Heart Attacks and Sleep Deprivation

Sleep is emerging as a new risk factor for heart disease.

Adequate sleep, both in terms of duration and quality, is proving to be essential for heart heath. The relationship may be a complicated one though. Excess sleep of more than 9 hours is harmful, and may understandably be making the body sluggish and vulnerable.

But those sleeping less than 7 hours a day on average have been found to have a higher frequency of heart disease.

The healthy sleep duration therefore seems to be between 7 and 8 hours. And early risers fare somewhat better than late ones.

The quality of sleep also seems to clearly matter: those with sleep apnea (orthostatic sleep apnea), snoring problems, sleeping disorders such as difficulty in falling asleep or waking up frequently at night, suffer more frequently from heart ailments.

Which then are the “types” of heart ailments associated with unhealthy sleep? Heart attack rates are clearly up, as are rates of high heart failures and coronary artery disease.

Experts attribute the increased cardiac risk to higher blood pressure levels and increased levels of certain circulating hormones during the night, in those with sleeping problems.

Cardiac disease is the largest killer in urban India today, and doctors as well as patients are familiar with the 7 conventional risk factors: tobacco, high BP, high cholesterol, Diabetes, strong family history, lack of exercise and obesity. “Sleep” is on the threshold of joining in as the 8^th risk factor for cardiac diseases.

Interestingly, some of the risk factors are intricately interrelated, and may not be so difficult to handle. Adequate physical exercise, for example, could additionally solve the problem of overweight as well as lack of sleep, apart from being protective to the heart.

What then prevents you from catching 7 hours of good sleep every night? Late night parties, television or late hours at work? Sleep therapists strongly advise an early light dinner, and switching off all electronic devices (TV and cellphone) at least an hour before sleeping time. It could be worth following their advice to protect your heart!

Advertisement

Eat Less to Live Long

Moderate limitation of calorie intake can make healthy people stay fit and live long. This has been the finding from a recently concluded controlled human CALERIE (Comprehensive Assessment of Long-term effects of Reducing Intake of Energy) trial undertaken by Yale School of Medicine and Pennington Biomedical Research Center.

The design of the trial was simple. Of the two hundred healthy volunteers who participated, some were asked to restrict their intake of calories by around 10-20% (14%) while others were asked to eat as they normally did, that is till they felt full.

Subjects were evaluated at baseline, 1 year and 2 years for subtle metabolic and immunogenic changes that could suggest effects on life span and health.

Interestingly, those who consumed a calorie restricted diet showed improvement in their metabolic and immune responses. This was primarily through harnessing PLA2G7, a macrophage produced protein platelet activating factor acetyl hydrolase, that has been established to correlate with healthier lives and longer life-spans.

This study conducted by two senior scientists, Dr Eric Ravussin and Dr Vishwadeep Dixit, went on to find what could be other reasons by which calorie restriction (CR) could be working o the body.

They noted that the thymus gland, located in the upper chest and considered to be the orchestra-master of the body’s immune system, showed much less age-related decline in CR subjects; their better-preserved thymus glands could produce more T-lymphocyes that regulate the body’s immune system.

Further, CR subjects showed less inflammation in the body. We know that the triad of disordered metabolism- immunity- inflammation is what causes aging, and age-related diseases shortening our life spans. Restricting calories slowed or reversed this process, allowing the body’s immune system and tissues to remain young and healthy.

One of the corollaries of this study is to address which of the 29 weight reducing diets is the healthiest. It appears that restricting calories in any form seems to be beneficial. Whether the focus is on carbohydrates or fats do not possibly matter much in the long term with regard to prolonging life-span.

The moral of the story seems to be: if you are healthy, get into the habit of reducing your calorie intake. The best way is to stop eating when you are two thirds full. That is you still have space in your stomach to fill. This could translate into less metabolic health problems and a longer healthier life.

Third Wave of COVID and the Omicron variant

Once yet again, when we had begun to think that the COVID pandemic had faded out, the number of new cases has suddenly spiked up in many parts of the world, largely due to the Omicron variant with its 30 plus mutations.

