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My name is Sanjay Gupta and I am a cardiologist in York.
Today’s blog is on the subject of heart attacks.
As many of you have probably come to know, the whole of India is in mourning after one of its brightest TV and film stars, Siddharth Shukla, died suddenly at the age of only 40 years.
Initial reports have suggested that Siddhartha died of a massive heart attack. Here was a wonderfully athletic, strong man who took exceptional care of his health and the whole of the world was shocked that someone that young and healthy could succumb to a heart attack out of the blue.
As we struggle to make sense of the chaos and emotional turmoil that Siddharth’s unfortunate death has left us in, I thought I would share what I have learnt about heart attacks from my own experience as a practising cardiologist.
I wanted to dedicate this blog to Siddhartha and pray for those that have been left bereft by his untimely passing including his mother and sisters.
We believe that most heart attacks occur because of a build-up of plaque in the heart arteries. Those people who have absolutely no plaque in their heart arteries generally fall in a very low risk category.
Why does plaque build up? Plaque builds up because of low grade chronic inflammation. I will try to explain inflammation to you.
Imagine if I take a sharp knife and run it across my arm. This insult will stimulate inflammation. My arm will become red, hot, painful, swollen and after a while as long as I have stopped insulting it with the knife it will heal. This is acute inflammation
Let’s talk about something far worse which is chronic inflammation. Imagine me taking a toothbrush and scraping away at my skin daily for the next 10 years – the insult is nowhere near as acute as with a knife but because the insult is ongoing, the skin will never heal and in 10 years time the skin will have changed in appearance and behaviour and it will be hard and yet fragile at the same time. It will never be the same again. This is chronic inflammation.
Whilst a lot of people believe that heart disease is about cholesterol, blood pressure, diabetes etc, the reality is that these are surrogate markers and perhaps the big underlying villain is chronic inflammation.
Chronic inflammation can cause build up of plaque over a period of time which may then manifest with a progressive narrowing of the blood vessels and gradually reduce blood flow to the heart muscle. This will then lead to angina and if that angina is not addressed may lead to a heart attack. This is not too terrible a situation because the patient gets a progressive warning and will go and seek help and then be found to have a narrowing which is then treated with a stent or a bypass.
However inflammation can do something even worse. Some people may have a mild amount of plaque which is not causing a significant narrowing and therefore will not cause any symptoms and then one day out of the blue that plaque will break off and the body thinks there is a wound where it has broken off and within a matter of minutes a blood clot can form which then blocks off the blood vessel. These are the patients that have a sudden heart attack without a warning and this is the mechanism behind sudden deaths. It is estimated that 50% of heart attacks present in this manner. The more inflamed we are the more likely this is to happen and this is probably what happened in Siddhartha’s case.
Let’s say Siddhartha had been checked out before this terrible event had happened. Could this have been prevented and the answer is probably not.
The reason is that we are good at identifying plaques that cause the most narrowing but we are not so good at identifying vulnerable plaque. Because stents and bypasses can only treat the most narrowed areas, they can’t be used as a treatment for vulnerable plaque that is not causing a significant narrowing.
Medications such as Aspirin and Statins also do not seem to confer a huge benefit in the primary prevention of a heart attack. In fact you would have to treat 1667 people with Aspirin for a year to prevent one non-fatal heart attack and you would have to treat 83 patients with statins for 5 years to prevent one death. So unfortunately we don’t get very good returns from preventative medications either.
So the question is what works? And to try and answer this we have to understand what causes chronic inflammation
There are 4 reasons:
Unfortunately as you can see we have no control over the first three. The only thing we have control over is lifestyle but we should understand that we can lead the best lifestyle possible but still have plaque buildup for any of the other 3 reasons.
Let’s talk about lifestyle:
Well there is plenty on Instagram and the media about the importance of healthy nutrition and avoiding smoking/ alcohol etc and exercise but there is much less on 2 other aspects of lifestyle which are perhaps even more important and dangerous to us and that is 1) lack of sleep 2) Stress.
I’ll try and address each of these one by one:
There is a lot more to nutrition than avoiding cake and chocolates. The truth is that the whole of the food industry is unscrupulous and are not motivated to cater for our health but instead they cater to our taste because if it tastes good, we come back to buy more. There are lots of aspects about nutrition that I wanted to quickly touch upon.
