heart attack

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Five Lessons From My Heart Attack Patients

Akl Fahed, MD, MPH

In only few months, I leave my clinic where I have been seeing patients with heart disease for the past three years. It was not until I started discussing with them the transition to a new cardiologist that I appreciated the unique relationship we have built.  It has only been few years since we first met in in the Emergency Department in the middle of the night as they were having a heart attack, but somehow this journey feels longer.  I witnessed their heart attacks change their lives in many different ways, as they learned to cope, recover and carry on in life with a story to tell. Being one of the characters in their stories, I learned five lessons about life that will stay with me.

 

1- You can make any terrible event a wake up call or the beginning of the end.

A big heart attack or sudden cardiac arrest is arguably the most terrible event one could experience. As my patients recovered from such an event and came to see me in clinic, I could tell that the event changed them, either to the better or to the worse. While some lost weight, started training regularly, left their high stress jobs, or decided to travel the world, others became even more sedentary, gained weight, and started lamenting their bad luck and “missed opportunity” for good health.  It was striking to observe those two trajectories of opposite directions. Like my heart attack patients, when you are faced with a terrible event in life, you can either use it as a wake up call to do better afterwards or fall off a ledge and spiral down. You decide your own fate.

 

2- A supporting family is worth all the medicine of the world.

One patient after another, it became clear to me that the presence of a supporting family member that cares for you during difficult times is worth the most state-of-the-art medicine. It is that person that ensures that your food is low in salt and has no butter, that you do your daily exercise and not miss your medication, that you come to your appointments and ask all the right questions, or that simply hold your hand and tell you it’s going to be okay when things turn sour.

 

3- You’re as old as you think you are.

I met a 90 year-old woman who had a big heart attack and went for the most aggressive therapies. A year later she still shows to my clinic fully groomed and cheerful telling me she picked up dancing and life could not be any better.  I also met a 50 year-old man who after a small heart attack gave up on enjoying life or hoping for better future and couldn’t be convinced otherwise.

 

4- Faith, hope, and courage are your best friends when you’re not in control.

When patients are waiting for a high risk surgery or intervention, they simply are not in control of their fate. I found that those that fared well had three unique characteristics. First, they had faith in themselves, their doctors, or God. Second, they always hoped for the best. Third, they had the courage to face a difficult reality when things don’t go as well.  Whenever you’re not in control, let faith, hope, and courage always be your best friends.

 

5- Write your best story today because you never know when it ends.

While I learned so much from the stories of those patients who made it to my clinic, many did not, and their stories ended in the hospital. As you go through life, live every day to the fullest and write your best story page by page, because you really never know when it ends.
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Aspirin: The Good, the Bad and the Ugly

Siddharth Sehgal, MD

Last week, I was talking to one of my patients about her ischemic stroke, which led her to be admitted to the hospital. I discussed that I would be prescribing a daily aspirin along with other medications to reduce her risk of recurrent stroke. She replied, “But doc! I just read on the news that aspirin is no longer recommended to prevent heart attack and stroke.” It took me a moment to realize that she was referring to the recently released guidelines for “primary prevention of cardiovascular disease.” I explained to her the rationale, benefits, risks and evidence supporting the use of aspirin for secondary stroke prophylaxis. She felt better after our detailed conversation and agreed to initiate the medication as recommended. Later that day, I read several potentially misleading headlines on major news media websites about this new guideline. The headline on CNN1 read, “Daily aspirin to prevent heart attacks no longer recommended for older adults,” while USA Today2 reported, “Don’t take an aspirin a day to prevent heart attacks and strokes.”

