Video : Coronary Artery Angioplasty - A way to treat atherosclerosis

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Video : First Aid for Stroke

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Video: Atherosclerosis in Action

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What is Stroke?

A stroke, also known as cerebrovascular accident (CVA), is the rapid loss of brain functions due to the lack of blood flow caused by blockage such as thrombosis, arterial embolism and hemorrhage. When the blood vessels get clogged, the brain cells become deprived from nutrients and oxygen as there is no blood supply. Eventually, that part of the brain starts to die. A stroke occurs. The results of having stroke are impairments in memory, speech ability and physical mobility.

 According to National Stroke Association of Malaysia, stroke is the third largest cause of death in Malaysia.

The types of stroke is divided into three:

• Ischemic stroke-It is main type of stroke. It is due to blockage of blood vessels supplying the brain.
• Hemorrhagic stroke-It is due to bleeding into or around the brain.
• Transient ischemic stroke(TIA)- A mini-stroke

Images are from Google Images
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Stroke is the third largest cause of death in Malaysia. Only heart diseases and cancer kill more. It is considered to be the single most common cause of severe disability, and every year, an estimated 40,000 people in Malaysia suffer from stroke. Anyone can have a stroke, including children, but the vast majority of the cases affect adults. - National Stroke Association Malaysia

References:

1. http://www.strokeassociation.org/STROKEORG/AboutStroke/Types-of-Stroke_UCM_308531_SubHomePage.jsp
2. http://en.wikipedia.org/wiki/Stroke

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Video : Stroke Animation

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A Hearty Diet

President of the Nutrition Society of Malaysia and nutritionist Dr Tee E Siong advises us to eat smart to prevent heart disease.

WHAT role does nutrition play in the causation of cardiovascular disease?

Unhealthy dietary habits have been recognised as a major leading cause of heart diseases. Excessive intake of energy (derived mostly from fat and simple sugars), animal fats, high cholesterol food and lack of dietary fibre can lead to overweight/obesity problems.

The overweight problem is a major risk factor for many diseases such as heart diseases, diabetes and other chronic diseases.

According to Dr Tee, to prevent heart disease, healthy eating must start at a very young age.

Thus, practising healthy eating habits is a crucial step that needs to be taken in order to reverse the development of heart diseases. Heart diseases are preventable if one practices healthy eating habits as well as lead an active lifestyle.

The prevalence of risk factors for heart diseases has also been on the rise in the past few decades. As president of Nutrition Society of Malaysia (NSM), what would your advice be to Malaysians in order to reduce their risk of heart diseases?

In order to reduce the risk of heart disease, one should always practise healthy eating. The Malaysian Dietary Guidelines have outlined 14 key approaches towards a healthy dietary pattern. Several of these approaches have direct relevance to reducing risk of heart disease.

First, one should limit intake of foods that are high in fats and oils. These include foods high in saturated fat (from animals), cholesterol (eg internal organ meats) and trans-fatty acids (hydrogenated margarines or foods prepared with “hardened fats”).

Other oily foods that are deep-fried should also be reduced to occasional treats. Practise healthier cooking methods like steaming or grilling instead of frying as much as possible in order to minimise fat intake.

The intake of deep-fried or oily foods should be reduced in order to reduce fat intake. 

The second key area to look at is salt. Salt is associated with raised blood pressure and this is one of the risk factors for heart diseases. Therefore, one should also choose foods that are less salty (avoid salted eggs, fish), avoid processed foods such as sausages, meat burgers and nuggets, as well as looking at the use of sauces in cooking.

Thirdly, sugar consumption should be kept to a minimum by avoiding foods that are prepared with high sugar (kuih, cakes, sweets) and replace with healthier options such as fruits.

Also, reduce consumption of drinks that are high in sugar content such as carbonated drinks, canned drinks, cordials, or drinks prepared with sweetened condensed milk such as teh tarik and coffee.