The prevailing sense of “coolness” in most people despite the rising numbers is due to two factors. One: many who have received two doses of the vaccine are enjoying a sense “protection” from future infections. And if indeed we do get infected, they feel, it is bound to be mild and transient. Second, initial evidence from South Africa has given us an indication that the outcome of infection with the Omicron strain is usually non-serious or non-fatal.

Why bother then?

The Omicron variant is 4 to 6 times more contagious than its predecessor, the Delta variant. Hence the number of people likely to be infected are huge. And due to its several mutations, protection from Omicron by vaccine derived antibodies are not likely to be good.

But why bother still, if it runs a mild course and does not have the potential to kill, as Delta did?

The best way I heard an international health expert sum up the situation was “A small portion of a very large number is still a large number!”

And as predicted, hospital admissions, have started climbing steeply in many parts of the world, many of whom are double-jabbed. Deaths are also not too far behind; Russia and east Europe are reporting large numbers already.

Further, children are falling ill much more this time than they did during the first two waves.

Governments of several countries who had become smug with the success of successful vaccination programs, are jerking up and imposing “restrictions” once again; closing restaurants, theatres, public gatherings and schools.

Health administrators are feeling the heat and sanctioning booster jabs, that they had been COVID Third Wave and the Omicron variant resisting. They are back once again to the drawing board “creating” beds and health care facilities, reminding me of the saying, “A mistake repeated twice is a conscious bad decision”.

And health administrators are once again in TV studios extolling the virtues of “mask” and “social distancing” while allowing crowds to swell in rallies and protests.

One silver lining is the availability of two new anti-viral drugs: Molnupiravir and Paxlovid, both at the threshold of their launch. If taken early in the infection, they seem to block viral replication and reduce the risk of “serious” outcome.

The COVID story seems far from over, and as the French president recently cautioned, “the next few weeks or months are likely to be challenging”. Let us err on the side of caution!

Sudden Cardiac Deaths: Looking the other way till it actually strikes?

An interesting event occurred recently when an otherwise healthy doctor suddenly lost consciousness and collapsed on the floor with a thud at his home. Attempts by anxious relatives to wake him up by calling or sprinkling water on his face did not work the way it normally does in fainting attacks we witness commonly brought on by prolonged standing in school assemblies or standing in line for long spells.

When partial consciousness returned, he checked his own pulse, and found it to be feeble and slow, around 20 per minute!

His pulse rate continued to be just 20 per minute (normally around 70), when he reached the emergency 40 minutes later, where he suffered another cardiac collapse. It was only when a wire could be inserted to his heart from his groin and his heart “paced” to 70, that circulation to his brain and body was restored.

After stabilizing him in the ICU for 2 days, a permanent pacemaker device containing a battery and two wires that reached down sending electric impulses to the muscles of the heart, that he could be sent home. He was of course lucky; most such cases are retrospectively given the label of unexpected sudden cardiac deaths.

While we are aware that the muscular heart pumps blood, we often overlook the sensitive network of pacemaker and “conduction tissue” that generates electric signals to initiate the “heartbeat”.   When the heart paces with fear or romance, it is brought on through this system. If it snaps, as in a condition called “heart block”, the heart finds it difficult to beat as there are no impulses to initiate the contraction.

Of the 2 million sudden cardiac deaths that occur in India every year, 20% are due to these “rhythm or electrophysiological disorders” that usually present as episodes of giddiness, or loss of consciousness. They differ from the common “heart attack”, a term that usually denotes blockage in the coronary arteries supplying blood to the heart of which chest pain remains an important symptom.

Electrophysiological disorders range from increase in rate to irregularity of rhythm to extreme slowness, and the range of therapies vary from medicines, to pacemakers to other fancy devices.

When the light does not come on when you turn the switch on, the problem might well be with the electricity supply, voltage or the wiring.  And these group of disorders are turning out to be important reasons for of increasing frequency of unexpected sudden cardiac deaths claiming apparently healthy lives.

Have you taken the Influenza vaccine?

Seasonal flu or Influenza comes around this time of the year with symptoms of running nose, fever, headaches and cough, and affects around 5 to 20 % people. It is caused by Influenza virus, and spreads easily from one person to another, in schools, colleges, offices or at home.

