Lifestyle modifications to reduce risk

As we previously in discussed in PCL, the major contributing factors of Heart Disease include;

High blood pressure (hypertension), High cholesterol levels, Diabetes, Obesity, Smoking, Inactivity, Hereditary, age, gender, alcohol intake, OCP and stress.
Although it is impossible to control some of the contributing factors such as age, gender etc there are many lifestyle modifications suggested in order to minimise the risk of developing heart disease:

Exercise
Regular exercise increases muscular strength including of the heart resulting in the ability to pump more blood around your body with less effort. The risk of a patient who exercises regularly is about half that of a sedentary patient.
Quit Smoking
Smoking speeds up the clogging and narrowing of coronary arteries. Smoking also damages other blood vessels. This can prevent blood circulation, particularly to your hands and feet. Peripheral arterial disease can result in blood clots, infection, gangrene and even amputation. Smokers have a 70 per cent greater risk of death from coronary heart disease than non-smokers.
Keep at a healthy weight or lose weight
Being overweight or obsess increases risk of high blood pressure and cholesterol levels and induces diabetes. All of which are causes of heart disease.
Reduce salt intake
Increases blood pressure
Learn to relax and reduce stress
There is a fair amount of circumstantial evidence that chronic emotional stress can be associated with heart disease and early death.
Reduce alcohol intake and maintain a “healthy” diet- all food groups, minimal amounts of processed and salty foods.

Also a patient may choose to monitor blood pressure, cholesterol and blood sugar levels in order to ensure they remain in a low risk area. The maintenance of desirable readings can be achieved by following the lifestyle modifications discussed above.

Different Symptoms for Men and Women with Heart Disease

Women's hearts are different from men's

Women's hearts are different from men's. This area of study is fairly new, and research is underway to further examine differences in the physiology and pathophysiology of women's hearts. We do know that women have smaller hearts and smaller arteries than men. Researchers from Columbia University and New York Presbyterian Hospital believe that women also have a different intrinsic rhythmicity to the pacemaker of their hearts, which causes them to beat faster. These same researchers believe that it may take a woman's heart longer to relax after each beat. Some surgeons also hypothesize that the fact that women have a 50 % greater chance of dying during heart surgery than men could be related to some fundamental difference in women's the way women's hearts work. These differences may also account for the fact that women are more likely to die after their first heart attack.

Heart attack symptoms different in women

Women are about as likely to have a heart attack as men, but the fact that they are more likely to die after their first heart attack may be because the symptoms of heart attack are different in women. Doctors and patients often attribute chest pains in women to noncardiac causes, leading to misinterpretation of their condition. Men usually experience crushing chest pain during a heart attack. Women may have a greater tendency to have pain just under the breastbone, or complain of abdominal pain, indigestion, difficulty breathing, nausea and unexplained fatigue. Women are therefore easily misdiagnosed of indigestion, gall bladder disease, or an anxiety attack. The likelihood of misdiagnosing a heart attack in women is also increased by the fact that women tend to have heart attacks later in life, when they often have other diseases (such as arthritis or diabetes) that can mask heart attack symptoms.

Significant differences exist between men and women in the clinical presentation of heart attack and in the response to treatment. Women having a heart attack are likely to be older and have a higher incidence of high blood pressure, diabetes, high cholesterol, and congestive heart failure than do men. They are less likely to be smokers. The symptoms of acute heart attack are slightly different in women. Women are more likely to have neck and shoulder pain, abdominal pain, nausea, vomiting, fatigue, and shortness of breath in addition to chest pain. Silent heart attacks are more common in women. Often, because of these atypical symptoms, women seek medical care later than do men.

Even after arrival at the hospital, women may encounter delay in establishing the diagnosis of heart attack. Women are somewhat less likely than men to have the typical EKG findings to diagnose acute heart attack. Women with heart attack are generally more ill than are men. Despite this, women are paradoxically less likely to receive aggressive clot-busting treatments and are more likely to receive it later than do men. Women are also less likely to be admitted to a coronary care unit.

range of cholesterol, BP and Blood sugar levels...

