American College of Cardiology

Angina Pectoris
Heart Attack
Sudden Death
Medical Strides In The Last Half Century
A Brighter Future

It was Aug. 14, 1949, and Tom, a 54-year-old auto-plant worker reported to work as usual. His wife had gotten after him again at breakfast about his high blood pressure—and his smoking—but as he entered the plant, he put their conversation out of his mind.

Tom and his co-worker George were returning to the line after their 10:00 a.m. break when a crushing pain struck Tom as though a vise were squeezing his chest. He put one hand on the wall to support himself. He felt sick to his stomach and found it hard to breathe.

"Are you OK, Tom?" George asked.

"I’m fine," Tom replied. "Just some powerful indigestion. It’ll pass." Tom’s forehead was wet with sweat. He went back to the line; but when the nausea and discomfort persisted for more than three hours, he asked George to drive him to the hospital.

Dr. Owings, Tom’s family physician, ordered an electrocardiogram (ECG), and the test confirmed that Tom had had a heart attack—a diagnosis that meant death for one in four middle-aged patients in 1949.

Tom was admitted to the hospital and given morphine to control pain and reduce anxiety. His treatment, true to the highest standards of the day, entailed a semistarvation diet for two days, then an 800-calorie, low-salt diet for the next several weeks. Tom remained in the hospital on bed rest for six weeks and was allowed only minimal activity eating, moving in bed, and doing leg exercises. Dr. Owings prescribed a new, experimental anticoagulant drug therapy, dicumarol, to keep blood clots from forming and causing another heart attack.

Tom survived the ordeal, but he’d been weakened. "You’re going to have to limit your stress and activities—including work," Dr. Owings warned him. Because Tom’s heart muscle had been damaged, Dr. Owings watched Tom’s health closely in the following years, concerned that recurrent heart attacks or congestive heart failure could result.

In 1949, Tom was one of the lucky ones.

Caused by cholesterol deposits, which block arteries, ischemic (is-KEY-mic) heart disease, also called coronary artery disease or coronary heart disease, is still the single biggest cause of death in the United States, killing nearly 500,000 Americans each year. But the situation is changing. According to a study in the Sept. 25, 1998, New England Journal of Medicine, deaths from coronary heart disease dropped 28 percent among men and 31 percent among women between 1987 and 1994 alone. This drop is primarily due to improved care.

An estimated 14 million people in the United States have ischemic heart disease. Of these, as many as 4 million have few or no symptoms and are unaware that they are at risk for angina (angina pectoris), heart attack (myocardial infarction), or sudden death.

Angina Pectoris
Plaque deposits on the interior linings of the heart’s arteries lie at the root of angina pectoris. The narrowed arteries prevent the heart from getting enough oxygen during exercise and the person experiences a chest pain beneath the breast bone—this pain is called angina pectoris. Mild or intense, the discomfort usually lasts only a few minutes. Every year, an estimated 350,000 new cases of angina occur. Today, angina pectoris can be dramatically reduced or eliminated by medications, heart surgery, or balloon dilation of narrowed arteries.

"The odd thing about anginal chest pain is its disarming nature," commented Thomas J. Ryan, MD, professor of medicine at Boston University School of Medicine. "Although it is usually described as unlike any other pain—‘like an elephant sitting on my chest’—it goes away quickly, often as soon as the person stops whatever he or she is doing at the moment. But the prompt disappearance of discomfort convinces many people that it can’t be serious. Absolutely false! Even fleeting angina means underlying abnormalities in the coronary arteries, and this requires attention."

Heart Attack
Acute myocardial infarction (heart attack) is a common complication of ischemic heart disease. Over time, the arteries of the heart narrow from a build up of fatty deposits (cholesterol plaques) on their interior linings and then can suddenly develop a blood clot on top of a fatty deposit. The clot lessens the flow of blood and oxygen to the heart muscle, and a portion of the muscle will die if the flow is not restored quickly. When some of the heart muscle dies, it is replaced by fibrosis, producing a scar. The heart’s ability to pump blood to the rest of the body is often impaired.

Although heart attack has long been considered a "man’s disease," more women than men over age 65 suffer heart attacks. Their symptoms and conditions often differ, however: women having heart attacks are more likely than men to complain of extreme fatigue, back pain, shortness of breath, and chest "pressure."

Sudden Death
Ischemic heart disease may also lead to "sudden" cardiac death—the cause of death for some 250,000 U.S. adults each year.

Although many call it a "massive heart attack," sudden cardiac death in patients with ischemic heart disease is usually caused by an abnormal heart rhythm called ventricular fibrillation, which prevents the heart from contracting and thus stops all blood flow to the brain and other vital organs. The patient will die unless he or she receives cardiopulmonary resuscitation (CPR) and electric shock with an external defibrillator to restart the heart and resume blood flow, quickly.

Medical Strides In The Last Half Century
Rapid medical advances since 1950 have dramatically increased the chance of surviving heart attack and living a full life with ischemic heart disease. "Instead of one in four working men, or 25 percent, dying from their first heart attack, as they did in 1949, now the death rate for such people is no more than three or four percent," said Dr. Ryan. Advancements in five areas have improved survival rates.

