17th March 2002

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Heart throb

A healthy outlook
Sri Lankans seem to be prone to high levels of cholesterol because of the food they eat - the quick and easy junk food.

Junk foods are prepared using fat or lard. They are highly saturated. The best would be no oil, but if you need oil it would be better to use polyunsaturated oils such as soya, corn, olive or gingelly oil, advises Dr. Kulatilake of Durdans. To him moderation is the key.

The other important factor is the prevention of diabetes in middle age. "Fifty percent of people coming for heart surgery are diabetics. Diabetes which sets in with age is preventable by keeping your weight, specially obesity of the tummy area, down. This could be done with exercise. A brisk walk of about three miles will do the trick," says Dr. Kulatilake. 

With the ever-growing demand for treatment at the Cardiology Unit, public support is always welcome. Maintenance and improvements to the Cardiology Unit are attended to with monies from the Cardiology Unit Trust Fund. Donations could be sent to The Cardiology Unit Trust Fund, C/o The Institute of Cardiology, Colombo National Hospital, Colombo 7.

By Kumudini Hettiarachchi
The "hole" of my heart is yours, boldly states a ceramic mug with a large heart cut into its side, on the table of the Chief Cardiologist. It stands cheek-by-jowl with a rubber heart. They are apt, for just outside the Chief Cardiologist's door stand an expectant mother, a woman carrying a baby with a large bandage on the chest, a gaunt young man and an old man on a stretcher. All carrying files full of paper. All awaiting help for some heart problem at the Cardiology Unit of Colombo's National Hospital. 

A pain in the chest is what has brought some of them to the Cardiology Unit. They have come for different ailments and what the cardiologists do here is treat them medically, carry out in-depth investigations at the well-equipped labs and if the diagnosis is such, refer them for surgery for such things as hole in the heart, valve replacement and, of course, by-passes. Admissions to the unit are through the outpatients department (OPD) of the National Hospital. 

The Institute of Cardiology has a coronary care unit (CCU) and also a step-down intermediate coronary care unit. All patients who are seriously ill are first kept in the CCU and once their condition improves sent to the step down unit.

If there are symptoms (see graphic) of a heart attack or someone suspects that he is about to get one, the most important thing to do is go to hospital immediately. "Do not delay," stresses Chief Cardiologist Dr. S.R. de Silva.

What is a heart attack? 

A heart attack occurs when a clot blocks the blood flow to the heart resulting in part of the heart muscle dying. If someone has suffered a heart attack, what the doctors will do is give a clot-busting drug (streptokinase) to dissolve the clot and ensure the flow of blood to the heart muscle, preventing it from getting damaged further. But this has to be done soon, within three to four hours of the heart attack occurring.

The Cardiology Unit is equipped with a wide range of machines, from basic X'ray machines to echocardiograms (ECGs) and treadmill machines. Different procedures, some invasive, others not, are carried out depending on the problem. 

Echocardiograms taken using an ultra-sound scanner give two-dimensional pictures of the heart. These "cuts" of the heart help the doctors to see structural defects such as holes in the heart, obstructed or leaking valves, whether the heart muscles are working properly, whether the blood flow is normal, whether there are any clots in the heart and even whether there is any problem with excess fluid around the heart. "By looking at these scans we can assess most of the heart defects," says Dr. de Silva.

The treadmill exercise test is done on a patient suffering from chest pains to evaluate whether the pains are due to a cardiac problem. The speed and elevation of the treadmill are gradually raised to increase the workload of the heart to precipitate ischaemia to the myocardia. This means a reduction of the blood supply to the heart muscles.

When doctors suspect blocked coronary arteries, cardiac catheterization (coronary angiography) is done to find out how many blocks there are. About five to seven of such procedures are carried out everyday at the Cardiology Unit. If the patient has only one or two blocks, coronary angioplasty is performed without opening the chest under anaesthesia. What coronary angioplasty entails is sending a catheter with a balloon, through a puncture in the groin, to correct the block by pushing the plaque closer to the artery wall. Some of these patients also have an insertion of stents, following the angioplasty. The stent or tube is placed in the artery, like a scaffolding to prevent the plaque from once again blocking the artery. 

However, if there are many arterial blocks, then the doctors would decide on coronary by-pass surgery. 

There are also "interventional procedures" for such problems as mitral stenosis, which is caused by the obstruction of the mitral valve, due to rheumatic heart disease. This is called percutaneous balloon mitral valvularplasty. Five years ago this disease required surgery. 