CHOLESTEROL:
For a normal healthy individual cholesterol should be lower than 5.5, and for patients who exhibit risks of heart disease (i.e overweight patients or family history of heart disease) level of cholesterol should be lower than 4.

BLOOD PRESSURE:
The standard blood pressure is 120/80 with a range of +/- 10. Fit people usually have a lower blood pressure. Older people generally have a higher blood pressure because they lose elasticity of the blood vessels.

BLOOD SUGAR LEVELS:
Fasting blood sugar levels for normal healthy people should be lower than 6-7. Generally after eating blood sugar levels are higher.

Reference: Oxford Dictionary of Clinical Medicine

Monica

Gender Differences in Heart Disease

Amber has pretty much covered everything to be said for this topic, so I thought I'd add some interesting information I found for some light reading! - Maria Nguyen

Pictured below is the Kalin and Zumoff graph, a well-known diagram depicting the gender differences in coronary heart disease (CHD) death rates in a wide range of countries. What is remarkable is that the male-to-female ratio for fatal CHD seems consistent over countries that have very different CHD mortality experiences, keeping a general ratio of 2.5 to 4.5. It seems that it is only in China that the CHD rates do not vary in terms of gender.

There have been many theories as to why there is such a gender gap in CHD rates. The idea that men engage in more unhealthy behaviours compared to women (e.g. cigarette smoking, alcohol abuse, eating red meat and less fruits and vegetables, and exposure to physical hazards), and are harmed by the pressures of their work, while women nurture and care at home, have been popular explanations for the higher rates of heart disease in men. However, studies have shown that only low-level work (e.g. clerks) and limited education are associated with increased risk of heart attack, and that women that enjoy success in their careers (e.g. executives) have more favourable heart disease risk factors than women who stayed home.

However, it has been suggested that social supports may be cardioprotective, and that men’s reluctance to share feelings and resulting inward anger may have biological consequences, with increased levels of stress hormones among others factors.

Coronary-Prone behaviour: In studies done by Friedman and Rosenman, it was shown that behaviours characterised by aggressiveness, anger, competitiveness, hostility and time urgency were associated with higher risk of heart disease in both men and women – however, these characteristics are more typical of the ‘masculine’ personality.

In terms of biology, coronary artery blood flow seems to be improved by oestrogen in women, rapidly reversing the vasoconstriction of atherosclerotic coronary arteries caused by acetylcholine in a London study by Collins et al. However, the administration of oestrogen doesn’t seem to affect blood flow in men.

Sources: http://www.circ.ahajournals.org/cgi/content/full/95/1/252

COMPLICATIONS OF ATHEROSCLEROSIS

Narrowing of the artery results in reduction in blood supply to the organs when needed most, this may cause damage to the organs and severe pain as well as heart attack or stroke as the organ would not be getting enough oxygen.
Aneurysms also are common complications. This is a weakened bulging on an artery which can slowly leak blood into the body or burst causing serious bleeding.

Heart disease

Blood clotting; multiple coagulums that are located in the blood stream due to the aggregation of blood factors.

Angina

Peripheral artery disease; this is actualy atherosclerosis in the limbs of the body,also known as atherosclerotic peripheral arterial disease.

Intermittent Claudication; Calf muscle pain from walking

Erectile disfunction; Impotence or "erectile dysfunction" is the inability to attain or sustain an erection for long enough for sexual activity.

Ex

INCIDENCE

INCIDENCE OF CARDIOVASCULAR DISEASES
Cardiovascular diseases (strokes, heart and blood vessel diseases) are most leading causes of deaths in developed countries Australia inclusive.
· Kills one Australia every ten minutes
· Affects more than 3.5 million Australians.
· In 2004 they claimed the lives of almost 48,000 Australians , accounting to 35% of all deaths
Factors which increase the chance of one getting cardiovascular diseases are as follows:
· Smoking
· Being overweight
· High blood pressure
· Diabetes
· Physical inactivity
· Depression and social isolation and lack of social support
References
www.heartfoundatons.org.au
by Leungo

Gender differences in Heart Disease

PCL 10 – Fred goes to the Doctor

Gender differences in Heart Disease
Amber Hartley


Both men and women are affected by heart disease, although general misperceptions often lead people to believe that women do not develop heart disease, or at a much lower risk than men. Many women have atypical symptoms of heart attack, which leads to lowered community knowledge about risk factors.

