Common Heart Disease Cardiac Specialist Centre
We hope this section gives you some simple understanding of a few of the commonest conditions. We will be adding more as we continue to have feed backs and questions from our esteemed friends.
Chest pain and Heart attack
Chest pain is the most common complaint in the cardiologist’s clinic. Luckily, 80% of people presenting with chest pain do not have any disease, heart or other wise. But that does not mean we should ignore chest pain.

The type of chest pain which suggests it is of heart origin would be described as; ‘tightness’, a pressure over the chest, like a cramp but in the chest or ‘heaviness over the chest’. Some patient may form a fist and describe it as ‘Like that!’.

It is also more likely to be distributed over the whole central part of chest rather than a single spot. If you can put a finger on the pain, it is unlikely to be from the heart. It may seem to travel to your jaw or left shoulder or down the left arm.

The severity tends to build up rather than of a sudden onset. In the case of ‘angina’, it comes on and worsens with continued effort. It will gradually subside with rest. In the case of heart attack, the pain may come on at rest and build up to a peak. It won’t subside even with rest. The pain then will remain until it is treated or will last for hours. It may be accompanied by shortness of breath or cold sweat. Sometimes there is palpitation or even fainting spells.

Heart attack is a part of Ischaemic Heart Disease and should be seen by a cardiologist without delay.

Palpitation
Palpitation means different things to people. Some would say ‘strong heart beat’. Others would say ‘fast heart beat’. Some would just say they could feel their heart beating.

Our hearts have to beat harder and faster when under stress or when doing some physical activities.

The palpitation which you should seek medical help occurs when your heart suddenly beats at 130/min or more when you are at rest and not stressed. Or when you feel irregular heart beat. This is when you feel your pulse, it feels totally chaotic without any regular rhythm.

You should also see your doctor if there is chest pain or breathlessness accompanying your palpitation. On the other hand, the occasional ‘dropped beat’ is usually benign. As long as they do not bother you and do not cause any other symptoms, it is usually harmless.

High Cholesterol "Hyper-cholesterolaemia"
Hyper-cholesterolaemia occurs when the cholesterol in your blood becomes too high. It will deposit itself in the walls of your blood pressure. Over years, the blood vessels will become narrowed. When the blood vessels supplying blood to your brain is narrowed, a stroke will occur. This is when a certain part of your body is not able to move. Sometimes, there may be lost of feeling over the affected area. The speech may be affected as may the eye sight. If the blood supply to your heart is affected, you may suffer from angina or heart attack.

High cholesterol produces no symptoms. It can only be detected during a blood test. You will be required to not take any food for at least 8 hours. Your blood will be drawn and sent to the laboratory. Results are usually obtained on the same day.

High Blood Pressure
What is high blood pressure or ‘Hypertension’?

High blood pressure occurs when the pressure, which pushes the blood around the body, is increased.

To find out your blood pressure, the doctor will place an inflatable cuff around your upper arm and inflate it. 2 readings will be obtained as the cuff is slowly deflated. The systolic pressure which is the pressure when the heart contracts, and the diastolic pressure, when the heart relaxes.

Normal reading should be 120 to 140 mm of mercury for the systolic pressure. The normal for diastolic pressure is between 80 to 90 mm of mercury.

The problem with high blood pressure is that with prolonged exposure to high pressure, the blood vessels become narrowed. The organs such as heart, lung or kidneys become damaged. This will lead to heart attack, stroke or kidney failure.

High blood pressure has no symptoms. Therefore, it is only picked up when a doctor checks your blood pressure in the clinic. Once you are found to have high blood pressure or ‘hypertension’, you will need to make some lifestyle adjustment and start taking medicines to prevent stroke, heart attack or kidney failures in the future.

Ischaemic Heart Disease (IHD)
This is the 2nd most common killer disease in the developed world. It is also known as Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD).

While the heart pumps blood to the rest of the body, itself also needs blood. Two small arteries curve around and sit on the surface of the heart to bring blood back to the heart. Conditions which cause narrowing of the blood vessels such as high blood pressure (Hypertension) or high cholesterol (Hyper-cholesterolaemia) contribute to this condition.

