Assignment

Hypertension
MedlinePlus Topics High Blood Pressure Monitoring blood pressure Untreated hypertension Lifestyle changes DASH diet High blood pressure tests Exercise can lower blood pressure Blood pressure check Blood pressure Read More Acute kidney failure Aortic dissection Atherosclerosis Blindness Blood pressure Cushing syndrome Glomerulonephritis Heart attack Heart failure Hemolytic-uremic syndrome Henoch-Schonlein purpura Hypertensive heart disease Injury - kidney and ureter Obesity Polyarteritis nodosa Radiation enteritis Renal vein thrombosis Retroperitoneal fibrosis Stroke Ventricular assist device Wilms tumor Patient Instructions ACE inhibitors Angioplasty and stent - heart - discharge Aspirin and heart disease

Butter, margarine, and cooking oils Cholesterol and lifestyle Clopidogrel (Plavix) Controlling your high blood pressure Diabetes - eye care Diabetes - preventing heart attack and stroke Diabetes - taking care of your feet Diabetes - tests and checkups Diabetes - what to ask your doctor - type 2 Dietary fats explained Fast food tips Heart attack - discharge Heart disease - risk factors Heart failure - discharge Heart failure - fluids and diuretics Heart failure - home monitoring Heart failure - what to ask your doctor High blood pressure - what to ask your doctor How to read food labels Implantable cardioverter defibrillator - discharge Kidney removal - discharge Low-salt diet The Mediterranean diet Hypertension is the term used to describe high blood pressure. Blood pressure readings are measured in millimeters of mercury (mmHg) and usually given as two numbers. For example, 120 over 80 (written as 120/80 mmHg).
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The top number is your systolic pressure, the pressure created when your heart beats. It is considered high if it is consistently over 140. The bottom number is your diastolic pressure, the pressure inside blood vessels when the heart is at rest. It is considered high if it is consistently over 90.

Either or both of these numbers may be too high. Pre-hypertension is when your systolic blood pressure is between 120 and 139 or your diastolic blood pressure is between 80 and 89 on multiple readings. If you have pre-hypertension, you are more likely to develop high blood pressure. See also: Blood pressure Causes Blood pressure measurements are the result of the force of the blood produced by the heart and the size and condition of the arteries. Many factors can affect blood pressure, including:
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How much water and salt you have in your body The condition of your kidneys, nervous system, or blood vessels The levels of different body hormones

High blood pressure can affect all types of people. You have a higher risk of high blood pressure if you have a family history of the disease. High blood pressure is more common in African Americans than Caucasians. Smoking, obesity, and diabetes are all risk factors for hypertension. Most of the time, no cause is identified. This is called essential hypertension. High blood pressure that results from a specific condition, habit, or medication is called secondary hypertension. Too much salt in your diet can lead to high blood pressure. Secondary hypertension may also be due to:
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Adrenal gland tumor Alcohol abuse Anxiety and stress Arteriosclerosis Birth control pills Coarctation of the aorta Cocaine use Cushing syndrome Diabetes Kidney disease, including: o Glomerulonephritis (inflammation of kidneys) o Kidney failure o Renal artery stenosis o Renal vascular obstruction or narrowing Medications o Appetite suppressants o Certain cold medications o Corticosteroids o Migraine medications Hemolytic-uremic syndrome Henoch-Schonlein purpura Obesity Pain Periarteritis nodosa Pheochromocytoma Pregnancy (called gestational hypertension) Primary hyperaldosteronism Renal artery stenosis Retroperitoneal fibrosis Wilms' tumor

Symptoms Most of the time, there are no symptoms. Symptoms that may occur include:
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Chest pain Confusion Ear noise or buzzing Irregular heartbeat Nosebleed Tiredness Vision changes

If you have a severe headache or any of the symptoms above, see your doctor right away. These may be signs of a complication or dangerously high blood pressure called malignant hypertension. Exams and Testsu hav Your health care provider will perform a physical y If you monitor your blood pressure at home, you may be asked the following questions:
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What was your most recent blood pressure reading? What was the previous blood pressure reading? What is the average systolic (top number) and diastolic (bottom number) reading? Has your bloo d pressure increased recently?of Do you have any record of having DM? What is the range of your BP?

Other tests may be done to look for blood in the urine or heart failure. Your doctor will look for signs of complications to your heart, kidneys, eyes, and other organs in your body. These tests may include:
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Chem-20 Echocardiogram Urinalysis Ultrasound of the kidneys

Treatment The goal of treatment is to reduce blood pressure so that you have a lower risk of complications. There are many different medicines that can be used to treat high blood pressure, including:
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Alpha blockers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) Beta-blockers Calcium channel blockers Central alpha agonists Diuretics Renin inhibitors, including aliskiren (Tekturna) Vasodilators

Your doctor may also tell you to exercise, lose weight, and follow a healthier diet. If you have pre-hypertension, your doctor will recommend the same lifestyle changes to bring your blood pressure down to a normal range. Often, a single blood pressure drug may not be enough to control your blood pressure, and you may need to take two or more drugs. It is very important that you take the medications prescribed to you. If you have side effects, your health care provider can substitute a different medication.

Outlook (Prognosis) Most of the time, high blood pressure can be controlled with medicine and lifestyle changes. Possible Complications
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Aortic dissection Blood vessel damage (arteriosclerosis) Brain damage Congestive heart failure Kidney damage Kidney failure Heart attack Hypertensive heart disease Stroke Vision loss

When to Contact a Medical Professional If you have high blood pressure, you will have regularly scheduled appointments with your doctor. Even if you have not been diagnosed with high blood pressure, it is important to have your blood pressure checked during your yearly check-up, especially if someone in your family has or had high blood pressure. Call your health care provider right away if home monitoring shows that your blood pressure remains high or you have any of the following symptoms:
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Chest pain Confusion Excessive tiredness Nausea and vomiting Severe headache Shortness of breath Significant sweating Vision changes

Prevention Adults over 18 should have their blood pressure checked routinely. Lifestyle changes may help control your blood pressure:
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Lose weight if you are overweight. Excess weight adds to strain on the heart. In some cases, weight loss may be the only treatment needed. Exercise regularly. If possible, exercise for 30 minutes on most days. Eat a diet rich in fruits, vegetables, and low-fat dairy products while reducing total and saturated fat intake (the DASH diet is one way of achieving this kind of dietary plan). (See: Heart disease and diet) Avoid smoking. (See: Nicotine withdrawal) If you have diabetes, keep your blood sugar under control. Do not consume more than 1 or 2 alcoholic drinks per day. Try to manage your stress.

Follow your health care provider's recommendations to modify, treat, or control possible causes of secondary hypertension.