The fourth key area to pay attention to is to eat adequate amount of whole grains/cereals and increase fruits and vegetables consumption to two and three servings (per day) respectively. Plant-based foods contain healthy components other than nutrients such as plant sterols, phytochemicals and dietary fibres,

Finally, to eat healthily, one can use the Malaysian Food Pyramid as a guide to achieve a well balanced diet, to eat in moderate amounts, and to always aim for a variety of food choices.

Besides eating, being physically active every day is another important component in combating heart disease. Even 30 minutes of walking every day can help, rather than doing nothing at all.

Lastly, maintain a healthy body weight and a healthy lifestyle by avoiding smoking and alcohol as much as possible.

You mentioned the importance of healthy eating for the prevention of heart disease. At what age must a person start to be concerned about his eating habits so as to reduce the risk of heart disease? 

To prevent heart disease, healthy eating must start at a very young age. If a child is overweight at 10 years old, he is very likely to remain overweight at 20 years and even 30 years, and he will be at risk of getting heart disease.

Fat and cholesterol build-up in the arteries have been known to commence from childhood.

Often, the dietary habits of a person is set from young. The influence of parents and the environment also shapes the eating habits of young children. Moreover, changing habits later on in life is a more challenging task as a lot more motivation is needed.

Hence, it is important that one starts practising healthy eating habits from childhood. The roles of parents are emphasised as they are important role models in cultivating healthy dietary habits in their children from young.

Sunday October 2, 2011
http://thestar.com.my/health/story.asp?file=/2011/10/2/health/9609507&sec=health

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Less Salt Please

By Dr TEE E SIONG

Reducing salt intake will lead to a decrease in blood pressure and reduce the risk of cardiovascular diseases.

SALT, or sodium chloride, is the main source of sodium in our diet. Sodium is an essential mineral that is required in minute amounts daily. However, excessive intake can increase risk of various adverse health effects.

Excessive dietary salt has been associated with high blood pressure and its related co-morbidities. Therefore, health authorities have recommended reducing salt intake so as to reduce health risks.

In this write up, I will highlight the ninth key message of the Malaysian Dietary Guidelines (MDG) 2010, which focuses on reducing excessive salt intake.

The MDG 2010 is a set of advisory statements aimed at promoting appropriate dietary patterns and active living. I have summarised the 14 key messages contained in the MDG 2010 and dealt in detail eight of the key messages in previous write-ups.

Too much salt in the diet can lead to high blood pressure and its related co-morbidities. 

Understanding salt and sodium

Salt, also known as common salt or table salt, is normally obtained from sea water or rock deposits. It is an inorganic compound consisting mainly of sodium and chloride ions, i.e. NaCl.

Both the sodium and chloride ions are needed by man in small amounts. The sodium component of salt is the element of concern in this key message of the dietary guideline.

Sodium (with the chemical symbol Na), is an essential mineral that is required daily in a minute amount. However, excessive intake is known to increase risk of adverse effects.

Salt is the major source of sodium in the Malaysian diet. One teaspoon or 5g of salt provides 2,000mg of sodium. It is, however, important to bear in mind that in addition to salt, sodium may also be present in food in other forms, such as monosodium glutamate (MSG), sodium nitrate and sodium benzoate.

Scientific basis for the recommendations

Two main types of scientific evidence have been used as the basis of the recommendations in MDG 2010. The first is data demonstrating that excessive intake of salt (sodium) is positively related to hypertension or high blood pressure.

Hypertension is a symptom, not a disease, but it is a strong risk factor for cardiovascular and kidney diseases. For over 15 years, the evidence of an association between dietary salt intake and blood pressure has been accumulating. Many epidemiological studies have demonstrated that high salt intake is associated with an increased risk of high blood pressure and its associated health conditions.

In Malaysia, the prevalence of high blood pressure has increased in the past decade. Results from the Second National Health and Morbidity Survey (NHMS) in 1996, indicated 33% of adults aged 30 years and above had hypertension. Ten years later, the figure has increased to even higher, at 43%, as reported by the Third NHMS in 2006. It is a major risk factor for cardiovascular disease and premature death. Heart diseases, diseases of the pulmonary circulation and cerebrovascular diseases contribute up to 25% of the cause of deaths in Health Ministry hospitals.