The symptoms are quite similar to Sars-Cov-2 virus, but tends to run a shorter course and is less dangerous, that is, kills less people. However, influenza (Strains A and B) often causes pneumonia, and remains one of the commonest causes of death in the elderly and in children during winter months.

Fortunately, there is a vaccine available to prevent seasonal flu (such as Influvac Tetra of Abbott, as well as by other manufacturers), that most vulnerable people can take around this time to protect themselves.

Who are at risk of catching the infection?

1. Health care workers such as nurses, hospital staff, doctors
2. School or college goers
3. Police and military personnel living in barracks
4. Those traveling by public transport, or who need to visit crowded places, or coming in contact with many people
5. Residents of old age homes, institutions/hostels or barracks.

Who are at most risk of taking a serious turn if infected?

1. Elderly people and those above 65
2. Those with bad lungs (chronic bronchitis, emphysema, asthma, smokers)
3. Those with co-morbidities such as heart disease, diabetes, renal disease, hypertension or other chronic diseases.
4. Small children especially those who are weak, have asthma or other health problems.

Why are they at increased?

1. They are more prone to develop pneumonia or severe lung infection, are not able to fight off the infection easily, and are at risk of respiratory failure or death.

What should we do?

1. Take the flu shot. As the Influenza virus keeps changing every year, an annual dose of vaccine made from the currently circulating strains are made every year. One dose of 0.5 ml IM is advisable in autumn or early winter.
2. Do not attend school, college or office if you have flu, as you may spread it to others.
3. Avoid people with running nose, fever or cough.
4. Wear a mask (similar to preventing COVID), and keep your hands sanitized frequently. Keep a hanky or tissues handy.

Do not confuse with the COVID vaccine that must be taken ( 2 doses) by every person for protection against Sars-Cov-2 virus or COVID.

That however does not protect against Influenza, another separate respiratory virus, which needs a separate vaccine and needs to be taken in addition.

Making Patients Active Participants in Treatment

The overwhelming majority of patients are quite accustomed to playing the passive role in treatment. When they have a symptom, they go to a doctor, get a few tests done if advised, take the pills or injections, and think no more!

If asked what the doctor diagnosed or what line of treatment he suggested, they are usually blank.

This “passive” approach does not work well in long-haul treatments where the patient and family has a significant role to play.

Take for instance the wide range of “life-style disorders” such as fatty liver, diabetes, hypertension, obesity and heart disease. If the nurse measures the height and weight, and calculates the Body Mass Index (a measure of how much one weighs for his height), he merely comes off with a figure not learning what it means, and what he needs to correct.

Studies have shown that engaging patients to discover themselves, could help convert them into “active” stakeholders. If each clinic provided a facility to assess a patient’s anthropometry (height, weight, body composition, BP) and the patient was asked to read off the BMI value on  chart provided, he would immediately get to know if he was off the mark.

Reading his measurements on a chart, and finding his value in the “red zone” prompt him to ask “what should my ideal weight be? how much off the range am I at present? What should I do to get back to the green zone?”.

And even more importantly, to ask the question, “What is the risk if I remain in the red zone?” This is the concept of HEALTH PROMOTION, where the patient gets educated as well.

Thanks to technology, there are enough gadgets available now that could tell your heart rate, rhythm, blood pressure, blood glucose, body composition and so on.

Patients are however clearly divided on two lines: some who use them too often and turn hypochondriacs, or the other who do not bother to learn at all!

I was disappointed when a friend of mine died of COVID recently after being in ICU for over 2 weeks. Both his otherwise well-educated gown up children rang up to ask “what is a ventilator?”. Worse, the son wanted to take the “body” home for a few days, completely oblivious of the risk it could pose to relatives and neighbors!

Awareness about health issues is no longer a matter of curiosity or general knowledge, but a necessity…and each person needs to play an ACTIVE role in it.

Heart Attacks in Young

The most shocking health news of the week was undoubtedly the sudden death due to heart attack of 46 year-old Kannada actor Puneeth Rajkumar in Bangalore.

