Diplomate, Board Certification of Emergency Medicine
Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua
Know Your Enemy
The next few columns will discuss the killers. Those who
steal from us the weak and the infirm, while occasionally
also murdering an unfortunate in the prime of their life. we
know the killers by name. We've learned much about them, and
can even interfere with their work, but they haven't been
The number one killer in the industrialized world remains
heart disease. The heart is the only organ that is
continually working, even when we sleep. It is just a muscle
and its job is to act like a pump. Like all organs, it
depends on oxygen and a good blood supply for its work.
However, the arteries supplying the heart are small compared
with the arteries of the big muscles of the body such as the
leg. If these arteries get blocked -- the area they supply
dies, and that is a heart attack. If enough of the heart is
affected, or it occurs in an area of important electrical
conduction, a person can chas vesholom die on the
How do arteries get clogged? High blood pressure can cause
mini tears in the artery wall which then can swell or fill up
with cholesterol which for some reason fills areas of damage
in the walls of the arteries. This narrows the walls, but the
body can grow new arteries and bypass the narrowing. In
people who exercise, there is lower blood pressure to start
with, and bigger arteries. In smokers and diabetics, there is
more disease in the arteries.
Now since the flow slows in areas that are narrow, the blood
can sometimes clot. If a clot forms, the artery can no longer
supply that part of the heart and if the clot doesn't move
on, that part of the heart dies and a heart attack occurs. If
it can be pushed further, some pain may occur which is soon
relieved. This is called Angina.
In the past, we could do little for this problem except give
medications that make the arteries relax and open up. Then in
the seventies we started doing bypasses, where arteries from
the leg were used to bypass the obstructions. Soon after, we
were able to do catheterization, which is the injection of a
dye into the arteries that allowed us to take pictures of the
arteries and see where the obstructions were.
The late seventies began the era of clot busting drugs which
dissolved the clot if used within 6 hours of a heart attack.
In the nineties, we began doing catheterization emergently to
open up the clogged arteries, and now we can put in Teflon
stents which keep these arteries open. This is not available
everywhere and is very dependent on the quality of the person
Who is at risk?
If you have had angina or a heart attack in the past, you are
at risk. Also high blood pressure, heart disease in the
immediate family, smokers, drinkers, those who are obese,
people with high cholesterol, diabetics. Men are at higher
risk before the age of menopause for women, but after
menopause women have the same risk. Interestingly enough,
women are unlikely to get the right therapy, for a number of
reasons. Some say since the electrocardiogram is the fastest
way to see if a heart attack is happening (although only 80%
reliable) and women have smaller hearts, we don't see it as
well on the EKG.
Of course, if you have any of the above risks, you should
control them with medication and lose weight and exercise.
Aspirin is protective and probably should be taken by
everyone over the age of 35. Blood pressure and even heart
attacks can be silent until it is too late. We'll talk more
next week. Write me in care of the Yated.
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