The guidelines issued by the ACC now recommend against routine use of aspirin for primary cardiovascular prophylaxis in adults older than 70 years. This new recommendation is based on the ASPREE trial, published in 20183. During this trial, healthy adults older than 70 years with no prior history of cardiovascular disease were randomized to receive 100 mg aspirin or placebo. The low dose aspirin lead to a significantly higher risk of major hemorrhage without a significant benefit in terms of cardiovascular event prevention. The guidelines recommend using low dose aspirin for primary prophylaxis of cardiovascular events only in adults aged 40-70 years who are at a higher risk of atherosclerotic cardiovascular disease. The guidelines no longer recommend using the 10 year estimated ASCVD risk threshold of 10%, but in fact propose a more tailored approach to primary cardiovascular prophylaxis.  Patients at a high risk of cardiovascular disease and whose risk factors are not optimized despite maximal medical therapy may be candidates for prophylactic aspirin at low doses. Physicians should have a careful discussion of the individual risks and benefit of aspirin before prescribing a daily aspirin regimen to their patients. Aspirin should not be prescribed for primary prophylaxis to patients with an increased risk of hemorrhage, such as a history of gastrointestinal bleeding or thrombocytopenia.

These guidelines are obviously for patients without a prior history of a cardiovascular events such as an MI or ischemic stroke. There is unambiguous data that supports the use of aspirin for secondary cardiovascular prophylaxis. My patient from last week belonged to this category and I started our aspirin discussion with her by explaining this clear distinction. She understood the rationale for aspirin in her case and how the new guidelines did not apply to her. The news headlines are sometimes sensationalized which can render them misleading for the reader. The two news articles did in fact report that the guidelines refer to use of aspirin in healthy older adults with no history of heart disease or stroke. In today’s world of fast paced digital information, there is a tendency to just read the headlines and move on to the next thing. This can be very problematic if patients on aspirin for secondary prophylaxis stop taking their medication after reading these news headlines.

As healthcare professionals, it is our responsibility to tackle this kind of misinformation which can lead to potentially bad outcomes for our patients. One of the ways to do that is to enhance our presence on social media platforms which are increasingly becoming the major source of news and information for the public. The AHA Early Career Blogging Program is one such avenue which can help young healthcare professionals strengthen their digital and social media footprint. This also helps facilitate collaborative projects and ideas among healthcare professionals and can lead to improved patient outcomes, which is the ultimate goal in all our endeavors.

 

References:

  1. https://www.cnn.com/2019/03/17/health/aspirin-heart-disease-guidelines/index.html
  2. https://www.usatoday.com/story/news/health/2019/03/18/aspirin-prevent-heart-attacks-strokes-doctors/3199831002/
  3. N Engl J Med 2018; 379:1509-1518 DOI: 10.1056/NEJMoa1805819

 
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How the Immune System Favors Females in Pulmonary Artery Hypertension? Another Regulatory T Cell Story.

Dalia Gaddis, PhD

While it is commonly thought that cardiovascular disease is a man’s disease, CVD is the number one killer of women with the same number of deaths per year as cancer, diabetes and respiratory disease combined (according to 2015 statistical data from AHA). In addition, women exhibit different and more silent symptoms of heart attacks. There is a lot of interest in the difference between how males and females respond to CVD. A lot of emphasis is put on hormonal differences, but the immune system also seems to play an important role in this disparity. Females have a more robust immune system and therefore respond faster to infections providing more protection than in males. However, a more responsive immune system also means a more reactive immune system that can result in increased incidence of autoimmune diseases, such as rheumatoid arthritis and lupus.

Part of the difference in the immune system response in females can be attributed to the fact that multiple immune-related genes are expressed on the X chromosome. Since females have two alleles of the X chromosomes and males have only one, it is evident that females express more genes that regulate immune system functions. One of these genes is Foxp3, the key transcription factor for regulatory T cells, an adaptive immune cell which I have discussed before in a previous post. Regulatory T cells play an important protective role in CVD, especially in atherosclerosis and hypertension.

Pulmonary artery hypertension (PAH) is a fatal cardio-pulmonary disorder where the pulmonary arterioles narrow leading to a right ventricular fibrosis, heart failure and death. Regulatory T cells play an important role in this disease as animal models that lack regulatory T cells are more susceptible to PAH. Adding regulatory T cells back prevents the development of PAH showing the protective power of these cells. A recent study published in the journal Circulation Research, shows that in the absence of regulatory T cells, females rats are more prone to PAH than male animals due to a lower levels of PGI2, a pulmonary vasodilator, and the lack of the enzyme COX-2 that regulated PGI2. The researchers conducting the study show that by transferring regulatory T cells into these rats, these immune cells were sufficient to restore the levels of COX-2 and PGI2, as well as other immune inhibitory molecules PDL1 and IL-10. The authors suggest that regulatory T cells have both a direct and indirect effects on the arteries. The direct effects are exerted on the endothelial cells directly via COX-2 and PGI2, and the indirect effect is through the release of inhibitory molecules such as IL-10 and TGF, both of which would result in immune suppression and preventing inflammation. The results from this report suggested that females are more reliant on regulatory T cells for protection against PAH.

