Your Heart & You:A Self Help Guide

Knowledge is Power
Knowing a disease condition and treatment options makes a tremendous difference. It makes patients and relatives understand what is the best treatment option available and how to take care of oneself after coming out of the hospital or doctors clinic. The main aim of this book is to make patients as well as general public aware of various disease conditions, tests and their treatment, and to equip them with the knowledge to get the best care possible. About the author : The author is a Senior Consultant and Interventional Cardiologist practicing at Indus Hospitals, Visakhapatnam, Andhra Pradesh, India.
Book - 2 Chest Pain Heart attack Angioplasty and bypass surgery Optimal Management of lipids Heart failure
YOUR HEART AND YOU : BOOK - I
Dedication
to My Countrymen Who Deserve the Best Health Care
Personal Information
Disclaimer
Name Address : :
This booklet is intended to spread understanding about the heart health and make people aware to have better care by imparting education. This booklet is not intended for any practice guide, or questioning any type of treatment offered to the patient by the physician. The content of this booklet has been written considering scenario in Indian Medical Practice. It may not be applicable to the practice outside India.
Phone Number
My Family Physician : My Family Physician Phone Number: Name and address of preferred Hospital:
Ambulance Service Phone Numbers: Name and phone number of persons to be contacted in case of emergency: 1: 2: 3:
This is for free distribution inside India & Not for sale or personal advertisement.
First Edition Printed at
: 2012 : Sree Meher Graphics, Visakhapatnam - 530 020
INDEX
1. 2. 3. 4. 5. 6. 7. Preface Finding the right Doctor Some Dos and Don'ts Some helpful terminology Some useful skills Our Heart-Basic Anatomy. Tests prescribed for when a Heart condition is suspected High Blood Pressure (Hypertension) High Blood Sugar(Diabetes Mellitus) 1 5 7 8 10 12
Preface
"An old patient is better than a new doctor." Many of us might have
heard this saying. I, as a doctor, would say that this saying is quite true to some extent. A patient who understands his diseases and the treatment of his condition, with its dos and don'ts, requires very little help from a doctor. On the other hand, a patient who has no knowledge of his disease or condition is usually frightful. This fear can create a mental block even before he enters the doctor's chamber. Due to his fear and mental block, this type of patient usually leaves the doctor's office as ignorant of his disease as when he first entered it. In his ignorant or confused state, this patient then begins to seek others opinions. He may seek the opinion of colleagues, friends, family and all sorts of people, who often, although well meaning, give wrong advice. As a result of heeding to unqualified advice the patient may land up in the hands of some untrained and unqualified person who claims to have a "CURE" for the health problem that the patient has. Hence, one should have a clear understanding of the role of medicine in society. The role of medicine is not to make someone immortal, but rather to relieve suffering, to reduce the risk of complications and to some extent, improve the chances of survival. Medical practice, be it, medicine or surgery, is Palliative. That means that the disease
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is not cured, but the problems arising from the disease have been taken care of for the time being. With the advent of sophisticated medical advances the aged "Vaidyo Narayano
8. 9.
Hari" has become outdated. The precious relationship between doctor and
patient has, like medical practice, undergone some changes too. Nevertheless, this relationship between doctor, patient and the patient's relatives remains a delicate one. It is so delicate that one can say that it floats on the filmsy surface of trust and faith. It is then of great importance to understand that all those involved, the doctor, the patient and his relatives share in the responsibility of developing mutual faith and trust. In the medical environment, the medical terminology used to describe a patient's condition is difficult to understand even by the most learned person. So one can safely assume, how much more difficult it must be for a person who has little or no education.
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When a
situation arises that calls to describe the presence of a common and simple problem as High Blood Pressure in a patient, this explanation can be overwhelming and come as thunderbolt to the patient and his relatives. The lack of proper understanding on the part of the patient about his condition leads to improper treatment and care of the disease. Because of the patients inappropriate knowledge of his condition and therefore, inappropriate management of it, the patient may perceive the treatment prescribed by the doctor as inefficient or even a failure. This misunderstanding in many cases, results in patients looking for alternative methods of treatment and cure. Quite often these alternative methods are provided by persons who have never been trained in any form of medicine. Thus, these easily available and inexpensive methods end up with detrimental results. Most often, these "short cuts" lead to the worsening of the underlying condition, and the development of complications which then become untreatable. Allow me if you will, to present a scenario. A patient with simple high blood pressure seeks the advice from a "quack" or untrained person practicing some form of medicine. Over a period of time on receiving unqualified treatment, the patient develops heart failure, brain hemorrhage (bleeding from ruptured blood vessels), or kidney failure. Now, at this stage of his condition the patient seeks the medical advice of a heart specialist or other specialists. These severe complications could have been prevented had the patient followed the treatment plan for control of Blood Pressure prescribed by his qualified physician. As a consequence, the patient now has life threatening complications which are not reversible. But all said and done, the patient is not solely to blame for the consequences of the malpractices by some unqualified, misguiding and unscrupulous practitioners. Unfortunately, in our country there is no system that safeguards the patients from these practitioners. There is no awareness program that educates the people on the choices that they have when choosing a medical provider. Also there are no laws that make such malpractices accountable. An even sadder situation is the fact, that no patient ever questions these so called doctors as to their medical credentials. It is no wonder that we have a plethora of self styled people, gurus who claim to have a cure for all those chronic and serious conditions, for which a highly qualified specialists have no treatment
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options. Using one's commonsense when in need of a doctor irrespective of whether the doctor follows Allopathy, Homeopathy or Ayurvedic medicine, is very important. One should ensure that the doctor sought to treat the disease condition has met all the medically required qualifications and that his professional credentials are of good standing. When medication is required to treat a disease or condition there may be side effects due to the medication, whether this medication is allopathic or ayurvedic. Even familiar food eaten since childhood can also have side effects like allergies. So in the medical field we say that if medicine has the desired effect, it will have side effects too. The aim of medical treatment is to look into the beneficial effects of the medicine and not into its side effects. It is always preferable to take a medicine-pill whose side effects are well known, than a pill for which it is claimed, that there are no side-effects. One should look with suspicion at such claims, since they are only marketing gimmicks. In Allopathic medicine, medication is released into the market after the medication has been tested in very large clinical trials involving people with related problem and for which the particular medication has been formulated. These clinical trials establish the safety and effectiveness of the medication, including its side effects. If the medication is found to be not good or safe, it is not released into the market for sale. If at any time the medication after been launched is found to be harmful in any way, the medication is immediately withdrawn and its sale prohibited. Unfortunately, these safety standards for allopathic medicine are not followed by other systems of medical practice. It's not prudent to give medication to any person without sufficient data for that medication. That's Commonsense and Science! A patient with little knowledge of his disease may develop a fear that would create a panic situation for himself and an advantage for any unscrupulous practitioner of any form of medicine. Such practitioners with their malpractice turn the reputation of the doctor being like a God, into one of being a Devil.
Please remember, do not panic irrespective of the severity of the disease. If you are not satisfied with the explanation given by your doctor of your condition, or you do not feel comfortable with the treatment plan suggested by him, I urge you to seek without hesitation, the expert opinion of another doctor or specialist. It is your right. As a physician, I feel very inadequate when a patient refers to himself as a consumer, and brings with him the consumer laws to the consulting chamber. After all, a Doctor-Patient relationship cannot be equated to that of a shopkeeper and his customers, and neither does it equate to a service provider-consumer relationship. The relationship between a doctor and his patient is a sacred one and should always remain the same. It is a doctor's ethical and moral responsibility to be sensitive not only to the patient's medical condition, but also to his financial one. To a doctor a patient should never be just a source of income. It is my humble intention with the printing to this booklet to create an awareness of various disease-conditions, laboratory tests and treatment methods available for those disease-conditions, with the hope that when in need of a doctor and treatment a person can make an educated choice. There words printed in this booklet are NOT intended to educate or license any one to practice medicine. I pray that the material presented here makes my fellow countrymen understand the meaning of prevention in relation to their health and the care of it. Before I finish, I would like to sincerely thank all those who show interest in improving their knowledge. Your feedbacks are valuable for further improvement of the book. Please write to me at scsinha_cardio@yahoo.com With best compliments Dr. Sudhir Chandra Sinha c.
Finding the Right Doctor

In India, medical education begins with a basic graduate degree called MBBS. This degree is then followed by post graduate one of MD or MS. After the post graduate degree one can further enhance ones knowledge, by obtaining a DM or MCh degree which are postdoctoral or super specialization degrees. Here are few simple things that will help make a better choice when in need of a doctor. 1) Qualifications: a. MBBS: Bachelor of Medicine and Bachelor of Surgery. This is a basic degree awarded and allows graduates to start allopathic medical practices. However, they have limited medical and surgical skills. b. BAMS: Bachelor of Ayurvedic Medicine and Surgery. These graduates are trained and qualified to practice Ayurveda. BHMS: Bachelor of Homeopthic Medicine and Surgery. With this degree graduates are trained and qualified to practice Homeopathy. d. BUMS: Bachelor of Unani Medicine and Surgery. Graduates are trained and qualified to practice Unani Medicine. Post graduation (MD/MS) is offered in all disciplines of medicine and Surgery. Post-graduate degrees are also offered in Homeopathy and Ayurveda. e. MD: Doctor of Medicine, is a degree awarded in General Medicine, Pediatrics etc. f. MS: Master of Surgery. These doctors are trained to perform various surgical procedures. Super-specialization is offered in many fields. Training is imparted to better understand and treat a particular organ-system.
g. DM: Doctor of Medicine. This is a Super-specialization degree obtained after and above MD degree. This super-specialization deals only with a particular organ system, such as : i. ii. DM (Cardiology)-Heart Specialist. DM (Gastroenterology)-Stomach and other abdominal organs related problems specialist. iii. DM (Neurology)-Brain specialist iv. DM (Endocrinology)-Diabetes and other endocrine problems specialist. v. DM (Neonatology)-new born baby specialist.
Some Dos and Don'ts

