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learn about coronary heart disease and how to prevent it

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Angina Pectoris

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By Julia Ann Purcell, RN, MN, FAAN Barbara Johnston Fletcher, RN, MN, FAAN Suzanne Cambre, RN, BSHA

This book is not meant to replace your doctor’s advice or treatment. It is to help you understand the symptoms, treatment and prevention of coronary heart disease.


Why Angina? Angina is a sign that something is wrong. In this case, the problem is coronary heart disease.* Angina symptoms are your heart’s way of telling you that it is not getting enough blood and oxygen.

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Coronary heart disease is the build up of fat in the arteries that feed the heart. You may not feel any symptoms during the gradual build up. Then, one day, you may feel discomfort. If the symptoms are brief (5-10 minutes) and go away completely, they are called angina pectoris. If the symptoms last longer than a few minutes, heart damage can occur (a heart attack). This need does not have to happen!

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There are things you can do to help your heart. As you read this book, you will learn why you have angina and how to treat it the minute you feel it. You will also find out how to change your life to prevent more fatty buildup in your heart’s arteries. In the long run, you may be able to reduce fatty buildup or prevent cracks in the fatty plaque that’s already there. Your actions will be the key to staying healthy and preventing heart damage.

* or coronary artery disease (CAD)

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oxygen

NOW!


Table of Contents How the Heart Gets Oxygen ......................................................................... 4 Spasm ......................................................................................................................... 5 Fatty Buildup ................................................................................................... 6–7 Angina................................................................................................................ 8–10 Treat angina when you first feel it ...................................................... 9 Heart Attack .................................................................................................11–13

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Preventing Angina ....................................................................................14 –17 Long-acting NTG .....................................................................................14 Other medicines ........................................................................................15 Make some changes.................................................................................17

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Preventing Coronary Heart Disease ...............................................18–26 Smoking ........................................................................................................18 High blood pressure.................................................................................19 High blood fats ......................................................................................... 20 Lack of exercise........................................................................................ 22 Overweight ................................................................................................. 23 Stress and tension .................................................................................... 24 Heredity........................................................................................................ 24 Diabetes........................................................................................................ 25 Make the changes that apply to you ................................................ 26 What if your angina changes?................................................................... 27

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Tests for Coronary Artery Disease ................................................. 28–29 Resting EKG’s .......................................................................................... 28 Exercise tests ............................................................................................. 28 Blood tests .................................................................................................. 28 Nuclear scans ............................................................................................. 29 Stress echocardiograms ........................................................................ 29 Cardiac catheterization.......................................................................... 29 Ultrafast CT (Electron Beam Tomography) ................................ 29 Treatments ................................................................................................... 30 –31 Angioplasty ................................................................................................ 30 Bypass surgery .......................................................................................... 31 Looking Ahead ................................................................................................... 32


How the Heart Gets Oxygen

1. right coronary artery (RCA)

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2. left anterior descending (LAD)

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3. circumflex artery

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The heart has to have a steady supply of oxygen. Two problems in the coronary arteries that can keep the heart from getting enough blood and oxygen are:

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The heart muscle gets oxygen from blood brought in by 3 major arteries and their smaller branches.

•

spasm (sudden squeezing of a coronary artery)

•

fatty deposits (atherosclerosis) that build up in the artery wall which can crack and lead to a blood clot

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Spasm

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Sudden spasm can cause angina or a heart attack. It all depends on how long the spasm lasts. If it lasts longer than 10–15 minutes, damage can occur to the heart muscle (a heart attack). Both normal arteries and those with fatty buildup can go into spasm. The exact reasons for this are not yet known.

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spasm (temporary)

If spasm is likely, your doctor may prescribe medicine to keep the artery relaxed and try to prevent more symptoms.