Heart disease is the leading cause of death in Australia. In general, the incidence of coronary heart disease is higher in men than in premenopausal women. After menopause, however, the incidence of atherosclerosis in women approaches the incidence in men. The cause of this change may be decreased levels of oestrogen present in the post-menopausal woman.

Women often have differing symptoms of myocardial infarction to men, which can be dangerous as women do not recognise the symptoms and are less likely to seek treatment. Aside from the classical symptoms of myocardial infarct, including chest pain, pain that spreads to the shoulders, neck or arms, shortness of breath, and tightness of the chest, women may experience unexplained fatigue, nausea, profound sweating, pain in the upper abdomen and dyspnea. Women generally have poorer survival rates of myocardial infarction than men do.

The normal heart of men and women also differs, with women’s hearts beating faster than men’s, even during sleep. Some women may have myocardial infarct even without any of the fatty build-up of plaque (atherosclerosis) seen in coronary heart disease, and this indicates that the physiology of the heart differs in men and women.

In 1995 in Australia, 80% of men, and 75% of women had at least one of the recognised cardiovascular risk factors (tobacco smoking, physical inactivity, hypertension, overweight).

Men are twice as likely to have a coronary event as women, and more likely to die from a coronary event at a younger age than women. This may be associated with higher rates of obesity in males, higher rates of smoking in males or other lifestyle factors, or it may have a physiological basis. Women tend to develop heart disease at a later age than men, but more likely (1.7 times) to die than men. This reflects overall differences in life expectancy between men and women.




Figure 1: Cardiovascular risk prediction charts for women.

Figure 2: Cardiovascular risk prediction charts for men

References:

Kumar and Clark, ‘Clinical Medicine’. 6ed. http://circ.ahajournals.org/cgi/content/full/103/19/2318 http://www.goredforwomen.org/statistics_and_tracking.aspx http://www.fda.gov/fdac/features/2005/405_sex.html http://www.heartfoundation.org.au/document/NHF/Men_and_Women.pdf

Heart Disease, Mental and Psychosocial

Mental Health and Psychosocial Factors of Heart Disease

By Josh

How you think, feel, and live affect’s your heart

Emotions behaviours and social situations all have an affect on heart disease. Depression, loneliness, negative outlook on life and stress increase the risk of heart disease were as a positive outlook on life, good friends, a good partner and support base help prevent heart disease.

Psychosocial Factors
Stress is one of the major psychosocial factors that cause’s heart disease. Hormones that are released during stress include norepinephrine (which is released in the fight or flight response for males or the tend and befriend response for males). This hormone thickens blood in anticipation of injury causing the heart to work harder to pump blood around the body. Over time this increases the workload of the heart increasing the chances of failure and heart disease. The other hormone is cortisol which is known as the stress hormone. It raises blood pressure and blood sugar levels again putting stress on the cardiovascular system.

Mental Health Factors of Heart Disease

Depression is a major cause of heart disease. Some of the signs of depression can include
Physical – tired all the time, can’t sleep.
Behaviours – not going out, not getting things done at work, relying on alcohol and sedatives.
Thoughts – thinking that “nothing good ever happens to me”, “I’m worthless”.
Feelings – guilty, unhappy, disappointed, no confidence

Post Heart Disease: Mental and psychosocial effects
People who are stressed or depressed have a higher chance of having a repeat incidence of heart disease than people who have a more enjoyable and stable life.

What do pathologists look for in cancer?

INTRODUCTION

Many medical conditions, including all cases of cancer, must be diagnosed by removing a sample of tissue from the patient and sending it to a pathologist for examination. This procedure is called a biopsy, a Greek-derived word that may be loosely translated as "view of the living." Any organ in the body can be biopsied using a variety of techniques, some of which require major surgery (e.g., staging splenectomy for Hodgkin's disease), while others do not even require local anesthesia (e.g., fine needle aspiration biopsy of thyroid, breast, lung, liver, etc). After the biopsy specimen is obtained by the doctor, it is sent for examination to another doctor, the anatomical pathologist, who prepares a written report with information designed to help the primary doctor manage the patient's condition properly.