1) Do not discuss personal health problems with everyone. Remember the words of cricketer Wasim Akram, who said, "Your sympathizers' advice will misguide you". The great percentage of the suggestions and advice given by good intentioned people, if followed may be harmful to your well being. Remember that! 2) Do not consult a doctor over the phone if any of these symptoms are experienced : chest pain, severe abdominal pain, sudden and acute pain anywhere in the body, sudden headache and vomiting, high fever or any other unusual symptoms. Some of these symptoms could be an indication of a serious problem and shouldn't be neglected. Visit a doctor or emergency department where the symptoms can be diagnosed and treated accordingly. A word of caution: Do not assume that a chest pain is a "gas" problem; it could be a heart attack and requires immediate attention. 3) Do not fret when visiting the doctor. Exercise patience. Waiting to see the doctor can provide an opportunity to ponder about positive changes that can be made to change, improve or enhance our lifestyles; remembering too, that the end of the wait we would have the doctor's undivided attention. 4) Do keep handy list of important telephone numbers that includes, family doctor, ambulance service, nearest hospital, specialty hospital, and those immediate family members to be contacted in case of emergency. 5) Do keep along with the list of phone numbers, an updated copy of any health insurance policy with all clear and pertinent information ready. With the policy is also a good practice to keep a note that indicates to which hospitals it could be presented. 3) Inpatient admission : Of course, no one wants to be admitted to a hospital, but certain circumstances may force one to be admitted. This can be due to an emergency or non-emergency circumstance. One must remember that in a hospital environment, there are many patients with a variety of problems and diseases, including serious infectious diseases. In our culture, it is customary to pour sympathy upon a near and dear one who has been admitted in hospital. When a patient for whatever reason is admitted in hospital his immunity goes down, therefore, increasing the risk of infection
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h. Mch: Master of Surgery. It is a degree like that of a DM. It is a superspecialization in specific fields like Neurosurgery, Heart Surgery, Gastrointestinal Surgery, Surgery related to Kidney and Urinary Bladder, Vascular Surgery, etc. These doctors are highly skilled in complex surgeries. i. DNB: Diplomat of National Board. -This diploma is given by the National Board of Examinations, which is directly under the Central Government, Ministry of Health and Family Welfare. At various levels, this diploma is equivalent to MD, MS, DM and Mch degrees. Having now the knowledge of the degrees and diplomas awarded to doctors, you are in a better position to choose a doctor that will best meet your needs. You should not be confused by the many "degrees" mentioned in the board or prescription slip of a medical practitioner. The majority these degrees and acronyms are fellowships or memberships to various medical or surgical societies. These do not add to the qualifications of the doctor. 2) Availability: A patient needs to know before choosing a physician the availability of the doctor in his particular consulting place or hospital, and of course, his appointment system. A patient should look for a doctor who has knowledge to treat the patient's condition, and is also empathetic to the patient's feelings of confusion or fear; a doctor who will be able to give his time to the patient.
and complications; the more number of visitors, the greater the risk. A visitor having a small problem like cough and cold, unintentionally could provoke a life threatening situation for the patient. All other patients in the hospital and all visitors are also at risk. Let's not forget that however clean a hospital may be, it still contains an infectious ambience. Hence, let the number of visitors be kept as minimal as possible. Because children and elderly persons are more susceptible to infections, they should not be allowed to visit any one in the hospital.
Orthopedician: Surgeon with MS or equivalent degree treating bone and joint related problems. Rheumatologist: Physician with degree and training in treatment of joint problems. Dermatologist : Physician having MD or equivalent degree in treatment of the skin disorders. Hematologist : Physician having training in blood related disorders. Pediatrician: Physician with MD or DNB degree in childhood diseases from infancy to adolescence. Pediatric Surgeon: Surgeon with Mch degree in pediatrics. Artery: Blood vessels which take pure blood from the heart to all other organs. Vein: Blood vessels which are seen on arms and legs and have a bluish color. They carry impure blood from other parts of the body to the heart. Nerves : Carry nerve impulses all over the body from the brain and the spinal cord. Terminology encountered in prescription O.D. B.I.D. TID HS Once Daily Twice Daily Three Times daily Bed Time
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Some Helpful Terminology

Neuro : (deals with the brain and neuro systems) Neurologist: Physician having a DM or DNB degree in Neurology. Neurosurgeon: Surgeon Having a Mch degree in Neurosurgery. Cardio (deals with the heart) Cardiologist: Physician having DM or DNB degree in Cardiology. Cardiothoracic Surgeon: Doctor holding a Mch or equivalent degree in Cardiac and Thoracic surgery. Chest/Pulmonary (deals with the lungs) Pulmonologist: Physician having MD or DM degree in chest medicine. Gastro (deals with digestive system) Gastroenterologist: Physician having DM or equivalent degree in gastroenterology; Gastric surgeon: Surgeon having Mch or equivalent degree in gastric and intestinal surgery. Uro (deals with kidneys, the urinary tract, and male reproductive system) Urologist: Surgeon with MCh degree in urology. Nephro (deals with kidneys and urinary tract) Nephrologist: Physician with DM or DNB degree in kidney diseases; Gynec (deals with female reproductive system) Gynecologist and Obstetrician: Physician holding a MD degree in gynecology and childbirth.
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Vein
SOS SC IM IV
As per requirement Subcutaneous Intra Muscular Intra Venous
Some useful skills

1) Checking Blood Pressure : Blood Pressure (BP) is written as Systolic BP/Diastolic BP. For example, 120/80 mmHg. Here 120 is the systolic BP and 80 is the diastolic BP. There are various types of instruments used to measure BP : the Mercury manometer, which is used most commonly in clinics, Electronic instruments which are available in the market for use at home, and Aneroid manometers. The mercury and the aneroid manometers require a need stethoscope to check the BP. When the BP is checked by any of these two instruments, a cuff is wrapped around the upper part of the arm and inflated with air. Then a stethoscope is put over the cubital fossa (the fold of the inner arm at elbow). As the air is released from the cuff, a no sound gap, followed by "tuk-tuk" sound is perceived. The appearance of this sound is the Systolic BP. When air is released further, this sound disappears at a particular point. At the particular point where the sound disappears is the indicator of the Diastolic BP. For example, if the sound appears at 120 and disappears at 80 in the scale, then BP is written as 120/80 mmHg (Hg stands for mercury).
2) Checking Body Temperature : To check the body temperature a clinical thermometer is inserted into the mouth or placed in the axilla (under the arm) for approximately 1 to 2 minutes. When the thermometer is removed and read, the temperature is recorded. There are several types of thermometers available in the market besides the old fashioned mercury ones. Available now, are electronic thermometers which can read and display temperature directly. Temperature can be displayed in degree Fahrenheit or degree Celsius. Depending on the type of thermometer used or where the thermometer is placed the reading may vary by about 1-2 degree. The best and most preferable temperature reading is the one taken orally (Putting Thermometer in the mouth, Beneath the tongue).
Clinical Thermometer
Electronic Thermometer
Normal Body Temperature : 97.60F to 98.80F (36.40C to 37.10C)

3) Checking Pulse Rate: To check the pulse rate place the hand face up, follow a line from the base of the thumb all the way to about of an inch from the fold of the wrist, place the thumb or index finger of the other hand over this spot. One should be able to feel the beating pulse. Once found, count each beat over a period of 10 seconds, then multiply that count by 6. The result will be the pulse rate per minute. For example, if the count is 12 beats over 10 seconds, then the pulse rate is 12x6=72/min.
Normal Blood Pressure : 100 - 130 / 60 - 85 mmHg
Mercury Manometer
Aneroid manometer
Normal Pulse Rate : 60 - 100 Beats / Min.
Electronic BP instrument
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How to feel pulse
Our Heart: Its Basic Anatomy

Our Heart is a muscular organ with four chambers, located on the left side of the chest. The main function of the heart is to pump blood to various parts of the body. The blood carries the nutrition to all body cells and tissues and hence, all organs, tissues and cells in the body depend upon the heart for survival.
Pulmonary Artery Aorta
Coronary Artery
Location of the heart in the chest
Heart-External appearance
Valves
Our heart has 4 chambers (partitions), divided into right side chambers and left side chambers. The right sided chambers are called Right Atrium (RA) and Right Ventricle (RV). The left sided chambers are called Left Atrium (LA) and Left ventricle (LV). Impure blood carried from different parts of the body through veins and superior and inferior venacavae is brought into the right atrium. From the right atrium it passes to the right ventricle and from the right ventricle to the lungs through a vessel called, pulmonary artery. The lung purifies the blood and returns to the left side of the heart for pumping and distribution of all organs of the body through aorta. Inside of the Heart
Heart Muscle Pericardium
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Different Structures related to the Heart

Our heart is protected from any external injury as well as to prevent sudden expansion when blood flows into it-there is a membrane called Pericardium. On the outer surface of the heart lies one of the most important structures-The blood supply to the heart itself-called The Coronary Arteries. It is the disease involving these coronary arteries what we commonly know as Heart Attack. Apart from heart muscle, inner side of the heart are 4 hollow chambers where blood comes for forward pumping.These chambers are two Atria and two Ventricles. The forward blood flow is guarded by Valves-so that blood could flow in only one direction. So now you understand that coronary arteries and valves are two different structures.
The Coronary Arteries

Coronary Arteries are one the most important structures of the heart. They lie on the outer surface of the heart beneath pericardium. Coronary Arteries are blood vessels carrying purified blood to the heart muscle to provide energy and nutrition so that heart can continue to beat without any problem. These arteries come out from the aorta near the heart. There are 2 types of Coronary arteries Right (Right Coronary Artery), and left (Left Coronary Artery). The Left Coronary artery immediately after the origin divides into 2 major branches - The Left Anterior Descending artery (LAD), and Left Circumflex Artery (LCX). The Left Anterior descending artery is the most important artery of the heart, also called "The Life Line" of the heart. The Right Coronary Artery (RCA) continues as a single artery for most of its course but later divides into 2 branches -the posterior LV branch (PLV) and posterior descending artery (PDA). After LAD, PDA is the next important blood vessel of the heart. The coronary arteries are prone to cholesterol deposition and blockage, producing a disease called Coronary Artery Disease (CAD), Ischemic Heart Disease (IHD) or Heart Attack (MI).
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continuous beating occurs in a very systematic and synchronized manner. This is possible due to the presence of a conduction system in the heart. The impulse for the heart beat originates from a specialized structure called Sino Atrial node (SAN) found inside the right atrium. From here, the impulse ("Current") travels through a conduction tissue to another similar structure called atrioventricular node (AVN); and from the AVN, the impulse travels down to both the ventricles. This conduction system is essential to the heart for it to function as a pump. Fast or slow heart beating can occur due to disease in the conduction system. The Coronary Arteries
The Valves
Valves are the structures located in the inner part of the heart muscle. There are 4 valves and their function is to ensure that the blood flows in one direction. Two valves are located on the right side and 2 on the left side. The right side valves are the Tricuspid Valve and the Pulmonic Valve. The left valves are the Mitral Valve and the Aortic valve. The heart valves can develop two types of problems; one stenosis (blockage), and second regurgitation (back-leak) apart from developing infection(Infective Endocarditis) . The conduction system of the heart. Sino Atrial Node Atrio Ventricular Node
Pulmonic Valve
Aortic Valve
The Pericardium :
Pericardium is the protecting membrane that surrounds the heart. It consists of two layers. Its function is to protect the heart from any external injury and to prevent sudden expansion of the organ when blood flows into it. Fluid can collect into this layer producing a disease called Pericardial Effusion. Summarizing, our Heart has
Mitral Valve Tricuspid Valve
The Valves of the heart
Four Chambers Four Valves Two Great vessels
Right Atrium, Right Ventricle, Left Atrium, Left Ventricle Tricuspid valve, Mitral valve, Aortic valve, Pulmonic valve Aorta, Pulmonary artery
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The conduction System-The wiring of the heart

