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| Sunday, 21 August 2005 |
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Features |  |
| News Business Features Editorial
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Health guide Acute chest pain:what doctors should do by Dr. D. P. Atukorale
If the acute chest pain is due to unstable angina or myocardial infarction, the patient should be immediately admitted to a hospital (preferably to a General Hospital, Base Hospital or a private hospital which has intensive care facilities) even if the E.C.G. is normal. Other causes There are other causes of acute chest pain such as: (a) pleurisy (inflammation of the pleura), (b) pneumothorax (c) pulmonary embolism, (d) escophageal reflux (e) gall bladder disease, (f) pericarditis (inflammation of the pericardium), (g) mitral valve prolapse (MVP), (h) pain arising from bones and muscles of the chest wall, (i) aortic dissection, (j) pain referred from the cervical spine or thoracic spine and (k) skin disorders such as shingles (herpes zoster) which can give rise to severe unilateral chest pain which precedes the zoster rash. Myocardial infarction (heart attack) pain is similar in location and character to angina; however the infarction pain is usually more severe and occurring at rest without provocation and usually lasts for more than 15 minutes and may last for hours. Patients who present an acute chest pain and ischemic E.C.G. changes requires admission and appropriate treatment. Even if the E.C.G. is normal, a good history of an unstable pattern of ischemic chest pain (particularly if chest pain lasts for more than 15 minutes) indicates that urgent admission is required for further evaluation and treatment. However, in a proportion of patients with chest pain the history will be non-specific, clinical examination unremarkable, E.C.G. will be normal or non-diagnostic and it will be impossible to exclude unstable angina or myocardial infarction (heart attack) on clinical grounds alone. In these patients cardiac enzymes and troponin (troponin T or troponin I) tests should be done if there are facilities for cardiac enzymes and troponin tests. If these tests are negative, the tests should be repeated after 12 hours and 12-20 percent of these patients will have detectable troponin elevation. If these tests are negative, these patients can be transferred to a medical ward or sent home after giving instructions for further investigations such as exercise E.C.G. Stress test Once unstable angina and myocardial infarction are excluded, the physician should arrange for an exercise ECG and this is the most widely used test for evaluating the patient with chest pain. Patient is usually exercised on a treadmill, the speed and slope of which can be adjusted to increase the workload gradually. The exercise ECG provides important diagnostic and prognostic information. The resting ECG is often normal in patients with coronary heart disease (CHD) but ECG changes (ST segment depression associated with typical angina) on exercise is very suggestive of C.H.D. There are conditions such as digitals therapy, mitral valve prolapse (MVP), cardiomyopathy, left bundle block and hypertension which can give rise to false positive exercise ECGs. In these conditions a stress echo or a Thallium scan, (if facilities are available) is very useful. If exercise ECG and stress echo are normal, there is no indication for invasive tests such as coronary angiography. Coronary angiography Coronary angiography (coronary arteriography) is the study of the anatomy of the coronary arteries which are visualised by X'ray by injecting a contrast material (radio-opaque dye) into the coronary arteries which supply oxygen and other nutrients to myocardium (heart muscle). Sending a catheter to coronary arteries is one of the most skilled jobs in medicine and is now done routinely and with little risk in most of the cardiology units of the world. At present in Sri Lanka this test can be performed in the Institute of Cardiology, National Hospital, Colombo, Teaching Hospital in Galle and some of our private hospitals in Colombo. The coronary catheter is passed either through the femoral artery of the lower limb or brachial artery of the upper limb by percutaneous approach under local anaesthesia, and radio-opaque dye is injected into each of the coronary arteries, and multiple views in different projections are taken. Occlusions of coronary arteries are nearly always caused by atherosclerosis and these occlusions are shown clearly in the angiogram. Coronary angiogram is the only way of telling how great the coronary problem is at present and establishes whether the patient will be best helped by medical management or by angioplasty (PTCA) or by coronary artery surgery (CABG). In patients with unstable angina, 30-35 percent of patients have one vessel disease, 10-20 percent of patients have no significant lesion, 5-10 percent of patients have significant left main stem steno sis (which needs urgent PTCA or CABG) and 40-50 percent have multi-vessel disease. Indications for coronary angiography Majority of cardiologists in Sri Lanka subject patients with chest pain and strongly positive exercise ECGs for coronary angiography. There are some cardiologists who subject all heart attack patients to coronary