Excess sodium intake has also been associated with a number of health conditions other than raised blood pressure. It also increases the risk of stomach cancer; it increases the rate of deterioration in kidney function of patients with renal disease; it is associated with urinary stones; and it may aggravate asthma and osteoporosis.

The second type of evidence is data revealing that lowering the average salt intake of populations can decrease the problem of hypertension. It has been generally accepted that reducing the average population salt intake would proportionately lower population average blood pressure levels and reduce risk of cardiovascular diseases.

The greatest reduction in blood pressure has been observed when a diet rich in fruits, vegetables and low-fat dairy foods is combined with a low-salt diet. This reduction in blood pressure has been shown to result in a significant reduction in strokes and coronary heart disease.

Consumers should read the nutrition information panel (NIP) and find out the amount of sodium in foods they intend to purchase.

Malaysians take too much salt

Data in the country show that the intake of salt and sodium amongst certain communities has exceeded the recommended amount. The Malaysian Adult Nutrition Survey reported that the mean sodium intake of Malaysian adults was about 2,575mg a day, with small differences between rural and urban population.

Not surprisingly, the Orang Asli were found to have the lowest daily intake of sodium of less than 1,000mg, whilst the Chinese had the highest mean intake of almost 3,000mg.

As will be discussed below, the recommendation is to limit sodium intake to 2,000mg per day.

The salt added in cooking and present in sauces and seasonings represent the major sources of sodium in our diet. Many of our dishes make use of ingredients such as soy, oyster and fish sauces as well as prawn paste, which are all high in sodium. Hence, this key message on reducing salt intake also includes cutting down on sauces.

Some dishes also use excessive amounts of flavour enhancers such as monosodium glutamate (MSG) and flavouring cubes. The consumption of highly salted fish, egg and vegetables are also not uncommon.

Malaysians also frequently eat “outside” foods, either as take-aways or eaten at the food premises itself. These foods could be rather salty, and are frequently added with various sauces and seasonings. These include various local dishes from coffee shops, cafes, restaurants as well as franchise fast food outlets.

Approaches to reducing salt/sodium intake

The Malaysian Dietary Guidelines have recommended limiting salt intake to no more than one teaspoon (2,000mg sodium) per day.

This should take into account total sodium intake from all dietary sources, for example, additives such as monosodium glutamate and preservatives such as sodium nitrate and sodium benzoate.

Various strategies are required to reduce salt intake. (For details of the dietary guideline recommendations, read MDG Key Message 9.)

The first approach would be to use less salt and seasonings in cooking at home. Instead, use various natural herbs and condiments to add flavour to your cooking. It is therefore recommended that you try preparing your meals such that you can control the amount of salt and sauces used.

The second approach relates to choosing foods with less salt and sauces when purchasing foods away from home, either as takeaways or when dining out. Malaysians eat out a lot, and with widespread use of salt and seasonings, large amounts of sodium can be ingested. It is therefore important to choose dishes wisely when dining out. Ask for less salt!

The third approach would be to reduce the salt content of processed foods and drinks. Consumers should read the nutrition information panel (NIP) and find out the amount of sodium in foods they intend to purchase.

Although it is currently not compulsory to include sodium content in NIPs, many food items have voluntarily included this in the list. Use the NIP to compare the sodium content of different brands of similar products.

As a further guide to food choice, you can look for claims on the label that say “low sodium”, “very low sodium” or “sodium free”.

These claims are permitted by the Health Ministry for products that contain low or very low amounts of sodium as specified by the food regulations.

You can do it

Those who are used to a higher salt intake will at first miss the taste of salt when they begin a lower salt intake. But the palate soon adapts to lower sodium levels, and people will eventually prefer foods with less salt.

Most people attempting to limit their salt intake are satisfied with many other ways of adding flavour to their foods and do not miss salt after their palates have adapted.

You can also do it. Make that change. Use less salt and sauces in your cooking. Ask for less salt when eating out. Read the NIP and purchase foods with less sodium.

Let the MDG 2010 guide you and your family members in adopting healthy eating habits and an active lifestyle.