In addition to valves and coronary arteries, the heart has one more important system called, the Conduction System. In the simplest sense, this is the wiring of the heart. As known, the heart beats continuously to pump out the blood. This
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Two Sets of Coronary Arteries* Conduction System * Pericardium
Left and Right coronary arteries
Tests Prescribed for when A Heart Condition is Suspected

When a patient complains of chest pain, breathing difficulty, palpitations, giddiness etc., approaches a physician or a heart specialist (cardiologist), he may be advised to undergo a variety of tests to diagnose the disease condition. The result of these tests is very important in helping the doctor diagnose the disease. These tests may be divided into:
Based on the above information, we may have a better understanding of the several problems which can arise with any of the structures of the heart. Below is a list of the problems found in specific structures. 1) The Valves . Blockage(stenosis) Leakage(regurgitation) Infections(Infective endocarditis)
A) Routine Investigations:
The routine investigation tests form the backbone over which a treatment can be safely prescribed. The results of these tests is relevant to the doctor before he can write a safe prescription. These tests include:Hemoglobin, Total Leucocytes Count (TLC), differential leukocyte count, Platelets. Fasting/Random Blood Sugar, HbA1C Blood Urea/Serum Creatinine, estimation of Creatinine clearance. Liver Function Tests. Urine Analysis. Chest X-Ray (some cases). An abnormality seen in the result of Platelets, Creatinine or Liver function tests seriously affects the decision of the doctor as to what medicine he should prescribe.
2) The Muscle. Cardiomyopathy Myocarditis Heart Failure (Pumping failure) Tumor Coronary Artery Disease(Angina) Heart Attack(MI) Arrhythmia (Fast or irregular Heart beating) Heart Block (Slow Heart beating) Pericardial Effusion (Fluid around the Heart) Constrictive Pericarditis
3) The Coronary Arteries
4) The Conduction System
5) The Pericardium
Please don't ignore these tests if you doctor has requested them. They are of vital importance.
It is my sincere desire that the information presented above would be of some help in understanding the function and structures of the heart. I pray that it may never happen, but if indeed the case arises that the reader may be in need of a doctor, he may find himself in a position to make an educated choice.
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B) Tests which are specific for the detection of any heart condition, especially risk of heart attack :
Triglyceride: > 150 mg/dl HDL-C < 40 mg/dl
Fasting serum lipid profile

Fasting serum lipid profile is a very important test because it indicates the cholesterol deposition in the blood vessels. These fatty deposits are the main culprit behind the symptoms of chest pain and heart attack. The test requires the patient to have a complete fast of 9-12 hours prior to the test. Complete fast means, no intake of tea, coffee juice, fruit, etc.
Small LDL particles The typical features of persons with this condition are abdominal obesity and a sedentary life style with little or no physical inactivity. METABOLIC SYNDROME This syndrome is much more common, and often causes premature Coronary Artery Disease and Heart Attack. The causes of this syndrome are physical inactivity, over weight/obesity, and genetic factors. It is diagnosed if 3 or more of the following parameters are present. 1) Abdominal obesity Male Female 2) Triglycerides 3) HDL Male Female 4) Blood pressure 5) Fasting Blood Sugar < 40 mg/dl < 50 mg/dl > 130/85 mg/dl > 110-125 mg/dl Waist circumference > 102 cm (40 in) > 88 cm (35 in) > 150 mg/dl
Normal Values
Total Cholesterol (mg/dl) < 200 Desirable Borderline High LDL-C (mg/dl) (bad Cholesterol) < 100 Optimal Near Optimal Borderline High Very High
200-239 > 240 -
100-129 130-159 160-189 > 190 -
Triglycerides (mg/dl) Normal Borderline High Very High < 150 mg/dl 150-199 mg/dl 200-499 mg/dl > 500 mg/dl
HDL-C(mg/dl) (good Cholesterol) < 40 > 60 Low High
A common question asked by patients," I have total cholesterol 235mg/dl and triglyceride 215 mg/dl. Should I take medicine?" The need for medicine in treatment of a patient is not decided by the numbers or results of a particular test; it is decided by risk status like a previous heart attack, brain stroke, diabetes, etc ., that the patient had. If a person does not have any of risk factors, then the person requires no medication. However, there may be a need for a change or modification in life style such as diet control and exercise.
(<-Less than;>-more than) Causes of Low HDL-C (good Cholesterol) : Elevated serum Triglycerides, Overweight and Obesity, Physical Inactivity, Cigarrete Smoking, High Carbohydrate Intake, Diabetes, Drugs (Betablockers), Genetic factors etc. Atherogenic Dyslipidemia This is a condition in which a patient exhibits an apparently normal lipid profile, but has a heart attack at an early age. This is characterized by:
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High-Sensitivity C-Reactive Protein (hsCRP)

hsCRP is a new important risk marker. It is elevated in various conditions. High sensitive CRP (hS CRP) is valuable in diagnosing and assessing the risk of coronary artery disease and its prognosis. hsCRP <1 mg/l - Low Risk ; 1 - 3 mg/l - Moderate Risk > 8 mg/l - Infection (unrelated to heart) 3 - 8 mg/l - High Risk ;
has no heart problem, the patient has Unstable Angina, or the patient has experienced a heart attack of less than 6 hours duration.
Electrocardiogram (ECG)
The electrocardiogram (ECG), is a basic investigation done for the heart. The result of this test tells the doctor the condition of a patient's heart rate, the regularity of heart beat (rhythm), enlargement of the heart, the way the electrical impulse travels into different areas of the heart, and whether a chest pain is due to a heart attack or not, or if the giddiness experienced by some patients is heart related or not. In families with history of sudden death at young age among primary family members, the ECG test becomes very useful in narrowing the diagnosis. If a person complains of chest pain or palpitations an ECG test should be immediately conducted and the results presented to a qualified doctor for interpretation. A patient or his doctor should never take for granted that the symptoms are not heart related even if clinical observation appears not to be. Like all tests the ECG too has its limitations. An abnormal ECG does not always signify that there is a heart problem; similarly, a normal ECG during a chest pain does not necessarily rule out the impending heart attack. The expert clinical suspicion of the doctor based on symptoms observed, are more important. Whenever in doubt whether the symptoms of a patient suffering chest pain are heart related or not, the patient should be admitted in hospital where serial ECG should be performed, along with two or more Troponins tests at intervals of 6 hours. Only after following these steps can a doctor safely and happily announce that the pain is, "Non Cardiac Chest Pain".
High hsCRP also predicts development of Diabetes and High Blood Pressure.
Serum Homocysteine
Elevated levels of Serum Homocysteine are associated with premature heart attack and stroke. Some patients may have genetic disease and serum Homocysteine more than 100 mmol/L. These patients develop heart attack, stroke or clotting in the veins at young age. Mild elevations (more than 15 mmol/L.) is more common in general population due to inadequate intake of folic acid in the diet. Routine supplementation of folic acid, vitamin B12 is not recommended for heart patients after heart attack.
Cardiac Enzymes
Cardiac enzymes are done to know whether or not a person has had a heart attack. These tests are useful especially, when the ECG is normal while the patient is experiencing chest pain, or shows abnormality and the diagnosis of a heart attack is not clear by ECG. Among the cardiac enzymes tests, the commonly used are creatine kinase (CK), Creatine kinase MB (CKMB), Troponin T and Troponin I. All these tests show a positive result after 6 hours of a patient suffering a heart attack. For diagnosis of a heart attack within 6 hours, another test called Myoglobin is used. However, this test has some limitations. A negative Troponin test result doesn't mean that patient has not suffered a Heart Attack! This test can be negative in a patient who has suffered a heart attack (even a major one), but the duration of severe chest pain is less than 6 hours. Based on Troponins results, patients who have had a heart attack are classified into 2 groups: Negative(Normal) Troponin: Unstable Angina Positive(Abnormal) Troponin: Acute Myocardial Infarction A negative Troponin test result can be interpreted in three ways, either the patient
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Can an ECG be normal in a patient with true chest pain or heart attack? Yes, approximately 25% patients presenting with true chest pain and having heart attack, will have "Normal ECG" during first check. Serial ECGs and serial Troponin done at 6 hours interval is useful in such cases.
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Echocardiogram (2D Echo and Color Doppler)

One of the most beautiful technical advances which revolutionized treatment of heart disease is the echocardiogram. The echocardiogram is nothing but an ultrasound of the heart. The heart, its 4 chambers, 4 valves and their function is visible to the doctor directly. The use of this test allows the doctor to: 1) Know about the condition of all the chambers and valves. 2) Determine Ejection Fraction or the pumping function of the heart (EF). The EF normal value varies between 55%-75%. 3) Know of any damage to the heart during a current or previous heart attack. 4) Know of any birth defect in the heart. 5) Know of any abnormal fluid collection around the heart. 6) Know if there are tumors, clots, etc., inside the heart. A normal heart scan in a patient with chest pain or breathlessness does not rule out a serious problem. The scan may show
Right Atrium Left Atrium Mitral Valve Right Ventricle Left Ventricle
Exercise ECG (Treadmill Test - TMT)

