Despite all the advances in the medical field, doctors have yet to find a way to prevent sudden heart attacks. But there are certain precautions that a person can take to avoid such an eventuality
ISCHAEMIC Heart Disease (IHD) is rated as the No.1 killer of adult population worldwide. Epidemiological studies have found South East Asia (Pakistan included) as the high risk region for IHD.
Acute myocardial infarction (AMI), commonly known as heart attack, is the main mode of presentation of Ischaemic Heart Disease (IHD) in the hospital as an emergency event. AMI carries very high mortality and morbidity. Fortunately, over the past three decades tremendous advancement in diagnosis and management of IHD have taken place.
Modern pharmacological, interventional and surgical treatments have reduced hospital mortality and morbidity significantly. Today we have more survivors of heart attack than the past. and this trend continues to grow in the future.
However, a number of people suffering from IHD and its complications continue to die all of a sudden before receiving any medical aid. Quite frequently now, people who seem to be in good health and are engaged in routine activity, die almost all of a sudden. Each day hospitals cater to a growing number of patients who are dead on arrival. This is what is called the syndrome of sudden cardiac death or SCD.
Unfortunately none of these patients undergo a post mortem examination and therefore to determine a precise cause is difficult. Other than Pakistan, data, especially that from the western world, suggests the following causes of SCD:
But not everyone is predisposed to SCD. Still, there are groups of individuals who have high susceptibility towards sudden cardiac death. They include:
* Individuals with known IHD (previous heart attack, angina, etc)
* Individuals with known arrhythmias (Supraventicular/ventricular Tachy Arrhythmias)
* Individuals with heart failure (significant left ventricular dysfunction)
* Individuals with known family history of heart disease and sudden death in the family
* Individuals who carry risk factors like high blood pressure, Diabetes Mellitus, Hypercholestrolaemia, Smoking, Obesity and Sedentary Living.
Some one dying all of sudden is a very serious and dramatic event, which has catastrophic consequences for the individual, family and the community at large.
The question that arises here is that can we do something to prevent such a catastrophe. The answer is yes. Though not significant, but a little effort can save many lives. And each life saved is worth the effort made.
Heart diseases in general run a very unpredictable course and the natural history of IHD, cardiomyopathies and heart failure have not yet been fully elucidated. However, a number of steps can be taken in the right direction which will result in reducing the chances of SCD syndrome.
* Individuals with known IHD should stick to the physicians prescription and advice, regarding lifestyle modification and further tests. They should comply with the specialist’s recommendation regarding angioplasty or coronary artery bypass surgery. Drugs like aspirin should be taken for life. Blood pressure, cholesterol and sugar lowering drugs should be taken on long term basis and only stopped on the advice of the physician.
Those who have undergone interventional (angioplasty) or surgical (coronary artery bypass surgery) procedures should follow the postoperative do’s and don’t religiously. Follow-up visits should not be missed at any chance and should not carry the impression that all is over. It should be borne in mind that IHD is at best only controlled, not cured.
* Individuals with known arrhythmias, whether primary or secondary, should receive long-term antiarrhythmic medications. These medications need to be properly monitored and their dosage adjusted accordingly. There are four classes of antiarrhytmic agents and almost all sorts of arrhythmias can be controlled with appropriate pharmacotherapy. In addition to antiarrhythmic medications, a number of interventional and surgical procedures can be adopted which cure or suppress the tendency towards arrhythmias.
In recent years high risk patients with refractory arrhythmias have been treated with Implantable Cardiovertor Defibrillator (ICD). This device is very expensive and can only be offered to very select patients. Facilities for such device do exist in Pakistan.
* Individuals with significant LV dysfunction or overt heart failure (HF) are at high risk for SCD. The main cause for sudden death in heart failure patients is intractable arrhythmias, thrombotic episodes and cardiac rupture. These patients need to be kept on long term antiarrhythmic, anticoagulant and anti-failure treatment. Some of them may benefit from surgical treatment and assist-devices.
Chances of heart failure survival are on the increase due to improved survival after myocardial infarction which is the result of advancement in pharmacological and interventional treatments. However, despite excellent pharmacological agents, management of heart failure remains a major challenge and still carries very high mortality and morbidity.
* Individuals with no clinically manifest IHD but carrying risk factors like hypertension, diabetes mellitus, hyperlipidaemia, obesity, smoking and sedentary living. These individuals are potential candidates for IHD at some stage in their life. They are also predisposed to sudden cardiac death. Such individuals should modify their risk factors through lifestyle modification and where necessary, with medicines.
They should also get themselves properly checked and investigated. Those who are over forty with any of the above major risk factors should preferably undergo an elective Exercise Tolerance Test (ETT) to rule out the possibility of latent heart disease. Persons suffering from diabetes mellitus need special attention. Diabetic sufferers of IHD have special features. They often lack the typical chest pain and can have ischaemic events including myocardial infarction in the absence of pain (a silent angina or heart attack).
ETT is an excellent screening test but is by no means 100 per cent specific or sensitive. Therefore it has be read with caution and whenever in doubt, patients must undergo advance test like thallium scan and coronary angiography.
To summarize, sudden death needs to be recognized as a disease entity rather than just an accident or a matter of destiny. Majority of the SCD occur in people with IHD, whether manifest or latent. Most of the patients with manifest IHD are under some form of treatment and therefore enjoy some degree of protection. Whereas individuals with latent (non-manifest) or diagnostically missed IHD are specially prone to SCD as they are neither taking any medicines nor practising any preventive measures.
It is the duty of medical profession to identify such individuals prior to the catastrophe. This needs great deal of public awareness and professional expertise. Family physicians are the best persons who can identify people at high risk and refer them to the specialist after preliminary tests.
A number of heart attack patients can be saved from SCD if they receive prompt medical attention. Community (family) physicians need to be trained in very early management of heart attacks, including defibrillation (DC Cardioversion). The way the IHD is spreading in our community there is a dire need for more and more local emergency cardiac centers. A number of patients are dying while on their way to major hospitals due to transit time and logistical reasons.
Tertiary care centers cannot be established in every corner of the country. But centers with emergency cardiac facilities capable of dealing with early phase of acute chest pain can be provided in various zones of the metropolitan cities.
As has been emphasized for the past many years, the solution of IHD lies in its prevention. Preventive measures must be reinforced all the time and all efforts made to identify high risk persons. Once identified, the management of high risk individuals is the responsibility of family, family physicians and the specialist involved. Every effort must be made to preempt catastrophic events including SCD.
Death is a reality and we all have to embrace it. But some untimely deaths can be averted by adhering to above measures. A single individual saved through preventive means is a 100 per cent success for that individual. While loosing an individual due to lack of early identification by the concerned physician is a 100 per cent failure which must be avoided.
Despite all the advances in the medical field, doctors have yet to find a way to prevent sudden heart attacks. But there are certain precautions that a person can take to avoid such an eventuality 