The complete MDG is obtainable from the Health Ministry website: www.moh.gov.my/v/diet. The Nutrition Society of Malaysia has also made available leaflets of those MDG suitable for the public (www.nutriweb.org.my).

Dr Tee E Siong pens his thoughts as a nutritionist with over 30 years of experience in the research and public health arena. For more information, email starhealth@thestar.com.my.

Sunday February 19, 2012

thestar.com.my/health/story.asp

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Keeping Hearts Alive

The latest developments in stent technology for treating coronary heart disease.

BASED on the latest WHO data published in April 2011, the number of deaths from coronary heart disease (CHD) in Malaysia accounts for 22.18% of total deaths.

In this modern day and age, however, there are various treatments for CHD, which include medication, coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI).

PCI is also called balloon angioplasty, in which a doctor threads a catheter into the coronary artery and inflates a balloon at the tip. Then, a wire-mesh structure called a stent is left behind to keep the artery open and prevent it from narrowing again.

Between the two methods of revascularisation in treating CHD, PCI is much less invasive, has a lower risk of procedural stroke, shorter hospital stay and recovery period, and is done through a pin-hole compared to bypass surgery.

The survival to 10 years is similar for both procedures. As a result, PCI is performed more commonly than CABG in the treatment of patients with CHD.

In Washington state in the US, the prevalence of PCI is almost five times more than CABG.

The latest developments in PCI procedures were recently highlighted by consultant interventional cardiologist Dr Yap Yee Guan. According to Dr Yap, Malaysians are still not fully aware of the existence of various stents in the country. He also explained that many Malaysians are unaware of PCI as a treatment for heart attacks.

Describing the procedure used in PCI, where stents are inserted to keep the artery open, Dr Yap said, “There are various types of stents, which have distinctive properties, as well as advantages and disadvantages. Patients should seek proper consultation from their respective cardiologist on the suitable type of stent to be used, as the indication for each patient may be different.”

Dr Yap explained about the three types of coronary stents available, namely, bare metal stents (BMS), drug eluting stents (DES), and bio-engineered stents (BES). Clinically, DES and BES are more efficacious and have better long-term outcomes, though at a higher cost than BMS.

Dr Yap highlighted that there will be a new innovative stent that has a drug as well as a bioengineered surface, known as dual therapy stent (DTS), which will be available in Malaysia by mid-2012. DTS combines properties of a drug-eluting stent (DES) and bio-engineered stent (BES) to address the issue of restenosis (renarrowing of the artery) and to improve healing and safety.

According to Dr Yap, post-surgery medication treatment such as dual-antiplatelet therapy (DAPT) is vital as it reduces the chances of blood clot after stenting.

REMEDEE, the trial of the new DTS stent, was presented last year at a major conference in San Francisco. This is a multinational trial with participation from 17 sites and eight countries. Two sites from Malaysia that participated in this trial were Institut Jantung Negara, Kuala Lumpur, and Pusat Jantung Hospital Umum, Sarawak.

Sunday March 4, 2012
http://thestar.com.my/news/story.asp?sec=health&file=/2012/3/4/health/10830306

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Causes of Atherosclerosis

Over time, as you gradually age, your arteries naturally begin to harden and get narrower, leading to atherosclerosis. However, there are many factors that can dangerously accelerate this process. These are described below.

High-fat diets and cholesterol

Cholesterol is a type of fat that is essential for the functioning of the body. Cholesterol helps to produce hormones, to make up cell membranes (the walls that protect individual cells) and to protect nerve endings.

There are two main types of cholesterol:

• Low-density lipoprotein (LDL-C) is mostly made up of fat, plus a small amount of protein. This type of cholesterol can block your arteries, so it is often referred to as 'bad cholesterol'.
• High-density lipoprotein (HDL-C) is mostly made up of protein, plus a small amount of fat. This type of cholesterol can help to reduce any blockage in your arteries, so it is often referred to as 'good cholesterol'.

Most of the cholesterol that your body needs is manufactured by your liver. However, if you eat foods that are high in saturated fat, the fat is broken down into LDL-C  or more commonly referred to as bad cholesterol.