These new findings highlight the subtlety of immune regulation between females and males and further proves that in addition to hormonal differences, immune regulation disparities between genders that can alter the outcome of cardiovascular diseases. By understanding more about gender differences in CVD and the immune system, and figuring out ways to manipulate these subtle differences, scientists hope to achieve a more personalized and effective therapies to women versus men to combat CVD.

 

Dalia Gaddis Headshot

Dalia Gaddis is a postdoctoral fellow at the La Jolla Institute for Allergy and Immunology. She has a Ph.D. in microbiology and immunology. She is currently working on understanding the interactions between the immune system and atherosclerosis development

 
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Women’s Heart Disease – The Interdisciplinary Road Ahead

Tanja Dudenbostel, MD

Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly found in men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. There have been significant improvements in cardiovascular mortality in women in the last two decades with narrowing of outcomes between women and men which have been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men. Gender differences have been recognized, but vast knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure remain. The AHA Scientific Statement “Acute Myocardial Infarction in Women” provides a comprehensive review of the current evidence.
 
At the opening plenary session of the American College of Cardiology ACC.18 meeting in Orlando, Florida, the pioneer of women’s cardiology Dr. Nanette Kass Wenger gave her inspiring Simon Dack keynote lecture on Heart Disease & Women titled “Understanding the Journey-The Past, Present and Future of CVD in Women.”
 
In “Steps on the journey” Dr. Wenger gave a comprehensive review of the early beginnings and showed how far we have come. Some interesting anecdotes were also shared such as that the first women’s heart disease meeting in Iowa in the 1950s was to help women prevent heart attacks in husbands.
 
Her impactful vision on how to expand the landscape of women’s cardiovascular health research in the next decade struck a nerve with me and made me re-think some of the concepts we are applying in academic cardiology. Dr. Wenger called for an expansion of women’s cardiovascular health research to include social determinants of health as nearly 80% of heart outcomes depend on social factors. Women’s Heart Health is not solely a medical problem and clinical research cannot happen in a vacuum in the hospital. A variety of factors contribute to women’s cardiovascular health and need to be considered for maintenance of health and cure of disease. Women’s Heart Heath needs to be extended. Factors like beliefs and behaviors, the local community, economic, environmental, ethical, legislative/political, public policy – all these social determinants need to be included in heart disease research in women.
 
My take away for the future was that we cannot longer compartmentalize and that programs focusing on Women’s Heart Heath need to involve all programs available- not only cardiology. It needs to be an interdisciplinary approach to learn more about physiology, psychology and ecology of health for best outcomes and to tackle Women’s Heart Health.
 
Dr. Wenger quoted the French Victor Hugo in her inspiring lecture.
 
“There is nothing as powerful as an idea whose time has come.”
Victor Hugo
Histoire d’un crime, 1977
 

Tanja Dudenbostel Headshot

Tanja Dudenbostel is an Internist, Hypertension Specialist within Cardiology at the University of Alabama at Birmingham where I divide my time as an Assistant Professor between clinical research and seeing patients in cardiology.

 
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Surviving A Deadly Heart Attack

Anberitha Matthews, PhD

With cardiovascular disease (CVD) being the leading cause of mortality and morbidity among the western population, it is not a long shot for one to think almost everyone knows someone that has encountered heart disease or the symptoms thereof. Not surprising that I had the opportunity to meet these people whom I am now writing.

