Issues of the heart

When heart attack strikes a healthy young woman

It was 1 a.m. on Sept. 28, 2005, when Michele Gorden was awakened by intense pain in the area between her sternum and throat. She was nauseous and began to think she had a severe case of indigestion. To avoid disturbing her husband, Robert, she quietly got out of bed and went to the bathroom to get some antacid tablets. In the living room, she sat in a reclining chair and proceeded to chew two pills. Within minutes she began to feel more nauseated and had to run to the bathroom to vomit. She was somewhat relieved from her nausea after vomiting, but the intense pain in her chest continued. She sat there in the chair and thought about the possible causes of the sudden manifestations which were something she had never experienced before. Was it a virus, food poisoning, or an ulcer? Heart attack was nowhere on the list. When someone like Michele, an athlete with a slim, agile figure and the cardiovascular profile of perfection, experiences chest pain, neither the patient nor the doctors suspect a heart attack as the cause.

Michele Gorden with her husband, Robert, and their two daughters, Ashley and Shelby, on the coast.

Recently, Michele had been overwhelmed from juggling the responsibilities of being a wife, a mother, and all the usual demands of a practicing dental hygienist. A culmination of feelings from sadness, anxiety, frustration, anger, fatigue, and now physical pain had her immobilized, as she sat in the chair with her clenched fist inseparable from her sternum. Hour after hour she tried to sleep in hope that she would awaken without pain. When that didn’t work she prayed for relief, and she prayed for those stricken by Katrina because it was so fresh on her mind.

The sun came up and Robert and their two little girls, Ashley and Shelby, came into the living room looking for Michele. When Michele told Robert about the persistent pain she had experienced throughout the night, he became very concerned and decided he should take her to the emergency room. It was there they learned that Michele was having a heart attack.

Everyone was stunned. Doctors, family, and friends could not believe that this healthy 40-year-old woman, who looked more like 30, could have a heart attack. Her lipid profile, inflammatory markers, blood pressure, heart rate, lifestyle, and family history were consistent with that of someone in perfect health. Yet, the routine tests showed a tiny fragment of cholesterol plaque had lodged in her left ascending coronary artery. There was a myocardial infarction in the left ventricle. It was the typical diagnosis of a “heart attack,” which more commonly occurs in a patient who has more than one predisposing factor to coronary heart disease.

Michele asked the doctor, “How could cholesterol plaque lodge in my coronary artery when my LDLs and triglycerides are so low?”

The doctor proceeded to tell her that regardless of how excellent the lipid profile, we all have arterial plaque and sometimes, albeit extremely rare in one as healthy as she, some unknown factor causes that plaque to break off and travel to the distal portion of the coronary artery, blocking blood flow to the myocardium of the left ventricle.

What could change the integrity of the vessels so much that cholesterol plaque moves from its stationary position to result in a heart attack? Scientists have theorized that stress and the fight-or-flight response can bring on a heart attack, and in individuals less healthy than Michele, it could cause sudden death.

Life after a myocardial infarction (MI)

Michele has continued with the healthy eating and exercising she did before her heart attack, but now she is taking four cardiovascular drugs. The area of the heart that was affected by the heart attack needs the help of cardiac drugs to help profuse the tissues of the myocardium and to decrease the demand on the heart. The biggest and most important lifestyle change for Michele is her perspective. She now knows that nothing is worth burdening herself with stress. No job, no person, and no situation can take her to the fight-or-flight symptoms of frustration, anxiety, sadness, or anger. A near-death experience puts everything in perspective and teaches us to see when the fight-or-flight response is appropriate, when we must physically fight or run for our lives.

The leading cause of death in women in the United States is heart attack. The numbers have risen in the past decade probably due to a multitude of factors, from the change in roles to the fast-paced lifestyle so common with many. Women have more stress in their lives now that they struggle to balance high-pressure professions and family needs. Dental hygienists in clinical practice are in very high-stress positions. They are caregivers who put patients, family, and others first, and too often it is at the expense of their own health and well-being.

Michele Gordon stands next to a photo of herself used in the American Heart Ball's "Portraits of Passion" event. In the photo, she holds a heart-shaped piece of wood as a symbol of survival. Her portrait, along with those of nine other survivors, travels the country to educate others about heart disease.

As Stephen Covey says in his book First Things First, “When what is urgent gets in the way of what is important, it is time for change.” Isn’t that typical of caregivers? Here we are putting ourselves and our own health on the back burner to cater to the needs and wants of others ... on the job, in the home, and in social circles. So often what is ”urgent” is keeping us from doing what is most important, TAKING CARE OF OURSELVES!

