Heart Attack

Heart Attack, Angina and Cardiac Arrest

The basic steps to ensure patient safety

Despite the fact that there are some differences between a heart attack, angina and cardiac arrest, they seem to be correlated in a way as most heart attacks do not lead to cardiac arrest. However, when cardiac arrest happens, a heart attack is a common cause.

There is a lot of confusion between heart attack and cardiac arrest, but they may both have the same symptoms. Although angina and heart attack are caused by arterial blockage, and the main difference between angina and a heart attack is that a heart attack causes damage to the heart muscle, and angina does not. A heart attack occurs when blood flow to the heart is blocked. The blockage is most often a buildup of fat, cholesterol and other substances, which form a plaque in the coronary arteries that feed the heart. Sometimes, a plaque can rupture and form a clot that blocks blood flow. The interrupted blood flow can damage or destroy part of the heart muscle. Angina is a type of chest pain caused by reduced blood flow to the heart. Its pain is not sudden like a heart attack, but it is present and the patient can feel it.

While the chances of survival for a person who suffers from a heart attack and a cardiac arrest vary widely, about 90 percent of people who experience an out-of-hospital cardiac arrest die. Also, there is no guarantee that someone will survive from being given CPR. Also, a heart attack is considered less serious; the blocked artery can be opened quickly with the appropriate treatment.

Heart Attack

It occurs when there is a sudden blockage in the arteries that supply blood to the heart. With time, the heart muscle begins to die because it isn’t getting enough blood flow. Doctors use the term myocardial infarction to refer to a heart attack. When a patient suffers from a heart attack, A HEART ATTACK OCCURS WHEN BLOOD FLOW TO THE HEART IS BLOCKED. THE BLOCKAGE IS MOST OFTEN A BUILDUP OF FAT, CHOLESTEROL AND OTHER SUBSTANCES, WHICH FORM A PLAQUE IN THE CORONARY ARTERIES THAT FEED THE HEART.

his heart would still be beating and working but not as efficiently. The longer it takes to treat the cause, the lower the chance of recovery.

A heart attack mainly occurs when one or more of your coronary arteries becomes blocked. Another less common cause of a heart attack is a spasm of a coronary artery that shuts down blood flow to part of the heart muscle. When a heart attack happens, blood flow to a part of your heart is hindered, which causes that part of your heart muscle to die. When a part of your heart can’t pump because it is dying from lack of blood flow, it can disrupt the pumping sequence for the entire heart. That reduces or even stops blood flow to the rest of your body, which can be deadly if it isn’t corrected quickly. Common heart attack signs and symptoms include pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, cold sweat, fatigue as well as blue fingers and toes.

Symptoms vary between men and women. Symptoms of a heart attack in men include:

• Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back • Heart palpitations • Shortness of breath • Cold sweat • Lightheadedness or sudden dizziness • Abdominal pain / discomfort

In most cases, women do not feel the common symptoms such as pain in the chest or arm, and symptoms may begin a month before the heart attack.

Symptoms of a heart attack in women include:

• Unexplained fatigue for several days-

Pressure or pain in the middle of the chest, which may spread to the arm • Sleep disturbances • Dizziness • Shortness of breath • Abdominal discomfort • Pain in the upper back, or shoulder • Pain in the throat and jaw COMMON HEART ATTACK SIGNS AND SYMPTOMS INCLUDE PRESSURE, TIGHTNESS, PAIN, OR A SQUEEZING OR ACHING SENSATION IN YOUR CHEST OR ARMS THAT MAY SPREAD TO YOUR NECK, COLD SWEAT, FATIGUE AS WELL AS BLUE FINGERS AND TOES.

But why these differences?

During a heart attack in men, a plaque can rupture and spill cholesterol and other substances into the bloodstream. A blood clot forms at the site of the rupture and can block blood flow through the coronary artery, starving the heart of oxygen and nutrients (ischemia).

While women are more likely to develop this buildup in the heart's smallest blood vessels, therefore, women are more likely to have small, non-fatal heart attacks.

Angina Pectoris

It is chest pain or discomfort caused when your heart muscle doesn’t get enough oxygen-rich blood. It occurs without causing death or permanent damage to the heart cells, and it is a risk factor for a heart attack. Angina is described as a feeling of pressure, heaviness, tightness, or pain in the chest. Angina is caused by reduced blood flow to your heart muscle. Your coronary arteries can become narrowed by fatty deposits called plaques. Besides physical activity, other factors such as emotional stress, heavy meals and smoking also can narrow arteries and trigger angina. Angina does not lead to death; however, it requires a doctor’s visit in order to know its causes and ways to treat it, because it indicates the presence of a problem that hinders the blood supply to the heart muscle. If not treated, it may cause a heart attack, which is an emergency that may lead to death. There are two types of angina:

