What is the difference between heart attack and heart failure?

The terms heart attack and heart failure are often confused.  While there is some overlap in both their symptoms and underlying cause, they are really two distinct entities.

Heart attack
A heart attack occurs when the flow of blood to an area of the heart is blocked.  Without a supply of oxygen-rich blood, the heart muscle dies.  Also known as myocardial infarction or MI, the Centers for Disease Control reports that 735,000 Americans experience heart attacks each year.

Most heart attacks develop in conjunction with coronary artery disease (CAD).  In CAD, a substance known as plaque gradually builds up in the arteries that supply the heart.  This disease process is known as atherosclerosis.  The combination of plaque formation along with a blood clot is the typical reason for blockage of the coronary artery causing the heart attack.

Prior to the complete blockage of a coronary artery, most people with narrowed coronary arteries will experience a symptom known as angina.  Angina occurs when the heart muscle is not being supplied with enough oxygen. It is usually described as a pressure or squeezing discomfort in the chest. This discomfort can also be felt in the arms (usually left), neck, or jaw.   Usually, this pain goes away with rest or after taking a medication to help improve blood flow to the heart muscle.

With complete blockage and death of the heart muscle (he
art attack) more severe symptoms typically occur. These symptoms include:

• Chest discomfort in the center of the chest that lasts for more than a few minutes, or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain.
• Discomfort in other areas of the upper body including one or both arms, the back, neck, jaw, or stomach.
• Shortness of breath, often occurring along with chest discomfort.
• Other symptoms may include breaking out in a cold sweat, nausea, or light-headedness.

A heart attack is a medical emergency causing over 370,000 deaths in the U.S. each year.

Heart Failure

When the term "failure" is applied to specific organs, e.g. kidney failure, liver failure, heart failure, etc., it conjures up thoughts of a final or terminal phase in the function of the organ.  In the case of heart failure, however, it does not mean that the heart has stopped working altogether; instead, it means that the heart's pumping power is weaker than normal. To compensate, the main pumping chambers of the heart (ventricles) become larger and the heart muscle thickens in order to maintain normal blood flow to the body. According to the American Heart Association, around 7.5 million Americans have some degree of heart failure which is one of the most common reasons for hospitalization among those over the age of 65.

One of the most common symptoms of heart failure is the buildup of fluid in various parts of the body. When this occurs, it is called congestive heart failure (CHF).   Symptoms of CHF vary, depending on whether the left or right chamber of the heart is primarily involved. With left sided heart failure, blood and fluid back up into the lungs causing shortness of breath, difficulty breathing when lying flat, and fatigue. With predominant right sided failure, blood and fluid back up causing swelling in the abdomen (ascites) and in the legs and feet (edema).

The most common reasons for developing heart failure include:

• Coronary artery disease which results in diminished blood flow to the heart muscle and heart damage.
• Heart attack with the development of "scar tissue" which interferes with the normal pumping action of the heart.
• High blood pressure which causes the heart to have to pump against higher resistance. Uncontrolled high blood pressure increases the risk of developing heart failure by two to three times.
• Disease or deformity of the heart valves. When the valves do not function normally, the heart muscle has to pump harder to keep the blood flowing as it should.
• Heart muscle disease (cardiomyopathy).  There are a number of causes for heart muscle disease including infections (e.g. viral myocarditis), alcohol abuse, and the toxic effect of certain medications including chemotherapy drugs.
• Congenital heart defects. These are problems affecting the heart's chambers or valves that are present at birth. If the heart and its chambers don't form correctly, the healthy parts have to work harder, which in turn may lead to heart failure.

In most instances, a heart attack is a life-threatening condition requiring emergency medical treatment. Likewise, when heart failure results from an acute event, such as a heart attack, immediate treatment is usually required.  More often, however,  heart failure, such as when it occurs in association with chronic hypertension, becomes more of a chronic, long-term condition.

Sources for article:
What is heart failure? from the American Heart Association
What is heart attack? from the National Heart, Lung, and Blood Institute

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Thoughts During Black History Month

February is Black History Month.  This is an appropriate time to reflect on the contributions of African-American physicians to medicine as well as point out some of the glaring differences in the health of black and white Americans. 

Contributions of African-American Physicians   Did you know that the first open heart operation was performed by an African-American?  In 1893 Dr. Daniel Hall Williams removed a knife from the heart of a stab victim. He sutured a wound to the pericardium (the fluid sac surrounding the myocardium), from which the patient recovered and lived for several years afterward. Another black surgeon and researcher, Charles Richard Drew, developed the concept of the blood bank which was responsible for saving many lives during World War II. Dr. Mae C. Jemison is both a physician and astronaut. In 1992, Dr. Jemison was aboard the space shuttle Endeavour making her the first black woman in space.  Pediatric Endocrinologist, Dr. Joycelyn Elders, was the first African-American to serve as U.S. Surgeon General. As Surgeon General, Elders argued the case for universal health coverage, and was a spokesperson for President Clinton's health care reform effort. In addition to these high profile examples, thousands of African-American physicians are providing medical care throughout the U.S., many working in underserved areas of the country.