Foods that are high in saturated fat include:

• butter
• biscuits
• cakes
• bacon
• sausages
• processed meat
• cream

The LDL-C l sticks to your artery walls in the form of fatty deposits which, over time, gradually build up, narrowing, or completely blocking, your blood supply. The fatty deposits are also known as plaques or atheroma.

As well as a high-fat diet, a lack of regular exercise, being obese and drinking excessive amounts of alcohol can also increase the levels of LDL cholesterol in your body. The medical term for having high cholesterol is hyperlipidemia.

Smoking

Smoking can damage the walls of your arteries. If your arteries are damaged by smoking, blood cells, known as platelets, will form at the site of the damage to try to repair it. This can cause your arteries to narrow.

Smoking also decreases the blood's ability to carry oxygen around your body, which increases the chances of a blood clot occurring.

High blood pressure

If you have high blood pressure (hypertension) it will damage your arteries in the same way as cigarette smoke. Your arteries were designed to pump blood at a certain pressure. If that pressure is exceeded, the walls of the arteries will be damaged. High blood pressure can be caused by:

• stress
• being overweight
• drinking excessive amounts of alcohol
• smoking
• a lack of exercise

Lack of exercise

As with being overweight or obese, a lack of exercise is not directly related to an increased risk of atherosclerosis and cardiovascular disease (CVD). However, it is linked to an increased risk of being overweight or obese and having high blood pressure (hypertension).

Obesity

Being overweight or obese does not directly increase your risk of developing atherosclerosis and CVD, but it does lead to related risk factors that do. In particular, people who are overweight or obese:

• have an increased risk of developing high blood pressure
• tend to have higher levels of cholesterol as a result of eating a high-fat diet
• have an increased risk of developing type 2 diabetes

Diabetes

If you have poorly controlled type 1 or type 2 diabetes, the excess glucose in your blood can damage the walls of your arteries.

Alcohol

Drinking an excessive amount of alcohol can cause high blood pressure (hypertension) and raised blood cholesterol levels, increasing your risk of developing atherosclerosis and CVD.

Most heavy drinkers also tend to have other unhealthy habits, such as smoking, eating a high-fat diet and not taking enough exercise.

Family history

If you have a first-degree relative (a parent, or a brother or sister) with atherosclerosis and CVD, you are twice as likely to develop similar problems compared with the population at large.

Ethnicity

Rates of high blood pressure and diabetes are higher among people of African and Afro-Caribbean descent. This means that people in this group also have an increased risk of developing atherosclerosis and CVD.

People of South Asian descent (those from India, Bangladesh, Pakistan and Sri Lanka) are five times more likely to develop diabetes compared with the population at large. Again, this increases this group’s risk of developing atherosclerosis and CVD.

Air pollution

Research that was carried out during 2009 suggested that air pollution, in particular traffic pollution, can cause a slight increase in levels of atherosclerosis.

Researchers found that people living within 50 metres of a major road had higher levels of atherosclerosis than would otherwise be expected.

Reference:
http://www.nhs.uk/Conditions/Atherosclerosis/Pages/Causes.aspx

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The Natural History of Atherosclerosis

The atherosclerotic process is associated with the aging process. Having been documented in the autopsies of ancient mummies, atherosclerosis appears to be universal in humans throughout the history of mankind. This natural history can be documented in every human.

The natural history of atherosclerosis begins at birth. The arteries are patent and clean at birth. Atherosclerosis begins in childhood ( by the age of 10) as deposits of cholesterol and its esters, referred to as fatty streaks, in the intima of large muscular arteries.


In some people and at certain arterial sites, more lipid accumulates and is covered by a fibromuscular cap to form a fibrous plaque. Further changes in fibrous plaques render them vulnerable to rupture, an event that precipitates occlusive thrombosis and clinically manifest disease (sudden cardiac death, myocardial infarction, stroke, or peripheral arterial disease).

In adults, the fibrous plaque invades a large part of the artery, damaging the artery to the extent of precipitating a clinical event. This stage of the disease is called "Clinical Lesions".  Elevated non-HDL-cholesterol concentrations, low HDL-cholesterol concentrations, hypertension, smoking, diabetes, and obesity are associated with advanced atherosclerotic lesions and increased risk of clinically manifest atherosclerotic disease.