What is congestive heart failure?
Congestive heart failure (CHF) is a term used by cardiologists to describe a patient whose heart does not pump enough blood out to the rest of the body to meet the body's demand for energy. This can be due to either a heart that pumps well but is very insufficient (due to a structural problem), or it can be a result of a weak heart muscle that does not pump a normal amount of blood to the body. Either situation will lead to backup of blood and fluid into the lungs if the left side of the heart is the problem or backup of blood and fluid into the liver and veins leading into the heart if the right side of the heart is problem. It is not uncommon for both sides of the heart to fail at the same time and cause backup into both systems simultaneously. For the purpose of the Cincinnati Children's Hospital Medical Center's Heart Encyclopedia, the focus is on backup or excessive blood flow into the lungs, which is the most common use of the term in pediatrics. Return to Top

Congestive heart failure causes
There are two main categories of causes of congestive heart failure. The first category is more common in babies and younger children. In this situation, the heart muscle pumps well, but the route that blood takes is very inefficient. It occurs when too much blood goes to the lungs, which the lungs and eventually the heart find difficult to handle. This happens with certain kinds of holes or connections with which some babies are born. With these connections (also known as shunts), blood that has already returned from the lungs filled with oxygen to the heart actually ends up back in the lungs then back in the heart again. Example of these types of lesions include:
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A patent ductus arteriosus is a blood vessel between the aorta and main pulmonary artery that all babies require in fetal life but which usually closes within the first couple of days of life. If it is large and does not close, the baby will have an excessive amount of blood flow to the lungs. This is a very common problem in premature infants. Another problem that leads to excessive blood flow to the lungs is a large ventricular septal defect (VSD) or a hole between the two lower pumping chambers of the heart. These will cause congestive heart failure only if the hole is big enough to allow so much extra blood flow to the lungs that the heart has to work a lot harder to pump blood out to the body. Some babies are born with other connections between the two main arteries leaving the heart, i.e., aortopulmonary window or truncus arteriosus. These babies are also at risk for having too much blood flow to the lungs. Holes between the two upper chambers of the heart (atrial septal defects) rarely cause problems with congestive heart failure no matter how large.

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The second cause for congestive heart failure is when the heart muscle is not strong enough to pump a normal amount of blood. This is usually seen in older children but can be seen in babies.

A major cause of this type of congestive heart failure in babies is when structures on the left side of the heart are so small or narrowed that blood has a difficult time ejecting from the heart leading to backup into the lungs. This can be seen in critical aortic stenosis, critical coarctation of the aorta, or hypoplastic left heart syndrome. In older children where the structure of the heart is normal, it is usually due to a weakening of the heart muscle, or cardiomyopathy, infection of the heart muscle (myocarditis) or Kawasaki Disease, which all can lead to congestive heart failure. Cardiomyopathy can also be seen in babies and can be due to a number of problems such as rhythm disturbances or infections.

Congestive heart failure symptoms
Symptoms are different for children of different ages. In babies, regardless of the cause of congestive heart failure, the end result of significant congestive heart failure is poor growth. This is because in babies with congestive heart failure a significant amount of energy is used up by the heart as it works harder to do its job. In addition, as the lungs fill with fluid, it becomes more difficult for babies to breathe and they will use more of the muscles of their chest and belly to compensate. These babies will also have a harder time eating and may not eat as fast or as well as other babies. They can become very sweaty with feedings because of the extra work needed to eat. Some babies work so hard that they wear themselves out and sleep more or have less energy than babies without heart problems, although this is hard to gauge as different babies will have different sleeping habits regardless of whether or not they have heart problems. All of this extra work will result in the baby's inability to take in enough nutrition to grow, which is an infant's top priority in the first year of life. These symptoms will not usually occur as soon as the baby is born. This is because the pressures in the lungs of all babies are equal to the pressures of the rest of the body when babies are first born. It can take anywhere from two days to eight weeks before the pressures in the lungs fall to normal. Babies with ventricular septal defects or other sources of extra flow to the lungs can often feed and grow as expected for all babies in the first one to two weeks of life because their high pressures in the lungs will prevent excessive blood flow to the lungs. The symptoms of poor growth -- difficulty with feeds and fast breathing -- will gradually appear during the first or second week of life as the pressures in the lungs begin to fall and blood flows across the hole into the lungs. Babies with obstruction to blood flow out of the left side of the heart or a weak heart muscle may have these symptoms much sooner, sometimes in the first few days of life depending on the degree of obstruction or weakness. Older children with congestive heart failure are beyond the time of rapid growth and therefore do not have major growth problems like infants. Their symptoms are usually related to their inability to tolerate exercise. They become short of breath more quickly compared to their peers and need to rest more often.

Shortness of breath can occur even with minimal exertion, such as climbing stairs or taking a walk if the heart failure is severe. These children will often lack energy when compared to their friends, although this may be harder to determine because all children have different levels of energy. In children with heart failure, passing out during exercise may be very serious and needs to be evaluated immediately. Appetite may be poor when heart failure is severe and weight loss or lack of weight gain can be seen even in older children. Some children will retain fluid and will actually gain weight with heart failure and appear puffy. As it is harder to determine parameters for heart failure in older children, it is important to look for change in exercise capabilities or progression of symptoms with time.

Diagnosing congestive heart failure
Congestive heart failure is a clinical diagnosis. The symptoms described above are important clues to the problem. A good physical examination is of major importance. Babies with congestive heart failure may be small and wasted appearing. They will often breathe faster than normal and their heart rates are often fast, even when asleep. Blood pressures and pulses can be normal or can be diminished in infants with left-sided obstruction. On examination of the heart, there may be a particular type of heart murmur called a diastolic rumble, which may indicate extra blood flow to the lungs. In addition, the heart is pumping so hard that one can feel or even see the heart impulse on the surface of the chest quite easily in babies with significant congestive heart failure. Sometimes there is an extra sound when listening to the heart, particularly in older children, called a gallop. This can also be a sign of significant heart failure. The liver may also be enlarged due to congestion on the right side of the heart and may be more easily palpated (felt). There may be puffiness of the eyes or feet as the right heart fails. An electrocardiogram may be helpful to indicate if the chambers of the heart are enlarged and can point to specific congenital heart diseases or rhythm disturbances that can cause heart failure. A chest X-ray can be very useful to determine if the heart is enlarged and if there is extra blood flow or fluid in the lungs. This can be very important in determining the progression of congestive heart failure. A graded exercise test can also be used to follow progression of heart failure in some instances for older children. An echocardiogram confirms the diagnosis of structural problems of the heart, and can be used in evaluating the function of the heart muscle. Sometimes a cardiac catheterization must be performed to further investigate the function of the heart. Finally, for some older children and adolescents, a cardiac MRI provides a useful means to evaluate heart function.