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Fatty Buildup (atherosclerosis)

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High levels of cholesterol and blood fats can lead to fatty buildup in the arteries. There are 2 main types of cholesterol: High Density Lipoproteins (HDL’s or the “good” cholesterol) and Low Density Lipoproteins (LDL’s or the “bad” cholesterol). LDL’s are attracted into the artery walls, causing fatty buildup. Triglycerides are another type of blood fat that plays a role in fatty buildup in some people.

LDL

LDL

HDL

HDL

HDL

HDL

LDL

LDL

LDL

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LDL

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HDL

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Fatty buildup is more likely when:

arteries have been damaged by nicotine, inflammation or high blood pressure

• • • • •

your diet is high in cholesterol and saturated fat

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you don’t exercise

you are overweight you have diabetes

you are tense from too much stress

Many people will need medicine to help reduce their blood fat levels. However, some people can lower their LDL’s and triglycerides while raising their HDL’s with regular exercise, weight loss and a diet low in cholesterol and saturated fat.

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The fatty layers (called plaque) build up slowly in the body’s arteries. This buildup is even more likely in smaller arteries such as those in the heart. When fatty buildup or a small clot narrows an artery, less blood reaches the heart muscle. Angina symptoms occur when there is a critical shortage of blood and oxygen to meet the heart’s needs. If angina symptoms last 5-10 minutes and go away completely, there is usually no heart damage.

angina

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fatty deposits

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If a crack develops in even a small plaque, a blood clot may form. When a clot blocks the artery, no blood gets through and heart damage (a heart attack) is likely, unless the artery can be opened within a few hours.

crack in the fatty plaque

blood clot

fatty deposits

heart attack

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Angina

a tightening, pressure, squeezing or aching feeling in the chest or arms

a “burning” feeling in the chest that may be confused with indigestion (heartburn)

a sharp, burning or cramping pain or an ache that starts in or spreads to the neck, jaw, throat, shoulder, upper back or arms

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When the heart needs more oxygen, most people have one or more of these symptoms:

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Angina varies from mild discomfort in some people to pain in others. Some people feel breathless, weak or sweaty instead of any of the above.

Angina is more likely during physical work, mental stress, after heavy meals or in cold, windy weather. But you can have angina when you are resting; it may even wake you when you are asleep. Angina often goes away after you slow down or stop what you are doing. This can tempt you to ignore the feelings.

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Treat angina when you first feel it NITROGLYCERIN (NTG) and REST are the quickest ways to relieve angina. Since angina is a warning that the heart needs more blood and oxygen, act fast when you first feel the symptoms.

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Stop what you are doing, and take a NTG tablet (or spray) under the tongue. Do this every 3 to 5 minutes until it goes away or you have taken 3 tablets or sprays. Angina should be completely relieved in less than 15 minutes using up to 3 doses of quick-acting NTG. If angina lasts longer than 15 minutes, go to the nearest hospital emergency room for help. You need medical care NOW.

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More about NTG

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A short-acting NTG tablet is a tiny white tablet which melts very fast when placed under the tongue. It does not work at all if swallowed. Keep the tablets in the brown bottle they come in. Then make sure the cotton comes out easily. Keep tablets at room temperature. NTG tablets must be fresh in order to work. The tablets are usually fresh one year after the bottle is opened. Replace them before the expiration date on the bottle. Short-acting NTG causes a brief headache for some people. If you have used Viagra™ within 24 hours, you are advised NOT to use any form of NTG for angina symptoms (see A Word of Caution on page 10). 9


NTG Spray NTG spray (Nitrolingual®) is a mist that should be sprayed onto or under your tongue. You should use no more than 1 spray every 5 minutes, up to a total of 3 sprays in a 15 minute period. If any discomfort continues after 15 minutes, call your doctor immediately or go to the nearest ER for help.

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NTG

A full bottle of spray contains about 200 doses. The pump spray comes in a see-through bottle. Replace it when the fluid level is low. It has a guaranteed two-year potency from first dose to last.