• The numbers of coronary care units (CCUs) in hospitals have grown dramatically since the 1960s, so heart patients now receive round-the-clock specialist care and monitoring.
• Interventions to restart stopped hearts have become the standard of care. Two such interventions are—
• starting the heart with a shock from an external defibrillator and performing CPR to deliver oxygen through manual chest compression and ventilation, and
• inserting an implantable cardioverter defibrillator(ICD) into the heart to deliver an electric shock whenever the heartbeat becomes dangerously irregular or too rapid.
• Diagnostic imaging technologies allow cardiovascular specialists to get a better view of the heart and heart vessels.
• Coronary angiography, an X-ray of the heart arteries, uses a contrast material injected through a catheter (a small tube).
• Nuclear myocardial imaging uses radioactive tracers to highlight blood flow to the heart muscle.
• Echocardiography machines send sound waves into the body creating an image of heart muscle and valve function.
• Drugs now treat and help prevent complications.
• Thrombolytic agents dissolve clots that cause heart attacks.
• Beta blockers treat angina by blocking the effects of adrenaline. Beta blockers relieve the effects of stress by slowing the heart rate, lowering blood pressure, and preventing irregular heartbeats. They also prevent recurrent heart attacks.
• Calcium channel blockers lower blood pressure, relieve angina, and control abnormal rhythms.
• Nitrates relieve angina.
• Statins lower blood cholesterol and prevent blood vessel narrowing, which in turn prevents angina, heart attacks, and stroke.
• Angiotensin converting enzyme (ACE) inhibitors lower blood pressure, help the heart heal after a heart attack and prevent recurrent heart attacks and death.
• Aspirin and newer antiplatelet drugs prevent platelets from sticking to each other and forming a clot.
• Techniques now improve blood flow to the heart. Two such techniques are—
• angioplasty, in which a cardiovascular specialist guides a balloon-tipped catheter to a blocked artery to force a wider opening, and
• bypass surgery or coronary artery bypass graft surgery (CABG), a form of open heart surgery in which a cardiovascular surgeon takes a vein from the patient’s leg, or preferably an artery from the chest wall, and attaches it from the aorta to the obstructed artery as a detour for blood to flow around the blockage. Multiple bypasses can be performed during the same operation.

Still, even the best medicines and latest technologies can be ineffective if patients aren’t treated soon after symptoms arise. For instance, recent studies suggest heart attack victims have the best recovery chance if they are given clot-busting (thrombolytic) agents and clot-preventing drugs (heparin, antiplatelet agents) and anticoagulants within an hour of their first symptoms to prevent the heart muscle from dying. In addition, observed Dr. Ryan, older Americans still face considerable risk: "The bad news is that for people 70 to 75 years old, the death rate for a heart attack is still about 20 percent to 25 percent. We are conquering premature death from heart disease by persuading society to adopt healthy lifestyles, but the basic disease is still with us and is taking its toll on older Americans."

A Brighter Future
"Advances over the last 50 years have had an enormous impact on the health of Americans because coronary artery disease is and will remain for some time the number one cause of death in this country," said J. Ward Kennedy, M.D., University of Washington Robert A. Bruce Professor of Medicine. "Progress has been centered primarily on better treatment once the disease has developed. Now, it looks as though we are making substantial progress in preventing or slowing the progress of this disease."

Unlike a half-century earlier, when Tom, the auto-plant worker had had a one-in-four likelihood of dying, his granddaughter Tina, a 62-year-old newspaper editor, faces a quite different future today.

In early 1998, Tina was running a staff meeting in the conference room when she felt sudden, severe discomfort in her chest and shooting pains in her left arm. Because of her family history of coronary artery disease and her own high cholesterol, Tina recognized the symptoms. She leaned over to her assistant and said, "Martha, please dismiss the meeting and call the emergency squad. I’m having chest pains."

Paramedics arrived within minutes. They performed an ECG in the conference room and confirmed that Tina was suffering a heart attack. She was given oxygen and transported to a nearby hospital. At the hospital, emergency room doctors immediately transferred her to the hospital’s state-of-the-art chest-pain center, where heart attack victims can be treated more rapidly.

Within 50 minutes of her first symptoms, Tina received aspirin, nitroglycerin for pain, and thrombolytic drugs to help dissolve the blood clot obstructing her heart vessel.

"What we’re trying to do," Dr. Morgan, a cardiovascular specialist, explained to Tina, "is re-establish blood flow to minimize damage to your heart muscle. Now that your ECG is back to normal, we’re going to admit you to the coronary care unit—the CCU. I’ll start you on a medication called ‘heparin’ to prevent further blood clots. I’m also prescribing aspirin, a beta blocker, and an ACE inhibitor—all part of our usual drug therapy after a heart attack."

The next morning, Tina’s heart rhythm and rate changed, and her chest pain returned. Because heart patients have continuous ECG monitoring in the CCU, Dr. Morgan spotted the changes immediately, suspected that the blood flow to her heart was obstructed again, and rushed her directly to the cardiac catheterization laboratory. There, a team inserted a catheter that had a balloon at its tip into Tina’s leg artery and guided it to the blockage in the coronary artery. The balloon was inflated and deflated several times to expand the opening‹a procedure called percutaneous transluminal coronary angioplasty (PTCA), and a metallic coil called a stent was placed to keep the artery open. After the PTCA, Dr. Morgan gave Tina a new antiplatelet drug (clopidogrel) to prevent clotting during the healing process.

After three days, Tina went home. She returned to work in a few weeks, but she has changed her lifestyle—and her waistline. She now takes a brisk walk or jog before leaving for the office, and she eats foods with less fat and cholesterol. She also takes a statin drug to lower her cholesterol. The statin (along with a beta blocker and aspirin) wards off occurrence of another heart attack. Her most recent checkup showed a normally functioning heart.