angiography without arranging for exercise ECG, with a view to PTCA or CABG if there are no contra-indications. I personally arrange all heart attack patients, a few days after the heart attack (if there are no contradictions such as heart failure or poor left ventricular functions) for an exercise ECG and arrange for coronary angiography if the exercise ECG is strongly positive (a) if the patients can afford to bear the cost of angiography (about Rs. 28,500) and if these patients can afford to undergo coronary artery surgery (CABG) (about Rs. 350,000) or PTCA (Rs. 400,000 to Rs. 600,000). Those patients who cannot afford coronary angiography and surgery or PTCA in the private sector are referred to the Institute of Cardiology, National Hospital, Colombo. Risks There is a very small risk involved with the procedure of coronary angiography (C.A.). The mortality rate of the procedure experienced in developed countries is less than 0.1 percent. As a rule the cardiologist or one of his assistants gets the patient or one of his or her guardians to sign a consent form after explaining the risks of the procedure to the patient or guardian. Rarely, in serious cases of CHD, the patient can develop very serious rhythm disturbances during C.A. ending in cardiac arrest and death. As mentioned earlier in the hands of experienced cardiologists the mortality and morbidity due to the procedure of C.A. is very low. In Sri Lanka there are few cardiologists in the private sector who subject all chest pain cases to angiography even if the ECG is normal, without subjecting the patients to exercise ECG. Doing coronary angiograms in cases of non-cardiac chest pain is not so uncommon in Sri Lanka. I have come across some of these innocent patients who have been taken for a ride in the private sector by doing highly unnecessary coronary angiograms. In conclusion, coronary angiography is not a risk free procedure I know of a number of deaths due to the procedure of angiography both in the government sector and private sector. The patients should be selected very carefully and the risks of the procedure should be explained to the patient or the guardian, before getting the consent for the angiogram. It would be very interesting for a Sri Lankan to do research regarding true mortality and morbidity due to the procedure of coronary angiography, and I am sure our mortality rates will be quite different from those of the developed countries. Better hygiene prevents Rota virus by Thusitha Malalasekera, Health Education Bureau World Health Organisation (WHO) has identified the development of a vaccine to prevent Rota virus infection as a priority. It is because that the infection of this virus causes 125 million episodes of gastro enteritis every year resulting in 02 million hospitalisation and 440,000 deaths around the world, a child a minute. The majority of deaths occur in the developing world including the Indian sub continent. According to WHO a vaccine would offer the best protection for the children and the community against rota virus infections. Already there are some vaccines either in use or in trial, for the prevention of this infection. A new oral vaccine - alive attenuated vaccine-developed from single human strain provide early prevention before the onset of rota virus infection, as well as effective protection against multiple rota virus strains. This new vaccine has shown up to 90% efficacy in protecting infants against rota virus gastro enteritis. 'Rota virus is everywhere and is universal. It affects children all over the world, no matter whether they are rich or poor,' are the words of Dr. Lulu Bravo, Professor and Chief Infectious and Tropical Diseases, Department of Paediatrics, College of Medicine, University of the Philippines, in addressing a recent seminar on Rota virus infections. According to Dr. Bravo, incidence of rota virus infection is similar in both developed and developing countries, which implies that improvements in hygiene, water supply and sanitation and healthcare cannot effectively protect against this child health menace. Rota virus which appears like a wheel (hence the name Rota) under the electron Microscope, causes an intestinal viral infection, resulting in fever (2-3 days duration) watery diarrhoea, (up to 10-12 times or more a day at least for 3 to 9 days or more), vomiting, abdominal pain and dehydration (the dehydration caused by rota virus infections are more severe than the other situations), which leads to hospitalisation or some times death. Most rota virus infections occur in children 6 months to 5 years and is more serious and common in between 6 months 2 years and is a self-limiting vital disease which carries a incubation period of 5-4 days after being transmitted through faecal-oral route. Rota virus is highly infectious and can survive for a reasonable period of time in the environment. The transmission can occur through person to person spread, ingestion of contaminated water or food and contact with contaminated surface such as toys. It can survive for hours on hands and for days on solid surface and could remain stable and infective in human focus for up to one week. Rota virus is a very common infection among the children, by the age of five, every child would have at least one episode of rota virus infection. It's a common cause of