 

Heart month heart image

There was a cardiologist at a well-known and respected institution that suggested, her patient, a 60 year old man with two occluded arteries and only a functioning aorta (widow maker) had on average 10 years to live. The patient had one silent heart attack and one where he sought medical treatment. During that time the cardiologist attempted to place a stent to reopen the artery, but had no success due to the “amount of scarring.” Which is why the patient was left with two arteries occluded. I am left to wonder, with all the research that is being conducted to extend life and improve cardiac health including but not limited to pharmaceuticals and the surgical techniques, why is there nothing that can be done other than sending this patient home with a bleak outlook on the next several years of his life. That patient is still alive and doing well, thanks for asking. That is not an isolated case of patients being sent home hopeless. I came across a story on Facebook (2014) about a 58 year old lady that was on hospice for the last four years. She presented to the hospital in full cardiac arrest. The emergency medical team was performing compressions until she arrived at the hospital; thankfully they were able to revive her. She previously suffered 3 heart attacks resulting in 2 triple bypass surgeries, but after that 4rd heart attack in August 2010 the doctors said there was nothing they could do to improve her [cardiac] health. Before you are alarmed, she had multiple chronic illnesses by this time: 3 myocardial infarction (MI), congestive heart failure, diabetes, breast cancer (resulting in double mastectomy), hypertension, and renal failure. Since she was not a good candidate for dialysis, she had a poor prognosis. She was taken off all her medications (from a cocktail of 19 pills to 4, which were for CVD symptoms and a morphine tablet for pain) and the end of life care team made worked diligently to make her comfortable until she passed.  The medical providers alerted the family that she could pass on at any time. That was in 2010, it is now 2018 and she is STILL alive and well! Both patients are.  So, what allowed this Facebooker to live so long with no major arteries? How is this even possible? Is it a case of faith/a miracle alone (which is what the Facebook post suggest) or something that can be medically/scientifically explained? What about the man from the former story? Is 10 years the best he could hope for or is the case with the latter possible in his case? Is there anything we can do pharmaceutically to drive the system toward the former?

the vascular endothelial growth factor graphic

In a 2018 study by Manavski et al, it was suggested that angiogenesis after ischemia is due to clonal expansion of endothelial cells. Indicating there is, indeed, a scientific rationale for the revascularization of the aforementioned hearts. After an MI there is significant scar tissue leading to the inability for the heart to provide the necessary oxygen and nutrients to other organ systems, known as ischemia. The newly ischemic environment potentiates the growth of new vessels to compensate for the loss of cardiac output due to the MI. These vessels are said to be generated through a mechanism known as angiogenic sprouting; in excess this pathological growth that can promote tumor formation. The signaling molecule vascular endothelial growth factor (VEGF) is hallmark in the formation of new vessels, but it is also highly expressed in cancers. Before we get off track, let’s think about the mechanisms in play in an MI. monocytes are attracted to an insult in the vessel, they differentiate into macrophages, those macrophages take up oxidized low density lipoproteins, and since they cannot process them, they die (undergo apoptosis). In ischemia macrophages promote the development of collateral vessels, but in tumors macrophages (M2) produce proangiogenic factors while educating the macrophage as what phenotype to take on – Tumor or cardiac. There are signals in the body that include VEGF and Ang1 that keep endothelial cells inactive to promote vessel stabilization. Furthermore, an oxygen sensor helps the endothelial cells to normalize and readapt to oxygen supply to the organ tissues. There are a battery of enzymes that play a role in vessel maturation which is too exhaustive for this blog, but mainly sprouting is impaired by inhibition of VEGF and S1P receptor signaling is the stabilizer for the vasculature.

In conclusion, having a heart attack is not necessarily a death sentence. Even when all the arteries to the heart of occluded. It is not the norm, but the human body is an overwhelmingly amazing in compensating for the loss of some pathways. Our bodies have system in place with mechanism to support life even when the answers evade medicine and science. With the passion to conduct research, we are finding ways to make our heart health better daily. As we explore mechanistic pathways to reduce oxidative stress, inflammation, and other underlying pathways, it is up to each individual to maintain a healthy heart by following the guidelines set in place by the American Heart Association. As for the patients above, they are working with their medical teams to maintain a healthy life. May I suggest you all continue to seek your physicians’ advice on how to improve/maintain your heart health?


Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.