This test is done basically to assess whether the symptoms of chest pain are a heart related problem. This test requires that the patient walk/ run over a moving belt which starts at slow speed and gradually increases the speed every 3 min. The test is done until a target heart rate is achieved (which is calculated as 220-Age), symptoms occur with ECG changes, or if the patient can't perform beyond certain stage. For most individuals, 9-12 minutes of exercise over the belt is enough. The ECG results are recorded continuously during the exercise interval over a monitor. The results shown on the monitor allow the doctor to verify if the chest pain is due to a heart related condition. It is recommended that a patient avoid having a heavy meal before the test. If the patient is taking drugs like beta-blockers for high BP, the medication must be stopped for 24 hours before the test. The patient's blood pressure must be under control prior to the test. Certain problems in the ECG like LBBB, WPW or a very high blood pressure (>180/100mmHg) make this test uninterpretable. During the test, the ECG is recorded continuously, and based on a parameter in the ECG, called ST segment, the test is concluded positive or negative. A positive test result, especially with chest discomfort during the exercise, indicates blockage in the blood vessels (coronary arteries) supplying the heart. A negative test is a good assurance that the chest pain is not related to heart problem. TMT is a very useful test, but it is not 100% accurate. In some case a positive test may not be due to a heart problem (especially in women). Similarly, Treadmill Test (TMT)
abnormality during a heart attack, but it may show normal results in patients who have problems only during exertion (angina).
Echo Cardiogram
If a patient has a normal echocardiogram, does this mean that everything is normal and there is no heart problem? No. A normal echocardiogram only means that the pumping function of the heart, the valves and the pericardium are normal. It doesn't show anything about other conditions that may be present, such as angina, palpitations etc.
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a negative test does not necessarily mean that there is no heart ailment. Everything is interpreted in the perspective of a patient's symptoms. After a heart attack, the test is done to know how much work a patient can perform and to establish a plan of rehabilitation. If a patient has a negative test after a heart attack, it is a reassuring indication that the patient can perform strenuous work. complications. Dobutamine Stress Echocardiogram There are patients who can't walk on a treadmill due to some reason such as joint pain etc. In such patients heart rate is increased with medicines like Dobutamine in stepwise manner, and at the same time, the contraction of the heart muscle is recorded by echo. Any weakness in contraction of the heart during the test indicates blockage of the coronary arteries. The test is also useful in patients after heart attack to know whether angioplasty (PTCA) or bypass surgery (CABG) is useful for the particular patient or not. The test is very informative, but does carry little risk of chest pain (which is likely in case of positive test) and irregularity in the heart beat. Both false positive and false negative results can occur. Sometimes the same test is done by using Adenosine or Dipyridamole. ECG - It is taken at rest and its result is abnormal only when there has been a heart attack. Echocardiogram - indicates the condition of the valves, function of the heart and damage to the heart muscle if there has been a previous heart attack. TMT. It tests the heart during exercise. TMT result shows problems which can occur during exercise, like chest pain or breathing difficulty while walking. A patient may be requested to have all these 3 tests done before a doctor gives a conclusive diagnosis since each test has different implications.
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Common terminologies encountered in TMT Test interpretation: Target Heart rate (THR) or Maximum Predicted Heart Rate (MPHR): This is derived by using formula: 220-age of the patient. During TMT patient is normally exercised to a heart rate which is 85% of THR. Positive TMT: Means the test is abnormal and requires further investigation, for example, a coronary angiogram. Negative TMT: Means the test is negative for provocation of coronary artery disease.This is a normal test. Inconclusive TMT: Means either 85% of THR is not achieved, or exercise duration was very brief so that the test cannot be inferred either positive or negative- a clueless test. Chronotropic incompetence: Means a heart rate of 85% of THR is not achieved even after 3 stages of exercise. Please note, a person with an abnormal test (positive test) may not necessarily have a diseased coronary artery. The test may become abnormal even without any disease in about 30% patients, especially females. Similarly, a negative test doesn't guarantee that everything is normal inside the heart. Approximately 10-15% patients with serious heart disease may show a negative or normal test. So, the opinion of your cardiologist is more valuable than the test itself.
The TMT test is very safe with very low risk of
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Radionuclide Tests
Radionuclides, commonly Thallium or Technetium and used to assess the same things as Dobutamine stress echo. This is done again to assess the blood flow to the heart, and in some cases, to assess the suitability for PTCA or CABG. Here an injection is given at the beginning of the test and pictures are taken from gamma camera. Then you are asked to exercise on treadmill like TMT or subjected to some stress induced by medicines like Dobutamine or adenosine, and again a gamma camera image is taken after the completion of the test. The picture taken during test and exercise are then compared, and the areas of the heart muscle with less blood flow, are noticed. This test is safe and informative but not 100% accurate.
C) Tests to Know blood flow to the Heart and Blockages:
Cardiac Catheterization and Coronary Angiography

Coronary angiography is a procedure by which a catheter is introduced through a very small incision on the upper part of the thigh (groin) or inner side of the right wrist. The catheter once introduced, is advanced to the heart, the blood vessels supplying the heart are directly injected and assessed for any blockage interrupting or diminishing the blood flow in these arteries. This procedure is done for the purpose of evaluating chest pain. The procedure is very safe and the patient can be discharged after 4 to 8 hours following the procedure. Most patients are able to return to work the next day. The percentage of complications arising from this procedure is very minimal, approximately 7 cases per 1000 procedures.
Radial Artery
Coronary angiography is the procedure the cardiologist ultimately would use to diagnose and treat the blockage in the coronary arteries. Based on the extent of the blockage the doctor would take future course of action like balloon treatment or bypass surgery. Coronary angiography is also used to assess the pumping function of the heart during angiogram. In other conditions like pericardial and
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Femoral Artery
myocardial diseases, where diagnosis is not clear, doctors may choose to perform this procedure to ascertain the diagnosis. Cardiac catheterization is done to assess various problems of the heart, including birth defects. In this procedure one catheter is passed through the vein (the 'blue' vessels draining impure blood into the right side of the heart), to the right side of the heart, and another catheter is passed through the artery. The pressure and oxygen content of the blood in various chambers is estimated and analyzed for various diagnostic purpose.
Presence of calcium in the walls of the blood vessels to the heart has been found to correlate with the lipid deposits in the wall of the blood vessels. Helical ultrafast CT and Electron Beam CT (EBCT) are good methods used in detecting calcium in these blood vessels. However, since not all the lipid deposits are calcified; nor does a scan clearly identifies a prospective victim of heart attack, this calcium detection scans have not been endorsed by cardiac societies for routine clinical use.
Coronary Angiogram Left Coronary Artery
Right Coronary Artery
Diagramatic Depiction
A CT Coronary angiogram in a patient showing normal coronary anatomy with no calcium or blockage presents (Images courtesy of Vijaya Medical Center, Visakhapatnam). Which test is better-a CT coronary angiogram or a conventional coronary angiogram? A CT coronary angiogram is a very useful technology .It tells not only about the lumen of the coronary angiogram, but also tells about the calcium presence in the walls of the artery. In addition, sometimes it gives more information which a cardiologist or cardiac surgeon wants. But it has limitations in presence of heavy calcification and previous stent. A conventional coronary angiogram is always required when there is an abnormal CT coronary angiogram when a decision of balloon treatment or bypass surgery is to be made .For diseases involving aorta, CT angiogram is the Gold Standard .A CT coronary angiogram is now being used in some centers also to evaluate quickly a chest pain,to rule out any heart attack which may be missed by an ECG. So, it is the cardiologist who decides which is better for a particular patient-a CT coronary angiogram or a conventional angiogram!
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CT Coronary Angiogram
CT Coronary Angiogram is a useful new modality to assess coronary anatomy and all other arteries in the body like neck vessels, aorta, limb vessels, etc. In addition to blocks inside the vessels, it shows the condition of the vessels' walls, the composition of the block, and many other relevant details which sometimes may not be possible to obtain from normal angiogram done in the Cath Lab. The presence and severity of calcium in the walls can also be detected with this test. CT Coronary Angiogram can conveniently be done in an out-patient setting. Currently CT scanners used for coronary angiogram are 64 or 128 slice CT machines. For coronary angiograms with 64 slice CT, the heart rate needs to be controlled to 60-70 beats per minute to obtain good images. Presence of severe calcification precludes a CT coronary angiogram.
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Cardiac MRI
MRI is a commonly used tool for brain scan. MRI of the heart can be used to detect blood flow in blood vessels, especially that of major arteries. It is especially useful in the diagnosis of diseases of the aorta and its branches, and complex defects of the heart. MRI technology is gaining momentum for its use in diagnosing cardiac patients. It is being used to assess the heart muscle after a heart attack and to rule out myocarditis a disease which many times mimics a heart attack. D) Tests to assess Giddiness and Unexplained Fainting Episodes:
Implantable Loop Recorder (ILR)

This new technique is used when the symptoms of giddiness or palpitation are infrequent, and the Holter test results are normal. In performing this test, a small device is put under the skin by a small surgery. This can record heart beat up to 14 month. Any episode of the symptoms during this time is recorded and then analyzed by the computer. To capture and store the electrocardiogram (ECG) that occurs at the time of the fainting episode, a patient places a hand-held, pager-sized activator over the Implantable Loop Recorder after waking from an episode, and presses a button. A family member or friend also can be the one to place the Activator over the patient's device to save the information. It is important for the patient to keep the Activator handy at all times (clipped to the clothes or looped over a belt). Later, a physician analyzes the stored information and determines whether the fainting episode was caused by an abnormal heart rhythm. Once the physician determines this, the device is removed and either treatment is begun or the patient is referred to a specialist. Placing the Implantable Loop Recorder takes about 15 to 20 minutes and can be done under a local anesthetic on out-patient basis. The physician makes an incision about 2 cm. in length (3/4 of an inch), creating a pocket the same size and shape as the Implantable Loop Recorder device. Once the device is inserted in the pocket, it is programmed to record the ECG during fainting episodes. Current devices can store ECG for more than a year. This test is very useful when patient has less frequent fainting episodes. Available now, are External Loop Recorders which do not require any surgery. These loop recorders are very small devices that can be activated at the time of an episode. The results of the ECG can be transmitted far-off to the physician through a hand-phone.
24 Hour ECG (Holter Test)

This test is required to diagnose symptoms like palpitations, giddiness which occur only sometimes and not necessarily when the patient visits his doctor. To perform the Holter test a small of device the size of a pager is attached to the body, and connected with some wires. This test has an electronic memory that continuously records the functions of the heart just as an ECG does. This test is done on outpatient basis. After the monitor has been placed, the patient wears the monitor for 24 hours; he is then called to the doctor's office for removal of the apparatus. The small pager like monitor is then connected to a computer that will display the recorded functions of the heart. This test is done to assess the regularity of your heart beat (rhythm), and to diagnose why a patient experiences palpitation or giddiness. The results of this test can also aid a doctor to diagnose episodes of silent ischemia to the heart.
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Implantable loop Recorder (Medtronic Reveal)