Spray

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If angina is not relieved by rest and NTG in 15 minutes, you may be having a heart attack.

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Keep your short-acting NTG (tablets or spray) with you at all times. If a certain activity often causes angina, your doctor may tell you to take NTG beforehand. This may help prevent angina. A Word of Caution: Do not use Viagra™ unless your doctor prescribes it. Viagra™ (silenafil citrate) can cause dangerous heart and blood pressure changes if taken within 24 hours of using short-acting or long-acting forms of nitroglycerin (including amyl nitrate “poppers”). If someone has used Viagra™ within the past 24 hours and has chest discomfort or pain, most doctors advise them not to use any form of NTG, but to go to the nearest emergency room.

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Heart Attack Suspect a heart attack and go to the emergency room if you feel pressure, tightness, heaviness, squeezing, burning or pain in the upper body that lasts longer than 15 minutes.* Just like angina, you can have these feelings anywhere, including:

the center of the chest

the upper part of the stomach

either arm

the throat, neck or jaw

the middle of the back, between the shoulder blades

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15 minutes

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The discomfort can stay in one part of the body or move into the back, either arm or the neck.

* Some experts advise that people who have never had any signs of coronary heart disease go to the nearest emergency room right away after several minutes of these symptoms.

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sweating

nausea

vomiting

shortness of breath

feeling weak

feeling faint or dizzy

palpitations or skipped heartbeats

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The symptoms of a heart attack may get worse or better, but you should always let your doctor know right away if you are having them.

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The pain of a heart attack is not always severe. Sometimes other symptoms go along with a heart attack such as:


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If you think you are having heart attack symptoms, take fast action. Sit or lie down. Loosen any tight clothes. Call your local rescue service* at once, unless someone can drive you to the nearest emergency room before the ambulance could arrive. Unlock your door if you are alone. Then call your doctor and call someone to stay with you. Some doctors suggest you chew a non-coated aspirin (if you can take aspirin) right away. Try to stay calm.

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A cardiac catheterization may be done right away to see if blood flow can be improved with angioplasty (page 30). Sometimes a drug can be given to dissolve a blood clot in a blocked artery. These drugs are called “clot busters� (thrombolytics). If blood flow can be restored quickly, less heart damage is likely. People with very little heart damage can go home in a few days. Others have more damage and may take longer to recover. The size of a heart attack can be limited by fast action. * In many places, you can call 911 for this purpose.

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Preventing Angina There are a number of things you can do to reduce how often you have angina.

Long-acting NTG Long-acting forms of nitroglycerin come in:

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tablets to be put under the tongue, swallowed, or chewed skin patches ointment

same time every day

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The skin patch and ointment have the longest effects of any kind of NTG. When using one of these, do this:

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• Put it on the upper arms or on the body above the waist. The patch works best if the skin is free of hair, rash, cuts, scars or callouses.

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• Don’t put the patch in the same place 2 times in a row. Don’t put it in a skin fold such as on the inner arm where it bends or under the breast. • Put the skin patch on at the same time each day. Don’t cut it. After a bath, wait until your skin is dry to put on the patch.

• If the patch gets wet while you swim or bathe, it’s OK. Water will not keep it from working. 14

Note: See A Word of Caution on page 10 about the effects of Viagra on people who take any form of NTG.


Other medicines Other drugs that may be given to people with narrowed heart arteries include:

Beta-blockers

Calcium channel blockers

Ace inhibitors

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Beta-blockers help the heart beat slower and use less oxygen during hard physical activity or mental stress. They also help reduce high blood pressure but do not often affect normal blood pressure.

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Calcium channel blockers are used to prevent artery spasm. They also help relax arteries all over the body, reducing the work of the heart. These drugs help lower high blood pressure.

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Although ACE* inhibitors are not a common treatment for angina symptoms, they can prevent or lessen the changes in heart size and shape that often occur with coronary artery disease. They also relax the body arteries and reduce the work of the heart.