This condition may be silent. The first symptom it produces may be your first heart attack. Therefore, regular screening is useful in picking this up.

In some people, the early symptoms may be angina. This is a feeling of tightness or pressure pain like a cramp over the front of the chest. This usually comes during some form of strenuous activities such as brisk walking, climbing up a flight of stairs or running. The feeling may radiate to the neck, jaw or down the arms. There may be accompanied by sweating or breathlessness.

If you have experienced any of these symptoms, there should not be any delay in seeing your doctor.

Heart Failure
Heart failure happens when the heart is unable to fulfill its job in pumping blood to the rest of the body. The muscle of the heart is weakened or dead.

This happens commonly in repeated heart attacks where each attacks kills off some amount of muscles. It also occurs in prolonged untreated high blood pressure.

Patient will experience swelling of the legs. Sometimes it may extend to the thigh or abdomen. There will be breathlessness either with just a little walking or even at rest. They may experience breathlessness when lying down or in the middle of the night.

The symptoms can be relatively easily treated with medicines. The more important issue is to discover the cause of this condition and treat it so as not to propagate or worsens the heart failure.

Mitral Valve Prolapse
As early as 40 years ago, experts have noticed that people who have a heart murmur or ‘clicky’ heart sound may be born with a thick and floppy mitral valve which falls backwards into the upper left chamber of the heart with each heartbeat. The abnormal valve is associated with a wide range of abnormalities such as abnormal ECG tracing, chest pain and leakage or backflow of blood into the left upper chamber. This condition is more common in women than in men.

It is only diagnosed on echocardiogram. During the examination, we can also assess how badly the valve is leaking. Patient will need long term follow up. In certain patient, the leaking may worsen and surgery may be needed.

Difference between Heart Bypass Operation and Angioplasty

What is by-pass surgery?

Coronary Artery By-pass Graft surgery is commonly shortened to CABG and pronounced as ‘Cabbage’ for short. It is also known as ‘by-pass’ or ‘by-pass surgery’ or ‘bypass operation’.

This is a big operation where patients need to be fully anaesthetized (‘fully asleep’). The chest bone (breast bone) is then split with a saw and the heart exposed. A long vein from the leg is carefully removed. Sometimes an artery from the forearm may also be removed. One end of this ‘harvested’ vessel is then joined to the narrowed heart artery at a point beyond the narrowing. The other end is joined to the large artery leaving the heart called ‘aorta’. In this way, blood rich in oxygen leaving the heart can travel down this newly implanted vessel and be diverted to the heart. Therefore, the narrowed diseased portion of the artery is ‘by-passed’. The breastbone is then sewn up with wires and skin closed. Patients usually need to stay in Intensive Care Unit for about 2-3 days and then another 4-5 days on the ward before discharged.

What is angioplasty?

Angioplasty is also known as ‘ballooning’, ‘stenting’, ‘spring’ or ‘ring’ colloquially. It is also known as Percutaneous Coronary Intervention or PCI for short in the medical circle.

"Angio" means blood vessel and "Plasty" means to make something big. Therefore "angioplasty" means to make a blocked vessel bigger. Another words, to unblock the artery. This is now done with catheter (tube), which is inserted into the artery (see section on angiogram). Once the catheter is in place, a wire the width of a human hair is slowly maneuvered across the blockage (plaque). Once it is through, a balloon is placed over the wire and pushed into the blockage. The balloon is then inflated. This pushes the plaque aside and the artery is made bigger. To prevent the recoil of the muscular artery, a stent (metal tube or dissolvable tube) is placed in the area of the plaque to hold the arterial wall in place. After this, the balloon, wire and catheter are all removed. The stent will remain in your artery and becomes part of you. The dissolvable stent will completely dissolve in 1-4 years’ time leaving nothing behind.