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Tilt Table Test

The tilt table test assesses whether the patient faints as a result of a sudden drop in blood pressure. The change in blood pressure may be due to a hyperactive reflex that causes the blood vessels to suddenly dilate (widen). The widening of the blood vessels may be due to dehydration, emotional stress or standing upright for a prolonged period of time. This type of fainting episode is known as neurocardiogenic syncope, although many physicians and patients still refer to it as vasovagal syncope. The tilt table test is conducted on a pivoting table by securing the patient on his back to the tilt table. The table is then tilted upright (head up and feet down), thus, simulating the factors leading to neurocardiogenic syncope. This test is designed to detect orthostatic hypotension, one of the most common causes of fainting.
SUMMARIZING Tests to know risk of heart attack and implement prevention Routine investigations, Lipid profile, hSCRP Tests to know if there is a suspicion of heart attack Troponin T or I,CK/CK MB,ECG, Echocardiogram Tests after the heart attack Stress tests, Coronary angiogram Tests to identify abnormal beating of the heart (arrhythmia) ECG,24-hour ECG(Holter),Loop Recorders, Electrophysiologic testing
Tilt Table Test
Electrophysiological Study(EPS)
Some patients have symptoms of palpitation accompanied by feelings of giddiness which require medical evaluation. For a proper diagnosis of these symptoms it is most important to have an ECG during the time that the patient is experiencing the symptoms. The ECG at that time may show increased heart rate, irregular beating (arrhythmia) or slow heart rate due to blockage. Through Electrophysiological study the doctor can assess these problems. In this procedure, through the thigh multiple catheters are introduced into the right side of the heart. The mapping of the heart is done by stimulus given to the heart. In case of fast rate arrhythmia "tachyarrhythmia" a curative procedure is done simultaneously, and it is called as RadioFrequency Ablation. In RadioFrequency Ablation a small energy current is delivered to the heart through the catheter which will cure the problem. This procedure is very safe and highly effective. The rate of complications is minimal.
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A word about PET scans: PET stands for Positron Emission Tomography. This is a new, sophisticated and a costly test used in certain conditions arising after a patient has had a heart attack. This test is done to assess perfusion of the heart muscle, and for some selected clinical studies basically for the purpose of research. It is not a test routinely recommended for heart patients. This test is not done as a routine to assess if a patient is at risk of a future heart attack.
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Risk Factors for Heart Attack

Coronary artery disease is more likely to occur if someone has the following risk factors: (> greater than, < lesser than) Age: Men More than 55 Years 65 Years
High Blood Pressure (Hypertension)

High blood pressure (BP) is a major heart condition present everywhere in the world. If neglected, it can lead to heart attack, heart failure, brain stroke, kidney failure and blockage of blood vessels in the abdomen and legs. If the blood pressure condition is taken care of properly, all the above mentioned complications can be avoided. Since High BP is the cause of such serious complications it is of vital importance that it may be identified and treated properly and promptly. What is High Blood Pressure ? Blood pressure is generated when the heart pumps the blood into the vessels called arteries. This pressure has got two components, systolic and diastolic. Most of us have seen doctors writing blood pressure as 120/80 mm Hg. The 120 value indicates the systolic BP, while 80 is diastolic BP and mmHg refers to mm of the mercury column. Both of these values are important in classifying normal and abnormal blood pressure. The guidelines classify BP as: Systolic BP Optimal Normal High Normal High BP < 120 120-129 130-139 > 140 and and or or Diastolic BP < 80 80-85 85-89 > 90 mmHg mmHg mmHg mm Hg
Women More than
Family History of premature CAD - MI or sudden death before 55 years of age of father or other first degree male relative, or less than 65 years of mother or other first degree female relative. Current Cigarette smoking Hypertension (BP > 140/90 mm Hg) Low HDL - Cholesterol (< 40 mg/dl) hS - CRP > 1 mg/dl Sedentary Life style Psychological or emotional stress Obesity Excessive use of Alcohol Aggressive behavior (type A personality) Post menopausal state (Natural or surgical) Diabetes Mellitus, (high blood sugar) can immensely increase the risk of having a Heart Attack.
The High normal value means that the value is 'normal' for a healthy person, but it is considered high for a patient who has diabetes, risk of heart attack or has had a previous heart attack. Why some of us have High BP ? In as many as 90-95% cases, the cause of high BP is unknown; this type of hypertension is called "Essential Hypertension". However, in 5-10% of the cases, high BP is due to other underlying conditions like kidney problem, congenital or acquired narrowing of blood vessels, tumors, certain drugs like birth control pills, hormone problems etc. This type of hypertension is called "Secondary hypertension".
I don't have any of the risk factors mentioned above. Can I get heart attack too? Those people who do not have the above mentioned risk factors, can also develop heart attack, but less frequently and often tolerate it better. What are "Modifiable" and "Non modifiable" risk factors? Modifiable risk factors are those which can be modified with diet, exercise and medicine , like diabetes,blood pressure,smoking. Non-modifiable risk factors are those which cannot be changed , like age, sex, family history.
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In most of the cases of secondary hypertension, the cause of it is remediable. "Secondary Hypertension" should be evaluated in all patients, especially those patients who present it as: High BP with heart failure High BP with kidney failure Young age or old age at presentation (less than 30 years or more than 65 years) First time detected severe hypertension (> 180/110) High BP which is inadequately controlled by drugs. -
The Diagnostic workup for the Detection of any Irregularity in BP

The tests required for the detection of any irregularity in BP helps the doctor to: know if there is any damage to internal organs like heart, eyes, and kidneys. identify any other curable factor responsible for high blood pressure. know the existence of other risk factor like diabetes mellitus and to treat that condition more aggressively. assess the 10 year heart attack risk using framingham table given below:
FRAMINGHAM TABLE
Risk Factor
Age 30-40 Years 35-40 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
Risk Point (Men)

0 2 5 7 8 10 11 13 14 15
Risk Point (Women)

0 2 4 5 7 8 9 10 11 12
A thorough check up is required to rule out secondary causes. A check up and advice by specialist doctor is essential. What are the symptoms of High BP ? In the majority of patients, high BP does not produce any symptom. It is only detected by routine evaluation. It is a false belief that high BP causes headache and increased anger. In fact, almost 75% of the patients with high BP are not aware of their problem. Unfortunately, most of these patients come to know that they have high BP only when they develop some complication like heart attack, heart failure, bleeding of the eyeball leading to loss of vision, brain hemorrhage, kidney failure, etc. It is unfortunate to develop a complication due to high BP, especially when so many excellent and effective drugs are available to treat the condition. Since the high BP is asymptomatic in the majority of people, it is recommended that all those above 20 years of age should have their BP checked.
HDL-C Level (mg/dL)

> 60 50 - 59 45 - 49 35-44 <35 -2 -1 0 1 2 -2 -1 0 1 2
Total Cholesterol Level (mg/dL)

< 160 160 - 199 200 - 239 240 - 271 >280 0 1 2 3 4 0 1 3 4 5
Systolic Blood Pressure (mmHg)

< 120 120 - 129 130 - 139 140 - 149 150-159 >160
Untreated
2 0 1 2 2 3
Treated
0 2 3 4 4 5
Untreated
-3 0 1 2 4 5
Treated
-1 2 3 5 6 7
Smoker
No Yes 0 4 0 3
Diabetes
No Yes 0 3 0 4
Total Score 10 years Risk Male
<-2
-1 <2% 2%
0 3% 2%
1 3% 2%
2 4% 3%
3 5% 3%
4 7% 4%
5 8% 4%
6 5%
7 6%
8 7%
10
11
12
13
14
15
16
>17
10% 13% 16% 20% 25% 31% 37% 47% 53% 53% 53% 53% 8% 10% 11% 13% 15% 18% 20% 24% 27%
10 years Risk Female <1%
Catergorisation of 10 years risk of CHD Event Very low risk <10% ; Low risk < 15% ; Moderate risk 15 - 20% ; High risk > 20% 36 37
The following test are routinely done in a patient with high BP : Hemogram Blood Sugar Fasting lipid profile Kidney Function tests Urine Examination, including tests for urine albumin excretion Ultrasound Scan of abdomen Electrocadiography (ECG) Eye check up (Fundoscopy)
Measuring Blood Pressure

There are various types of blood pressure measurement instruments available; some are used by doctors, and some are for home use. The instrument used by the doctor in the clinic is called sphygmomanometer. This instrument contains a mercury column and is the most accurate in measuring blood pressure. The cloth wrapped around the arm is called "Cuff". Either arm can be used to measure the blood pressure. Before taking BP measurement, the patient should be at rest for 5 minutes. After the cuff is wrapped over the arm, it is inflated with air to a limit perceived by the doctor. The stethoscope is placed over the cubital fossa to hear a sound (called 'korotokoff sound') which appears when the blood flow resumes as the air is slowly released. The point in the mercury manometer at which this sound appears is labeled as 'Systolic Blood Pressure'. Air is released further and then at one point no sound is heard. The demarcation on the column of the mercury where the sound disappears is called "Diastolic Blood Pressure". So, the blood pressure of a person is written as 120/80 mmHg, where 120 is systolic and 80 is diastolic blood pressure. The other instruments used: 1) Aneroid sphygmomanometer 2) Digital monitors Digital electronic equipments have been manufactured for self monitoring of blood pressure at home. Normally, the clinically tested blood pressure is higher than when tested at home. Measuring the blood pressure at home helps the doctor to correctly diagnose and treat high blood pressure. Although, electronic devices are not as accurate as the mercury manometer, still they are helpful in managing the condition. It is therefore, advisable to have one of such equipments if a person has high BP. Some of the most accurate BP measuring equipments in the market are Omron Hem 705 CP, 735C, 713C; A & D UA - 767; BPM - 100.
Other special tests may include : Thyroid function test Renal Doppler Echo cardiogram Angiogram etc.
Although routine tests are required in all patients, special tests are prescribed by the physician according to the need of the patient. Low Blood Pressure: Some people have blood pressure less than 100/60 mmHg. Most of these patients don't have any problem, but some of them feel weakness or giddiness. Normally, these 'Low Blood Pressure' patients live longer than patients with normal or high blood pressure. Most of the time low blood pressure does not require workup or treatment. For some patients having low blood pressure increase of fluid and salt intake may be helpful. In some cases elastic stockings are useful. In some cases low blood pressure can be the result of various heart disease conditions which require special treatment. Low blood pressure can be a symptom of depression which requires psychiatrist evaluation. Prolonged illness can also lead to low blood pressure. Adequate calorie intake can improve this situation.
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24 Hours BP Monitoring : Known as Ambulatory Blood Pressure monitor (ABPM), is used to assess the 24 hours trend of the blood pressure fluctuation. In this method a cuff is wrapped around the arm and is connected to a small personal stereo size device which automatically inflates and deflates the cuff at regular intervals. Daily activities can be carried out without any discomfort except, taking bath. After 24 hours the patient returns to his doctor to have the monitor removed. Once removed the monitor's information is analyzed by a computer. This method of monitoring the blood pressure helps to identify persons in whom blood pressure fluctuates because of anxiety or blood pressure medicines produce side effects like episodes of unexplained giddiness. Measuring the blood pressure by this method gives the doctor an insight as to how well the patient is controlling his blood pressure.
Life Style Management