* Angiotensin Converting Enzyme

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There may be mild side effects from any of these drugs. Let your doctor know if you become light-headed, have swollen ankles or notice a change in: • energy • bowel habits • mental state • sex drive or performance • breathing You may need a different dosage or kind of medicine.

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Routine doses of aspirin, an antiplatelet drug (Plavix®) or a blood thinner may keep clots from forming. Ask your doctor about this. (Don’t take daily aspirin without first checking with your doctor.)

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Here is a place to list your medicines and how to take them. You may want to clip out the list to carry with you in your wallet or purse.

name

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how much/how often

times


Make some changes The pace of your life has a lot to do with how often you have angina. The heart needs more oxygen when you are in a hurry, very active or upset. Slowing down can reduce the heart’s need for oxygen.

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Rest after meals. Give your heart a chance to pump blood to the stomach where food is being absorbed. Avoid mental stress and heavy exercise just after eating. Eat a number of small meals instead of 1 or 2 large meals each day.

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Cut down on things that seem to cause your angina or make it last longer than usual. Limit walking up steep hills and a lot of steps. Limit hard upper arm work like raking leaves, lifting heavy things and straining to open windows or tight jar lids.

rest after meals

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If you notice angina about the same time each day, find ways to make it easier for your heart. Take a short rest or slow your pace at that time.

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Preventing Coronary Heart Disease

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Changes in your risk factors for coronary heart disease can not only prevent fatty buildup in the arteries, but also may help get rid of blockage already there. Decide now to make changes in your lifestyle to slow or stop the fatty buildup in your arteries.

Smoking

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Smoking is one of the worst things you can do to your body. Breathing others’ smoke is also harmful. Snuff and chewing tobacco also increase your risk of coronary heart disease. Nicotine damages the lining of your arteries and tightens them so less blood and oxygen get to the heart. Smokers who have coronary heart disease are at greater risk for heart attacks and sudden death. If you stop smoking, these risks soon begin to go away. After 2 years of not smoking, your risk for heart disease is the same as that of a person who never smoked.

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High blood pressure 190 180 170 160 150 140

100 80 60 40

BLOOD PRESSURE

130 120

110 90 70 50 30

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High blood pressure is often the result of a tightening of the body arteries. High blood pressure causes wear on the artery linings. This makes it easier for fat in the blood to move into the artery walls. Over time, the fat becomes hard. This keeps the arteries from relaxing enough for a lower pressure. Symptoms are not likely unless high blood pressure is extreme.

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The ideal goal for your blood pressure at rest should be less than 120 (top number) and less than 80 (bottom number). Slightly higher goals are sometimes used. Your doctor will set a BP goal for your situation. To control high blood pressure and limit artery damage: • eat a balanced, low-salt, low-fat diet with at least 5 servings of fruits and vegetables a day • lose weight (if you are overweight) 1 drink = • take the prescribed medicine(s) • exercise 1.5 oz 80 proof liquor • don’t smoke 4 oz wine limit alcohol to 1 drink a day (women) • 12 oz beer or 2 drinks a day (men) With exercise and weight loss, many people can reduce high blood pressure to the point they no longer need blood pressure medicine. Controlling high blood pressure can decrease how often you have angina. 19


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High blood fats

A diet high in fat and cholesterol adds to the blood fat made by your body. The more fat in your blood stream, the easier it is for some of it to move into the artery wall. If you have coronary heart disease, your HDL cholesterol level should be 40 mg/dl or more, your LDL level 100 mg/dl or less* and your triglyceride level 150 mg/dl or less. Total cholesterol should be less than 200 mg/dl.