1. Stable angina: Stable angina is the most common and is usually triggered by physical activity. When you climb stairs, exercise or walk, your heart demands more blood, but narrowed arteries slow down blood flow. Besides physical activity, other factors such as emotional stress, cold temperatures, heavy meals and smoking also can narrow arteries and trigger angina. 2. Unstable angina: It typically occurs when a person is resting. If fatty deposits in a blood vessel rupture or a blood clot forms, it can quickly block or reduce flow through a narrowed artery. This can suddenly and severely decrease blood flow to your heart muscle. Unstable angina can also be caused by blood clots that block or partially block your heart's blood vessels. Unstable angina is a dangerous type of chest pain that can be the start of a heart attack if left untreated.

The following risk factors increase your risk of angina:

• High level of low-density lipoprotein (LDL) cholesterol (also known as bad cholesterol) or triglyceride levels • High blood pressure • Obesity which is linked with high blood cholesterol levels, high blood pressure and diabetes, all which increase your risk of angina and heart disease. • Diabetes increases the risk of coronary artery disease, which leads ANGINA IS DESCRIBED AS A FEELING OF PRESSURE, HEAVINESS, TIGHTNESS, OR PAIN IN THE CHEST. ANGINA IS CAUSED BY REDUCED BLOOD FLOW TO YOUR HEART MUSCLE. YOUR CORONARY ARTERIES CAN BECOME NARROWED BY FATTY DEPOSITS CALLED PLAQUES.

to angina and heart attacks by speeding up atherosclerosis and increasing your cholesterol levels. • Stress can increase your risk of angina and heart attacks. • Smoking • Lack of exercise • Family history of heart disease

Cardiac Arrest

Sudden cardiac arrest is the abrupt loss of heart function, breathing and consciousness. The condition usually results from a problem with your heart's electrical system, which disrupts your heart's pumping action and stops blood flow to your body. If not treated immediately, sudden cardiac arrest can lead to death. Cardiopulmonary resuscitation (CPR), using a defibrillator — or even just giving compressions to the chest — can improve the chances of survival until emergency workers arrive.

Sometimes signs and symptoms such as chest discomfort, shortness of breath, weakness and heart palpitations can occur before sudden cardiac arrest. Cardiac arrest may be caused by irregular heart rhythms called arrhythmias. A common arrhythmia associated with cardiac arrest is ventricular fibrillation. In ventricular fibrillation, the heart's lower chambers suddenly start beating chaotically and don't pump blood.

Sudden cardiac arrest isn't the same as a heart attack, when blood flow to a part of the heart is blocked. However, a heart attack can sometimes trigger an electrical disturbance that leads to sudden cardiac arrest. Cardiac arrest occurs when your heart suddenly stops beating. Unlike heart attacks, which are due to blocked arteries, this condition occurs when there’s a problem with your heart’s electrical system. It is life threatening and requires immediate treatment. When cardiac arrest occurs, blood stops flowing to the brain and other vital organs.

Causes of Cardiac Arrest

• Scarring of the heart tissue as a result of a prior heart attack. • Thickened heart muscle (cardiomyopathy): Damage to the heart muscle can be the result of high blood pressure,

heart valve disease or other causes. • Blood vessel abnormalities: These rare cases occur particularly in the coronary arteries and aorta. Adrenaline released during intense physical activity can trigger sudden cardiac arrest when these abnormalities are present.

Sudden cardiac arrest can happen in people who have no known heart disease. However, a life-threatening arrhythmia usually develops in a person with a preexisting, possibly undiagnosed heart condition such as coronary heart disease, in which the arteries become clogged with cholesterol and other deposits, reducing blood flow to the heart. Enlarged heart (cardiomyopathy) occurs primarily when your heart's muscular walls stretch and enlarge or thicken. Then your heart's muscle is abnormal, a condition that often leads to arrhythmias.

Leaking or narrowing of your heart valves can lead to stretching or thickening of your heart muscle. When the chambers become enlarged or weakened because of stress caused by a tight or leaking valve, there's an increased risk of developing arrhythmia. A sudden cardiac arrest can occur due to a congenital heart disease or electrical problems in the heart. CARDIAC ARREST MAY BE CAUSED BY IRREGULAR HEART RHYTHMS CALLED ARRHYTHMIAS. A COMMON ARRHYTHMIA ASSOCIATED WITH CARDIAC ARREST IS VENTRICULAR FIBRILLATION. IN VENTRICULAR FIBRILLATION, THE HEART'S LOWER CHAMBERS SUDDENLY START BEATING CHAOTICALLY AND DON'T PUMP BLOOD.