Angioplasty is now becoming treatment of choice when it comes to narrowed coronary artery. It is minimally invasive. Patients can usually be discharged the next day. There is minimal pain at the site where the tube is inserted. Some patients may even return to sedentary work as early as 3rd day after the procedure. There are no big scars anywhere. The risk of stroke is lower than by-pass operation although the chances for repeat stenting may be higher. Nowadays, ever very complicated narrowings such as Chronic Total Occlusion (CTO) or Left Main disease may be treated with stenting.

What is the difference between ‘By-pass’ and ‘Stenting’/’Ballooning’/’Spring’

Under the respective description of What is angioplasty and What is by-pass surgery we describe each of the processes. The main differences between these 2 procedures are;

  1. 1) By-pass is a major operation with big scar on the front of the chest. Angioplasty is done with 2-3mm tubes inserted from the wrist or groin. It is minimally invasive.

  2. 2) By-pass requires 3-4 hours to perform. Angioplasty is completely typically in 1 hour.

However, there are some very complex blockages that may also take a few hours.

  1. 1) By-pass operation is known to have higher stroke risk compared to angioplasty.

  2. 2) Angioplasty may have higher chance of repeat procedure a few years later.

  3. 3) By-pass requires patient to stay in hospital for about 5-7 days. Angioplasty patients typically go home the next day with minimal discomfort.

  4. 4) By-pass is typically more expensive than angioplasty. Although the very complicated angioplasty may come close to the cost of by-pass operation.
How to avoid Bypass Operation
Nobody likes to have an open-heart operation. This is usually recommended when there is either one or some of the following:

  1. 1. Left main artery disease,
  2. 2. Chronic total occlusion and
  3. 3. Multiple vessel disease.

However, the more recent literatures have shown that certain Left Main diseases are very treatable with stenting. In the hands of experienced doctors, the results are good and patients remain well for long period of time. Furthermore, the recovery period is shorter and the cost lower. Having extensive experience in a world-renowned hospital specializing in Left Main stenting, Dr. Tan has already performed many such procedures and his patients are all doing well.

The other common reason for bypass is chronic total occlusion (CTO). This means that the artery has been 100% blocked for a long time. The usual success rate for opening these types of blockage is only 50%. Furthermore, it takes a much longer procedural time to open such blockages. Therefore, most doctors prefer to send patients for bypass operations. However, Dr. Tan has a success rate exceeding 80%. He has one of the largest collections of such cases, treating an average of 1 such patient a week. He has been an invited faculty in these types of conferences.

The final category involves patients who have a few arteries blocked. However, since not all blocked arteries need to be opened, we may still be able to treat you with stenting. We are able to perform the appropriate tests to determine which arteries need to be stented. Thereby avoiding a bypass operation.

We will be happy to provide consultation to you. Just bring along your most recent angiogram for an opinion.

Women's Health
Heart Disease in Women

Heart disease is as important in women as in men. Although men as a whole are more likely to suffer from heart disease, the risk in women rises steadily as age catches on.

It is usual to speak of heart disease together with stroke and peripheral vascular disease. In fact, they are collectively known as cardiovascular disease. This is because all these conditions share common risk factors and often exist together in the same patient.

For both men and women, cardiovascular disease is the leading cause of death accounting for one-third of deaths every year. Complications such as heart failure and stroke are also becoming common health problems in our population.

Symptoms of Heart Disease in Women

The commonest symptom of ischemic heart disease (due to blocked heart artery) is chest pain. Known as angina pectoris, it is classically a gripping pain in the middle of the chest, which comes on during physical activity and goes away when the person rests. When a woman experiences this symptom, she needs to see her doctor early for proper evaluation and treatment. However, not all cases of ischemic heart disease experience the classical pain. Some may just feel that they get breathless much more easily than usual or cannot perform as much physical activity as before. Yet others may just have unexplained weakness or fatigue, indigestion, anxiety or other vague chest discomfort. These are non-classical symptoms that people tend to ignore.

Compared to men, women are more likely to have non-classical symptoms or even no symptom. Women are also more likely to ignore their symptoms. All these factors make heart disease more difficult to diagnose in women.

