REMEMBERING PROF. MANSOOR HASSAN BY HIS LECTURE ON MYOCARDIAL INFARCTION

Whenever one thinks of Prof. Mansoor Hassan, the image that comes to our mind is that of an extremely soft spoken, wise, pious and profoundly knowledgeable person steeped in Lucknavi tradition of tehzeeb and tameez. By his very appearance in all whites he radiated an aura of gentle grace and divinity that was simply unmatched. He was loved by students, held in absolute awe by his residents, and literally worshiped by his patients. Whether his patient was a minister or a labourer, his behavior towards them was always the same – gentle, reassuring and loving. Every patient considered him to be a member of their extended family and knew that in his presence and under his treatment they were getting the best treatment in the world.

 

We, the under-graduate students, were convinced that he was specially gifted, and had he been in the Indian Foreign Services, there would have been no wars. Though he was invariably surrounded by a swarm of sick patients and a hive of their anxious relatives, Prof. Mansoor Hassan never lost his cool, never raised his voice, and the ever-present smile never left his face. His presence among his patients was almost like that of a peer or saint among his disciples, pious, somber and always reassuring.

 

Prof. Mansoor Hassan was awarded the Fellowship of Royal College of Physicians of London and Edinburgh. He was extremely sophisticated in his demeanor and a very well read person. He could quote with effortless ease from Vedas, Shrimad Bhagwat Geeta, Quran and Bible and mesmerize his audience with his treasure trove of Urdu Shairi. We all knew great things awaited him and he went on to establish the Lari Cardiology Centre, a comprehensive cardiac diagnostic and therapeutic service and started the superspeciality DM Cardiology program of King George’s Medical College there.

 

Being one of the best cardiologist in Lucknow, he has joined Divine Hospital with a mission and project to make the finest cardiology services available to the state of UP at an appropriate and yet affordable cost. His keen interest in Preventive and Rehabilitative Cardiology is evident from his intimate involvement in various social and outreach programs. 

 

I had a very long association with him even after he superannuated from King George’s Medical College. We were together in Sahara Hospital and during this time the Government of India decorated him with Padmashree. The recognition came late but for a person of his stature and popularity the Award was blessed by being associated with him. Prof. Hassan taught us Cardiology and we had to rush to his class to take the front rows because he spoke so softly that he was often not clearly audible at the back. There was usually pin drop silence, lest we miss what he was saying. This is one such lecture on Myocardial Infarction, which I could salvage from my class notes.

 

If anyone wakes up in the middle of the night with chest pain, his mind might automatically think he is having a heart attack. After all, it’s the number one killer disease. And the number one symptom is the vague term “chest pain”, which can be misleading because it’s not always painful nor always in the chest. In most cases, people imagine they will have severe chest pain and dismiss the actual symptoms of a heart attack, go back to sleep and suffer one. So, it is vital to understand the symptoms your patient will and won’t feel if he/she is having a heart attack This should be clearly understood by all who are at risk of a heart attack so that they know exactly what to do, and when to seek immediate medical attention.

 

Who is at risk of a Heart Attack (Myocardial Infarction)?

1. Older Age

The older you get, the more you are at risk of a heart attack. Although you can have a heart attack at any age, the risk increases significantly after age 45 for men and after menopause, i.e. around age 50 for women.

2. Gender

Heart disease is the number one killer of both men and women, however, men have a greater risk than women of heart attacks. At older ages, women are more likely than men to die from a heart attack. The women get it less frequently, but tolerate it poorly.

3. Heredity

The risk of a heart attack increases with a family history of heart disease. Race also has an impact on the risk. This has been studied in the U.S and African Americans, Hispanic Americans, and American Indians have higher risks than Caucasians of heart attacks.

4. Smoking

One out of five deaths from a heart attack is due to smoking. Smoking cigarettes can double to quadruple the risk of having a heart attack. Risk is higher for smokers because smoking limits the amount of oxygen to the heart, increases blood pressure, damages blood vessels, and increases the likelihood of blood clots. So every patient, who is a smoker, must be advised to quit smoking immediately.

5. High Blood Cholesterol

Cholesterol levels in the blood can be affected by uncontrollable factors, but there are things we can do to make sure the cholesterol level stays within healthy limits. Increasing the dietary fiber intake, eating healthy and low-fat foods, and exercising can help lower cholesterol levels.

6. High Blood Pressure

High blood pressure is a very common risk factor of heart disease. When the blood pressure is high, it makes the heart work harder. This can stiffen the heart muscle and lead to heart attacks. Anti hypertensive drugs, proper exercise, a low-salt and low-fat diet, limited intake of alcohol, healthy weight, and stress management, can lower the blood pressure.

7. Physical Inactivity

Lack of physical activity can lead to many problems, including heart disease. On average, people should exercise at least 30 minutes a day.

8. Obesity

Excess body fat can contribute to higher blood pressure, higher cholesterol, and a higher risk of heart attacks. A healthy diet and proper exercise are essential for getting to and maintaining a healthy weight.

9. Diabetes

Diabetes can have a damaging effect on heart, especially if it is not controlled. Nearly 68% of diabetics over the age of 65 die from heart disease. Diet, drugs and exercise I judicious combination, can help in managing diabetes.

10. Stress

A negative response to stress can increase the risk of a heart attack. Physical exercises, non-competitive sports, breathing exercises, better inter-personal relationships and better time management can all contribute in de-stressing..

 

How chest pain from a heart attack feels?