He was just 46 and in the prime of life, did not have any major risk factors, was remarkably fit and had appeared to be in perfect health till the previous day! A similar story has unfolded in recent times with not just celebrities in their forties such as Sidharth Shukla, Raj Kaushal, Remo D’Souza, but to a very large number of young people in their most productive phase of life.

The concern is that heart attacks, that usually occurred in 50 to 65 years old, has started striking younger people with marked increase in frequency, making doctors wonder if conventional risk factors are still as relevant.

Around 3.5 to 4 million Indians suffer from heart attacks every year, around half of whom are “young” (less than 50 years). Many in their 30 s are also suffering heart attacks, the average age steadily coming further down.

We are aware by now that the conventional major risk factors that are known to predispose to heart disease are diabetes, hypertension, smoking, high blood cholesterol levels and strong family history many of which do not seem to apply to “young patients”, who are often very conscious about their health, eat healthy, exercise with great regularity, do not smoke and maintain ideal body weight.

While we are still groping for answers, two issues that are coming under suspicion are “stress” and “high intensity” exercise.

Most would instinctively argue that stress levels, driven by ambition and insecurity, are on the rise. The problem however is to quantify or measure it in some way, and to attribute a causal role to it. At present we have neither, hence stress remains subjective and vague, and further study of its role remains a major challenge.

The other concern being voiced is the role of high intensity exercise. Many have been “fitness-freaks” and very regular with fitness measures including high intensity exercise.

The answer in not evident yet, but the recent surge in heart attacks amongst young Indians is emerging a major health concern, challenging the medical profession to provide clearer answers and suggest preventive steps.

The Killer this time is Dengue!

While we have been obsessing for the last 17 months with masks and social distancing, and keeping a close watch on the front door to keep COVID away, Dengue has recently sneaked into our homes through the windows and caught us with shirts and pants down!

Dengue is yet another viral infection, in a way like SARS-Cov2, but it enters the body in a different way and targets different organs. Both however have mild as well as serious forms, and kill around 1-2% of those they infect.

Dengue virus, now designated officially as DENV are of 4 types, (quite like the delta and alpha of SARS-COV2) and vary in their epidemiology and seriousness. Unlike COVID which spreads from an infected person fairly directly through droplets in the breath, Dengue requires another agent, a mosquito, to transmit.

The focus of attention for preventing Dengue is therefore in controlling mosquitoes, called vector (another name for transmitter), which breed in stagnant water pools left by monsoons. Female members of the striped Aedes Aegypti, the main culprit strain, then visit our homes for a drink of human blood required for their further breeding, during which they transmit the virus.

Dengue usually presents with fever, at times high grade and back-breaking, that may last 4 to 7 days. Symptoms suggesting a serious turn are severe abdominal pain, persistent vomiting, rapid breathing, restlessness, bleeding gums and low blood pressure, and require hospitalization for supportive care.  Two major complications to watch out for are bleeding (from any site such as gums, intestine, under the skin, into lungs) due to low platelets in the blood, and shock (low BP, fall in urine out-put) that may kill.

If the war against Dengue has to be won, understanding the behavior of the Aedes mosquito is essential: it is a day-time biter, coming in mornings or at dusk. It is therefore essential to replace half-sleeved shirts and shorts with full-sleeved ones, pajamas or trousers. Socks are helpful to cover potential biting sites, as are mosquito repellents on the exposed portions of skin or the room.

And of-course, cleaning stagnant water pools in the neighborhood of homes and schools are essential. A bunch of young volunteers can often lead the fight against mosquitoes which paid professionals often fail to achieve!

Under-estimating the reach and might of the Aedes-Dengue combo can prove costly. It had claimed the life of our Bollywood Mogul Yash Chopra, a few years ago.

And by the way, vaccines do not work well for every infection, Dengue being an example although there are 2 approved. It is mosquitoes then which need targeting this time!

Chest discomfort: “acidity” or heart attack?

The sudden untimely death of popular actor Sidharth Shukla’s at the young age of 40 has left many fans and the public shaken and gasping for answers.

From what I could gather, he was young, and fit and popular, and seemed to have been “fine” and “normal” till the previous evening.