Treating congestive heart failure
Treatment can vary with age and type of disease. A treatable cause, such as a rhythm problem, may require specific medications or procedures. In babies with ventricular septal defects, medical therapy can be used as a temporary solution to allow the hole to get smaller or close on its own, or to give the baby a little time to grow prior to heart surgery. In more complex problems such as aortopulmonary window, truncus arteriosus, or hypoplastic left heart syndrome, when it is known that surgery will be needed, it is currently the practice in most centers to perform surgery in the first weeks of life. Some congenital heart disease cannot undergo surgery and a heart transplant is the only option. In older children with weak heart muscles, medication can help decrease the workload of the heart to give it time to heal, though some of these children will also eventually require transplants. There are several types of medications used to treat congestive heart failure. A diuretic like furosemide (Lasix), which helps the kidneys to eliminate extra fluid in the lungs, is often the first medicine given both in babies and older children. Sometimes medicines to lower the blood pressure like an ACE inhibitor (Captopril) or more recently betablockers (Propranalol) are used. Theoretically, lowering the blood pressure will decrease the workload of the heart by decreasing the amount of pressure against which it has to pump. Sometimes a medication called Digoxin is used to help make the heart squeeze better, and help pump blood more efficiently. Since weight gain is a major challenge for infants with congestive heart failure, giving babies high calorie formula or fortified breast milk can help give the extra nutrition they require. Sometimes babies will need to have extra nutrition given to them via a tube that goes directly from the nose to the stomach, a nasogastric feeding tube. This is good for babies who work hard or get very tired from feeding in order to prevent them from using up all the extra calories needed for growth. Older children with significant heart failure can also benefit from nasogastric feeding to give them more calories and energy to do their usual activities. Oxygen can worsen blood flow to the lungs in babies with large ventricular septal defects but may be helpful as a buffer to children with weak hearts. Some kids with cardiomyopathy may also need restriction of certain kinds of exercise and competitive sports, although they may benefit from light activity like swimming.

Congestive heart failure outcomes / survival
All outcomes depend on the cause. If congestive heart failure is due to a structural problem of the heart that can be fixed, the outcome is excellent. Babies with large ventricular septal defects whose holes get smaller or are closed surgically are able to lead a normal life. Babies with more complex congenital heart disease may have more variable results.

Older children with cardiomyopathy tend to progress, unless the cause of the cardiomyopathy is reversible. The key in managing heart failure is making the proper diagnosis, having close follow-up with a cardiologist and taking medications prescribed on a daily basis. Angina Angina is chest pain or discomfort you get when your heart muscle does not get enough blood. It may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw or back. Angina is a symptom of coronary artery disease (CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow. There are three types of angina: stable, unstable and variant. Unstable angina is the most dangerous. It does not follow a pattern and can happen without physical exertion. It does not go away with rest or medicine. It is a sign that you could have a heart attack soon. Not all chest pain or discomfort is angina. If you have chest pain, you should see your health care provider.

What Is Angina?
Angina (an-JI-nuh or AN-juh-nuh) is chest pain or discomfort that occurs when an area of your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. It can feel like indigestion. Angina itself isn't a disease. Rather, it's a symptom of an underlying heart problem. Angina is usually a symptom of coronary artery disease (CAD), the most common type of heart disease. CAD occurs when a fatty material called plaque (plak) builds up on the inner walls of the coronary arteries. These arteries carry oxygen-rich blood to your heart. When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-O-sis).

Atherosclerosis

Figure A shows a normal artery with normal blood flow. Figure B shows an artery containing plaque buildup. Plaque causes the coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to the heart muscle is reduced. This causes pain and can lead to a heart attack.

Types of Angina
The three types of angina are stable, unstable, and variant (Prinzmetal's). Knowing how the types are different is important. This is because they have different symptoms and require different treatment.

Stable Angina
Stable angina is the most common type. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. If you know you have stable angina, you can learn to recognize the pattern and predict when the pain will occur. The pain usually goes away in a few minutes after you rest or take your angina medicine. Stable angina isn't a heart attack, but it makes a heart attack more likely in the future.

Unstable Angina
Unstable angina doesn't follow a pattern. It can occur with or without physical exertion and isn't relieved by rest or medicine. Unstable angina is very dangerous and needs emergency treatment. It's a sign that a heart attack may happen soon.

Variant (Prinzmetal's) Angina
Variant angina is rare. It usually occurs while you're at rest. The pain can be severe. It usually happens between midnight and early morning. This type of angina is relieved by medicine.

Overview
It's thought that nearly 7 million people in the United States suffer from angina. About 400,000 patients go to their doctors with new cases of angina every year. Angina occurs equally in men and women. It can be a sign of heart disease, even when initial tests don't show evidence of CAD. Not all chest pain or discomfort is angina. A heart attack, lung problems (such as an infection or a blood clot), heartburn, or a panic attack also can cause chest pain or discomfort. All chest pain should be checked by a doctor.

Other Names for Angina
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Angina pectoris Acute coronary syndrome Chest pain Coronary artery spasms Prinzmetal's angina Stable or common angina Unstable angina Variant angina

What Causes Angina?
Underlying Causes
Angina is a symptom of an underlying heart condition. Angina pain is the result of reduced blood flow to an area of heart muscle. Coronary artery disease (CAD) usually causes the reduced blood flow. This means that the underlying causes of angina are generally the same as the underlying causes of CAD.

Research suggests that damage to the inner layers of the coronary arteries causes CAD. Smoking, high levels of fat and cholesterol in the blood, high blood pressure, and a high level of sugar in the blood (due to insulin resistance or diabetes) can damage the coronary arteries. When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. Plaque narrows or blocks the arteries, reducing blood flow to the heart muscle. Some plaque is hard and stable and leads to narrowed and hardened arteries. Other plaque is soft and is more likely to break open and cause blood clots. The buildup of plaque on the arteries' inner walls can cause angina in two ways. It can:
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Narrow the arteries and greatly reduce blood flow to the heart Form blood clots that partially or totally block the arteries

Immediate Causes
There are different triggers for angina pain, depending on the type of angina you have.

Stable Angina
Physical exertion is the most common trigger of stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low (such as when you're sitting). But with exertion, like walking up a hill or climbing stairs, the heart works harder and needs more oxygen. Other triggers of stable angina include:
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Emotional stress Exposure to very hot or cold temperatures Heavy meals Smoking

Unstable Angina
Blood clots that partially or totally block an artery cause unstable angina. If plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. A clot may grow large enough to completely block the artery and cause a heart attack. For more information, see the animation in "What Causes a Heart Attack?" Blood clots may form, partly dissolve, and later form again. Angina can occur each time a clot blocks an artery.

