Dr Olulola Oladapo is the head of the cardiology unit of the University College Hospital (UCH), Ibadan. In this interview with Sade Oguntola, she expresses concerns about the decreasing age of people with heart attacks and how best to avoid the problem.
What is a heart attack?
The heart is the organ that pumps blood around the body. It starts beating at 21 days of age for the baby in the mother’s womb, and it continues throughout the person’s life. On average, the heart beats about 70 times per minute to push blood around the body. Therefore, it needs its own blood supply to do this work. The vessels that supply the heart are called the coronary vessels. The vessels in a newborn are nice and clean. Naturally, as the baby grows older from 9 months of age onwards, all blood vessels, including the coronaries, gradually accumulate fatty streaks and plaque deposits on the lining of their walls. This process progressively makes the vessels stiffer and narrower, making the heart work harder as it pumps blood around the body. Angina, known as chest pain during physical activity, develops when the blood vessel supplying the heart narrows up to 50% or more. Sudden-onset, greater than 70% narrowing of these vessels by blood clots can result in their blockage and death of heart muscle cells. This is what we refer to as MI, or heart attack, which is a life-threatening condition.
How true is it that cases of heart attacks are rising, particularly among those in the 30- to 50-year-old age group in Nigeria?
That is true. In recent times, we’ve seen younger age groups, both male and female, who are the breadwinners of their families, come down with angina and MI. It is a spectrum of disorders, with the end of the spectrum being sudden death. Decades ago, heart attacks occurred in men who were older than 50 years and in women after menopause who were older than 60 years of age. But now, in both genders, heart attacks are occurring earlier in life, sometimes as early as the fourth decade. It is about a decade and a half lower than what we used to have.
At what time was the disparity in the age range of individuals with heart attacks noticed?
This was quite a while ago; it has been more than 10 years now. However, the rate at which it occurs is getting worse progressively. Therefore, it’s critical to inform Nigerians about this and encourage them to take appropriate actions to reduce its morbidity and mortality. But more importantly, there is a need for awareness creation and primary prevention of heart diseases generally so that people do not end up having heart failure, heart attacks, or, in the extreme case, cardiac arrest, which is at the end of the spectrum. However, the focus of this discussion is on heart attacks. The goal is one heart for life, so keep it healthy!
How many cases did you see a decade ago, and how many do you see now? Also, are more men affected than women?
Ten years ago, we had less than 10 cases annually at our centre, but now within 3 months, we can see 10 cases or more. Just like in other countries, men are more affected than women. However, the gender differences in incidence decrease with age. Gone are the days when MI was thought to be exclusively a man’s disease, but we know better now, based on evidence. Women were overlooked in the past because they don’t often have the classical squeezing, excruciating, “worst pain of my life” chest pain radiating down to the left arm, back, or neck that men usually present with. We have come to understand that sudden-onset feelings of pressure in the upper part of the back, jaw pain, shortness of breath, indigestion, profuse sweating, nausea, excessive tiredness, and lightheadedness may indicate a heart attack in women. Therefore, we no longer dismiss such symptoms in women but investigate them further.
So, what may be responsible for this observation of an increasing rate of heart attack?
Globally, there has been an epidemiologic transition in disease patterns, with a shift from infectious diseases to non-communicable diseases. Unfortunately for us, we are grappling with the double burden of communicable and non-communicable diseases and their attendant effects. Our forefathers were agrarian hunters, but our society has become more mechanised and motorized. Heart illnesses used to be caused by infections such as rheumatic heart disease, but these days, lifestyle changes are the main cause of non-communicable diseases, including heart attacks. Our lifestyle has become sedentary, especially for those of us living in urban communities. People, especially youths, have moved into urban centres, where most commute more by motorization than trekking. Apart from this, the challenges of living in squalor in the inner city have aggravated the situation.
What causes a heart attack?
Things that are associated with and contribute to people developing heart attacks are hypertension, diabetes mellitus, high blood cholesterol levels, obesity, male gender, ageing, and a history of sudden death in a young first-degree relative. Other risk factors include a sedentary lifestyle, smoking, alcohol consumption, unhealthy diets, the use of psychoactive substances such as cocaine, air pollution, excessive stress, and sleep disorders. Air pollution could be from factory emissions, vehicular exhausts, electrical generators, or even cooking with fossil fuels. This is why green energy and no-smoking environments are advocated.
It is common to say that stress can trigger a heart attack. Is it true?
