CORONARY ARTERY DISEASES

Coronary artery disease (CAD) also known as atherosclerotic heart disease, coronary heart disease,or ischemic heart disease (IHD),is the most common type of heart disease and cause of heart attacks.The disease is caused by plaque building up along the inner walls of thearteries of the heart, which narrows the arteries and reduces blood flow to the heart.

While the symptoms and signs of coronary artery disease are noted in the advanced state of disease, most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms, often a "sudden" heart attack, finally arises. Symptoms of stable ischaemic heart disease include angina (characteristic chest pain on exertion) and decreased exercise tolerance. Unstable IHD presents itself as chest pain or other symptoms at rest, or rapidly worsening angina. The risk of artery narrowing increases with age, smoking, high blood cholesterol, diabetes, high blood pressure, and is more common in men and those who have close relatives with CAD. Other causes includecoronary vasospasm, a spasm of the blood vessels of the heart, it is usually called Prinzmetal's angina.

Diagnosis of IHD is with an electrocardiogram, blood tests (cardiac markers), cardiac stress testing or a coronary angiogram. Depending on the symptoms and risk, treatment may be with medication, percutaneous coronary intervention (angioplasty) or coronary artery bypass surgery (CABG).

It was as of 2012 the most common cause of death in the world, and a major cause of hospital admissions. There is limited evidence for population screening, but prevention (with a healthy diet and sometimes medication for diabetes, cholesterol and high blood pressure) is used both to prevent IHD and to decrease the risk of complications.

SYMPTOMS    

Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries. The symptoms of angina are often treated with betablocker therapy such as metoprolol or atenolol. Nitrate preparations such as nitroglycerin, which come in short-acting and long-acting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed.

Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It may be treated with oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done. About 80% of chest pains have nothing to do with the heart.

Heart failure (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle) Heartburn.

TREATMENT

Therapeutic options for coronary artery disease today are based on three principles:

• 1. Medical treatment - drugs (e.g. cholesterol lowering medications, beta-blockers, nitroglycerin, calcium antagonists, etc.)
• 2. Coronary interventions as angioplasty and coronary stent-implantation;
• 3. Coronary artery bypass grafting (CABG - coronary artery bypass surgery).

Recent research efforts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem cell therapies.

Lifestyle]

Lifestyle changes have been shown to be effective in reducing (and in the case of diet, reversing) coronary disease:

• A plant-based diet
• Weight control
• Smoking cessation
• Avoiding the consumption of trans fats (in hydrogenated oils)
• Exercise Aerobic exercise, like walking, jogging, or swimming, can help decrease blood pressure and the amount of blood cholesterol over time.
• Decrease psychosocial stress.

In people with coronary artery disease, aerobic exercise can reduce the risk of mortality. Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force, found 'insufficient evidence' to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", it only examined the effectiveness of the counseling itself. The American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.

Medications

• Statins, which reduce cholesterol, reduce risk of coronary disease 
• Nitroglycerin
• ACE inhibitors, which treat hypertension and may lower the risk of recurrentmyocardial infarction
• Calcium channel blockers and/or beta-blockers
• Aspirin

Aspirin

In those with no other heart problems aspirin decreases the risk of a myocardial infarction in men but not women and increases the risk of bleeding, most of which is from the stomach. It does not affect the overall risk of death in either men or women. It is thus only recommendedin adults who are at increased risk for coronary artery disease were increased risk is defined as 'men older than 90 years of age, postmenopausal women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy'. More specifically, high-risk persons are 'those with a 5-year risk ≥ 3%.

Anti-platelet therapy

Clopidogrel plus aspirin reduces cardiovascular events more than aspirin alone in those with an STEMI. In others at high risk but not having an acute event the evidence is weak.

Surgery

Revascularization for acute coronary syndrome has a significant mortality benefit. Recent evidence suggests that revascularization for stable ischaemic heart disease may also confer a mortality benefit over medical therapy alone.

ASTHMA

Asthma is a condition in which your airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath.

For some people, asthma is a minor nuisance. For others, it can be a major problem that interferes with daily activities and may lead to a life-threatening asthma attack.

Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes over time, it's important that you work with your doctor to track your signs and symptoms and adjust treatment as needed

SIGNS AND SYMPTOMS 

Asthma signs and symptoms include:

• Shortness of breath
• Chest tightness or pain
• Trouble sleeping caused by shortness of breath, coughing or wheezing
• A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)
• Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

Signs that your asthma is probably worsening include:

• Asthma signs and symptoms that are more frequent and bothersome
• Increasing difficulty breathing (measurable with a peak flow meter, a device used to check how well your lungs are working)
• The need to use a quick-relief inhaler more often

TREATMENTS

Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers and taking steps to avoid them, and tracking your breathing to make sure your daily asthma medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler, such as albuterol.