The pathologist is a physician specializing in rendering medical diagnoses by examination of tissues and fluids removed from the body. To be a pathologist, a medical graduate (M.D. or D.O.) undertakes a five-year residency training program, after which he or she is eligible to take the examination given by the American Board of Pathology. On successful completion of this exam, the pathologist is "Board-certified." Almost all American pathologists practicing in JCAHO-accredited hospitals and in reputable commercial labs are either Board-certified or Board-eligible (a term that designates those who have recently completed residency but have not yet passed the exam). There is no qualitative difference between M.D.-pathologists and D.O.- pathologists, as both study in the same residency programs and take the same Board examinations.

TYPES OF BIOPSIES

1. Excisional biopsy.
   
   A whole organ or a whole lump is removed (excised). These are less common now, since the development of fine needle aspiration (see below). Some types of tumors (such as lymphoma, a cancer of the lymphocyte blood cells) have to be examined whole to allow an accurate diagnosis, so enlarged lymph nodes are good candidates for excisional biopsies. Some surgeons prefer excisional biopsies of most breast lumps to ensure the greatest diagnostic accuracy. Some organs, such as the spleen, are dangerous to cut into without removing the whole organ, so excisional biopsies are preferred for these.
   
   
2. Incisional biopsy.
   
   Only a portion of the lump is removed surgically. This type of biopsy is most commonly used for tumors of the soft tissues (muscle, fat, connective tissue) to distinguish benign conditions from malignant soft tissue tumors, called sarcomas.
   
   
3. Endoscopic biopsy.
   
   This is probably the most commonly performed type of biopsy. It is done through a fiberoptic endoscope the doctor inserts into the gastrointestinal tract (alimentary tract endoscopy), urinary bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity (arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system (laryngoscopy and bronchoscopy), either through a natural body orifice or a small surgical incision. The endoscopist can directly visualize an abnormal area on the lining of the organ in question and pinch off tiny bits of tissue with forceps attached to a long cable that runs inside the endoscope.
   
   
4. Colposcopic biopsy.
   
   This is a gynecologic procedure that typically is used to evaluate a patient who has had an abnormal Pap smear. The colposcope is actually a close- focusing telescope that allows the physician to see in detail abnormal areas on the cervix of the uterus, so that a good representation of the abnormal area can be removed and sent to the pathologist.
   
   
5. Fine needle aspiration
   
   (FNA) biopsy.This is an extremely simple technique that has been used in Sweden for decades but has only been developed widely in the US over the last ten years. A needle no wider than that typically used to give routine injections (about 22 gauge) is inserted into a lump (tumor), and a few tens to thousands of cells are drawn up (aspirated) into a syringe. These are smeared on a slide, stained, and examined under a microscope by the pathologist. A diagnosis can often be rendered in a few minutes. Tumors of deep, hard-to-get-to structures (pancreas, lung, and liver, for instance) are especially good candidates for FNA, as the only other way to sample them is with major surgery. Such FNA procedures are typically done by a radiologist under guidance by ultrasound or computed tomography (CT scan) and require no anesthesia, not even local anesthesia. Thyroid lumps are also excellent candidates for FNA.
   
   
6. Punch biopsy
   
   This technique is typically used by dermatologists to sample skin rashes and small masses. After a local anesthetic is injected, a biopsy punch, which is basically a small (3 or 4 mm in diameter) version of a cookie cutter, is used to cut out a cylindrical piece of skin. The hole is typically closed with a suture and heals with minimal scarring.
   
   
7. Bone marrow biopsy
   
   In cases of abnormal blood counts, such as unexplained anemia, high white cell count, and low platelet count, it is necessary to examine the cells of the bone marrow. In adults, the sample is usually taken from the pelvic bone, typically from the posterior superior iliac spine. This is the prominence of bone on either side of the pelvis underlying the "bikini dimples" on the lower back/upper buttocks. Hematologists do bone marrow biopsies all the time, but most internists and pathologists and many family practitioners are also trained to perform this procedure.
   