Variant Angina
A spasm in a coronary artery causes variant angina. The spasm causes the walls of the artery to tighten and narrow. Blood flow to the heart slows or stops. Variant angina may occur in people with or without CAD. Other causes of spasms in the coronary arteries are:
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Exposure to cold Emotional stress

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Medicines that tighten or narrow blood vessels Smoking Cocaine use

Who Is At Risk for Angina?
Angina is a symptom of an underlying heart condition, usually coronary artery disease (CAD). So if you're at risk for CAD, you're also at risk for angina. Risk factors for CAD include:
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Unhealthy cholesterol levels. High blood pressure. Cigarette smoking. Insulin resistance or diabetes. Overweight or obesity. Metabolic syndrome. Lack of physical activity. Age. (The risk increases for men after 45 years of age and for women after 55 years of age.) Family history of early heart disease.

You can read more about CAD risk factors in "Who Is At Risk for Coronary Artery Disease?"

Populations Affected
People sometimes think that because men have more heart attacks than women, men also suffer from angina more often. In fact, angina occurs equally among women and men. It can be a sign of heart disease, even when initial tests don't show evidence of CAD. Unstable angina occurs more often in older adults. Variant angina is rare. It accounts for only about 2 out of 100 cases of angina. People who have variant angina are often younger than those who have other forms of angina.

What Are the Signs and Symptoms of Angina?
Pain and discomfort are the main symptoms of angina. Angina is often described as pressure, squeezing, burning, or tightness in the chest. It usually starts in the chest behind the breastbone. Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. It may feel like indigestion. Some people say that angina discomfort is hard to describe or that they can't tell exactly where the pain is coming from.

Symptoms such as nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, or weakness also may occur. Women are more likely to feel discomfort in their back, shoulders, and abdomen. Symptoms vary based on the type of angina.

Stable Angina
The pain or discomfort:
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Occurs when the heart must work harder, usually during physical exertion Doesn't come as a surprise, and episodes of pain tend to be alike Usually lasts a short time (5 minutes or less) Is relieved by rest or medicine May feel like gas or indigestion May feel like chest pain that spreads to the arms, back, or other areas

Unstable Angina
The pain or discomfort:
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Often occurs at rest, while sleeping at night, or with little physical exertion Comes as a surprise Is more severe and lasts longer (as long as 30 minutes) than episodes of stable angina Is usually not relieved with rest or medicine May get continually worse May mean that a heart attack will happen soon

Variant Angina
The pain or discomfort:
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Usually occurs at rest and during the night or early morning hours Tends to be severe Is relieved by medicine

Lasting Chest Pain
Chest pain that lasts longer than a few minutes and isn't relieved by rest or angina medicine may mean you're having (or are about to have) a heart attack. Call 9±1±1 right away.

How Is Angina Diagnosed?
The most important issues to address when you go to the doctor with chest pain are:
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What's causing the chest pain Whether you're having or are about to have a heart attack

Angina is a symptom of an underlying heart problem, usually coronary artery disease (CAD). The type of angina pain you have can be a sign of how severe the CAD is and whether it's likely to cause a heart attack. If you have chest pain, your doctor will want to find out whether it's angina. He or she also will want to know whether the angina is stable or unstable. If it's unstable, you may need emergency medical attention to try to prevent a heart attack. To diagnose chest pain as stable or unstable angina, your doctor will do a physical exam, ask about your symptoms, and ask about your risk factors and your family history of CAD or other heart disease. He or she may also ask questions about your symptoms, such as:
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What brings on the pain or discomfort and what relieves it? What does the pain or discomfort feel like (for example, heaviness or tightness)? How often does the pain occur? Where do you feel the pain or discomfort? How severe is the pain or discomfort? How long does the pain or discomfort last?

Diagnostic Tests and Procedures
If your doctor suspects that you have unstable angina or that your angina is related to a serious heart condition, he or she may order one or more tests.

EKG (Electrocardiogram)
An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. However, some people with angina have a normal EKG.

Stress Testing
During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. During exercise stress testing, your blood pressure and EKG readings are checked while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time. If you're unable to exercise, a medicine can be injected into your bloodstream to make your heart work hard and beat fast. Nuclear heart scanning or echocardiography is then usually done. When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

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Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

Chest X Ray
A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Coronary Angiography and Cardiac Catheterization
Your doctor may ask you to have coronary angiography (an-jee-OG-ra-fee) if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization (KATH-e-ter-i-ZA-shun). A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through the coronary arteries. Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

Blood Tests
Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD. Your doctor may order a blood test to check the level of C-reactive protein (CRP) in your blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CAD and heart attack. Your doctor also may order a blood test to check for low hemoglobin (HEE-muh-glow-bin) in your blood. Hemoglobin is an iron-rich protein in the red blood cells that carries oxygen from the lungs to all parts of your body. If you have low hemoglobin, you may have a condition called anemia (uh-NEE-me-eh).

How Is Angina Treated?
Treatments for angina include lifestyle changes, medicines, medical procedures, and cardiac rehabilitation (rehab). The main goals of treatment are to:
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Reduce pain and discomfort and how often it occurs Prevent or lower the risk of heart attack and death by treating the underlying heart condition

Lifestyle changes and medicines may be the only treatments needed if your symptoms are mild and aren't getting worse. When lifestyle changes and medicines don't control angina, you may need medical procedures or cardiac rehab. Unstable angina is an emergency condition that requires treatment in the hospital.

Lifestyle Changes
Making lifestyle changes can help prevent episodes of angina. You can:
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Slow down or take rest breaks if angina comes on with exertion. Avoid large meals and rich foods that leave you feeling stuffed if angina comes on after a heavy meal. Try to avoid situations that make you upset or stressed if angina comes on with stress. Learn ways to handle stress that can't be avoided.

You also can make lifestyle changes that help lower your risk of heart disease. An important lifestyle change is adopting a healthy diet. This will help prevent or reduce high blood pressure, high blood cholesterol, and obesity. Follow a heart healthy eating plan that focuses on fruits, vegetables, whole grains, low-fat or no-fat diary products, and lean meat and fish. The plan also should be low in salt, fat, saturated fat, trans fat, and cholesterol. Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the Dietary Approaches to Stop Hypertension (DASH) eating plan. Your doctor may recommend TLC if you have high cholesterol or the DASH eating plan if you have high blood pressure. Even if you don't have these conditions, you can still benefit from these heart healthy plans. Other important lifestyle changes include:
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Quitting smoking, if you smoke. Avoid secondhand smoke. Being physically active. Check with your doctor to find out how much and what kinds of activity are safe for you. Losing weight, if you're overweight or obese. Taking all medicines as your doctor prescribes, especially if you have diabetes.