The typical pain described is a feeling of tightness, squeezing or heaviness in the chest. The Latin term angina pectoris, meaning sensation in the chest, is a more accurate description. This pain has been described as feeling like a band or weight is being tightened around the chest. The pain is often on the left side and above the bottom ribcage, although it’s often difficult to determine its exact location. Other typical symptoms include:

·        Shortness of breath

·        Cold sweating

·        Nausea

·        Anxiety

·        Pain in the left arm, jaw or neck

·        Light headedness

·        Racing heart

Some atypical symptoms of MI are:

·        Pain not on the left side but is located on the right, center or top of the abdomen

·        Abdominal pain and indigestion

·        No pain – some people don’t experience pain and only feel shortness of breath.

·        Pain is often referred to other areas of the body – neck or throat, shoulders, upper back – between the shoulder blades, left or right side of jaw and left or right mid to upper arm.

 

How long should the chest pain last?

The next indication of whether you are suffering a heart attack is pain duration. Consider the following 3 factors:

1.      Heart-attack-related chest pain comes on over several minutes and not suddenly. Sudden severe pain is a reason for concern, but it is not consistent with angina.

2.      The chest pain lasts for at least 5 minutes and doesn’t last continuously for more than 20 to 30 minutes.

3.      Pain that comes on during rest, or doesn’t go away after exertion, also indicates a heart attack.

 

What it shouldn’t feel like

Some chest pain is not consistent with having a heart attack.

·        Sharp and brief pain – stabbing pain that lasts only a few seconds is not coming from the heart.

·        Persists for hours – heart attack chest pain will last for 20-30 minutes at the most and typically ends with a heart attack.

·        Gets worse with movement – the sort of pain that worsens when pressed on is usually from chest bone or muscle pains and not the heart.

·        One can pinpoint the pain with a single finger – heart chest pain tends to be difficult to locate exactly.

But, when in doubt, treat a chest pain like heart attach, unless proven otherwise by investigations.

 

Investigations

Tests to diagnose a heart attack include:

• Electrocardiogram (ECG or EKG). This is the first test done to diagnose a heart attack. It records electrical signals as they travel through the heart. Sticky patches (electrodes) are attached to the chest and sometimes the arms and legs. Signals are recorded as waves displayed on a monitor or printed on paper. An ECG can show ST elevation or T wave inversion.
• Blood tests. Certain heart proteins slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these proteins (cardiac markers) - creatine kinase-MB (CK-MB) and lactate dehydrogen-ase-1 and -2 (LDH-1/2).
• Chest X-ray. A chest X-ray shows the condition and size of the heart and lungs
• Coronary Angiography. A long, thin catheter is inserted into an artery, usually in the Femoral artery in the groin, and guided to the heart. Dye flows through the catheter to help the arteries show up more clearly on images made during the test. The coronary arteries – Rt. Coronary A. and Left Main Coronary A. are examined for blockage

 

Treatment

Each minute after a heart attack, more heart tissue is damaged or dies. So urgent treatment is needed to fix blood flow and restore oxygen levels. Oxygen is given immediately. Specific heart attack treatment depends on whether there's a partial or complete blockage of blood flow.

Medical Treatment

Medications to treat a heart attack might include:

• Aspirin. Aspirin reduces blood clotting. It helps keep blood moving through a narrowed artery. 300 mg Aspirin should be given at home before transporting the patient to a hospital.
• Other blood-thinning medicines. Heparin may be given by an intravenous (IV) injection. Heparin makes the blood less sticky and less likely to form clots.
• Nitroglycerin. This medication dilates the blood vessels. It helps improve blood flow to the heart. Nitroglycerin is used to treat sudden chest pain (angina). It's given as a pill under the tongue, as a pill to swallow or as an injection. Again it should be given at home, before transporting the patient to the hospital.
• Morphine. This medicine is given to relieve chest pain that doesn't go away with nitroglycerin.
• Beta blockers. These medications slow the heartbeat and decrease blood pressure. Beta blockers can limit the amount of heart muscle damage and prevent future heart attacks. They are given to most people who are having a heart attack.

Surgical Treatment

• Coronary artery bypasses grafting (CABG). This is open-heart surgery. A surgeon takes a healthy blood vessel , usually the Great Saphenous Vein from the leg and use it to bypass the blocked Coronary Arteries and create a new path for blood in the heart. The blood then goes around the blocked or narrowed coronary artery. It may be done as an emergency surgery at the time of a heart attack. Sometimes it's done a few days later, after the heart has recovered a bit.
• Balloon Angioplasty. This is now being practiced in the Western countries and will soon be available here. A thin, flexible catheter is passed into the narrowed part of the heart artery. A tiny balloon is inflated to help widen the blocked artery and improve blood flow. A small wire mesh tube (stent) may be placed in the artery during angioplasty. The stent helps keep the artery open. It lowers the risk of the artery narrowing again. Some stents are coated with a medication that helps keep the arteries open.

 

Complications

The complications of Myocardial Infarction are:

·        Arrhythmias

·        Heart Failure

·        Heart valve issues

·        Stroke

·        Sudden Cardiac Arrest

·        Cardiogenic Shock

·        Depression and Anxiety      

 

That is how our class on Myocardial infarction ended. Those were the days when there was no echo-cardiography, Heart MRI, Heart CT, MUGA Scan, and Nuclear Heart Scans – SPECT or PET. Even Troponin T test, ACE inhibitors and statins were not there. Good history taking, physical examination, ECG and a good clinical sense was all that was there at our disposal. But teachers like Prof. Mansoor Hassan were patient with us and taught us the highest standards of clinical medicine.