The figure below shows the natural history of atherosclerosis against the ageing process:

The development of the fatty streak in childhood is depicted as a reversible process. In adolescence, some fatty streaks accumulate more lipid and begin to develop a fibromuscular cap, forming the lesion termed a fibrous plaque. In subsequent years, fibrous plaques enlarge and undergo calcification, hemorrhage, ulceration or rupture, and thrombosis. Thrombotic occlusion precipitates clinical disease, depending on which artery is affected.

Reference:
http://www.indiana.edu/~k562/athero.html

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Coronary Heart Disease Prevention and Treatment

Prevention

The best way to prevent coronary heart disease are by monitoring and modifying certain risk factors and live with a healthy lifestyle at a young age.

You can’t change some risk factors such as age and family history but you can change the following risk factors :

• High blood fats, the bad LDL , good Hdl and triglycerides
• Diet
• Smoking
• Diabetes
• High blood pressure
• Obesity
• Inactivity
• Emotional stress

Self-care at Home

The most important ways to reduce the risk of heart disease is yourself and not the control of your health care provider. First way is to change your lifestyle . Lifestyle changes are the most effective way to prevent heart disease from getting worse or reducing the risk of getting heart disease.

Everyone should take the following measures to lower the risk of heart disease:

1. Eat a heart-healthy diet
2. Lower your fat intake
3. Lower your blood cholesterol to a certain level , especially the LDL cholesterol
4. Engage in regular exercise
5. Quit smoking
6. Control high blood pressure and diabetes
7. Take a low-dose aspirin daily
8. Eat 1 or 2 servings of fish or seafood each week
9. Eat nuts that are rich in monounsaturated fats, such as hazelnuts, almonds, pecans, cashews, walnuts, and macadamia nuts(small amount)
10. Cooking foods with garlic, which may have cholesterol-lowering effect
11. Not more than 2 drinks of alcohol per day for men and 1 drink per day for women is recommended to raise the HDL 

Note: People who have liver or kidney problems, problems with alcohol abuse are not recommended to use alcohol

Medical Treatment

Aspirin

Aspirin will redice the risk of developing angina or heart attack by reducing the tendency of blood to clot

• It reduces the chance that a clot will form in the coronary artery
• There are some side effects of aspirin such as bleeding problems or ulcers

Calcium channel blockers

Calcium channel blockers causes the coronary artery to dilate which improves the flow of blood. They also reduce blood pressure and slows down the heart beat rate. Angiotensin-converting enzyme inhibitors a.k.a ACE inhibitors works by dilating the blood vessels .Thus increasing blood flow.

Beta- blockers

Beta-blockers will decrease your heart beat rate and blood pressure. Therefore reducing your heart oxygen demand.                                              

Nitroglycerin

This medication reduces angina , both by decreasing your heart’s oxygen demand and by dilating the coronary arteries, increasing the oxygen supply.

Statins

Statin drugs work by reducing the amount of cholesterol and other fats in your blood.

• This will change the inner lining of the blood vessels so plaques are less likely to form
• They slow down the progression of coronary heart disease
• Examples of statins: atorvastatin(Lipitor),pravastatin(Pravachol), simvastatin(Zocor), lovastatin(Mevacor) and rosuvastatin(Crestor) 

Statin drugs

  

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Risk factors for strokes

Controllable risk factors

• High blood pressure

The arteries wall will weaken when high blood pressure constantly passes through it because it puts unnecessary strains on the blood vessels of the circular system. Eventually, it bursts. It will bleed into the brain tissues and spaces between skull and brain. This affects the brain and causes strokes. If a person has an untreated hypertension, he will have 4 times the risk of getting a stroke. High blood pressure also leads to aneurysm. Aneurysm is a ballooning of a portion of a blood vessel due to the weakening part of its wall. When the pressure is too high, it burst and leads to stroke again.

• Diabetes mellitus

Uncontrolled diabetic mellitus causes an increase in the systolic blood pressure. This increases the blood pressure and leads to stroke.