Medicines
Nitrates are the most commonly used medicines to treat angina. They relax and widen blood vessels. This allows more blood to flow to the heart while reducing its workload. Nitroglycerin is the most commonly used nitrate for angina. Nitroglycerin that dissolves under your tongue or between your cheeks and gum is used to relieve an angina episode. Nitroglycerin in the form of pills and skin patches is used to prevent attacks of angina. These forms of nitroglycerin act too slowly to relieve pain during an angina attack. You also may need other medicines to treat angina. These medicines may include beta blockers, calcium channel blockers, ACE inhibitors, oral antiplatelet (an-ty-PLAYT-lit) medicines, and anticoagulants (AN-te-koAG-u-lants). These medicines can help:
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Lower blood pressure and cholesterol levels Slow the heart rate Relax blood vessels Reduce strain on the heart Prevent blood clots from forming

Medical Procedures
When medicines and other treatments don't control angina, you may need a medical procedure to treat the underlying heart disease. Angioplasty (AN-jee-oh-plas-tee) and coronary artery bypass grafting (CABG) are both commonly used to treat angina. Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores blood flow. Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. During CABG, healthy arteries or veins taken from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. Bypass surgery can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Your doctor will help decide which treatment is right for you.

Cardiac Rehabilitation
Your doctor may prescribe cardiac rehab for angina or after angioplasty, CABG, or a heart attack. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists. Rehab has two parts:
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Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests. Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk of future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.

For more information on cardiac rehab, see the Diseases and Conditions Index Cardiac Rehabilitation article.

How Can Angina Be Prevented?
You can prevent or lower your risk for angina and coronary artery disease (CAD) by making lifestyle changes and treating related conditions.

Making Lifestyle Changes
Healthy lifestyle choices can help prevent or delay angina and CAD. To make lifestyle changes, you can:
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Follow a healthy eating plan. (See "How Is Angina Treated" for more information.) Quit smoking, if you smoke. Avoid secondhand smoke.

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Be physically active. Check with your doctor to find out how much and what kinds of activity are safe for you. Learn ways to handle stress and relax.

Treating Related Conditions
You also can help prevent or delay angina and CAD by treating related conditions, such as:
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High blood cholesterol. If you have high cholesterol, follow your doctor's advice about lowering it. Take medicines as directed to lower your cholesterol. High blood pressure. If you have high blood pressure, follow your doctor's advice about keeping your blood pressure under control. Take blood pressure medicines as directed. Diabetes. If you have diabetes, follow your doctor's advice about keeping your blood sugar level under control. Take medicines as directed. Overweight or obesity. If you're overweight or obese, talk to your doctor about how to lose weight safely.

Living With Angina
Angina isn't a heart attack, but it does mean that you're at greater risk of having a heart attack than someone who doesn't have angina. The risk is even higher if you have unstable angina. For these reasons, it's important that you know:
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The usual pattern of your angina, if you have it regularly. What medicines you take (keep a list) and how to take them. Make sure you're medicines are readily available. How to control your angina. The limits of your physical activity. How and when to seek medical attention.

Know the Pattern of Your Angina
Stable angina usually occurs in a pattern. You should know:
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What causes the pain to occur What angina pain feels like How long the pain usually lasts Whether rest or medicine relieves the pain

After several episodes, you will learn to recognize when you're having angina. It's important for you to notice if the pattern starts to change. Pattern changes may include angina that occurs more often, lasts longer, is more severe, occurs without exertion, or doesn't go away with rest or medicines. These changes may be a sign that your symptoms are getting worse or becoming unstable. You should seek medical help. Unstable angina suggests that you're at high risk for a heart attack very soon.

Know Your Medicines
You should know what medicines you're taking, the purpose of each, how and when to take them, and possible side effects. It's very important that you know exactly when and how to take fast-acting nitroglycerin or other nitrates to relieve chest pain.

It's also important to know how to correctly store your angina medicines and when to replace them. Your doctor can advise you on this. If you have side effects from your medicines, let your doctor know. You should never stop taking your medicines without your doctor's approval. Talk to your doctor if you have any questions or concerns about taking your angina medicines. Tell him or her about any other medicines you might be taking. Some medicines can cause serious problems if they're taken with nitrates or other angina medicines.

Know How To Control Your Angina
After several episodes, you will know the level of activity, stress, and other factors that can bring on your angina. By knowing this, you can take steps to prevent or lessen the severity of episodes.

Physical Activity
Know what level of activity brings on your angina and try to stop and rest before chest pain starts. For example, if walking up a flight of stairs leads to chest pain, then stop halfway and rest before continuing. When chest pain occurs during exertion, stop and rest or take your angina medicine. The pain should go away in a few minutes. If the pain doesn't go away or lasts longer than usual, call 9±1±1 for emergency care.

Emotional Stress
Anger, arguing, and worrying are examples of emotional stress that can bring on an angina episode. Try to avoid or limit situations that cause these emotions. Exercise and relaxation can help relieve stress. Alcohol and drug use play a part in causing stress and don't relieve it. If stress is a problem for you, talk with your doctor about getting help for it.

Eating Large Meals
If this leads to chest pain, eat smaller meals. Also, avoid eating rich foods.

Know the Limits of Your Physical Activity
Most people with stable angina can continue their normal activities. This includes work, hobbies, and sexual relations. However, if you do very strenuous activities or have a stressful job, talk to your doctor.

Know How and When To Seek Medical Attention
If you have angina, you're at a higher risk for a heart attack than someone who doesn't have angina. So it's very important that you and your family know how and when to seek medical attention. Talk to your doctor about making an emergency action plan. The plan should include making sure you and your family members know:
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The signs and symptoms of a heart attack How to use aspirin and nitroglycerin when needed

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How to access emergency medical services in your community The location of the nearest hospital that offers 24-hour emergency heart care

Be sure to discuss your emergency plan with your family members. Take action quickly if your chest pain becomes severe, lasts longer than a few minutes, or isn't relieved by rest or medicine. Sometimes, it may be difficult to tell the difference between unstable angina and a heart attack. Either way, it's an emergency situation, and you should call 9±1±1 right away.

Key Points
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Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina is the symptom of an underlying heart condition, usually coronary artery disease (CAD). CAD occurs when a fatty material called plaque builds up on the inner walls of the coronary arteries. Plaque causes the coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to the heart muscle is reduced. Angina may feel like pressure or a squeezing pain in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. The most common types of angina are stable angina and unstable angina. A rare type of angina is called variant angina. o Stable angina occurs when the heart is working harder than usual. Pain from stable angina goes away when you rest or take your angina medicine. Angina medicine, such as nitroglycerin, helps widen and relax the arteries so that more blood can flow to the heart. o Unstable angina is a very dangerous condition and needs emergency treatment. Unstable angina is a sign that a heart attack may happen soon. Unstable angina can occur with or without physical exertion. It isn't relieved by rest or medicine. o Variant angina is caused by a spasm (tightening) in a coronary artery. This narrowing of the artery slows or stops blood flow to the heart muscle. The pain may be severe. This type of angina is relieved by medicine. Nearly 7 million people in the United States have angina. It occurs equally in men and women. Because angina is usually a symptom of CAD, its risk factors are usually the same as those for CAD. Pain and discomfort are the main symptoms of angina. Nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, or weakness also may occur. If you have chest pain, your doctor will want to find out whether it's angina. To diagnose angina, your doctor will do a physical exam and ask about your symptoms, risk factors, and family history of heart disease. He or she also may order tests to confirm the diagnosis. Treatments for angina include lifestyle changes, medicines, medical procedures, and cardiac rehabilitation. Lifestyle changes include following a healthy eating plan, quitting smoking, being physically active, losing weight, and learning how to handle stress and relax. You can prevent or lower your risk for angina and CAD by making lifestyle changes and treating related conditions. If you have angina, it's important to know the pattern of your angina, what medicines you take (keep a list) and how often you should take then, how to control your angina, and the limits on your physical activity. You should know how and when to seek medical help.