Valluvan Jeevanandam, MD, is a world-renowned heart surgeon

HEART SURGEON DEDICATES ILLUSTRIOUS CAREER TO HELPING PATIENTS NO OTHER DOCTORS CAN SAVE

Provided by UChicago Medicine

Valluvan Jeevanandam, MD, was six months into his first job as a heart surgeon nearly three decades ago when a critically ill patient pleaded with him: Get me a heart transplant today, or I am going to die.

Determined to meet the deadline, yet without an organ match for the 220-pound man, Jeevanandam did what would become a signature throughout his storied career: He looked for an unorthodox solution.

Typically, a heart needs to come from a donor who is within 20% of the patient’s body size. In this case, that would mean a donor roughly between 180 and 260 pounds. But that’s not what was available.

“We found a heart nearby that matched for most requirements but had belonged to an 80-pound child,” Jeevanandam said. “So, I asked the cardiologist, ‘How fast does a heart grow?’” Confident that science and skill were on his side — and with the patient’s consent to try — Jeevanandam transplanted the child's heart into the man’s body. At first, the small heart raced, unable to keep up with the body’s demands and produce enough power to fully circulate blood.

Then, after one week, the care team was able to take the man off a ventilator. After six months, the heart had grown to the normal size found in adults.

At just 32, Jeevanandam had performed the world’s first successful adult transplant using an undersized pediatric donor, a procedure not many surgeons would attempt even today. It was the first in a long line of record-setting accomplishments for the cardiac surgeon.

Now the director of the Heart and Vascular Center and Chief of Cardiac Surgery at the University of Chicago Medicine, Jeevanandam, UNDER JEEVANANDAM’S DIRECTION, UCHICAGO MEDICINE HAS A 5-STAR RATING FROM THE SCIENTIFIC REGISTRY OF TRANSPLANT RECIPIENTS FOR OUR EXPERTISE IN HEART TRANSPLANT. WE ROUTINELY TAKE EXTREMELY CHALLENGING CASES, WHICH INCLUDE PATIENTS WHO ARE DENIED CARE AT OTHER HOSPITALS AROUND THE COUNTRY, AND PROVIDE THE LIFESAVING TREATMENT THEY NEED.

recently led the surgical teams that performed the world’s first back-to-back triple-organ transplants of two 29-year-old patients, both with failing hearts, livers and kidneys. In the 12 months since that historic December 2018 event, the teams performed four more of these multi-organ transplants.

Now UChicago Medicine has performed 13 of these complex transplants since 1999, more than any other institution.

Under Jeevanandam’s direction, UChicago Medicine has a 5-star rating from the Scientific Registry of Transplant Recipients for our expertise in heart transplant. We routinely take extremely challenging cases, which include patients who are denied care at other hospitals around the country, and provide the life-saving treatment they need. Our esteemed 5-star rating is a recognition that we offer exceptional care to heart transplant patients, which includes the:

Shortest We have the shortest wait times in the nation for receiving a donor heart. Best We have the best survival rates in the country for heart transplant patients. Highest We have the highest proportion of African American patients transplanted in the United States.

Excellence early on

The innovation and drive Jeevanandam has brought to the operating room for the past 30 years might be in his DNA.

His grandfather, despite being born with no wealth in a class-based society, became the most prominent man in his hometown after building a successful produce business that began with a bicycle delivery route. His father — a PhD who helped establish India’s nuclear energy program and contributed greatly to the field of surgical metabolism — was able to attend college only after a teacher paid his application fee, the $10 price tag being too great for the family to spare.

Even in his early years, Jeevanandam was searching for the most efficient, effective solutions to any challenge. He spent the first decade of his life in Tuticorin on India’s southern tip until he, his parents and older sister immigrated to New York City in 1970. At age 15, he was accepted to Columbia University, where he would graduate summa cum laude with a biochemistry degree at 19.

At Columbia’s medical school, while other students crammed for hours before tests, Jeevanandam worked smarter. He spent the daily commute from home studying so he would have two hours of preparation before class began. The hard work paid off. He earned the school’s top awards in surgery, medicine and physiology during his final year.

His mentor at Columbia — where he stayed for his residency and fellowships — was Eric Rose, MD, a giant in the field of cardiothoracic surgery and the first surgeon to perform a successful pediatric heart transplant. Rose described Jeevanandam as being “insatiably curious” and “an incredibly special human being, who is brilliant, energetic and compassionate.”

It was perhaps this curiosity that led Jeevanandam to leave New York after 22 years to start a career at Temple University in Philadelphia as the associate director of the heart transplant program. He anticipated working alongside Temple’s senior surgeon, but that plan was dashed when, just months after Jeevanandam took the position, the entire heart transplant physician team but him left for another hospital.

Promoted to Program Director, Jeevanandam took over and thrived, performing 52 heart transplants that year and shattering the hospital’s previous record.Initially, though, the young surgeon had doubts. He called Rose to seek advice on whether to stay.