Well, we are all stressed. Stress is a universal thing, and it is getting worse for Nigerians. Stress in any form—economic, psychological, or emotional—ends up pouring some hormones into the bloodstream that worsen the process that damages the blood vessels. They also cause palpitations due to arrythmias. Consequently, stress management is very important. Our forefathers lived in communities. They could manage their expectations, and they were more realistic. But nowadays, a young man is hustling, going from one job to the next or from one contract to the next. They don’t even sit down to rest or take cognizance of how they are living. As such, they are on the edge all the time, and this is not good for the heart. There is also what we call broken heart syndrome, which is common in women. The stress that follows a betrayal might lead a lady to have a heart attack and die.
Are there blood tests to determine people’s risk of a heart attack?
Yes, there are. We advocate that periodic medical checkups should be started as early as possible in the young adult age group. Most of the risk factors are silent until they cause end-organ damage. Simple things such as checking, knowing, and controlling your body mass index, waist circumference (both indicating overweight and obesity), blood pressure measurement, blood sugar levels, blood cholesterol levels, urine test, and kidney function test are cost-effective ways of preventing heart disease. Sadly, most of the time, our people don’t bother with periodic medical checkups, and when they do, they don’t follow up properly until they present with catastrophic events such as strokes and heart attacks. Know your numbers and fix them!
How would someone know that they are having a heart attack, and what should they do?
The classic symptoms are sudden onset, extremely severe chest pain usually below the left breast, squeezing, gripping, and heavy pressure radiating to the arm, shoulders, jaw, and back, which can be associated with shortness of breath, sweating, nausea, vomiting, and feelings of imminent death. Prior to this event, the individual might have been having similar but less severe episodes of chest pain (angua) brought on by different levels of activity and relieved by rest and nitrates. Anyone having angina symptoms should consult their healthcare provider for comprehensive management so that they don’t develop full-blown MI. As I said earlier, the symptoms of MI in women are more subtle and may be non-specific. It is the same with elderly and diabetic patients. They may present with feelings of unusual fatigue, a feeling of being unwell, or shortness of breath.
Immediately after one starts having feelings suggestive of MI, the patient and relatives must act fast because time is a muscle! Chew and swallow one Aspirin tablet, as this will prevent further sticking together of some blood cells and reduce further clot formation in the coronary artery. In high-income, advanced countries, patients call 911, and paramedics arrive at home with a fully functional ambulance equipped to start care right from that point, even before getting to the emergency room. Such services are few and far between in our own environment, so my advice is that the patient should get to the nearest emergency room as quickly as possible. This is because the rate of death is highest within the first hour of the event due to the complications of the abnormal malignant heart rhythm accompanying the MI.
Are there tests to determine if a patient has a heart attack?
Yes, there are. At the emergency room, the patient is quickly accessed; amongst others, serial ECGs are acquired, and blood is taken for cardiac enzymes to rule in or rule out MI. Once a diagnosis is made, the goal is to open up the blocked blood vessels, either by medical treatment with drugs or if there is a facility for onsite intervention at a cardiac catheterization laboratory where the coronary arteries are visualised and the blocked area is opened up. These will restore blood supply to the heart so that the patient doesn’t suffer extensive loss of heart cells. The chance of surviving has improved.
We need to create awareness and improve access to care within the first 30 minutes to one hour, or up to 3 hours of the event. Most of our patients present days after the event, and in them, the damage is quite extensive with poor outcomes. Also, we need easier access to functional medical ambulances and well-trained paramedics to ensure prehospital care and increase the chain of survival. A situation in which our patients are transported to the emergency room by taxi or motorcycle is not good enough.
Once the patient has been managed during this acute phase, they will have to continue treatment that will help manage their modifiable risk factors as well as start the process of cardiac rehabilitation. A healthy lifestyle involves a smoking cessation plan, weight management, and a healthy diet that includes 5 servings of fruits and vegetables daily, low saturated fat intake, low salt, and increased physical activity. More than 30 minutes of brisk walking daily, 7-8 hours of sleep daily, and compliance with medical treatment will help in the primary prevention of heart problems in family members and secondary prevention in heart attack survivors.
Q: What is the difference between a heart attack and a cardiac arrest?
The heart is a pump that requires its own blood supply, and progressive or sudden blockage of these vessels results in the death of the muscle cells, which is what we call a heart attack. On the other hand, like all pumps, the muscles of the heart are activated by electrical cells around them to enable them to contract and pump blood. Miss-firing of the electrical cells may cause life-threatening palpitations and chaotic contractions leading to fibrillation and cardiac arrest. The person may die unless effective cardiopulmonary resuscitation is started immediately. So they are two different conditions, but one may lead to the other.
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