The Health Curve

Heart Attacks: The Essentials - with Dr. Jaspal Gill, Cardiologist and Clinical Research Fellow at the University of London (Heart Health Series)

• Dr. Jason Arora • Season 1 • Episode 13

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Every 40 seconds, someone in the U.S. has a heart attack. It’s one of the most feared medical emergencies—and one of the most misunderstood. 

In this episode, we cover exactly what a heart attack is, what’s happening inside the arteries and the heart muscle, and how to recognize the warning signs before it’s too late. We’ll talk about risk factors, from cholesterol and stress to family history and lifestyle—and what you can do today to lower your chances of experiencing one.

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In this special 4-part series on heart diseases, we're going to give you something that's getting harder and harder to come by: time with a cardiologist. 

Access to medical care is a growing challenge—especially when it comes to specialists. In the U.S. today, a single cardiologist may be responsible for thousands of patients, and nearly half of all U.S. counties don’t even have one. 

We’re joined by Dr. Jaspal Gill, Cardiologist and Clinical Research Fellow at the University of London, to break down the fundamentals of the most common—and most critical—heart conditions: high blood pressure, heart attacks, stroke, and arrhythmia.

SPEAKER_01:

Hello and welcome to The Health Curve. I'm your host, Jason Arora. In this special four-part series on cardiovascular health, we're going to give you something that's getting harder and harder to come by. Time with a cardiologist. This episode is on heart attacks. Heart attacks are a result of heart disease, the leading cause of death and disability worldwide, regardless of gender or race. In the US, it is responsible for one in four deaths, with someone suffering from a heart attack every 40 seconds. This is our second session with Dr. Jaspal Gill. Thanks again for joining us, Jaspal. Heart attacks. Everyone's heard of a heart attack. Can you walk us through what it is, what's happening in the body, and why it happens?

SPEAKER_02:

Yeah, so it's a slightly confusing word because it actually means different things to different people. And what I'm going to separate out here are two different conditions. one which is called a myocardial infarction, which is I think what most people call a heart attack, and one which is called a cardiac arrest. Now, a myocardial infarction is when part of your heart is not getting the blood supply that it needs because the blood vessel that's supplying it is blocked, and that bit of the heart is not getting that blood. It's not getting that oxygen, and that means that it can't pump. So that's why it can affect then the whole body going down with it because then if the heart's not able to pump the rest of the blood not going around the body then the other tissues are not getting what they need so that's what we mean by myocardial infarction and the mechanism for that is what we previously discussed about having fatty inflexible arteries and then when you've got that little fatty deposit that's sitting within the artery that can rupture at any time and there is still a lot of research being going into what makes it more likely to rupture or what makes it less likely to rupture. So we're still trying to figure out exactly how that happens. But that essentially can rupture at any time. And when it does rupture, there's clot that forms there and that blocks your artery. So that's when people have heart attacks, we think, oh, well, there's a blocked artery. We need to open it up. That's exactly what we're talking about. Now, some people call a cardiac arrest a heart attack and that's a related but different a cardiac arrest is when your heart is not able to pump blood at all that can be because someone's had a myocardial infarction because they've got a blocked artery but it could also be for a whole host of other reasons for example someone's kidneys are not working and because their kidneys are not working the salts are all over the place in the blood that means that muscles don't work properly and that can mean that the heart's not working and so That's a cardiac arrest, but it's not a myocardial infarction. And you can have someone who's having a myocardial infarction, who's having a heart attack, who's awake and chatting to you. So their heart's not getting the blood that it needs, but it's still able to pump enough to get that blood around, keep your brain getting its blood, so that person can be in front of you talking. Whereas if someone's had a cardiac arrest, they're unconscious. They're out. Because Their heart's not pumping, or it's functionally not pumping, and the rest of their body is not getting the blood. So they're definitely going to be unconscious of them. Obviously, the myocardial infarction can cause a cardiac arrest, but there are actually two different things that people frequently call a heart

SPEAKER_01:

attack. And most of the time, people are talking about the first, right, a myocardial infarction.

SPEAKER_02:

Yeah, most of the time, people refer to it the first, but I've heard that term for all sorts of different things.

SPEAKER_01:

Right. And the reason it's happening is basically what we were talking about earlier, right? The blood vessel getting blocked, the same reasons as for high blood pressure, but much further along. And we're talking about the blockage specifically rather than just the stiffening of the arteries, right?