• Cigarette smoking

 

Smoking doubles the risk of stroke. It causes artherosclerosis, which is hardening of blood vessels. When it hardens, the blood vessels become narrow. This also leads to high blood pressure, another main risk factor of stroke. The atherosclerotic plaque that dislodges increases the likelihood of blood clotting. This reduces the amount oxygen passed to the brain. Eventually some brain cells die due to lack of oxygen which leads to stroke.

• High blood cholesterol and lipids

High blood cholesterol and lipids causes artherosclerosis. The formation of plaques on the wall of blood vessels decreases the amount of blood flow to the brain. At severe condition, the blood vessel is blocked and the blood supply to the brain is cut off. This causes stroke.

• High red blood cell count

 

Excessive amount of red blood cell thickens the blood which increases the chance of blood clotting.

Other controllable risk factors include heart disease, history of transient ischemic attacks, lack of exercise and physical inactivity, obesity, substance abuse, abnormal heart rhythm and cardiac structural abnormalities.

Uncontrollable risk factors

• Age

 

After the age of 55, the risk of getting stroke may be more than double.

• Race

 

Africans, south Asians, Hispanic and people from first nations have higher rates of diabetes mellitus and high blood pressure. This two are the major risk factors of stroke.

• Gender

 

Female before menopause has lower possibility of getting stroke compared to male. However, the survival rate of female patients with stroke is lower than that of males.

Other uncontrollable risk factors include history of prior stroke and heredity.

References :

http://cholesterol.about.com/lw/Health-Medicine/Conditions-and-diseases/Cholesterol-and-Stroke-Risk.htm

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What is coronary heart disease(CHD)?

Coronary heart disease is also known as coronary artery disease(CAD). This disease is caused by the narrowing of the small blood vessels that supply blood and oxygen to the heart. It is a major cause of illness and death. 


 Coronary heart disease is generally caused by atherosclerosis - when plaque (cholesterol substances) accumulates on the artery walls, causing them to narrow, resulting in less blood flow to the heart. Sometimes a clot may form which can obstruct the flow of blood to heart muscle. Coronary heart disease commonly causes angina pectoris (chest pain), shortness of breath, heart attack (myocardial infarction) and other symptoms. 


 The coronary arteries are called so because they encircle the heart like a crown (corona in Latin means crown). 


Statistics
 According to the National Institutes of Health (NIH), USA, coronary heart disease is the leading cause of death for males and females in the USA. 17.6 million Americans were thought to have had the condition in 2006. It caused the death of over 425,000 people in the USA in 2006. 


 According to the National Health Service (NHS), UK, coronary heart disease causes the death of 1 in every 4 men and 1 in every 6 women in the United Kingdom - it is the UK's biggest killer. The risk of developing the disease increases with age. More males are affected than females.


References :
http://www.medicalnewstoday.com/articles/184130.php

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What is Atherosclerosis?

Atherosclerosis (also known as arteriosclerotic vascular disease or ASVD) is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol. It is a syndrome affecting arterial blood vessels, a chronic inflammatory response in the walls of arteries, caused largely by the accumulation of macrophage white blood cells and promoted by low-density lipoprotein ( LDL-C - plasma proteins that carry cholesterol and triglycerides) without adequate removal of fats and cholesterol from the macrophages by functional high-density lipoproteins (HDL-C). It is commonly referred to as a hardening or furring of the arteries. It is caused by the formation of multiple plaques within the arteries.

The atheromatous plaque is divided into three distinct components:

1. The atheroma ("lump of gruel," from ἀθήρα, athera, gruel in Greek), which is the nodular accumulation of a soft, flaky, yellowish material at the center of large plaques, composed of macrophages nearest the lumen of the artery
2. Underlying areas of cholesterol crystals
3. Calcification at the outer base of older/more advanced lesions.

Reference:

http://en.wikipedia.org/wiki/Atherosclerosis

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Treatment for Stroke

Investigation of acute stroke is to confirm the vascular nature of the lesion, distinguish cerebral infarction from haemorrhage and identify the underlying vascular disease and risk factors.