Diet and Exercise for people with High Blood Pressure
Whether one has normal blood pressure or high blood pressure, one should always apply life-style modifications. This is mandatory in addition to the medicine. The life style modifications include : Healthy diet plan : A general diet plan for everyone should haveTotal fat Saturated fat Polyunsaturated Fats(PUFA) Monounsaturated Fats(MUFA) Protein Carbohydrate Fiber Sodium Potassium Calcium Magnesium Cholesterol 25-35% of total Calories <6% of total Calories upto 10% of total Calories up to 20% of total Calories 18% of total Calories 55% of total Calories 30 g/day less than 2.3gper day 4.7g/day 1.250g/day 500mg/day <200mg/day
White Coat Hypertension

It is known that some people when they enter physician's chamber, develop anxiety, and their blood pressure shoots up. The same person checked outside in a friendly environment usually has a normal blood pressure. This phenomenon is known as "white coat hypertension", white coat refers to the doctor. An opposite phenomenon is also seen-some people have lower blood pressure in physician's chamber, and higher outside, probably related to work stress. Ambulatory blood pressure recording (ABPM) can help us in these conditions to identify true hypertension (high blood pressure). A person, who has normal blood pressure in physician's office but high blood pressure on ABPM, is hypertensive, whereas a person, who has high blood pressure in physician's office, but normal blood pressure on ABPM, is NOT hypertensive.
Treating High Blood Pressure

Treatment of High Blood Pressure has two facets involving: 1) Changes in diet, exercise and life style. 2) Medical treatment. Life style changes, diet control and exercise are compulsory even if a person is taking medication for the control of high blood pressure. Life style management is as essential as drug management.
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* 1,500 mg sodium was a lower goal tested and found to be even better for lowering blood pressure. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high blood pressure. g = grams; mg = milligrams. Patients with High Blood Pressure should eat plenty of fresh vegetables, fresh fruits, dried fruits, legumes, dairy products, limit-canned and other processed
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food, avoid-fatty food, pickles, salty food, alcohol and caffeine. In 1997,National Institute of Health, US carried out a study called "DASH" for Dietary Approaches to Stop Hypertension and it was found that this diet plan was able to significantly reduce blood pressure, in some cases as much as a pill, and was able to prevent hypertension. As I said earlier,our knowledge in allopathy is based upon large controlled trials and not on whims and fancies. This is an example of that. The DASH guidelines in general were: Grains and grain products: Vegetables: Fruits: Low-Fat/non-fat dairy food: Meats, poultry, and fish: Nuts, seeds ,or legumes: Fats: Sweets: 7-8 serving /day 4-5 serving/day 4-5serving /day 2-3 serving/day < 2 serving/day 4-5 serving / Week 2-3 serving /day; avoid saturated fat < 5 per Week
One medium size vegetable or fruit(e.g.apple,orange,banana) A couple of small fruits(e.g. two plums) One cup of a very small fruit(e.g. grapes) -1 tbsp dried fruits(e.g. dates) 2-3 tbsp of cooked or canned fruit 2 tbsp raw,cooked,frozen or canned vegetables A bowl of salad 3 heaped tbsp beans or lentils A glass of fruit juice(only counts once per day) There is a considerable evidence that diet rich in fruit and vegetables, is associated with reduced incidence of heart attack and stroke, cancers, lung diseases and cataract. One should eat at least 5 portions a day of fruit and vegetables. In addition to vitamins like B, C and E, they contain antioxidants which provide immunity and help to prevent serious diseases. Some of these antioxidants are available in capsule form too, but these capsule formulations are not useful. So it is better to take natural form of these antioxidants rather than artificial ones. Look for minerals : Potassium, calcium and Magnesium are friendly minerals. Look for foods rich in them. Garlic : Many clinical studies have been performed to validate the claims of garlic in high BP but the studies failed to prove its efficacy. However, it gives quite unpleasant breath and body odour. Although it is available as odorless pills, it is not known whether these pills have the same benefits. Fish Oil: n-3 fatty acids present in fish oil may help to reduce blood pressure. Folic Acid: Some studies have shown that use of folic acid, a component of
Readers are hereby requested to visit "DASH diet eating plan" on internet. Eat more fresh fruits & vegetables : Five Portions a day : Fresh fruit & vegetables are low in sodium salt and it is good to consume more of them on a daily basis. Fresh fruit and vegetables are important in regulating the bowel. They provide antioxidants that help reduce the level of harmful free oxygen radicals in the blood.
What constitutes a "portion" or "serving"?

A portion is generally considered to be approximately 80gram.This corresponds toA piece of a large fruit ( e.g. half an avocado or grapefruit,a large slice of melon, a couple of rings of pineapple)
vitamin B-complex ,can prevent development of high BP in women.
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Smoking : Smoking is detrimental to good health. Quitting smoking is one of the most important steps towards managing high blood pressure and preventing complications that may arise from high BP. It is the best gift one can give to oneself and to society as both, active and passive smoking, are harmful. Physical activity: A sedentary life style, not only increases blood pressure, but also increases the risk for various heart diseases. Daily walking, jogging, cycling or swimming are good for health. Walking at least three to four times a week for 30-40 minutes is a good way to keep active. Exercise like weight lifting is not useful and may be harmful. If exercise has not been previously a part of a healthy routine, it is best to start slowly and gradually increase the intensity and duration of the exercise to personal capacity. It is not necessary to overdo it. If angina and high blood pressure are present, one should exercise only until chest pain is felt. Once the pain is felt one should stop exercise. It is best to avoid activities which produce chest pain. A
suggestion is to walk only to a distance and at a speed which doesn't produce chest pain. "Exercise is the most effective anti-ageing pill ever discovered." This is applicable for a healthy person as well as one with disease. Weight control Losing weight is helpful not only in controlling high blood pressure, but also in preventing various complications such as obesity, heart attacks, sleep disorders, brain conditions, joint disorders, etc. The excess weight should be shed slowly and steadily. Rapid loss of weight is not advisable. It is important to lose weight by a combination of diet control and exercise, rather than by medicines and other methods which may be harmful. The initial goal of weight loss should be to reduce body weight by 5 - 10% from base line. Weight Normal BMI* (Kg/m2) < 25 25-29 > 30 Height in Cm - 100 (+ 5) Kg Normal Over Weight Obese
BMI* (Body Mass Index) =
Weight in Kg (Height in meter)2
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Waist circumference - Measured horizontally at the iliac crest

Men <37 inch 37-40 inch >40 inch Women <32 inch 32-35 inch >35inch Normal Over Weight Obese Normal Over Weight Obese
contain adequate amount of salt. Cooking without salt is a good practice to minimize sodium intake. Cooking without salt may be unpalatable initially, but after a month the taste buds get used to it. Alcohol intake : Moderate drinking 1-2 units of alcohol a day may have a protective effect on the heart. Heavy drinking can lead to various heart and liver problems. If a person has suffered a heart attack or some other disease, it is best to avoid alcohol completely. it is advisable for people in India to avoid alcohol. Less amount of alcohol in western world has been found protective, but no such studies have been conducted in our country. Considering differences in climatic conditions(studies showing beneficial effects of alcohol are from cold climates) ,difference in education status and awareness towards health,lack of exercise and more stressful life in our country, I suggest not to extrapolate those effects to our people. Those with higher triglyceride or elevated liver enzymes should stop alcohol immediately. Stress: Stress is an important factor in the development of high blood pressure. Activities such as Yoga, walking, meditation, active participation in religious faith, etc. can help manage stress. Yoga is good for health but is not a substitute for daily walking. If one has to choose between yoga and daily walking it is advisable to choose daily walking. Yoga reduces high blood pressure but does not prevent heart attack. Please remember, Life style modifications should be added to all patients with hypertension, and these are not a substitute for a medicine prescribed. Patients who have BP more than 160/100 will require medicine in addition almost always. Don't stop medicines.
Obese people may develop high blood pressure which may not be linked to salt. This is a simple side -effect of obesity. Control of weight helps to control blood pressure without medicine. A 10 kg reduction in weight can reduce BP by 20/10 mmHg! However, this weight control should better be achieved by diet control and exercise and not by medicines. A simple consultation of a good dietitian is helpful. And the weight reduction should be gradual-meaning not more than 6 Kg in 6 months or 1-2kg per month. Caloric requirement (K Cal) for weight maintenance : Obese or very inactive person Individuals >55 yr age, active women, sedentary men Active men, Very active women Thin or very active men Kcal in the diet. Restrict your daily salt intake A high salt intake rich in sodium leads to hypertension and reduction in salt intake reduces BP.This is especially very important for those who have family history of high BP,obese ,smokers or with sedentary life style.It is better to avoid added table salt and replace it with potassium salt. Most of the extra salt comes from market products like, namkeens, processed foods etc. One should restrict the daily intake of salt to no more than 2 grams of sodium. Vegetables naturally
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20 Kcal/Kg weight 25 Kcal/Kg weight 30 Kcal/kg weight 40 Kcal/ Kg weight
To lose one pound weight (450 gram) in a week, one needs to decrease about 500
Medicines for High Blood Pressure