"But not anymore. Now it needs only one puncture under local anaesthesia to enter a vein and send a balloon catheter to correct the obstruction. We also do percutaneous pulmonary balloon valvularplasty and aortic balloon valvularplasty to correct the obstruction of the pulmonary (which takes blood to the lungs) and aortic (which takes blood all over the body) valves respectively," explains Dr. de Silva.

In the case of patients with a history of blackouts or palpitations, a recording of the heart rhythm during 24 hours is taken, in an investigation called 24-hour Holter monitoring. Sometimes patients with giddy spells or blackouts are found to have a very slow heart rate and would require the insertion of a permanent pacemaker. Though a very expensive procedure, it is performed free of charge at the Institute of Cardiology.

Dr. de Silva says that the Cardiology Unit has a daily outpatients' clinic where about 150 are treated. Around 100 echocardiograms are done everyday at the lab. He is also in the process of getting a cardiac electrophysiology unit installed at the Institute, for investigation of irregular heartbeats (cardiac arrythmias). Those with arrythmias could be treated by radiofrequency ablations of the heart, for which earlier they had to seek treatment abroad. 

Private sector

"By-pass ekak karaganna puluwanda?" (Can a by-pass be done?), queries a middle-aged man from the receptionist in the airy and disinfected lobby of a private hospital. The man is accompanied by his wife, who is carrying a polythene bag with medical reports. The couple from a middle class background are directed to the 'Heart Centre' of Durdans, indicating how easy it is to get by-passes done, unlike in those days when patients had to go abroad for surgery.

When a patient with chest pain is brought, he is first attended to in a resuscitation area, where his condition is monitored and the required drugs given. "The first six hours are critical," says the Medical Administrator of Durdans. The area is equipped with syringe pumps, which monitor the quantity of drugs given to the patient. There is minute control of the drugs being given unlike in those days when they were administered through the drip. 

In exceptional cases where the heart stops after a heart attack, a defibrillator is used to "shock" the heart into beating again. Once the patient's condition has been stabilized, he is moved to the eight-bed Coronary Care Unit (CCU) where he comes under the care of consultants and specially trained staff. Usually the patient is kept there for about three to four days, necessary treatment given and transferred to a room.

At the CCU every patient has an individual monitor, while there is also a central monitor which would beep if there is any problem with a patient. "This is an added precaution to alert the staff," says the Medical Administrator. Durdans and Nawaloka, the two hospitals we contacted in the private sector have all the equipment ranging from echocardiographs to treadmill machines. They too have cardiac catheterization laboratories where angiography is done to check out where the blocks are. "Under this procedure, a measured dose of radio opaque dye is injected to blood vessels and filmed to detect where the blocks are," the Durdans' Medical Administrator explained. 

As at the Cardiology Unit of the National Hospital, they too carry out angioplasty, but if there are too many blocks, the patient is taken in for heart surgery.

"The facilities at Durdans are equal to those found all over the world, even in places like Cardiff," says Dr. Nihal Kulatilake who had the honour of setting up the Durdans Heart Centre and also the Nawaloka heart unit in 1995. The theatre and intensive care unit facilities are equal. "However, a step down or high dependency unit is needed," says Dr. Kulatilake, who shuttles between Durdans and the University Hospital of Wales every six months. 

Within two to three hours after a by-pass, if the patient's condition is stable, he is not bleeding, the pressure is stable and the blood gases are normal, then he can be ex-tubated. An ex-tubated patient (when the patient is off the ventilator), should be moved out of the CCU. He is off the danger list and should be sent to a step down unit to make room for a more critical patient, says Dr. Kulatilake.

Talking casually about CABAGE (not the eating variety but medical jargon for coronary artery by-pass grafts), he says in Sri Lanka there is a slight problem in treating heart patients because "people don't tell the truth about their drinking". The doctor must know, because that has a significant impact on the patient's management. Tell him the truth. Be honest with your doctor, he has to deal with your life, stresses Dr. Kulatilake. 

Nawaloka Private Hospital too has similar facilities, starting with an Emergency Treatment Unit, where a resuscitation team is on hand to attend to patients even with cardiac arrest. "We have the full gamut of equipment and also a special coronary care unit and a cardiac theatre where we perform open-heart surgery, by-pass surgery, valve replacement and also correct heart abnormalities," explains Nawaloka's Medical Director, adding that there is also very strong lab support. Adds he, "Nawaloka does two heart surgeries a day and about 75 a month."

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