SPEAKER_02:

Yes, that's right. And the blockage specifically in the arteries that are supplying the blood to the heart. And so the heart actually, when it's pumping, the first place that the blood goes is that it pumps blood to itself. And so it's those blood vessels that we're referring to, which are called the coronary arteries.

SPEAKER_01:

So what are the different types of heart attacks and how do they present? What are the symptoms?

SPEAKER_02:

So the main symptom that you need to be aware of for a heart attack or myocardial infarction is chest pain. That is by far and away the most important symptom. There are other symptoms that can be associated with it. You can have some shortness of breath. Sometimes some people can feel a little bit dizzy or faint or they can feel nauseous or vomit with it. But the most important symptom is chest pain. And that's typically described as center of the chest. So it's not over the heart. It's not over the left side. It's over the center or the whole of your chest. And it feels like a crushing pain or a pressure. A lot of people describe it as there's an elephant sitting on them or something like that. Or they feel like there's a band that's going around the chest. And that can often radiate into your left shoulder, up into your jaw, and up into your arm. Unfortunately, it's not a hard and fast rule. Some people can present with slightly unusual symptoms with it. People can feel very nauseous and they can vomit. And a lot of people can think that this is indigestion or heartburn, which is why it's called heartburn, because it can be very easily mistaken for pain in the chest. And so people who have indigestion, if you've got an indigestion, it just feels a little bit different to usual. If it's more severe, not going away, taking your antacids or something like that. And if you've got any of these risk factors for having any heart problems, it's definitely worthwhile getting checked out.

SPEAKER_01:

We've done an episode already, actually, on how heart disease or heart attacks can present differently in women compared to men and that the symptoms are often what we call atypical, therefore leads to underdiagnosis in women compared to men. Can you comment on that?

SPEAKER_02:

Yeah, definitely. I mean, what you've said is completely true. we definitely have the higher rate of atypical symptoms in women. And by atypical symptoms, we mean that that main symptom, which is chest pain, is either absent or it's not the main part of that patient's spectrum of symptoms. And that means that, you know, sometimes the chest pain can be slightly different. Instead of it being that central chest pain, they can be like, oh, actually it's on the right side and it feels more like I've bumped it or something like that, or it's a stabbing pain on that side. And in some patients, they don't have any chest pain at all. Sometimes they just feel short of breath. for example, like the nausea that we spoke about. So that's definitely something that we take into account, both when we're describing what the symptoms are, the patients so that they're aware, but also when we're assessing patients as well as the clinician.

SPEAKER_01:

Hence the art of medicine, I suppose, right?

SPEAKER_02:

Yeah,

SPEAKER_01:

definitely. So can you tell us what angina is?

SPEAKER_02:

Yeah, so angina is a symptom of chest pain or chest tightness, which occurs when you're exercising. which is then relieved by rest. And that's the definition of angina. Now, angina is a symptom which is representing something that's different to a heart attack. Because in a heart attack, you've got a blood vessel that's completely blocked or blocked so much that the blood flow is severely impacted for that part of the heart that it's supplying. In angina, there is a reduction in the blood flow because of this fatty plaque that's sitting within that blood vessel. but it's not actually starving that bit of your heart from a significant amount of oxygen and blood. So their blood is still getting there. But it only becomes apparent when your heart is working hard because when it's resting, we don't have the symptoms. And that symptom of chest pain comes from that heart not getting the oxygen, not getting the blood that it needs. And so that's what's triggering your chest pain. So in angina, if people have those symptoms which are coming on when they exercise but then going away when they rest, that makes us very suspicious that they have got some narrowings in those blood vessels around the heart, in those coronary arteries. And that makes us want to investigate that more, figure out what's going on there and how we can help that patient and help treat them.

SPEAKER_01:

Right. So you have angina where you have a partial blockage and the heart muscle may not be getting the blood and the oxygen for a short period of time, but then it recovers. And then you have a heart attack or a myocardial infarction where a part of the heart is not getting the blood supply and it's not able to recover that blood supply because there's a complete blockage of the artery that supplies that part of the heart. How are these conditions diagnosed? So obviously we talk about the symptoms and we talk about chest pain, nausea, all these things, but how do we confirm a diagnosis of angina or a heart attack?