Links to Other Information About Angina
NHLBI Resources
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"Aim for a Healthy Weight" Patient Booklet Act in Time to Heart Attack Signs Coronary Artery Disease (Diseases and Conditions Index) Heart Attack (Diseases and Conditions Index) Cardiovascular Information for the Public "Your Guide to Living Well With Heart Disease" "Your Guide to Lowering Your Blood Pressure" "Your Guide to Lowering Your Blood Pressure With DASH" "Your Guide to Lowering Your Cholesterol With TLC"

Non-NHLBI Resources
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Angina (MedlinePlus) Coronary Artery Disease (MedlinePlus) Heart Attack (MedlinePlus) Angina: Interactive Tutorial (MedlinePlus Patient Education Institute) Heart Attack: Interactive Tutorial (MedlinePlus Patient Education Institute)

Clinical Trials
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Current Research (ClinicalTrials.gov)

What is a heart attack?
A heart attack (also known as a myocardial infarction) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen. Blockage of a coronary artery deprives the heart muscle of blood and oxygen,causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue. Approximately one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack.

What causes a heart attack?
Atherosclerosis Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery. Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain normal function of the parts of the body they supply. For example, atherosclerosis of the arteries in the legs causes reduced blood flow to the legs. Reduced blood flow to the legs can lead to pain in the legs while walking or exercising, leg ulcers, or a delay in the healing of wounds to the legs. Atherosclerosis of the arteries that furnish blood to the brain can lead to vascular dementia (mental deterioration due to gradual death of brain tissue over many years) or stroke (sudden death of brain tissue).

In many people, atherosclerosis can remain silent (causing no symptoms or health problems) for years or decades. Atherosclerosis can begin as early as the teenage years, but symptoms or health problems usually do not arise until later in adulthood when the arterial narrowing becomes severe. Smoking cigarettes, high blood pressure, elevated cholesterol, and diabetes mellitus can accelerate atherosclerosis and lead to the earlier onset of symptoms and complications, particularly in those people who have a family history of early atherosclerosis. Coronary atherosclerosis (or coronary artery disease) refers to the atherosclerosis that causes hardening and narrowing of the coronary arteries. Diseases caused by the reduced blood supply to the heart muscle from coronary atherosclerosis are called coronary heart diseases (CHD). Coronary heart diseases include heart attacks, sudden unexpected death, chest pain (angina), abnormal heart rhythms, and heart failure due to weakening of the heart muscle. Atherosclerosis and angina pectoris

Angina pectoris (also referred to as angina) is chest pain or pressure that occurs when the blood and oxygen supply to the heart muscle cannot keep up with the needs of the muscle. When coronary arteries are narrowed by more than 50 to 70 percent, the arteries may not be able to increase the supply of blood to the heart muscle during exercise or other periods of high demand for oxygen. An insufficient supply of oxygen to the heart muscle causes angina. Angina that occurs with exercise or exertion is called exertional angina. In some patients, especially diabetics, the progressive decrease in blood flow to the heart may occur without any pain or with just shortness of breath or unusually early fatigue. Exertional angina usually feels like a pressure, heaviness, squeezing, or aching across the chest. This pain may travel to the neck, jaw, arms, back, or even the teeth, and may be accompanied by shortness of breath, nausea, or a cold sweat. Exertional angina typically lasts from one to 15 minutes and is relieved by rest or by taking nitroglycerin by placing a tablet under the tongue. Both resting and nitroglycerin decrease the heart muscle's demand for oxygen, thus relieving angina. Exertional angina may be the first warning sign of advanced coronary artery disease. Chest pains that just last a few seconds rarely are due to coronary artery disease. Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery has narrowed to such a critical degree that the heart is not receiving enough oxygen even at rest. Angina at rest infrequently may be due to spasm of a coronary artery (a condition called Prinzmetal's or variant angina). Unlike a heart attack, there is no permanent muscle damage with either exertional or rest angina. Atherosclerosis and heart attack

Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack (see picture below). The cause of rupture that leads to the formation of a clot is largely unknown, but contributing factors may include cigarette smoking or other nicotine exposure, elevated LDL cholesterol, elevated levels of blood catecholamines (adrenaline), high blood pressure, and other mechanical and biochemical forces. Unlike exertional or rest angina, heart muscle dies during a heart attack and loss of the muscle is permanent, unless blood flow can be promptly restored, usually within one to six hours.

While heart attacks can occur at any time, more heart attacks occur between 4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to rupture of cholesterol plaques. Approximately 50% of patients who develop heart attacks have warning symptoms such as exertional angina or rest angina prior to their heart attacks, but these symptoms may be mild and discounted.

What are the symptoms of a heart attack?
Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a variety of symptoms including:
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Pain, fullness, and/or squeezing sensation of the chest Jaw pain, toothache, headache Shortness of breath Nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort Sweating Heartburn and/or indigestion Arm pain (more commonly the left arm, but may be either arm)

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Upper back pain General malaise (vague feeling of illness) No symptoms (Approximately one quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus.)

Even though the symptoms of a heart attack at times can be vague and mild, it is important to remember that heart attacks producing no symptoms or only mild symptoms can be just as serious and life-threatening as heart attacks that cause severe chest pain. Too often patients attribute heart attack symptoms to "indigestion," "fatigue," or "stress," and consequently delay seeking prompt medical attention. One cannot overemphasize the importance of seeking prompt medical attention in the presence of symptoms that suggest a heart attack. Early diagnosis and treatment saves lives, and delays in reaching medical assistance can be fatal. A delay in treatment can lead to permanently reduced function of the heart due to more extensive damage to the heart muscle. Death also may

What are the complications of a heart attack?
Heart failure

When a large amount of heart muscle dies, the ability of the heart to pump blood to the rest of the body is diminished, and this can result in heart failure. The body retains fluid, and organs, for example, the kidneys, begin to fail. Ventricular fibrillation

