and sudden cardiac death.

A recent study has suggested that obesity alone can increase the risk of a fatal heart attack even excluding the effect of other risk factors such as hypertension and diabetes. Healthday (2/14 Mozes) has reported that obese men have a dramatically higher risk of dying from a heart attack. In the study of 6,000 middle age men followed for about 15 years, there was an increased risk of fatal heart attack independent of risk factors such as high blood pressure, diabetes, and high cholesterol.

Obese middle-aged men had a 60% increased risk of dying from a heart attack compared to non-obese middle age men after taking out the effect of these risk factors. This suggests that obesity itself may be causing the heart attack. One theory is that obesity may be related to inflammation as a factor in a fatal attack. In addition, obese individuals have larger hearts because of their increase in body size and their hearts may already be “stressed” prior to a heart attack.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center, states that our office advocates an aggressive approach about not only treating traditional risk factors but also obesity with nutrition counseling and also early diagnostic testing to detect heart disease prior to the development of a heart attack.

Healthday (8/10, Mozes) reports that a study of patients in the United Kingdom in those admitted to the hospital for a heart attack revealed that a decrease of just one degree celsius on a single day gives rise to a cumulative two percent rise in the number of heart attacks in the next twenty- eight days. This study shows that cold weather increases the risk for having a heart attack in particular for the elderly and those with a previous history of heart disease. It appears that those who are taking aspirin were less vulnerable to this increase in risk. The author suggested that prior research has shown that as temperatures goes down blood pressure may go up and the blood may become thicker causing the heart to work harder and may also increase the possibility of blood clotting.

Dr. Steven Reisman, Director of The New York Cardiac Diagnostic Center and a Manhattan Cardiologist states that the risk of heart attack that is associated with a drop in outdoor temperature is relatively small compared to the usual cardiovascular risk factors such as smoking, obesity, high cholesterol, high blood pressure, family history, and diabetes.

Bloomberg news (7/12/2010) reported that hospitals in the United States are delivering more urgent and faster emergency medical care to heart attack patients which results in increased survival. Bloomberg reported that in 2009 88% of patients with heart attacks received procedures within the recommended 90 minutes of arriving at the hospital compared to only 64.5% in 2007. The original study was published in the Journal of the American College of Cardiology.

According to the American College of Cardiology about 770,000 Americans this year will have their first heart attack. A heart attack is an acute disruption of blood flow to the heart causing the death of the heart tissue. About 38% of those heart attacks will result in death.

These findings showing improved urgent care to these heart attack patients gives hope for increasing survival of heart attack patients brought to the hospital early on. Patients at risk for heart attack include those with cardiac risk factors such as hypertension or high blood pressure, diabetes mellitus, a history of smoking, hyperlipidemia or elevated lipids, a family history of heart disease and obesity. These individuals need early testing to evaluate their risk for heart attack.