SPEAKER_02:

So the diagnosis of angina is basically done from taking the patient's history. So it's from what their symptoms are. It's a clinical diagnosis that is made from that. There is no blood test or bedside test that we do to be like, bingo, this is angina. This is a qualitative assessment of the patient's symptoms. With a heart attack, on the other hand, we do have bedside tests that can give us that answer. And the ones that we do are something called an ECG, which is an electrocardiogram or EKG. That is where they're putting little dots on your arms, your shoulders, around your chest, and they're taking the electrical readings of the heart. Because in people who have got a blocked blood vessel, we can detect changes in the electrical reading of the heart, and we can then diagnose if people are having a heart attack. In addition to that, we can use blood tests to measure something what we call cardiac enzymes or a troponin, which allows us to measure if there has been any damage to the heart and what the magnitude of that damage might be.

SPEAKER_01:

So you do the blood tests, you do the ECG, and based on that, there is a confirmation that there's been a heart attack. What happens then?

SPEAKER_02:

There are different kind of gradations, if it were, in terms of heart attack, in terms of severity. And at the most severe end, what happens is that you'll often have the ambulance or they'll recognize from the EKG that they do, that this is a heart attack or possibly a heart attack. And they often call through to their local cardiac center and say, look, we've got this patient coming in. We need you guys ready to assess them. So you'll get there, you'll be assessed. They can often do something called an ultrasound of the heart called an echocardiogram to see what the function is like, to see if it looks like on that, if they can assess whether there's been a heart attack And if they do think it is, then you'll go forward and have something called an angiogram. And that's a procedure where your physician, your cardiologist, will be entering one of the blood vessels, either in your wrist or in the top of the leg, and we're moving wires and tubes up to the heart to try and then put dye in those blood vessels that supply blood to the heart, take pictures with the x-ray to then see if there's a blockage or not. If there is a blockage, then we aim to open it up by using balloons or stents and stents are little wire meshes that then can go into that blood vessel, which is blocked, and open it up, and then they help keep it open. And they aim to do that to try and then preserve the blood flow to that tissue and try and keep that tissue alive, keep that heart alive.

SPEAKER_01:

Right. And so there are tubes that are inserted into either the groin or into the wrist, basically to get access to the heart. Then the wires are put through. And then if you need to put in a stent or anything like that, that's also put through the tube. Is the patient awake while this is all happening? Typically, yeah.

SPEAKER_02:

This is a procedure we do on the local anesthetic. So that means that we usually numb that area, whether it's the top of the groin or whether it's the wrist. We numb it with local anesthetic. And then after that, we enter the blood vessel there. So although it can be a little bit uncomfortable just having that little initial local anesthetic injection, once that's in, actually they shouldn't be feeling much and they should be feeling significantly better when they're doing the procedure and when they're opening that blood vessel up. Their chest pain should be hopefully improving once it's been opened up. But usually that patient is awake. We want them conversant. We often want to be able to speak to them during the procedure.

SPEAKER_01:

Right. And so the stent is put in to open up the blood vessel, right? To basically restore the blood flow to that part of the heart.

SPEAKER_02:

That's

SPEAKER_01:

correct,

SPEAKER_02:

yeah.

SPEAKER_01:

What do people mean when they say they've had a bypass?

SPEAKER_02:

So a bypass is a type of cardiac surgery. Now, this is an altogether much bigger procedure. This is a procedure where you're definitely under general anesthetic, completely knocked out for it. And this is where you have a cardiac surgeon who's opening up the chest, and they are basically trying to plumb vessels around where those blockages are. So in terms of the cardiologist, we're working within the blood vessels using wires and tubes and x-rays to see where we are and open up those blood vessels using these devices called stents. A cardiac surgeon is working on the outside of the heart. So they've opened up the chest. They are then using blood vessels, which they've either harvested from the legs or from the arm, or some of the spare blood vessels are within the chest itself to try and get the blood to the part of the blood vessel, which is after the blockage. And they're doing that by plumbing that new blood vessel onto that bit of that coronary artery after the blockage to try and restore that blood flow. This isn't something that's usually done in the emergency setting. Occasionally it is done in the emergency setting, but this is usually done in a more of an elective setting.

SPEAKER_01:

Right. And are there cases where you would do an emergency bypass rather than a stent?