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a My goal is:

LDL

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HDL

My current level is:

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Test results: date: date:

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The American Heart Association suggests you change high fat food in your diet to fat-free or low-fat foods. Eating less meat along with more vegetables and whole grain foods also helps. Your goal is to reduce the number of calories from fat you eat to less than 30%. Research shows that even less fat in the diet may be needed to reduce or prevent narrowed arteries in some people. A very, very low-fat diet and lowering other risk factors may cause fatty buildup already there to go away. (This is called regression of atherosclerosis.) Check with your doctor before starting any new diet, especially a very low-fat diet.

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* If your doctor thinks you have a very high risk for a heart attack, your LDL goal may be set for 70 mg/dl or less.


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To lower the fat in your diet, get a complete food list. (Ask your doctor or a dietitian to suggest one, or look in a bookstore.) Read food labels with care! Many pre-packaged foods have fat added to them. Foods such as beef, pork, organ meats, lamb, whole milk, butter, egg yolks, whole milk cheese and ice cream are high in fat. Fish, poultry without skin, skim milk, fresh fruits and vegetables are much lower in fat. Use very little fat in your cooking, and when you do, use one of these: monounsaturated oil (canola, olive, peanut)

polyunsaturated oil (safflower, sunflower, corn, soybean, sesame)

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Here are some low-fat ways to cook your food: bake, broil, poach, grill, steam or stir fry (with very little oil). Trim all fat off meat before cooking. It’s OK to cook poultry with the skin on, but don’t eat the skin. It has a lot of fat. Season foods with herbs, spices, fruits and vegetables.

DILL BASIL

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Lack of exercise

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A regular program of exercise can raise the body’s good cholesterol and better control the fatty buildup in the arteries. Exercise and diet can help you lose weight, feel more relaxed and lower blood pressure.

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With regular exercise training, the heart can do more work with less effort. If you have angina, you may not be able to play sports like singles tennis, basketball or football. Things like golf, doubles tennis, walking, fishing, short swims and sex are OK for most people. Since your heart needs more oxygen during exercise, always check with your doctor before starting any exercise program. Pick an exercise you like that matches what your heart can do. A cardiac rehab program can help you design an exercise plan suited just for you. It can also help you in changing your other risk factors.

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Overweight People who are overweight increase their risk of heart disease. The way you “wear” your weight is also a factor. Apple-shaped people (weight around the middle) are more likely to have heart disease than pear-shaped people (weight around the hips).

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Choose a diet that lets you lose weight slowly. Ask your doctor or dietitian to suggest one that will be safe for you. Don’t choose diets that claim fast weight loss in a short time. These diets can make it harder to keep the weight off. Very low-calorie diets (under 1000 calories/day) can be dangerous. Anyone on such a diet should be under a doctor’s care.

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Heredity

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Stress refers to any pressure from the outside that makes us feel tense on the inside. It comes at us from all sides, and some of us handle it better than others. Since stress makes the heart work harder, try to find ways to relieve the pressure when you feel stressed. Many people find yoga, meditation and regular, suitable exercise helpful.

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Stress and tension

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These are some things that tend to run in families and may lead to heart disease: • high blood fat levels • high blood pressure • angina or heart attack at a young age (less than 55) • diabetes If heart disease runs in your family, it is even more important that you get rid of or control any other risk factors. 24

IN


Diabetes

yoo-hoo!

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People with diabetes are more likely to have coronary heart disease. Diabetes can damage artery walls and lead to fatty buildup. Since high blood sugar also leads to nerve damage, people with diabetes may not feel symptoms of angina or heart attack. They are more likely to have a “silent� heart attack. A person with diabetes must be alert to any symptoms of angina or a heart attack and take fast action. Proper diet and exercise may reduce the need for insulin or oral agents (pills to lower blood sugar).

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Make the changes that apply to you Making lifestyle changes will not only help prevent fatty buildup in the future but will make less work for your heart right now. Make your plans to: stop smoking

lower high blood pressure

eat a diet low in saturated fat and cholesterol

exercise regularly

keep an ideal weight

control stress and tension

control high blood sugar

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With lifestyle changes and taking your medicines as prescribed, you may have angina less often. You may also be able to keep fatty plaque stable and prevent cracks from developing.