hospitalisation of young children and is one of the leading causes of death among the children in developing world. Treatment of rota virus infection relies on the measure to relieve the symptom caused by rota virus such as maintaining of effective body fluid and electrolyte balance with oral rehydration through (eg. giving Jeewani and other fluids) replacing the loss fluids through intravenous route (eg. giving saline) and fever management, since there is no specific treatment available for rota virus infection. Although the improved general hygiene and sanitation standards do not effectively reduce the incidence of rota virus infection, significantly parents are still advised to breast feed their children (exclusively for 4-6 months and up to 2 years with weaning foods) frequency preparing food freshly and cleanly from fresh raw food, frequent hand washing, regular disinfections of play areas, cots and toys, use of boiled cool water effective control of flies and other insects that could spoil the food and by use of sanitary latrines for defecating and destroying of infant stools as support measures in preventing rota virus infection. Holistic healing Managing common cold by Dr. danister L. Perera According to Ayurveda this is very common and is caused by aggravation of Kapha. It may sometimes, be caused by weak digestion. When the food we eat is not fully digested it changes into ama. This mucus or ama reaches the respiratory system and causes cold or cough. Often, the earliest symptoms include a scratchy throat, twitching in the nose, runny nose or congestion, or sneezing. The most common symptoms of the common cold are nasal discharge and obstruction, sneezing, sore throat, cough, and hoarseness. In modern medicine this is caused by some types of viruses, which infect the nose and upper respiratory system. The upper respiratory system includes the nose, mouth, the throat (or pharynx), and the sinuses. The lower respiratory system includes the trachea and the lungs. Upper respiratory infections (common cold) are the most frequent acute illnesses in the world. In Western countries being exposed to a common cold virus is almost inevitable in the winter, but coming down with symptoms of the common cold is not inevitable. There are at least two hundred different viruses that cause the common cold. Half of these are rhinoviruses although coronaviruses, influenza, and other types of viruses also play a role. With time, many individuals become exposed to a number of these viruses, build an immunity against them, and will not easily succumb to these germs again. The odds of catching a common cold are thus reduced with age, except in the elderly since their immune system often begins to falter. But remember, cold symptoms usually develop about two or three days after you are exposed to the virus. If you are more prone to develop aggravated Kapha in your body your respiratory system is easily invaded by the virus. If you have a congested nose, warm, hot baths can help clear it up, especially before going to bed so you can at least get a few hours with a clear nose before it clogs up and as a result you have to breathe through your mouth. It is a germy world out there, but there are some steps you and your family can take to protect yourself from being infected with the latest virus circulating around your home or office. Wash your hands frequently if you happen to shake hands with many or are in contact with many people at the office or home. Keep your hands away from your eyes and nose. Maintain moist mucous membranes by drinking plenty of water and using a humidifier during cold, dry season. Have a good, deep sleep at least six to eight hours a night. Eat plenty of fruits and vegetables (these foods are rich in vitamins and phytonutrients). Limit your intake of alcohol, caffeine and sugar. Exercise regularly. This will help you to reduce the tendency of aggravating Kapha and the body will be light. In such environment viruses are not able to activate in their natural capacity. Only in a phlegmatic situation these pathogens are capable of living and producing any ill-effect. Therefore it is important to keep to the following routine in your lifestyle. Body should be kept warm especially feet, chest, throat and head. Sweating is very helpful. The simplest way to do it is drink hot spiced tea (dried ginger and coriander) or some other hot drink and lie down on the bed Use some warm cover like blanket and let the body sweat for 15 to 20 minutes. A glass of warm water mixed with one teaspoon of lemon juice and one teaspoon of honey could be taken 2-3 times a day. Add several drops of eucalyptus oil to water, which is boiling but just taken off the stove. Breathe in the steam 5-10 minutes at a time for 2-3 days. Gargle with sesame oil two to three times a day. (first gargle with warm water for 30 seconds then gargle with sesame oil for 3-5 minutes. Then gargle with warm water. |
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| Produced by Lake House |
When a middle aged or elderly person presents a case of acute chest pain
to his family physician (G.P.) it is the duty of the G.P. to exclude
unstable angina (severe angina) by making a careful study of history, and
doing a good clinical examination and arranging for an urgent E.C.G. if
facilities are available. 