Hopefully, Michele’s story will make you more aware of the importance of taking care of yourself by developing healthy habits that include your reactions to all forms of stress. This article contains some new information about predisposing factors that are not as well-known as the physical conditions proven to predispose one to heart attacks: high blood pressure, elevated LDL blood cholesterol and triglycerides, diabetes, smoking, obesity, inactivity, age, and family history. The emotional and physical effects that result from everyday stresses may predispose someone to heart disease.

Heart disease risk factors

Several heart disease co-factors and independent risk factors affect people in their daily lives:

A sense of time urgency➨ A recent study demonstrated that a sense of time urgency has been associated with a risk of nonfatal MI, independent of other risk factors. Just think, there is always a sense of time urgency when a dental hygienist is keeping her eye on the schedule of patients for the day. Not only do we play “beat the clock,” but we do it on an emotional roller coaster by dealing with the various patient personalities, from those who are misbehaving to those who are apprehensive, demanding, or a sheer delight. Even the latter keeps us on the roller coaster as we constantly keep an eye on the clock.

Job strain and low decision latitude➨ In a recent study conducted with 6,895 male and 3,413 female civil servants aged 35 to 55, those with concurrent low decision latitude and high demands (job strain) were at the highest risk for coronary heart disease. As dental hygienists, we have high-demand jobs that include both physical and mental strain. Our decision latitude is high with regard to our own patient treatment plans, but usually low with regard to decision-making for the clinic or office operations as a whole. If we are looking the other way to avoid dealing with an office philosophy that we feel compromises patient care, we may be repressing feelings of guilt and dissatisfaction that increase our stress levels enough to contribute to the physical predisposing factors of heart disease, such as hypertension and elevated lipid levels.

Job insecurity➨ Job insecurity may increase the short-term risk of nonfatal heart attacks in women. From the Nurses’ Health Study, 36,910 women from the ages of 46 to 71 with clear health histories answered job insecurity questionnaires in 1992. Four years later, the study showed job insecurity appeared to significantly increase the risk of nonfatal heart attacks in the short term (two-year follow-up: RR = 1.89, 95 percent CI [confidence interval], 1.03 to 3.50), though not over a longer follow-up period (RR = 1.28, 95 percent CI, 0.82 to 2.00).

Psychosocial stress➨ The recent INTERHEART study showed that psychosocial stress accounted for approximately 30 percent of the risk of acute myocardial infarction. The study indicated that hostility, depression, and anxiety are all related to increased risk of coronary heart disease and cardiovascular death. The need to employ measures to reduce response to psychosocial stress is emphasized as an important preventive measure against heart disease. Natural lifestyle changes that include exercise, meditation, and spiritual and social support may be sufficient, but some individuals require medications that alleviate anxiety and depression.

Another study (n = 304 women) was conducted by using a questionnaire on psychosocial burden prior to diagnosis of coronary heart disease. Data collected showed 37 percent of women reported depression, 50 percent reported anger, and 41 percent reported social isolation.

Depression and heart disease➨ In a study (n = 1,767) of coronary heart disease among depressed patients, data showed that developing coronary artery disease was strongest for those less than 40 years old. Health-care providers should identify young to middle-aged women and men who present with depression and high blood pressure and/or other predisposing factors to coronary artery disease. In dental hygiene practice, this identification can be made by checking patient medical histories for combinations of antidepressants, anticholesteremia, and antihypertensive drugs, and by taking blood pressure readings and thoroughly questioning patients about all other aspects of their medical history.

Anger and heart disease➨ Stephen T. Sinatra, MD, author of Heartbreak & Heart Disease, says that anger can be a factor in coronary heart disease and many other health conditions. Numerous studies have shown that anger increases cholesterol and blood pressure. “I personally consider anger the Achilles heel of heart disease,” says Sinatra, a cardiologist and assistant clinical professor of medicine at the University of Connecticut School of Medicine and director of the New England Heart Center in Manchester, Conn.

Family history➨ Family history may be a predicting factor for heart attack in young women according to one population-based case-control study. The study consisted of female residents (n = 107) aged 18 to 44 of western Washington State and control subjects (n = 526) who were women of the same region and age identified without a history of coronary heart disease. The rate of heart attacks among first-degree relatives of heart attack cases was twice as high as among first-degree relatives of those in the control group (relative risk, 1.96; 95 percent CI, 1.46 to 2.48); this association was present for each familial relationship. A person is considered at risk for coronary heart disease if a parent has a heart attack before age 65 and/or a sibling before age 55.

When the physical predisposing factors of heart disease are not present and someone has a heart attack, there can be other causes that cannot be discovered through medical testing procedures. Yet if studies show that psychosocial stresses increase blood pressure and LDL cholesterol and triglyceride levels, we now know that the way we deal with day-to-day stress can predispose us to cardiovascular disorders such as heart attack and stroke. Making changes in our lives to prevent heart disease may mean changing jobs, moving, ending relationships, and saying “no” to the requests of others to make time for personal prevention of heart disease.