Injury to heart muscle also can lead to ventricular fibrillation. Ventricular fibrillation occurs when the normal, regular, electrical activation of heart muscle contraction is replaced by chaotic electrical activity that causes the heart to stop beating and pumping blood to the brain and other parts of the body. Permanent brain damage and death can occur unless the flow of blood to the brain is restored within five minutes. Most of the deaths from heart attacks are caused by ventricular fibrillation of the heart that occurs before the victim of the heart attack can reach an emergency room. Those who reach the emergency room have an excellent prognosis; survival from a heart attack with modern treatment should exceed 90%. The 1% to 10% of heart attack victims who later die frequently had suffered major damage to the heart muscle initially or additional damage at a later time. Deaths from ventricular fibrillation can be avoided by cardiopulmonary resuscitation (CPR) started within five minutes of the onset of ventricular fibrillation. CPR requires breathing for the victim and applying external compression to the chest to squeeze the heart and force it to pump blood. In 2008, the American Heart Association modified the mouth-to-mouth instruction of CPR, and recommends that chest compressions alone are effective if a bystander is reluctant to do mouth-to-mouth. When paramedics arrive, medications and/or an electrical shock (cardioversion) can be administered to convert ventricular fibrillation back to a normal heart rhythm and allow the heart to pump blood normally. Therefore, prompt CPR and a rapid response by paramedics can improve the chances of survival from a heart attack. In addition, many public venues now have automatic external defibrillators (AEDs) that provide the electrical shock needed to restore a normal heart rhythm even before the paramedics arrive. This greatly improves the chances of survival.

What are the risk factors for atherosclerosis and heart attack?

Factors that increase the risk of developing atherosclerosis and heart attacks include increased blood cholesterol, high blood pressure, use of tobacco, diabetes mellitus, male gender, and a family history of coronary heart disease. While family history and male gender are genetically determined, the other risk factors can be modified through changes in lifestyle and medications.
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High Blood Cholesterol (Hyperlipidemia). A high level of cholesterol in the blood is associated with an increased risk of heart attack because cholesterol is the major component of the plaques deposited in arterial walls. Cholesterol, like oil, cannot dissolve in the blood unless it is combined with special proteins called lipoproteins. (Without combining with lipoproteins, cholesterol in the blood would turn into a solid substance.) The cholesterol in blood is either combined with lipoproteins as very low-density lipoproteins (VLDL), low-density lipoproteins (LDL) or high-density lipoproteins (HDL). The cholesterol that is combined with low-density lipoproteins (LDL cholesterol) is the "bad" cholesterol that deposits cholesterol in arterial plaques. Thus, elevated levels of LDL cholesterol are associated with an increased risk of heart attack. The cholesterol that is combined with HDL (HDL cholesterol) is the "good" cholesterol that removes cholesterol from arterial plaques. Thus, low levels of HDL cholesterol are associated with an increased risk of heart attacks. Measures that lower LDL cholesterol and/or increase HDL cholesterol (losing excess weight, diets low in saturated fats, regular exercise, and medications) have been shown to lower the risk of heart attack. One important class of medications for treating elevated cholesterol levels (the statins) have actions in addition to lowering LDL cholesterol which also protect against heart attack. Most patients at "high risk" for a heart attack should be on a statin no matter what the levels of their cholesterol.

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High Blood Pressure (Hypertension). High blood pressure is a risk factor for developing atherosclerosis and heart attack. Both high systolic pressure (when the heart beats) and high diastolic pressure (when the heart is at rest) increase the risk of heart attack. It has been shown that controlling hypertension with medications can reduce the risk of heart attack. Tobacco Use (Smoking). Tobacco and tobacco smoke contain chemicals that cause damage to blood vessel walls, accelerate the development of atherosclerosis, and increase the risk of heart attack. Diabetes (Diabetes Mellitus). Both insulin dependent and non-insulin dependent diabetes mellitus (type 1 and 2, respectively) are associated with accelerated atherosclerosis throughout the body. Therefore, patients with diabetes mellitus are at risk for reduced blood flow to the legs, coronary heart disease, erectile dysfunction, and strokes at an earlier age than non-diabetic subjects. Patients with diabetes can lower their risk through rigorous control of their blood sugar levels, regular exercise, weight control, and proper diets. Male Gender. At all ages, men are more likely than women to develop atherosclerosis and coronary heart disease. Some scientists believe that this difference is partly due to the higher blood levels of HDL cholesterol in women than in men. However, this gender difference narrows as men and women grow older. Family History of Heart Disease. Individuals with a family history of coronary heart diseases have an increased risk of heart attack. Specifically, the risk is higher if there is a family history of early coronary heart disease, including a heart attack or sudden death before age 55 in the father or other first-degree male relative, or before age 65 in the mother or other female first-degree female relative.

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How is a heart attack diagnosed?
When there is severe chest pain, suspicion that a heart attack is occurring usually is high, and tests can be performed quickly that will confirm the heart attack. A problem arises, however, when the symptoms of a heart attack do not include chest pain. A heart attack may not be suspected, and the appropriate tests may not be performed. Therefore, the initial step in diagnosing a heart attack is to be suspicious that one has occurred. Electrocardiogram. An electrocardiogram (ECG) is a recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with heart attacks and can identify the areas of heart muscle that are deprived of oxygen and/or areas of muscle that have died. In a patient with typical symptoms of heart attack (such as crushing chest pain) and characteristic changes of heart attack on the ECG, a secure diagnosis of heart attack can be made quickly in the emergency room and treatment can be started immediately. If a patient's symptoms are vague or atypical and if there are pre-existing ECG abnormalities, for example, from old heart attacks or abnormal electrical patterns that make interpretation of the ECG difficult, the diagnosis of a heart attack may be less secure. In these patients, the diagnosis can be made only hours later through detection of elevated cardiac enzymes in the blood. Blood tests. Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK), special sub-fractions of CPK (specifically, the MB fraction of CPK), and troponin, and their levels can be measured in blood. These cardiac enzymes typically are elevated in the blood several hours after the onset of a heart attack. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlates with the amount of heart muscle that has died. The most important factor in diagnosing and treating a heart attack is prompt medical attention. Rapid evaluation allows early treatment of potentially life-threatening abnormal rhythms such as ventricular fibrillation and allows early reperfusion (return of blood flow to the heart muscle) by procedures that unclog the blocked coronary arteries. The more rapidly blood flow is reestablished, the more heart muscle that is saved. Large and active medical centers often have a "chest pain unit" where patients suspected of having heart attacks are rapidly evaluated. If a heart attack is diagnosed, prompt therapy is initiated. If the diagnosis of heart attack is initially unclear, the patient is placed under continuous monitoring until the results of further testing are available.