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What if your angina changes? Be alert for any changes in your angina. Let your doctor know if your angina: comes on more often than usual

occurs with less and less physical effort (or when you are resting)

lasts longer each time

takes more NTG than usual for relief

wakes you in your sleep

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Any of these changes can be a warning that the artery blockage is more severe, and a heart attack is likely.

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If you have changes in your angina, see your doctor soon. Treatment may be needed to prevent a heart attack.

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Tests These are some of the tests that may be done to find out if there is blockage in the heart arteries and whether the symptoms are likely to lead to a heart attack in the near future.

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Resting EKG’s record the electrical activity of the heart and are likely to show changes during or after a heart attack. EKG changes occur during times when the heart needs more oxygen.

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An exercise test can be useful if your doctor suspects blockage in a heart artery. For this test an EKG (and blood pressure) is taken while you walk on a moving belt (treadmill) or ride a bike.

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exercise test

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Certain blood tests look for a specific protein (C-reactive protein or CRP) found in the bloodstream when inflammation is present. Although it can help predict when a heart attack is about to occur, high CRP’s can also be caused by inflammation in other parts of the body.


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Nuclear studies can often tell if narrowed heart arteries are slowing blood flow. These include Thallium, Sestamibi, or gated blood pool scans. Nuclear scans are sometimes done along with an exercise test. Stress echocardiograms use sound waves to look at the heart. Both nuclear studies and stress echocardiograms can be done with an exercise test or by giving medicine to make the heart pump harder and faster. catheter blockage

dye

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Many times a cardiac catheterization (angiogram or dye test) is needed to see if there is blockage in the heart arteries. It also shows the pumping strength of the heart muscle and how well the valves are working. A small catheter (tube) is put into a blood vessel in your leg or arm and passed up to the heart. Once the catheter is in place, dye is injected and x-ray moving pictures are made of the heart and arteries.

Ultrafast Computerized Tomography (CT) or Electron Beam Tomography (EBT) EBT is a rapid and painless scan of the chest using ultrafast electron beams to see if there is an abnormal amount of calcium in the arteries. Calcium in the heart artery walls is a sign of coronary disease. An abnormal EBT can lead to more testing to find the extent of coronary risk and the need for more treatment. 29


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Treatments

Medicine, rest and changes in lifestyle can relieve or prevent angina. But if tests show that artery blockage is about to cause heart damage, angioplasty or bypass surgery may be needed.

Angioplasty

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Angioplasty involves placing a catheter (tube) in a narrowed artery (or vein bypass graft) to make a bigger channel for blood flow. Although balloon catheters are used most often to inflate and compress the fatty buildup, there are other ways to widen a narrowed artery. Sometimes cutting balloon catheters are used to make tiny cuts in the fatty layers. When the removal of the fatty build-up is needed, an atherectomy catheter can be used. Often one or more pieces of stainless steel mesh (stents) are left at the site to help keep the artery open. If close-up pictures are needed of the fatty blockage, a catheter can be inserted for intravascular cardiac ultrasound.

artery narrowed by fatty buildup

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before

during

balloon catheter

stent

after

artery open

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Rapid growth of smooth muscle cells at the angioplasty site can block heart arteries widened by angioplasty. This is called restenosis. Sometimes radiation (called brachytherapy) is used inside a stent to get rid of or block smooth muscle cell growth (in-stent restenosis). Newer stents coated with a drug that discourages cell growth help prevent this. But these stents can’t be used in all narrowed arteries.

Bypass surgery

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This surgery is sometimes needed to bypass several blockages in the coronary arteries and increase blood flow to the heart muscle. A leg vein or an artery from the upper body is used for the bypass graft. The kind of graft depends on the number of blockages and where they are.