Stress factors lead to these predisposing physical factors for heart disease:

• High blood pressure
• High LDLs and triglycerides
• Weight gain, sometimes

High blood pressure➨ Since this condition usually presents no symptoms, it is less likely to cause alarm in those with the condition. The long-term effects of hypertension are hardening of the arteries and an enlarged heart. The step regimen for reducing mild hypertension begins with lifestyle changes of diet, exercise, and elimination of tobacco use, especially cigarette smoking. In individuals who are unable to make the lifestyle changes, or if such changes do not accomplish a reduction in blood pressure, antihypertensive agents are prescribed. The most commonly prescribed antihypertensive is an ACE inhibitor such as Lisinopril (Zestril, Prinivil) or Enalapril (Vasotec). Thiazide diuretics are equally effective in lowering blood pressure and less expensive than ACE inhibitors, but the adverse effects of impotence, hypokalemia (potassium depletion), and hyperglycemia are reasons Thiazide diuretics are less prescribed. More recently, Angiotensin II antagonists such as Losartan (Cozaar) have become prescribed as part of Step II or III in the regimen. Both the ACE inhibitors and the Angiotensin II antagonists have been known to cause angioedema. Depending on other cardiovascular findings, a physician may choose to prescribe beta blockers such as atenolol (Tenormin), or calcium channel blockers such as nifedipine (Procardia) alone or in combination with diuretics or other antihypertensive agents. All antihypertensive agents are of concern in dentistry with regard to adverse effects such as xerostomia and orthostatic hypotension. (Refer to drug references for interactions with drugs used in dentistry, especially vasoconstrictors.)

Above: On Feb. 2, 2006, Michele (second from left) spoke at City Hall to the council and the mayor about her experience, as well as to promote the “GO RED” for women campaign. She explained that her heart attack was caused by a tear in the artery, and the chances of it happening with survival were one in a million. She told the council that when her doctor explained that it was caused by a piece of plaque tearing off, she replied, “That is impossible, because I am a dental hygienist and I don’t have plaque!”

Dietary supplements and other forms of alternative medicine are used in the treatment of hypertension, but studies to support this usage of supplements are limited. Biofeedback, acupuncture, hypnosis, and dietary supplements such as garlic have been shown to lower blood pressure in some patients.

Today, we are told we must strive to reduce the LDL to 100 mg/dL or lower, and the HDL up to 60 mg/dl or greater to reduce our risk of coronary artery disease. Triglyceride levels should be below 150 mg/dL. To achieve these blood levels may be very difficult for some individuals and impossible for others without the aid of cholesterol-lowering drugs. The cholesterol-lowering medications (statins) Atorvastatin (Lipitor), Semivastatin (Zocor), Pravastatin (Pravachol), Ezetimbe/semivastatin (Vytorin), and others are included in the list of 90 million prescriptions written for treatment of elevated cholesterol in the last year.

The statins have an excellent benefit/risk profile, but many people cannot tolerate the drugs’ muscle-related adverse effects (myalgia and myopathy). The cost of the drugs are a great concern for those who do not have health insurance that covers the cost of prescription drugs.

In the sources at the end of this article, some excellent Web sites are listed that provide a wealth of information on how to prevent heart disease. Hopefully you will not have to experience a heart attack, but if you do, follow the plan in the accompanying charts taken partly from www.hearthealthywomen.com and partly from an EMT’s recommendation.

Changes in CPR guidelines

There will be a change in the procedures for CPR by summer of 2006, when all CPR instructors will be calibrated for teaching the new techniques. Until such time that you are retrained, continue to perform CPR according to the standards to which you were trained. Here is a preview of the changes:

The new guidelines are “push hard and push fast” with chest compressions, and avoid interruptions and reductions in blood flow to vital organs. The new recommendation will be 30:2 ratio of compressions to breaths for adults and children, except for two health-care rescuer CPR on children and infants at 15:2 excluding newborns. Health-care providers trained in basic life support are to minimize interruptions in chest compressions.

One shock scenario with AEDs is recommended followed by two minutes of CPR prior to analyzing and shocking again.

For the full version of the new guidelines, along with carefully researched rationales for these dramatic changes, go to www.americanheart.org/eccguidelines.

It is the hope of this months’s RDH cover model, Michele Gorden, RDH, that you spread the awareness of the causes, the prevention, and the treatment of heart disease. Do this for yourself, your loved ones, and your patients.

References

• www.ncbi.nlm.nih.gov/entrez/query.fcgi

• www.womenheart.org/

• www.nlm.nih.gov/medlineplus//heartdiseaseinwomen.html

•www.healthgate.partners.org