It was around 3 at night that he experienced chest pain which he possibly attributed to “acid” or “gas”, drank some water and tried going back to sleep. The pain persisted in the morning, for which his doctor advised him to go to the hospital but by the time he did, he was dead.

Most “cardiac” chest pains are no longer as typically described in text books: “crushing” type in the center of the chest, radiating to the left shoulder or arm, associated with sweating or breathlessness.

More often the initial symptoms are of “gaseousness” or “heartburn” or vomiting, and are often put down to “indigestion” or GER (Gastro-esophageal reflux). Many patients pop antacid pills or drink cold water to soothe their food pipes. Further, symptoms of the two can overlap considerably!

For doctors too, the line dividing “don’t worry, take some antacids” or “rush to a hospital right away” pieces of advice is becoming blurred. The traditional differentiators: age, sex and fitness are not so predictable anymore!

Cardiac deaths are making us redraw our guidelines. They are occurring with increasing frequency in younger people, even in females, and in many who seem to be “eating right”, going regularly to the gym, and maintaining normal body weights. “Stress” of course remains an unmeasurable factor!

The “heart scare” has already set in. A study revealed that over 50% of those who presented to the emergency at night with discomfort in the chest had normal cardiac tests.

But what about the other 50%? My 35-year old colleague had attended a hospital at 9 PM when a nagging chest pain had refused to die down through the day, Four hours and 2 hospitals later, he was diagnosed to have suffered a heart attack. He is luckily well 6 years later after undergoing a coronary stenting.

It is good to remember that” acidity” and “gas” do not kill, but heart attacks may. The embarrassing choice is between waking others up at night and going to the emergency and being taunted as a hypochondriac should the test be normal, or wait till the morning!

Time can sometimes be of essence in matters of the heart.

Monsoon Health Hitches

When the monsoons finally arrive to break the hot summer spell, it brings with it a basket of health snags that may be of concern particularly in the recent backdrop of the 2^nd wave of COVID.

Fever, sore throat, cough and running nose are indeed common, especially if you have got drenched in the rains or have been drinking chilled water from the fridge. The special concern this year is to be sure that it is not COVID again as the symptoms can overlap. And  while the COVID numbers are down overall, we can never be sure when and how the 3^rd wave will announce its arrival into our lives and homes.

If in doubt, and especially if one is physically interacting with the public, such as doctors, nurses, school teachers, it makes perfect sense to get a SARS-Cov 2 RT-PCR done to be sure. Much of the preventive and treatment strategies will however remain unchanged: masks to prevent spreading, keeping a safe distance from others, taking leave for a day or two, analgesics and cough lozenges. If your tonsils are swollen and painful or you continue to run fever beyond a day or two, or your cough goes deeper into your lungs, your doctor may suggest a short course of antibiotics.

Typhoid, malaria and Dengue are the common causes of high fever.

It is not quite time yet for Malaria and Dengue. The rain water needs to collect in stagnant pools encouraging mosquitoes to breed in them, and then come into your home to suck your blood…All this can be expected from around the end of August. The good news is that malaria has shown a significant decline in the last 2-3 years, while Dengue was obscured last year by the raging COVID outbreak.

It is sensible to keep your surroundings drained and dry. A biweekly inspection to ensure that rainwater is not collecting in in your surroundings in pits, drains, water coolers and pots, and periodic spraying of mosquito repellents can be hugely helpful.

Typhoid occurs by the typhoid bacteria spreading through contaminated foods and drinks. Avoid eating uncooked food, such as salads, outside these days.

A simple rule of thumb is that a fever that disappears within 3 days is unlikely to be typhoid; if the fever climbs and persists beyond 5 days, it well could be. Typhoid antibodies develop around the end of 1^st week. It is medically unwise therefore to get the typhoid antibody test done too quickly; many labs give positive reports even in the early phase, which are not accurate, and result in unnecessary consumption of antibiotics.

Waterborne infections do get common during these times as overflowing rivers, streams and ponds contaminate our tanks and water supplies. Hepatitis A and E are caused by viruses that spread through water, as does Cholera which remains one of the major causes of illness and death in flooded areas.