Not all patients require medicines for high blood pressure. The need for medicines and the type of medicines to be prescribed depends upon initial blood pressure readings, the evidence of any associated disease producing high BP, the damage produced (if any), by high BP, and other conditions. Medicines are not substitute for good habits or life style modification, but are required to be taken conjunction with them. Not all the patients who have been prescribed medication for the control of BP require lifelong treatment. Approximately 20% of patients having mild to moderate
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high blood pressure can reduce their BP by simply changing their life style, and may not require medication at all. Starting drug treatment for high BP involves careful assessment of: Level of BP, (at least 3 different readings, with one reading preferably taken at home). Associated conditions like kidney failure, heart failure, heat attack, stroke and diabetes.
Group II These are medicines which lower BP but don't protect against heart attack & stroke. Centrally acting agents. (Reserpine, Clonidine) Alpha blockers. (Prazosin) Some calcium channel blockers. (Amlodipine, Nifedipine)
A person with mild to moderate high BP without any associated condition can be observed by his physician for 3-6 months. If after this period of observation there is no improvement of the condition, the doctor may choose to prescribe medication for the control of the high BP. However, a patient who exhibits severe hypertension on his first visit to the doctor enquires immediate attention and may be asked to be admitted in hospital for further evaluation. One must remember that even when taking medication for BP control, one must: Not smoke (active or passive). Reduce Alcohol intake. Walk or exercise regularly. Eat plenty of fresh fruit & vegetables Reduce stress.
It is always wise to start a drug with both effects (Group I). However, associated conditions may preclude the use of these medicines too. Often, a patient is required to take more than one drug to help control his high BP condition. After starting medication The patient should continue to follow life style modification as stated above. Initial follow up visits to the doctor may be weekly or fortnightly. The patient should be aware of any side effects produced by the drug and consult his physician immediately before discontinuing the medication on his own. It may take 3-4 visits to the doctor before adequate control of BP occurs. What is optimal control If a patient has diabetes, heart disease, stroke or kidney problem, the BP should be lowered below 130/80 mmHg. It doesn't matter that this goal is achieved by taking one, two or three drugs. Unless this goal is achieved, the patient will not get adequate benefit from the medical treatment. How long should medication for control of BP be continued? Almost 80% of the patients, who start treatment for high BP will require to take medication lifelong. Treatment should not be discontinued at any time without the doctor's advice. BP of elderly people Previously, it was believed that it was normal for the elderly to have higher BP. However, doctors now know that elderly people with BP more than 140/90 mmHg
Medicines for management of high BP The medicines used to treat high blood pressure can be classified into 2 groups. Group I These are medicines which lower BP and protect against heart attack & stroke. ACE Inhibitors. (Ramipril, Lisinopril etc.) Angiotensin receptor blockers. (Losartan, Telmisartan etc.) Diuretics. (Thiazides) Beta blockers. (Atenolol, Metoprolol etc.) Calcium channel blockers. (Verapamil, Diltiazem)
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have an increased risk of stroke and heart attack. Elderly persons should monitor their BP regularly and have adequate control as stated above. Common side effects of medicines used to treat high blood pressure : Amlodipine, Nifedipine, Diltiazem Ramipril, Enalapril etc., Prazosin, Clonidine Beta - Blockers Swelling of Feet Cough Giddiness Nightmares
Curable forms of high BP In some cases (5-7%) high BP is due to some other problem in the body like Thyroid problems. Diseases of blood vessels supplying the kidneys. (Renal Artery Stenosis) Obesity. Hormone problems. Coarctation of aorta. Tumors like pheochromocytoma.
I have been diagnosed high BP. Do I need to take medicine? Not all patients who are diagnosed as having High BP require treatment from the very first visit.A person with BP between 140-160/80-90 mmHg doesn't require medicine from very first visit if he does not have diabetes, heart attack, stroke or kidney disease in the past. How many tablets do I need to take? Patients with BP between 140-160/80-100 mmHg often requireonly one tablet(if at all required!).Those with BP more than 160/100 usually require two or more tablets.It is not at all important to count number of tablets,but if you are taking medicine,your BP should be under control. Do I need to take medicine life-long? Those in whom medicine has been started when BP was 140-160/90100 mmHg and didn't have any other problem like diabetes, heart attack,heart failure,brain stroke or kidney disease,the medicine can be tapered and stopped overtime with effective institution of life style modifications.
Renal Artery Stenosis Coarctation of aorta.
Women with high blood pressure

A woman taking oral contraceptive pills should check her BP regularly. Oral contraceptive pills can increase the BP. If the woman has high BP, she should inform her doctor before starting oral contraceptives. If a woman plans to get pregnant and takes medication for control of high BP, she should know that certain group of ant-hypertensive medications like ACE Inhibitors and Angiotensin receptor blockers must be stopped before conception. She should inform her doctor before conceiving. The doctor may decide to change her treatment for one that it is safe to follow during pregnancy. A patient should not discontinue BP medication on her own. If she does, she puts herself at risk of serious complications.
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Patients who have never suffered from high BP may develop it for the first time during pregnancy. This condition is called "Pregnancy induced Hypertension". If untreated, this can lead to serious complications like preeclampsia and eclampsia. These conditions manifest themselves by unusual swelling of the body. If preeclampsia or eclampsia develops it requires immediate attention and close monitoring by the doctor since these conditions could be dangerous. An elderly or postmenopausal woman taking hormone replacement medication can continue the therapy along with the BP medicines. Hormone replacement therapy has little effect on BP. Management of High Blood Pressure during Pregnancy 1) 2) 3) 4) A Normal diet with NORMAL Salt is recommended during pregnancy. Calcium supplementation, at least 1g per day is recommended. Fish-oil or other vitamins have no role in BP control. Low-dose Aspirin (75-100 mg/d )at bed time is recommended in patients with very high BP. 5) 6) Weight reduction is NOT recommended in obese pregnant females. Normally, a BP lowering medicine is recommended only if BP during pregnancy is more than 150/95 mm Hg, unless someone is having high BP unrelated to pregnancy and taking medicine for the same. 7) Unsafe medicines: ACEI (all medicines ending with pril, like Ramipril) ,ARB(all medicines ending with tan, like Losartan) and Direct rennin inhibitors.If taken inadvertently during first trimester,switching to another medication and close monitoring with ultrasound is advised.Don't panic. 8) Safe Medicines: alpha Methyl Dopa,Labetalol,Metaprolol,Amlodipine, Nifedipine
Resistant Hypertension and Renal Denervation Therapy

Let's study a patient whose initial blood pressure was 200/110 mmHg or 200/80 mmHg. While a reading like 200/100 mmHg is seen in young adults, a reading like 200/80 is seen in elderly. These patients normally require high dosages of 2 or 3 blood pressure lowering medicines. Most of such patients will have blood pressure adequately controlled with medicines, but in some patients even after using high dosage of 4 different blood pressure lowering medicines, the blood pressure recording reads 180/100 or 180/80 mmHg. These patients are labeled as "Resistant Hypertension". Mostly it occurs due to inadequate salt restriction or lack of implementation of life style modifications or inadequate dosages of medicine. Almost 15-25% patients who had very high blood pressure at the first visit, will have resistant hypertension. Renal Denervation therapy is a new emerging treatment for patients with resistant hypertension. This is done by putting a catheter into renal artery and passing a current to ablate nerves in the kidney. This therapy is currently advised only for the patients who are on high doses of 4 different blood pressure lowering medication, and blood pressure is still not adequately controlled. The long term effects of this therapy are yet to be seen.
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High Blood Sugar (Diabetes Mellitus)

Diabetes mellitus (DM) is a disease that occurs as a result of inadequate production of a hormone in the body called Insulin. This inadequate production of insulin can be due to a variety of reasons. Most often the cause is either genetic or genetic predisposition to it. Based upon the need of insulin in the body the patients are classified as: Type 1 DM - In this type of diabetes there is an absolute deficiency of insulin production. This type 1 DM, is predominantly seen in younger age group. Type 2 DM - In this type of diabetes, there is a relative deficiency of insulin production, and it mainly involves adults and older age group. DM is diagnosed if : 1) 2) 3) 4) Random plasma glucose is > 200 mg/dl along with symptoms of DM like increased urination, increased thirst, and unexplained weight loss. Fasting plasma glucose is > 126 mg/dl. 2- hours post meal plasma glucose is >200 mg/dl. HbA1C > 6.5
Framingham Score for prediction of 8-Year Risk of Type 2 Diabetes in Middle-aged Adults
Points Fasting glucose level 100-126 mg/dL BMI 25.0-29.9 BMI >30.0 HDL-C level <40 mg/dL in men or <50 mg/dL in women Parental History of diabetes mellitus Triglyceride level >150 mg/dL Blood pressure >130/85 mmHG or receiving treatment Risk for Type 2 Diabetes in Middle-aged Adults Total Points 8 Year Risk, % Optimal care desired for Diabetes today. Detailed treatment advice for a patient with Diabetes patient is out of purview of this booklet. However, optimal care because it is of vital importance is discussed below. <10 <3 11 4 12 4 13 5 14 6 15 7 16 9 17 11 18 13 19 15 20 18 21 21 22 25 23 29 24 33 >25 >35 10 2 5 5 3 3 2
Given Total Points from Previous Table, there is an APPROXIMATE Percentage
Risk factors for DM Some people in the society are prone to develop DM in the future. This group of people include: 1) 2) 3) 4) 5) 6) 7) 8) Over weight persons with BMI > 25 or obese persons with BMI > 30. Physically inactive individuals. Age > 45 years. First degree relative with diabetes. BP > 140/90 mmHg. HDL -C <35mg/dl, Triglyceride > 250 mg/dl. Patients who have vascular disease. Women who have delivered a baby > 9 pounds / 4kgs of weight.
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Why optimal care?

Diabetes is a disease which damages all vital and important organs of the body like the brain, heart, kidney, eyes, blood vessels etc. This damage can be very severe if preventive steps, or optimal care is not provided. With optimal care of the disease about 70% risk of complications can be reduced.
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What is optimal care? Optimal care of diabetes means to provide care so as to minimize the risk of complications in the long term. This includes the doctor's responsibility to: 1) Educate the patient regarding possible complications of the disease or those produced by medication. 2) Prescribe drugs to adequately control : Diabetes. Blood Pressure. Cholesterol. 3) Recommend Life Style modification which includes : Weight control. Quitting smoking. Regular exercise. 4) Advise patients to have routine, Eye care. Foot care. Vaccinations. A diabetic patient should be treated and helped to reach a target which is optimal. Adequate Control 1) Blood sugar levels Before meals 2-hours after meal Glycated HbA1C 2) 3) Blood pressure Total cholesterol
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LDL-C HDL-C
below 70 mg/dl above 40 mg/dl in men above 50 mg/dl in women
4)
Triglycerides
below 150 mg/dl
Once in a year the 24 hour urine test should be done to check for protein excretion called microalbuminuria. This test is the earliest marker of possible kidney damage, at which point, treatment is required to slow down or prevent this damage. The patient may be prescribed ACEI and ARBs and Verapami as part of their treatment. Micro albuminuria Macro albuminuria 30-300 mg/day > 300 mg/day
Regular check up of eye (fundus) is a must at least once a year. Because of poor circulation in diabetic patients it is imperative that strict podiatric care is followed. Any ulcer, crack or wound must be shown to the doctor. Vaccination with Pneumo 23 - (Pneumococcal Vaccine) once in 5 years is highly recommended if your age is below 65 years. People over 65 need to take the vaccine only once. Injection Vaxigrip (flu vaccine) should be taken once every year irrespective of the age of the diabetic patient. Vaccination is recommended for diabetics of all ages. These letters will help us remember optimal care : ABC A for A-1-C B for BP 90-130 ml/dl below 180 mg/dl below 7% below 130/80 mmHg below 150 mg/dl
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Targets
C for Cholesterol
Treat to reach their targets
Medicines which provide optimal care in diabetes treatment include : 1) 2) ACE I like Ramipril, Enalapril, Lisinopril etc. ARB like Telmisartan,Olmesartan, Losartan etc.
3) 4) 5)
Verapamil Statins Aspirin 1.
Evaluation of a patient with Diabetes Mellitus