Health-related inequality between blacks and whites in the U.S.  The efforts to promote civil rights championed by Dr. Martin Luther King and others have made a major positive impact on societal acceptance, economic opportunities and quality of life for many African-Americans.  Unfortunately, a division remains in regard to health of blacks and whites in the United States. Blacks have higher death rates than whites for several causes of death including heart disease, cancer, stroke, lung disease, diabetes, homicide, and HIV/AIDS. In fact, for the two leading causes of death in the U.S.—heart disease and cancer—blacks have death rates approximately 30 percent higher than whites. Other examples of this disparity in health between blacks and whites:

• Black Americans have almost twice the risk of developing diabetes as white Americans.
• The incidence of end-stage renal disease (ESRD) for blacks, primarily related to the adequacy of diabetes management, is 4 times higher than that for whites.
• Black Americans have more asthma than any racial or ethnic group in America.  More than four times as many black children as white children are hospitalized for asthma, and more than five times as many black children die from the disease.
• African American men are diagnosed with prostate cancer much later, and the mortality rate is 2.4 times higher among African Americans than Caucasians.
• High blood pressure tends to be more common, happens at an earlier age, and is more severe for many African Americans.
• African Americans account for a higher proportion of new HIV diagnoses, those living with HIV, and those ever diagnosed with AIDS, compared to other races/ethnicities

Reasons for the differences in disease and death rates between blacks and whites. This is a complex issue with a number of factors being involved including genetics, environmental issues, access to medical care, differences in the response to treatment, and social factors. Some specific examples are that:

• African-Americans appear to have a greater genetic susceptibility to developing certain diseases such as diabetes.
• Despite a lower rate of cigarette smoking blacks are more likely to die from lung disease than whites.
• Black Americans receive fewer operations, tests, medications and other life-saving treatments than whites.
• Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.
• A higher percentage of African-Americans live in communities non-compliant with federal air pollution standards or that are located near toxic waste sites.
• Clinical trials show blacks and whites respond differently to treatments for high blood pressure.

How can we close this health gap?   There actually has been some progress related to the health of African-Americans in the U.S., particularly related to death rates from homicide and cancer.  The National Center for Health Statistics has reported a 40 percent decrease in homicides from 1995 to 2013 among blacks as compared to a 28 percent drop for whites. Also, the death rate from cancer fell by 29 percent for blacks over that period, compared with 20 percent for whites. To continue to narrow the health gap between blacks and whites, society must continue to address racial segregation, narrow the income gap, and improve medical care, especially preventive services, for vulnerable populations. Additionally, medical science must learn more about how the effects of various diseases and the response to treatment differ among races.  Through these measures we can continue to make progress in realizing the dream of racial equality envisioned by Dr. King.
 
 Sources for article:
Why 7 Deadly Diseases Strike Blacks Most from WebMD
Racial health inequalities in the USA: the role of social class from Public Health. 2008 Dec; 122(12): 1440–1442.
Gap Between Death Rates for Blacks and Whites Remains as Large as in 1950 from Circulation. 2000;101:e9026

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When does a wound need stitches?

It's tricky to know when a cut needs stitches or some other means of closure.  Many minor lacerations will heal by themselves, but some will heal faster and with less likelihood of complications when one of the methods of primary wound closure are used.  There are several ways of closing a wound such as:

• Traditional stitches (sutures). Suturing is the most common method used for wound closure. Much like repairing a tear in a shirt, suturing involves the use of sterile needles and suture material (usually made from silk or nylon) to sew the wound edges together.
• Skin staples. Stapling is most commonly used for deeper wounds that have straight, sharp edges.  Wound stapling is particularly useful in closing wounds in the scalp and is often employed in closing surgical wounds. 
• Adhesive strips (butterfly, Steri-Strip™, etc.)  Strips are effective for small cuts and wounds that are not under tension.  A laceration on the forearm, for example, would have less tension on the wound edges than one over a knuckle that is stressed each time the finger is moved.  A major advantage of adhesive strips is that application is essentially painless.
• Skin adhesive (skin glue).  Similar to "Super Glue", a skin adhesive such as Dermabond (2-octylcyanoacrylate) is best suited for small, superficial lacerations.  The adhesive forms a bond over the wound edges allowing healing to occur below. 