“Eric said, ‘You stay and get the job done.’ And that’s always been my theme,” he recalled. “I want to think outside the box and do something different. Instead of reading about it first and then doing it, I’d rather create it and then write about it for other people to read and learn from.” PROMOTED TO PROGRAM DIRECTOR, JEEVANANDAM TOOK OVER AND THRIVED, PERFORMING 52 HEART TRANSPLANTS THAT YEAR AND SHATTERING THE HOSPITAL’S PREVIOUS RECORD.INITIALLY, THOUGH, THE YOUNG SURGEON HAD DOUBTS. HE CALLED ROSE TO SEEK ADVICE ON WHETHER TO STAY.

Triple-organ transplant patient, Sarah McPharlin, hugs heart transplant surgeon, Dr. Valluvan Jeevanandam.

Helping the helpless

When he was 8, Jeevanandam watched his grandfather collapse from a massive heart attack and die before his eyes.

From then on, he became fascinated with how to help others avoid this fate and was drawn to heart transplant because of the intellectual and technical challenge.

He has relentlessly sought innovative ways to save lives. That includes perfecting so-called bloodless cardiac surgeries for patients, such as Jehovah’s Witnesses, who will not accept blood transfusions, and conducting pioneering research on mechanical assist devices to provide a bridge to transplant or a long-term solution for patients who may not be transplant candidates.

Colleen LaBuhn, APN, UChicago Medicine’s Cardiac Surgery Program Coordinator, admires how Jeevanandam never gives up on patients, even when the most sick, complicated or underinsured are sent his way. “He will fight for pa-

tients who have nothing,” she said. “He thrives on helping people nobody else can really help.”

A heart to give back

Jeevanandam is one of the last pioneers of heart transplant and mechanical assist devices still practicing medicine. And for a man with more accolades, awards, publications and world records to count, one would expect a commensurate ego. However, the very nature of transplant — the lack of complete control even when a procedure is performed technically perfectly — has driven him to a devout spirituality.

“In my faith, we are told ego is the biggest problem in the world,” he said. “If you think it’s all you doing it, then that becomes a real barrier. It’s not ‘I’ but the collective ‘we’ who have been entrusted with a person’s life.”

Leilani Miles, RN, has worked alongside him in the operating room for all 22 of his years at UChicago Medicine. Make no mistake, she said, Jeevanandam has high expectations of his team members. But he also treats them with the utmost respect, reserving his harshest criticisms for himself. She points to the 10- and 15-year tenures of many colleagues as a testament to the cohesion and loyalty they have, to their patients and to Jeevanandam.

“We see a lot of high-risk patients, people no other hospitals will take,” she said. “But Val is always calm, and that sets the tone for the entire team. He’ll never say no unless he’s truly maximized all of his options to save someone.”

Jeevanandam also has not forgotten the $10 his father received that changed the trajectory of his family’s life. Strong proponents of education as a way to end cyclical poverty, Jeevanandam and his family created a fund to support children in India who have dreams of attending college but no resources to get them there. Currently, they support nine students per year, and he’s looking to expand that. Additionally, he makes annual trips back to Puttaparthi in his home country to perform volunteer surgeries, a commitment he has honored for the past 24 years.

Another milestone in medicine

Jeevanandam will never be satisfied slowing down or resting on his laurels, despite being the world’s most experienced heart transplant surgeon nearing the sunset of his career.

Each year, he sets a seemingly unattainable goal for himself and his team with every intention they’ll reach it. For 2020, he has set his sights on conquering one of the biggest remaining barriers to transplant: antibody rejection rates.

Some people develop antibodies that will attack donated organs at much higher rates than normal, drastically limiting their pool of available organs and a transplant’s chances of success. No reliable method exists for decreasJEEVANANDAM IS ONE OF THE LAST PIONEERS OF HEART TRANSPLANT AND MECHANICAL ASSIST DEVICES STILL PRACTICING MEDICINE.

ing antibodies. But Jeevanandam’s research and extensive experience with multi-organ transplants have shown that the body’s most effective way of eliminating these agents is through a liver — which acts like a sponge — that belongs to the same body as the heart.

What if a patient has a failing heart but a healthy liver? Jeevanandam and his team are working to perfect the domino transplant, where the patient with a failing heart would receive both a new heart and a new liver and would donate the healthy liver to a different person with a failing one.

They aren’t there yet, with both political and technical obstacles to overcome, but their success could mean a lifesaving breakthrough for those who previously had no hope.

It also could be the capstone to an already-impressive career. But Jeevanandam doesn’t think like that. He sees himself and those around him as vessels for a higher power to do good work on Earth.

“Every day, I do as much as I can, but, ultimately, the pressure is off,” he said. “If the cosmos wants it to happen, it will.”

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