Remember
1. Do not ignore your symptom
2. Listen to your body
3. Seek medical attention if in doubt

What Kind of Screenings do Women Need?

1. Screening for risk factors:

It is very useful to screen for risk factors as early detection and treatment can prevent not only heart disease but also related conditions such as stroke and peripheral vascular disease.

The important risk factors are hypertension, diabetes mellitus, high cholesterol levels, obesity, cigarette smoking, sedentary lifestyle and family history. Proper screening should include measurement of blood pressure, body weight, height and waist circumference. Fasting blood samples for glucose and a full cholesterol profile are essential.

Those with strong family history and cigarette smokers are at especially high risk. A stressful lifestyle is also harmful for the heart.

2. Screening for heart disease:

Heart disease can be difficult to detect at the early stage. If a person has some symptom of chest discomfort, a stress test should be done to determine if there is evidence of reduced blood flow to the heart. The commonest stress test is treadmill test during which the patient does brisk walking on a treadmill machine and electrocardiogram (ECG) is continuously monitored to detect for signs of reduced blood flow to the heart.

Depending on individual conditions, other types of stress tests may be recommended by your doctor. These include stress echocardiography and nuclear perfusion scan. Patients who cannot exercise, e.g. due to knee problem, have the option of stress test using an injectable medication.

Another available type of test is CT angiography. This can measure the amount of calcium in the heart arteries and detect narrowing of the arteries.

Which test to use will depend on the risk profile and condition of each individual. The doctor performing the screening will evaluate each patient carefully before the most suitable test is recommended.

Advice:

1. Screening for heart health really does not stop at stress tests or heart scans. It is the opportunity to detect any risk factor early so that proper preventive measures can be started.

2. Even if all tests are normal, this is the time to reassure the woman that she is fit to commence a regular exercise program with the aim to maintain a healthy body weight and lead an active lifestyle.

Preventive Cardiology

What is Preventive Cardiology?

Heart disease is the number 1 global cause of death and also a major disease burden. Some of the risk factors such as obesity and diabetes are predicted to reach epidemic levels in the coming decade. Preventive Cardiology can play a big role in curbing these trends. There are 2 levels of prevention - Primary and Secondary.

PRIMARY PREVENTION

Who is it for?

This is targeted at the general population who do not have established heart disease yet.

What does it include?

Primary prevention begins with establishing the risk profile of an individual through a systematic health check. This typically includes checks for hypertension, obesity, diabetes and cholesterol. This kind of assessment is recommended for all individuals above 40 years old; even earlier if there is some other indicator e.g. family history of heart disease. In fact, for hypertension and obesity, regular checking has been recommended for anyone above 18 years old. Based on the results of the health check, each individual can be stratified into low, intermediate or high global risk for cardiovascular disease. In particular, intermediate and high risk individuals may have silent disease that will benefit from early detection and treatment. Based on each person’s risk level, the doctor can also determine the specific target for treatment, for example the target level of cholesterol. In general, higher risk individuals will need more aggressive control of their risk factors.

SECONDARY PREVENTION

Who is it for?

Individuals who already have evidence of heart disease, stroke or peripheral vascular disease.

What does it include?

Secondary prevention refers to intensive therapy to prevent recurrence of disease, prolong life and improve quality of life. Good secondary prevention also means patients are less likely to undergo procedures to open their heart arteries in the long run. Secondary prevention is mainly done through intensive control of risk factors, more stringently than in primary prevention. This include lifestyle modification, mainly regular exercise, heart healthy diet, smoking cessation and stress management. For specific cases, such as after discharge from hospital for heart attack or heart failure, a structured cardiac rehabilitation program is highly beneficial.

How does Preventive Cardiology help?

There is medical evidence that adopting the principles of preventive cardiology saves lives and reduce heart attacks and strokes. If a person has no risk factor at all or control the risk factors very well, they are likely to stay active longer and have a better quality of life, in both physical and mental wellbeing, in their old age.

Consultation
Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.