In evaluating a wound, the medical professional must make an assessment of the method of wound closure that is most appropriate.  Reasons to seek a medical opinion on the need for stitches or some other method of primary wound closure include:

1. Deep wounds that extend beneath the dermis of the skin into underlying fat or muscle layers.
2. Wounds that have jagged edges or that gape open.
3. Wounds located over a joint, such as a knuckle or the knee, that would be repeatedly stressed by movement of the joint.
4. Wounds on the face, lips, eyelids, or other areas of the body where a cosmetic result is important.
5. Wounds longer than ¾ in or that are deeper than a ¼ inch.
6. Wounds affecting the genitalia.   
7. Wounds that bleed profusely or continue to bleed despite application of pressure to the wound. 
8. A wound in which there is a possibility that a foreign object, such as a piece of glass, remains within the wound. 
9. Wounds that result from an animal or human bite.  In addition to stitches, these may require a tetanus booster or antibiotics. 
10. Dirty or contaminated wounds that require thorough cleaning before closure options are considered.  

Primary wound closure with one of the methods described above should generally be accomplished as soon as possible following the injury. The risk of the wound becoming infected increases the longer a wound remains open. In fact, waiting too long to seek medical attention following a laceration may require that the wound remain open so that adequate cleaning and treatment with antibiotics can be instituted prior to the closure. 

Sources for article:
Does Your Cut Need Stitches? Find Out How to Tell from the Cleveland Clinic
Cuts: When Stitches Are Needed  from WebMD

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Palpitations, harmless or cause for concern?

Palpitations are the unpleasant and sometimes alarming sensations of rapid, irregular or forceful beating of the heart.  The term "palpitations" is fairly non-specific since it can refer to a number of different types of disturbances of the heart's normal "rhythm". Depending on the nature of the rhythm disturbance, palpitations may be described as "skipped beats", "fluttering" or "racing".  In most instances, palpitations are harmless, and in fact, in certain instances, may even be considered normal.
   
Normally, the heart beats between 60-100 times per minute.  When the heart beats faster than this, it is called "tachycardia".  Under certain circumstances, tachycardia can be considered to be normal. For example, when you are exercising vigorously or frightened, your heart normally beats faster and more forcefully.  This allows the heart to pump more blood to the muscles and lungs.  If, on the other hand, heart "racing" occurs while you are at rest, this may indicate an abnormal heart rhythm (dysrhythmia), such as atrial fibrillation.

One common dysrhythmia is known as premature contractions or ectopic beats.  These are usually described as "skipped beats" or as the heart briefly "stopping".  In this type of dysrhythmia, the heart contracts earlier than the next normal beat, followed by a pause.  When the heart resumes beating, a more forceful beat or "thump" may be felt.  When these occur infrequently, they may be entirely benign.  Premature contractions occurring frequently, on the other hand, can be an indication of a heart condition.

What causes palpitations?   Some of the most common causes for palpitations are:

• Diseases of the heart valves (mitral valve prolapse, aortic stenosis, etc.)
• Excess thyroid hormone (hyperthyroidism)
• Stress, fear, anxiety
• Fever
• Caffeine, nicotine, cocaine, diet pills 
• Anemia
• Low blood oxygen level (hypoxia)
• Medications such as thyroid replacement, diet pills and asthma drugs

Palpitation "red flags"   Anyone with known heart disease should consider palpitations to be a cause for concern.  Actual blackouts or near blackouts associated with palpitations should be taken very seriously because they are often due to underlying heart disease.  Chest pain or shortness of breath occurring during episodes of palpitations suggests that the heart is not pumping adequately and should also prompt medical evaluation.

How are palpitations evaluated?   Should palpitations occur frequently, cause alarm, or if any of the "red flags" mentioned previously are present, medical attention should be sought. The object of the evaluation is to determine if the palpitations are "physiologic" or whether they are caused by an underlying medical condition.  The evaluation starts with a medical history to consider the circumstances under which the palpitations occurred (drinking too much coffee, drinking alcohol, stressful work situation, etc.).  A review of medications that one is taking as well as other symptoms that could suggest a medical problem such as hyperthyroidism or anemia is also done. Following this, a physical examination and often a resting electrocardiogram is performed. For suspected heart-related problems, other diagnostic tests include a 24-hour recording of the heart rhythm (Holter scan), an exercise stress test, and tests to study the electrical system of the heart (electrophysiologic study).

How are palpitations treated?   Palpitations can be relieved in many patients by stress reduction, stopping cigarettes, and reduction of caffeine and alcohol.  In the case of underlying heart disease, taking a medication to suppress the dysrhythmia or specialized surgical procedures may be necessary. If a condition such as hyperthyroidism is found to be responsible, measures to reduce the level of thyroid hormone will address the problem.

Sources for article:
Heart palpitations from Mayo Foundation for Medical Education and Research
Skipping a beat — the surprise of heart palpitations from Harvard Health Publications
Heart palpitations from Medline Plus

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