Evaluation Heart If the person has High blood pressure, High cholestrol, Smoking, Family History of CAD, Micro / Macro albuminuria 2. Kidney Spot Urine Albumine - to - creatinine ratio Frequency
Aspirin should be part of the prescribed medication of all diabetes patients who : Are more than 55 years old if male and more than 65years old if female. Have BP more than 140/90 mmHg. Smoke. Are obese. Have family history of heart disease. Have high cholesterol. So, It is clear that most diabetic patients require these medications in addition to that used to regulate blood sugar levels : 1) Angiotensin Converting Enzyme Inhibitors( like Ramipril etc.) / Angiotensin Receptor Blockers ( Like Telmisartan etc.). 2) 3) Statins(like Rosuvastatin,atorvastatin,simvastatin). ASPIRIN 75-150 mg/day. A patient should not count the number of pills he is required to take rather, he should count the number of diseases that pills will prevent. So if you are a diabetic person, do you think you are getting optimal treatment now ? 3.
} }
}
}
Once in a year may need TMT in addition to other evaluation
First check at the time of diagnosis of DM Repeat once in 6 - 12 months
Eye No Retinopathy
First check at the time of diagnosis of DM Repeat once in 12 months As advised by Ophthalmologist First check in first Trimester and close monitoring during pregnancy and for 1 year postpartum. First check at the time of diagnosis of DM Every visit once in a year
Retinopathy present Women with preexisting DM during pregnancy
}
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4.
Foot Care Routine foot checkup comprehensive foot checkup
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Dietary Strategy In a Patient with Type 2 Diabetes Mellitus

The overall advice in a patient, who is diabetic, is the same as outlined before in the patients of high blood pressure. However, a diabetic person needs to have: Breakfast (by 8AM) Small snack (by 11AM) Lunch (by 2PM) Evening tea with 1-2 pieces of biscuits (by 5-6PM) Dinner (by 8-9PM) Milk or equivalent at bed time. This is just to highlight that 3 meals in a diabetic patient are not correct. This may lead to wide swings in blood sugar. Smaller, supplementary food items need to be taken in between major meals. The diabetic person needs to follow the same percentage distribution of carbohydrate, fat and protein as mentioned earlier. Briefly: Carbohydrates: Protein: Fats: Fiber: Cholesterol: Plant stenols/sterol: Out of various fats, the recommendations are: Saturated fat: Monounsaturated fats (MUFA): Polyunsaturated Fats (PUFA): Less than 10 % of total calories Upto 20% of total calories Upto 10% of total calories 50-60% of total calories 15% of total calories 25-35% of total calories 20-30 g/day less than 200 mg/day 2g/day
Effects of various types of fats on Lipid Profile:

T.Cholesterol MUFA Decrease Cholesterol Omega-6 PUFA Unknown Triglyceride Decrease Triglyceride LDL-C Decrease LDL-C Unknown HDL-C Increase HDL-C Unknown Source Olive oil, canola oil, peanut oil Corn oil, safflower oil, sunflower oil, soybean oil Flaxseed oil, canola oil Lard, butter, cream, cream cheese
Omega-3 PUFA Saturated Fats
Unknown
Decrease Triglyceride
Increase LDL-C Increase LDL-C
Increase Cholesterol
Polyunsaturated fatty acids (PUFA) causes reduction in LDL cholesterol (bad cholesterol) but can also cause small reduction in HDL-cholesterol (good cholesterol).Monounsaturated fatty acids (MUFA) lower LDL but don't lower HDL. All plant oils are normally safe for cooking except coconut oil and palm oil .One should avoid butter and ghee. Fruit and Vegetables : All diabetics are encouraged to consume more fresh fruit and vegetables. Avoid potatoes, rice cakes, cornflakes, softdrinks and fruits which are very sweet like Sapota. One can take Apple, oranges, water-melon(limited quantity),a cup of grapes, papaya, grape fruits, kiwis,pears,etc. Barley,bran cereals,pasta,peas,beans,milk and yogurt can be taken. Foods rich in chromium like wheat bran, whole grains ,chicken breast, mushrooms are advisable.Radish,carrots,turnips can be taken. One can take Apple-1; banana-1/2 ; cherries-12 ; dried fruit cup; canned fruit juice-1/2 cup; grapes-12-15; raisins 2 table spoon; apple, orange or grapefruit juice-1/2 cup; cranberry, grape or prune juice 1/3 cup in a day (not all items in the same day).Beets, broccoli, cabbage, carrots, mushrooms, onions, pea pods, spinach, tomatoes and water chestnuts can be taken.
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Preferred sources of Protein : (Non Vegetarian) Skinless chicken Lean cut meat All types of fish, but those high in omega-3 fatty acids preferred, like salmon, tuna, mackerel and sardines Low fat cottage cheese Egg white Alcohol intake in a patient with Diabetes: May cause hypoglycemia May adversely interact with the medication Alcohol use in moderation may be advisable after doctor's consent.
4) Limit sugar: a. b. Avoid sugar. Sugar substitutes like saccharin, Aspartame may be used for tea or coffee, but use in moderation. It is better to take beverages in their natural form without sweetener.
5) Eat carbohydrates in moderation: a. b. Avoid carbohydrates which raise blood sugar too much like potatoes. Don't eat too much at one time.
6) Limit Fat and Salt intake: a. Check a product before taking in terms of fat and salt.
7) Increase Fiber intake: a. b. c. Choose high fiber food. Try to eat whole fruit than fruit juices. Eat whole grains, whole fruits and raw vegetables.
Guiding principles in a person with Diabetes:

1) Good nutrition is the key: a. b. c. d. Don't be so strict that it adversely affects your health and concentration in work. Don't go behind buying special foods. Don't think it as a Diet; rather think as "Healthy meal." Try to manage everything from your day-to-day grocery.
8) Increase Fluid intake: a. Take at least 3 liters of water daily unless you are having a weak heart (heart failure) and you have been asked to reduce liquid intake.
9) Maintain a Healthy body weight: a. Maintain a healthy weight which is roughly: Height in centimeters minus 100 5 Kg.
2) Eat Variety: a. b. Mix your meal plan with variety of seasonal fruits, salads, poultry products and try various types of oils in permitted quantity. Low fat milk or buttermilk or cocoa mix can be taken.
10) Avoid Hypoglycemia: a. b. Don't diet too much which may cause hypoglycemia. Avoid or reduce diabetes medication on the day of fasting, or when you are having vomiting or loose motion, or if due to some reason food intake on that very day is uncertain.
3) Maintain timings: a. b. c. Eat at least 3 times a day and have snacks in between. Try not to skip meals. Eat about same amount of food each day.
11) It is advisable to consult your diabetologist or a trained Dietitian for proper dietary advice which suits you and your kitchen.
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Bibliography:
1) 2) 3) 4) 5) 6) 7) 8) 9) National Cholesterol Education Programme ATP III 2001. Donna Zazworsky, Jane Nelson Bolin,Vicky B Gaubeca (editors): Handbook of Diabetes Management;2006. Braunwald's Heart Disease :A Textbook of Cardiovascular Medicine,9/e Cardiovascular disease : Diet, Nutrition and Emerging risk factors : Sara Stanner (Editor) : 2005, British Nutrition foundation : Framinghamheartstudy.org Dashdiet.org Cvtoolbox.com Mykentuckyheart.com Cardiologycentre.com.au
Acknowledgement
I express my sincere appreciation and gratitude to : 1) 2) Indus Hospitals, Visakhapatnam Dr. V. Satyanarayana, MD DM Neurologist, Indus Hospitals, Visakhapatnam 3) Dr. V. Sujatha, MD DM, Senior Cardiologist, Indus Hospitals, Visakhapatnam 4) Dr. Anil Kumar Mahapatro, MD DM, Cardiologist, Indus Hospitals, Visakhapatnam 5) 6) 7) 8) Poonam Shah Srinath Srinath Sambandan Dr. Gopi Chand, MD, Dermatologist, Indus Hospitals Dr. K.D. Modi, MD DM, Endocrinologist, Medwin Hospital, Hyderabad 9) 10) 11) 12) 13) Dr. G.R. Prasad, MS M Ch, Pediatric Surgeon Torrent Pharmaceuticals Lupin Pharmaceuticals Vijaya Medical Centre, Visakhapatnam All my friends, my family members.
10) www.nhs.uk 11) Studynursing.blogspot.com 12) www.kevaind.com
Useful websites:
1) 2) 3) 4) 5) www.cardiosource.org www.americanheart.org www.diabetes.org www.diabetes-exercise.org www.cdc.gov
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Notes
Notes
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Your Heart &amp; You:A Self Help Guide

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Your Heart &amp; You:A Self Help Guide

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Knowledge is Power

YOUR HEART AND YOU : BOOK - I

to My Countrymen Who Deserve the Best Health Care

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

First Edition Printed at

: 2012 : Sree Meher Graphics, Visakhapatnam - 530 020

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Finding the Right Doctor

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Some Dos and Don'ts

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Some Helpful Terminology

As per requirement Subcutaneous Intra Muscular Intra Venous

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Some useful skills

Normal Body Temperature : 97.60F to 98.80F (36.40C to 37.10C)

Normal Blood Pressure : 100 - 130 / 60 - 85 mmHg

Normal Pulse Rate : 60 - 100 Beats / Min.

How to feel pulse

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Our Heart: Its Basic Anatomy

Location of the heart in the chest

YOUR HEART AND YOU : BOOK - I

Different Structures related to the Heart

The Coronary Arteries

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Mitral Valve Tricuspid Valve

The Valves of the heart

Four Chambers Four Valves Two Great vessels

The conduction System-The wiring of the heart

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Two Sets of Coronary Arteries* Conduction System * Pericardium

Left and Right coronary arteries

Tests Prescribed for when A Heart Condition is Suspected

3) The Coronary Arteries

4) The Conduction System

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Triglyceride: > 150 mg/dl HDL-C < 40 mg/dl

Fasting serum lipid profile

200-239 > 240 -

100-129 130-159 160-189 > 190 -

HDL-C(mg/dl) (good Cholesterol) < 40 > 60 Low High

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

High-Sensitivity C-Reactive Protein (hsCRP)

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

Echocardiogram (2D Echo and Color Doppler)

Exercise ECG (Treadmill Test - TMT)

YOUR HEART AND YOU : BOOK - I

YOUR HEART AND YOU : BOOK - I

The TMT test is very safe with very low risk of

YOUR HEART AND YOU : BOOK - I

C) Tests to Know blood flow to the Heart and Blockages:

Your Heart & You:A Self Help Guide

Your Heart & You:A Self Help Guide