   With the patient lying on his/her stomach, the skin over the biopsy site is deadened with a local anesthetic. The needle is then inserted deeper to deaden the surface membrane covering the bone (the periosteum). A larger rigid needle with a very sharp point is then introduced into the marrow space. A syringe is attached to the needle and suction is applied. The marrow cells are then drawn into the syringe. This suction step is occasionally uncomfortable, since it is impossible to deaden the inside of the bone. The contents of the syringe, which to the naked eye looks like blood with tiny chunks of fat floating around in it, is dropped onto a glass slide and smeared out. After staining, the cells are visible to the examining pathologist or hematologist.
   
   This part of procedure, the aspiration, is usually followed by the core biopsy, in which a slightly larger needle is used to extract core of bone. The calcium is removed from the bone to make it soft, the tissue is processed (see "Specimen Processing," below) and tissue sections are made. Even though the core biopsy procedure involves a bigger needle, it is usually less painful than the aspiration.

SPECIMEN PROCESSING

After the specimen is removed from the patient, it is processed in one or both of two major ways:

1. Histologic Sections: This involves preparation of stained, thin (less than 5 micrometers, or 0.005 millimeters) slices mounted on a glass slide, under a very thin pane of glass called a coverslip. There are two major techniques for preparation of histologic sections:
   
   
   1. Permanent Sections: This technique gives the best quality of specimen for examination, at the expense of time. The fresh specimen is immersed in a fluid called a fixative for several hours (the necessary time dependent on the size of the specimen). The fixative, typically formalin (a 10% solution of formaldehyde gas in buffered water), causes the proteins in the cells to denature and become hard and "fixed." Adequate fixation is probably the most important technical aspect of biopsy processing.
      
      The fixed specimen is then placed in a machine that automatically goes through an elaborate overnight cycle that removes all the water from the specimen and replaces it with paraffin wax. The next morning, a technical professional, called a histologic technician, or "histotech," removes the paraffin- impregnated specimen and "embeds" it in a larger bloc of molten paraffin. This is allowed to solidify by chilling and is set in a cutting machine, called a microtome. The histotech uses the microtome to cut thin sections of the paraffin block containing the biopsy specimen. These delicate sections are floated out on a water bath and picked up on a glass slide.
      
      Then the paraffin is dissolved from the tissue on the slide. With a series of solvents, water is restored to the sections, and they are stained in a mixture of dyes. The most common dyes used are hematoxylin a natural product of the heartwood of the logwood tree, Haematoxylon campechianum, which is native to Central America, and eosin, an artifcial aniline dye. The stain combination, casually referred to by pathologists as "H and E" yields pink, orange, and blue sections that make it easier for us to distinguish different parts of cells. Typically, the nucleus of cells stains dark blue, while the cytoplasm stains pink or orange.
      
      
   2. Frozen Sections: This technique allows one to examine histologic sections within a few minutes of removing the specimen from the patient, but the price paid is that the quality of the sections is not nearly as good as those of the permanent section. Still, a skilled pathologist and a knowledgeable surgeon can work together to use the frozen section's rapid availability to the patient's great benefit.
      
      
2. Smears: The specimen is a liquid, or small solid chunks suspended in liquid. This material is smeared on a microscope slide and is either allowed to dry in air or is "fixed" by spraying or immersion in a liquid. The fixed smears are then stained, coverslipped, and examined under the microscope.
   
   Like the frozen section, smear preparations can be examined within a few minutes of the time the biopsy was obtained. This is especially useful in FNA procedures (see above), in which a radiologist is using ultrasound or CT scan to find the area to be biopsied. He or she can make one "pass" with the needle and immediately give the specimen to the pathologist, who can within a few minutes determine if a diagnostic specimen was obtained. The procedure can be terminated at that point, sparing the patient the discomfort and inconvenience of repeated sticks.

More info including definitions of different types of things that pathologists look for in specimens at
http://www.cancerguide.org/pathology.html

-Satwik