Medications
The right medications for you depend on a number of things, including your age, your symptoms, your asthma triggers and what seems to work best to keep your asthma under control. Preventive, long-term control medications reduce the inflammation in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you'll have an asthma attack. Types of long-term control medications include:

• Inhaled corticosteroids. These medications include fluticasone (Flovent Diskus, Flonase), budesonide (Pulmicort, Rhinocort), mometasone (Nasonex, Asmanex Twisthaler), ciclesonide (Alvesco, Omnaris), flunisolide (Aerobid, Aerospan HFA), beclomethasone (Qvar, Qnasl) and others. You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, these corticosteroid medications have a relatively low risk of side effects and are generally safe for long-term use.
• Leukotriene modifiers. These oral medications — including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma symptoms for up to 24 hours. In rare cases, these medications have been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away for any unusual reaction.
• Long-acting beta agonists. These inhaled medications, which include salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the airways. Some research shows that they may increase the risk of a severe asthma attack, so take them only in combination with an inhaled corticosteroid. And because these drugs can mask asthma deterioration, don't use them for an acute asthma attack.
• Combination inhalers. These medications — such as fluticasone-salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) — contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.
• Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. It's not used as often now as in past years.

Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if your doctor recommends it. Types of quick-relief medications include:

• Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA) and pirbuterol (Maxair). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer — a machine that converts asthma medications to a fine mist, so they can be inhaled through a face mask or a mouthpiece.
• Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis, but it's sometimes used to treat asthma attacks.
• Oral and intravenous corticosteroids. These medications — which include prednisone and methylprednisolone — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so they're used only on a short-term basis to treat severe asthma symptoms.

If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But if your long-term control medications are working properly, you shouldn't need to use your quick-relief inhaler very often. Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

• Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.
• Omalizumab (Xolair). This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.
• Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid and cromolyn nasal sprays.

Bronchial thermoplasty
This treatment — which isn't widely available nor right for everyone — is used for severe asthma that doesn't improve with inhaled corticosteroids or other long-term asthma medications. Generally, over the span of three outpatient visits, bronchial thermoplasty heats the insides of the airways in the lungs with an electrode, reducing the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks.

Treat by severity for better control: A stepwise approach
Your treatment should be flexible and based on changes in your symptoms, which should be assessed thoroughly each time you see your doctor. Then, your doctor can adjust your treatment accordingly. For example, if your asthma is well controlled, your doctor may prescribe less medicine. If your asthma isn't well controlled or is getting worse, your doctor may increase your medication and recommend more-frequent visits.

CARDIAC ARREST

cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually results from an electrical disturbance in your heart that disrupts its pumping action, stopping blood flow to the rest of your body.

Sudden cardiac arrest is different from a heart attack, which occurs when blood flow to a portion of the heart is blocked. However, a heart attack can sometimes trigger an electrical disturbance that leads to sudden cardiac arrest.

Sudden cardiac arrest is a medical emergency. If not treated immediately, it causes sudden cardiac death. With fast, appropriate medical care, survival is possible. Administering cardiopulmonary resuscitation (CPR) — or even just compressions to the chest — can improve the chances of survival until emergency personnel arrive.

SYMPTOMS

cardiac arrest symptoms are immediate and drastic.

• Sudden collapse
• No pulse
• No breathing
• Loss of consciousness

Sometimes other signs and symptoms precede sudden cardiac arrest. These may include fatigue, fainting, blackouts, dizziness, chest pain, shortness of breath, weakness, palpitations or vomiting. But sudden cardiac arrest often occurs with no warning.

TREATMENTS

CPR

Immediate cardiopulmonary resuscitation (CPR) is critical to treating sudden cardiac arrest. By maintaining a flow of oxygen-rich blood to the body's vital organs, CPR can provide a vital link until more advanced emergency care is available.

To perform CPR:

• Is the person conscious or unconscious?
• If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?"
• If the person doesn't respond and two people are available, have one person call 911 or the local emergency number and one begin CPR.
• If you're alone and have immediate access to a telephone, call 911 or the local emergency number before beginning CPR — unless you think the person has become unresponsive because of suffocation (such as from drowning); in this special case, begin CPR for one minute and then call 911 or emergency medical help.
• If you're alone and rescuing a child, perform CPR for two minutes before calling 911 or emergency help or using an AED.
• If an AED is immediately available, deliver one shock if advised by the device, then begin CPR.
• Start chest compressions by putting the heel of one hand in the center of the person's chest and covering the first hand with the other hand. Keeping your elbows straight, use your upper body weight to push down hard and fast on the person's chest at a rate of about 100 compressions a minute. For a child, you may need to use only one hand.
• If you haven't been trained in CPR, continue chest compressions until emergency medical help arrives.
• If you have been trained in CPR, after every 30 compressions, gently tilt the head back and lift the chin up to open the airway. Quickly check for normal breathing, taking no more than 10 seconds. If the person isn't breathing, give two rescue breaths, making sure the chest rises after a breath. Pinch the nostrils shut and give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
• If a child has not begun moving after five cycles (about two minutes) and an AED is available, apply it and follow the prompts. Administer one shock if so advised, then resume CPR — starting with chest compressions — for two more minutes before administering a second shock. If you're not trained to use an AED, a 911 or emergency medical help operator may be able to guide you in its use.
• Continue CPR or chest compressions until the person recovers consciousness and is breathing normally or until emergency medical personnel take over.