Initial investigations includes simple blood tests, an electrocardiogram and brain imaging. When there is uncertainty about the nature of stroke, further investigations are carried out. This usually applied to younger patient who are less likely to have atherosclerotic disease.

Brain imaging using CT scan or MRI should be carried out in all patients with stroke. CT  is widely available and the most practical method of imaging the brain. It will usually exclude non-stroke lesions like subdural haematomas and brain tumours. CT scan is used to look for bleeding within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA.

MRI is not as widely available as CT, scanning times are longer and it cannot be used in some individuals with contraindications. However, MRI diffusion weighted imaging can detect ischaemia earlier than CT and other MRI sequences can also be used to demonstrate abnormal perfusion. MRI is more sensitive than CT in detecting strokes that affects the brain stem and cerebellum. An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram).

Stroke can also be investigated by computerised tomography with angiography. This can be done by using dye and inject it into a vein in the arm. Images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. Besides, other abnormalities of brain blood flow may be evaluated.

Tissue plasminogen activator (TPA). Alteplase (TPA) is used  to dissolve the blood clot that is causing the stroke. The earlier it is given, the better the result. TPA must be given within four and a half hours after the onset of symptoms. For patients who waken from sleep with symptoms of stroke, it counts when they were last seen in a normal state.TPA is injected into a vein in the arm but the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. This technology is not availble in all hospitals.TPA may reverse stroke symptoms in most patients but it may also cause bleeding in some patients, causing stroke to become worse.

Heart tests are often performed in stroke patients to search for the source of an embolism. Electrocardiograms (EKG or ECG) can be used to detect abnormal heart rhythms .

Blood tests are done to check for kidney and liver function, electrolyte abnormalities, blood clotting function and anaemia.

Heparin

Formal anticoagulation with heparin has been widely used in treating stroke in the past. This does improve the patient’s recovery. However, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes.

Aspirin

Aspirin should be started immediately after an ischaemic stroke unless  rt-PA has been given, in which case it should be withheld for at least 24 hours. Aspirin reduce the risk of early recurrence and has a small but measurable effect on long-term outcome.

Corticosteroids, haemodilution, vasodilators and ‘neuroprotective’ agents

Routine use of these agents should be avoided because they may have adverse effects. None of it has been shown to improve patient outcomes.

Managing other Medical Problems

• Patient will be given fluids because if the patient is having a stroke, he or she may often be dehydrated.
• Patients who have difficulty in breathing will be assessed and treated.
• Oxygen may be given to make sure that the brain is getting the maximal amount.
• Patients are not allowed to eat or drink until his or her ability to swallow is assessed.
• Medicine including pills, nitroglycerin paste or IV injections can be used to lower the blood pressure. However,  blood pressure should not be too low so that the brain can get enough oxygen. If the blood pressure is very high, patients would be placed on a continuous IV flow of medication.
• The blood sugars level of patients with diabetes is often elevated after a stroke. The glucose level in patients should be controlled to minimise the size of strokes.
• Patients who have ischemic attacks  may undergo  blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels.
• No smoking .

Management is aimed at minimising the volume of brain that is irreversibly damaged, preventing complications , reducing the patient’s disability and handicap through rehabilitation, and reducing the risk of recurrent episodes.

The rehabilitation process is shown in the following:

1. occupational therapy - To regain the  function in the arms and hands .
    
2. physical therapy-  To improve strength  and help in walking.
3. speech therapy -  To relearn talking and swallowing. 
4.  family education - To help them in facing and coping with types of challenges in life.

However, total recovery is not really possible in many cases but  many stroke patients can return to their independent lives.

Patients who have more severe stroke are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.

Reducing the risk of further strokes and other vascular problems

The average risk of having a further stroke is 5-10% within the first week of stroke or TIA, perhaps 15% in the first year and 5% per year thereafter.  Patients with ischaemic events should be put on long-term antiplatelet drugs and statins to lower down cholesterol level. The risk of recurrence after strokes can be reduces by blood pressure reduction,even for those with blood pressure in the normal range.

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