The first and foremost is sugar. Sugar is very much a sweet poison and because it is virtually in everything that we eat, the problem is that we are getting a sugar hit all day long. Increasingly we are beginning to realise that when we are constantly taking more and more sugar, we have to produce more and more insulin to to try and get rid of this excess sugar and our pancreas has rot work harder and harder to produce insulin and it is now thought that perhaps this excessive insulin is what contributes to bad vascular health. This is termed insulin resistance.
In addition, let’s talk about farming methods, especially when it comes to animals. If you have ever had the misfortune to see an animal farm you will know what terrible conditions these animals have to face. In addition the sole purpose of that animal to that farmer is to make it as fat as quickly as possible for it to render the most meat. The animals are fed the most fattening food, they are often pumped full of steroids and they are often psychologically very distressed. These are not healthy animals. If we are what we eat, then it is not surprising why we put on weight and why we become unhealthy.
There’s tonnes more including processing, additives, pesticides etc
When I was young I had never even heard of food allergies and now food allergies are rampant and it therefore makes you question whether we are allergic to food or whether we are allergic to what is being done to our food. I will do a more detailed video on food soon
We are beginning to live an increasingly sedentary lifestyle and there is little doubt that exercise is perhaps one of the most effective anti-inflammatory agents known. It is good for our physical health and our mental health. We know that in general if you study a population of people who exercise regularly compared to a population of patients who don’t exercise at all then in general we would expect the exercise group to outlive the non-exercising group.
There is also another good reason to exercise. Let’s say if you do have a slowly narrowing plaque in your arteries then exercising will increase the demand of the heart and slowly the blood will find another way to get to its destination – much like a motorway which has had major roadworks going over a number of years.. the traffic will find a way to bypass the motorway. This is called collateralisation – ie the development of smaller blood vessels which allow the blood to bypass the narrowed segment. If you have collateral blood flow then even if the main motorway blocks off the area damaged as a consequence is likely to be much smaller and therefore the heart attack is not going to be as big as it would have been had there not been a collateral circulation.
I think there are 2 additional points to make – Excessive exercise can also be unhealthy so you come across some people who want to do back to back ultramarathons etc and that type of exercise can be paradoxically inflammatory. Secondly it is always good to build up gradually. Exercise has been painted somewhat unfairly as a trigger for heart attacks. Usually this is due to sudden unaccustomed exercise rather than moderate exercise which you gradually build up to.
Another hugely important aspect of health’s sleep. Sleep disturbance is an epidemic. In the western world, as many as 1 in 5 patients suffer from underlying sleep apnoea and up to 85% of sleep apnoea remains undiagnosed. People who have sleep apnea have higher risk of sudden death, heart attacks, stroke, diabetes, high blood pressure and road traffic accidents. 1 in 3 people have chronic insomnia and many don’t do anything about it but instead choose to mask the symptoms with large amounts of caffeine first thing in the morning.
Finally and perhaps the most important component of lifestyle is stress. Stress seems everywhere and even with all the advancements in technology, we are now more stressed than ever before. Everywhere we see we are sold the message that work hard, play hard then work harder and then play harder and then you can buy more things and happiness is just round the corner and people find themselves on a hamsters wheel, where they work harder, buy and accumulate more things, take on more stress, become more lonely because we fail to devote time to our loved ones, stretch rather than grow and eventually we become more unhappy and need more medications to make us happy and never really realise that promise of happiness being just around the corner.
So as you can see the only things that we can really do (at least in the majority of us) to prevent a first heart attack is to try and live as healthy a lifestyle as possible. Unfortunately this is the best we can do and in some cases even doing that is not going to necessarily prevent a heart attack. It is therefore important for us to realise that even with the best efforts we really have no control over our length of life. Even if we do everything right to prevent a heart attack that does not make us immune from a road traffic accident or cancer or something else. We do however have control over our quality of lives and we should all aspire to work towards improving our quality of lives.
Our quality of life and our quality of lives can be improved by living a life of simplicity and moderation, investing in our health, spending time with our loved ones and investing in our own growth.
A lot of people come to me and say ‘look i have 2 young children. I want to be be there for them when they grow up’. My answer to them is ‘start off by being there for them now.’ My advice to everyone is something Steve Jobs once said – live each day as if it were your last and one day you’ll be proven right.
Here is a link to the video:
This post is also available in: हिन्दी (Hindi)