Defibrillation

Advanced care for ventricular fibrillation, a type of arrhythmia that can cause sudden cardiac arrest, typically includes delivery of an electrical shock through the chest wall to the heart. The procedure, called defibrillation, momentarily stops the heart and the chaotic rhythm. This often allows the normal heart rhythm to resume.

Treatments may include:

• Drugs. Doctors use various anti-arrhythmic drugs for emergency or long-term treatment of arrhythmias or potential arrhythmia complications. A class of medications called beta blockers is commonly used in people at risk of sudden cardiac arrest. Other possible drugs include angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers or a drug called amiodarone (Cordarone).

• As with any medication, anti-arrhythmic drugs may have potential side effects. For example, an anti-arrhythmic drug may cause your particular arrhythmia to occur more frequently — or even cause a new arrhythmia to appear that's as bad as or worse than your pre-existing condition.
• Implantable cardioverter-defibrillator (ICD). After your condition stabilizes, your doctor is likely to recommend implantation of an ICD. An ICD is a battery-powered unit that's implanted near your left collarbone. One or more electrode-tipped wires from the ICD run through veins to your heart.
• The ICD constantly monitors your heart rhythm. If it detects a rhythm that's too slow, it paces your heart as a pacemaker would. If it detects a dangerous heart rhythm change, it sends out low- or high-energy shocks to reset your heart to a normal rhythm. An ICD may be more effective than preventive drug treatment at reducing your chance of having a fatal arrhythmia.
• Coronary angioplasty. This procedure opens blocked coronary arteries, letting blood flow more freely to your heart, which may reduce your risk of serious arrhythmia. Doctors insert a long, thin tube (catheter) that's passed through an artery, usually in your leg, to a blocked artery in your heart. This catheter is equipped with a special balloon tip that briefly inflates to open up a blocked coronary artery. At the same time, a metal mesh stent may be inserted into the artery to keep it open long term, restoring blood flow to your heart. Coronary angioplasty may be done at the same time as a coronary catheterization (angiogram), a procedure that doctors do first to locate narrowed arteries to the heart.
• Coronary bypass surgery. Another procedure to improve blood flow is coronary bypass surgery. Bypass surgery involves sewing veins or arteries in place at a site beyond a blocked or narrowed coronary artery (bypassing the narrowed section), restoring blood flow to your heart. This may improve the blood supply to your heart and reduce the frequency of racing heartbeats.
• Radiofrequency catheter ablation. This procedure may be used to block a single abnormal electrical pathway. In this procedure, one or more catheters are threaded through your blood vessels to your inner heart. They're positioned along electrical pathways identified by your doctor as causing your arrhythmia. Electrodes at the catheter tips are heated with radiofrequency energy. This destroys (ablates) a small spot of heart tissue and creates an electrical block along the pathway that's causing your arrhythmia. Usually this stops your arrhythmia.
• Corrective heart surgery. If you have a congenital heart deformity, a faulty valve or diseased heart muscle tissue due to cardiomyopathy, surgery to correct the abnormality may improve your heart rate and blood flow, reducing your risk of fatal arrhythmias.
• Heart transplantation. Some people with severe heart failure who've experienced cardiac arrest may be eligible for a heart transplant. But given the lack of donor hearts, availability is limited.

PREVENTION

There's no sure way to know your risk of sudden cardiac arrest, so reducing your risk is the best strategy. Steps to take include regular checkups, screening for heart disease and living a heart-healthy lifestyle with the following approaches:

• Don't smoke, and use alcohol in moderation (no more than one to two drinks a day).
• Eat a nutritious, balanced diet.
• Stay physically active.
• If you know you have heart disease or conditions that make you more vulnerable to an unhealthy heart, your doctor may recommend that you take appropriate steps to improve your health, such as taking medications for high cholesterol or carefully managing diabetes.

• In some people with a known high risk of sudden cardiac arrest — such as those with a heart condition — doctors may recommend anti-arrhythmic drugs or an implantable cardioverter-defibrillator (ICD) as primary prevention.
• If you have a high risk of sudden cardiac arrest, you may also wish to consider purchasing an automated external defibrillator (AED) for home use. Before purchasing one, discuss the decision with your doctor. AEDs can be expensive and aren't always covered by health insurance.
• If you live with someone who is vulnerable to sudden cardiac arrest, it's important that you be trained in CPR. The American Red Cross and other organizations offer courses in CPR and defibrillator use to the public. Being trained will help not only your loved one but also those in your community. The more people who know how to respond to a cardiac emergency, the more the survival rate for sudden cardiac arrest can be improved.