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Recovery is longer, and complications happen more often with bypass surgery than for angioplasty. But it may be the treatment of choice when a number of blockages are present. If a complication does occur during angioplasty, bypass surgery can be life-saving.

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Your doctor will advise you about the treatment choices for your coronary artery blockage.

artery bypass from chest

blockage vein bypass from leg blockage

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Looking Ahead As research tells us more about the causes of coronary heart disease, we are better armed to control or prevent it. New tests are found and current treatments are improved nearly every week, including: surgical techniques for smaller bypass chest incisions— “keyhole” surgeries and robot techniques that allow much quicker recovery

drug(s) that act like the gene (APO A1 Milano) causing a “Drain-o®” effect in body arteries

gene therapy to correct high blood pressure, abnormal cholesterol levels and diabetes

techniques to encourage growth of new blood vessels in the heart (angiogenesis)

improved drug-coated stents to help keep arteries opened with angioplasty from closing up again

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blood tests that detect early inflammation in the heart arteries to warn of a heart attack in the near future

improved exercise prescriptions for people with limited blood supply to the heart

magnetic resonance imaging (MRI) of the heart

better medicines for the heart and blood vessels and better use of medicines already available

new findings about antioxidants, multivitamins and other alternative therapies to help prevent coronary artery disease

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Order this book from:

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2010 Edition Copyright © 1976, 1985, 1994, 2001, 2004 by Pritchett & Hull Associates, Inc. All rights reserved. No part of this book may be photocopied, reprinted or otherwise reproduced without written permission from Pritchett & Hull Associates, Inc.

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Write for our catalog of other product descriptions and prices.

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Library of Congress Cataloging-in-Publication Data Purcell, Julia Ann, 1943Angina pectoris. Includes index. 1. Angina pectoris. I. Fletcher, Barbara Johnston, 1945- . II. White, Suzanne Cambre, 1946III. Title. RC685.A6087 1985 616.1’22 84-26382 ISBN 0 939838-77-X

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®

PRITCHETT & HULL ASSOCIATES, INC. 3440 OAKCLIFF RD NE STE 110 ATLANTA GA 30340-3079

Published and distributed by: Pritchett & Hull Associates, Inc. Printed in the U.S.A.


Controlling risk factors is the key to preventing coronary heart disease. We hope this book will help you make choices for a healthier lifestyle.

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Notes

®

Pritchett & Hull Associates, Inc.

Unique Health Education Materials Since 1973

Topics Include: • Heart disease • Heart disease risk factors • Heart surgery • High blood pressure • Stroke

• • • • • •

Kidney failure Diabetes Nutrition Exercise Head injury Brain surgery

• • • •

Home care Asthma Chronic lung disease Hip, knee or back surgery • Bowel surgery

Write or call toll-free for a free catalog of products and prices: 1-800-241-4925


Authors:

Consultants:

Julia Ann Purcell, RN, MN, FAAN Clinical Nurse Specialist, Cardiology 1968-1996 Emory University Hospital Atlanta, GA

Gerald F. Fletcher, MD Professor of Medicine Mayo Clinc College of Medicine Division of Cardiovascular Diseases Mayo Clinic Jacksonville Jacksonville, FL

Barbara Johnston Fletcher RN, MN, FAAN

Mark E. Silverman

Clinical Associate Professor College of Health School of Nursing University of North Florida Jacksonville, FL

MD, MACP, FRCP, FACC

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Suzanne Cambre, RN, BSHA Cardiology Piedmont Hospital Atlanta, GA

(1939-2008) Emeritus Professor of Medicine Emory University School of Medicine Chief of Cardiology Piedmont Hospital Atlanta, GA

We believe that you have the right to know as much as you can about your health.

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Our goal is to give you enough facts to get the main points clearly in mind. We do this with medical accuracy, warmth and humor. The result for you: less tension, more healing and a good idea of what to ask your doctor, nurse or others.

Pritchett & Hull Associates, Inc.

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Angina Pectoris  

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