What about heart attacks in women? What are the risk factors for heart attack in women?
Coronary artery disease (CAD) and heart attacks are erroneously believed to occur primarily in men. Although it is true that the prevalence of CAD among women is lower before menopause, the risk of CAD rises in women after menopause. At age 75, a woman's risk for CAD is equal to that of a man's. CAD is the leading cause of death and disability in women after menopause. In fact, a 50-year-old woman faces a 46% risk of developing CAD and a 31% risk of dying from coronary artery disease. In contrast, her probability of contracting and dying from breast cancer is 10% and 3%, respectively. The risk factors for developing CAD in women are the same as in men and include:
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increased blood cholesterol, high blood pressure,

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smoking cigarettes, diabetes mellitus, and a family history of coronary heart disease at a young age. cigarettes

Smoking

Even "light" smoking raises the risk of CAD. In one study, middle-aged women who smoked one to 14 cigarettes per day had a twofold increase in strokes (caused by atherosclerosis of the arteries to the brain) whereas those who smoked more than 25 cigarettes per day had a risk of stroke 3.7 fold higher than that of nonsmoking women. Furthermore, the combination of smoking and the use of birth control pills increase the risk of heart attacks even further, especially in women over 35. Quitting smoking immediately begins to reduce the risk of heart attacks. The risk gradually returns to the same risk of nonsmoking women after several years of not smoking. Cholesterol treatment guidelines in women

Current NCEP (National Cholesterol Education Program) treatment guidelines for undesirable cholesterol levels are the same for women as for men.

Heart Attack (Myocardial Infarction)
A heart attack or myocardial infarction is a medical emergency in which the supply of blood to the heart is suddenly and severely reduced or cut off, causing the muscle to die from lack of oxygen. More than 1.1 million people experience a heart attack (myocardial infarction) each year, and for many of them, the heart attack is their first symptom of coronary artery disease. A heart attack may be severe enough to cause death or it may be silent. As many as one out of every five people have only mild symptoms or none at all, and the heart attack may only be discovered by routine electrocardiography done some time later.

Heart Attack Symptoms
Not everyone has the same heart attack symptoms when having a myocardial infarction. Common ones include:
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About 2 out of every 3 people who have heart attacks have chest pain, shortness of breath or feel tired a few days or weeks before the attack A person who has angina (temporary chest pain) may find that it happens more often after less and less physical activity. A change in the pattern of angina should be taken seriously. During a heart attack, a person may feel pain in the middle of the chest that can spread to the back, jaw or arms. The pain may also be felt in all of these places and not the chest. Sometime the pain is felt in the stomach area, where it may be taken for indigestion. The pain is like that of angina but usually more severe, longer lasting and does not get better by resting or taking a nitroglycerin pill. About 1 out of every 3 people who have heart attacks do not feel any chest pain. These people are more likely to be women, non-Caucasian, older than 75, someone with heart failure or diabetes and someone who has had a stroke. Faintness Sudden sweating Nausea Shortness of breath, especially in older people

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Heavy pounding of the heart Abnormal heart rhythms (arrhythmias), which occur in more than 90% of the people who have had a heart attack Loss of consciousness, which sometimes is the first symptom of a heart attack Feelings of restlessness, sweatiness, anxiety and a sense of impending doom Bluishness of the lips, hands or feet Older people may have symptoms that resemble a stroke and may become disoriented Older people, especially women, often take longer than younger people to admit they are ill or to seek medical help

During the early hours of a heart attack, heart murmurs and other abnormal heart sounds may be heard through a stethoscope.

Causes of Heart Attacks and Risk Factors
A heart attack (myocardial infarction) is usually caused by a blood clot that blocks an artery of the heart. The artery has often already been narrowed by fatty deposits on its walls. These deposits can tear or break open, reducing the flow of blood and releasing substances that make the platelets of the blood sticky and more likely to form clots. Sometimes a clot forms inside the heart itself, then breaks away and gets stuck in an artery that feeds the heart. A spasm in one of these arteries can cause the blood flow to stop.

Diagnosis of Heart Attacks
Because a heart attack (myocardial infarction) can be life threatening, men older than 35 or women older than 50 who have chest pain should be examined to see if they area having a heart attack. However, similar pain can be caused by pneumonia, a blood clot in the lung (pulmonary embolism), pericarditis, a rib fracture, spasm of the esophagus, indigestion or chest muscle tenderness after injury or exertion. A heart attack can be confirmed within a few hours of its occurrence by:
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Electrocardiography (ECG) Blood tests to measure levels of serum markers. The presence of these markers shows that there has been damage to or death of the heart muscle. These markers are normally found in the heart muscle, but they are released into the blood when the heart muscle is damaged. Echocardiography can be performed if the above tests do not give enough information Radionuclide imaging can also be done

Treatment of Heart Attacks (Myocardial Infarction)
Half the deaths from a heart attack occur in the first 3 or 4 hours after symptoms begin. It is crucial that symptoms of a heart attack be treated as a medical emergency. A person with these symptoms should be taken to the emergency department of a hospital in an ambulance with trained personnel. The sooner that treatment of a heart attack begins, the better. Chewing an aspirin tablet after an ambulance has been called can help reduce the size of the blood clot. A beta-blocker may be given to slow the heart rate so the heart is not working as hard and to reduce the damage to the heart muscle. Often a person who is having a heart attack is given oxygen, which also helps heart tissue damage to be less. People who may be having a heart attack are usually admitted to a hospital that has a cardiac care unit. People who may be having a heart attack are usually admitted to a hospital that has a cardiac care unit. Heart rhythm, blood pressure and the amount of oxygen in the blood are closely monitored so that heart damage can be

assessed. Nurses in these units are specially trained to care for people with heart problems and to handle cardiac emergencies. Drugs may be used to dissolve blood clots in the artery so that heart tissue can be saved. To be effective, these drugs must be given intravenously within six hours of the start of the symptoms of a heart attack. After six hours, most damage is permanent. (People who have bleeding conditions or severe high blood pressure and those who have had recent surgery or a stroke cannot be given these drugs.) Instead of drug therapy, angioplasty may be performed immediately to clear the arteries. This approach is preferred as primary therapy in heart attacks. If the blockages are extensive, then coronary artery bypass surgery may be necessary. Chances of surviving a heart attack can improve when an individual recognizes the symptoms early and seeks immediate medical attention. One out of every 10 people who have heart attacks, however, die within a year usually within the first three or four months. Typically, these people continue to have chest pain, abnormal heart rhythms or heart failure. Older people and smaller people tend to not do as well after a heart attack as younger people and larger people. This may be one reason why women tend to fare less well than men after a heart attack - they tend to be both older and smaller, as well as have other disorders. They also tend to wait longer after a heart attack before going to the hospital. After a heart attack (myocardial infarction), a doctor may require additional tests or treatment, including:
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Wearing a Holter monitor for continuous monitoring of the heart's electrical activity An exercise stress test Drug therapy, including taking a daily aspirin, beta-blockers Coronary angiography Angioplasty Bypass Lowering cholesterol levels Rehabilitation

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surgery