SPEAKER_02:

I think in the context of someone having a myocardial infarction, I think it would be unusual to go for an emergency bypass. Often that would mean something's gone wrong. So if they've tried to put a stent in and they haven't been able to, they haven't been successful, or they've had a problem with their procedure, then they might need to go into an emergency bypass after that. Or sometimes if people are having syndromes or problems which are similar to a myocardial infarction, could be very similar in terms of the symptoms and what's going on, for example, what we call the dissection, where there's actually a tear in the blood vessel itself, that often we can't fix with a stent or we can't fix it very well with a stent. Actually, the way to fix that is with open heart surgery, which may or may not include a bypass. So in those kind of circumstances, it is used, but it's not routine.

SPEAKER_01:

So let's stick with the stents and the angiography and the angioplasty, as we call it, which is what happens in most cases when people have heart attacks, right? What happens afterwards? So usually

SPEAKER_02:

the procedure itself, it will take about an hour, but it can be a little bit shorter. It can be a little bit longer, just depending on the complexity of it, depending on everybody's anatomy is individual and everybody's slightly different. After that, you're usually cared for in a coronary care unit, somewhere called a CCU. Sometimes in some hospitals, it's an intensive care unit where you're closely monitored and you're closely monitored for a few different reasons. The heart, when it's gone through this, when it's had that blocked vessel, it's had that part of it which hasn't got that blood that it needs, it becomes a little bit irritable. And when the heart's irritable, it can go into funny heart rhythms. And funny heart rhythms can be very dangerous. They can stop the heart being able to pump properly. And so you're being monitored, usually for at least a couple of days, two, three days, sometimes as long as five days afterwards, in order to make sure that you don't develop any of these heart rhythms And if you do develop these heart rhythms, you can be treated for them using either medications to try and treat those funny heart rhythms or sometimes using different types of therapy such as things like defibrillators and things like that to treat them. So that's what you would expect after you've had that. You'll obviously have a little wound either at the top of the leg or at the wrist from where you've had the procedure and that usually heals within a week or so.

SPEAKER_01:

And people can have a stent put in more than once, right? Definitely, yeah.

SPEAKER_02:

You can have lots of different stents, either in the same place or in different parts of the coronary arteries. Often, if there is one narrowing in one place, you often have some narrowings elsewhere as well.

SPEAKER_01:

Right. And so once this has happened, the patient has come in, they've been assessed, they've had a stent put in, they've been put on the intensive care unit. Then what happens after that more long term? They're discharged with some medications, lifestyle advice, that sort of thing. Can you tell us a bit more about that?

SPEAKER_02:

So I think you've already done an episode about cardiac rehabilitation. And I think that actually encompasses a lot of what the aftercare is for people who've had a heart attack. And what you've actually mentioned just now are the core principles of it. So adjusting the lifestyle to try and reduce the chance of this happening again. Getting people on the right medication to A, try and reduce this happening again. B, some of the medications are blood thinners. And that's absolutely imperative to take if you've had a stent. put in if you don't take the blood thinners the stent just blocks off so really really important if you've had a stent to be taking your blood thinners and see if you've had any damage to the heart that's meant that its pumping function has been reduced then some of those medications will help the heart to try and recover some of that heart pumping function so those are the three groups of medicines that we have that we usually start on patients if we need to in terms of the follow-up for these patients there's a very good chance that you'll be seeing cardiologists if not for life, for a good five years or so. If you've had one heart attack, we obviously want to prevent any further heart attacks from happening again. And we're always on the lookout for symptoms of angina, so any further chest pains or anything like that, which might give us an indication that something is brewing that we need to address.

SPEAKER_01:

Can you tell us about some of the common misconceptions and misunderstandings you come across when it comes to heart attacks?

SPEAKER_02:

I think the most common one that I've seen is that people who are at both ends of the spectrums in terms of family members who are very blasé, they're like, oh, no, that's fine. You'll just put a stent in and he'll be fine. We are going to do that, but it's not always so straightforward. And you've also got people at the other end of the spectrum who've got a family member who's having a heart attack, who are convinced that they're not going to survive even before we've even done anything. We've even figured out what's going on. And I think Both are obviously extremes. Having a heart attack is by no means a benign thing. There's definitely a mortality rate associated with it. But as the years go on, we're getting better and better at what we do. And we're getting better at being able to reopen those vessels up and being able to try and save people, to try and save as much of that heart tissue. A lot of what will influence that is how long it takes for that person to get to hospital after recognizing that this is a heart attack. Someone has those symptoms of a heart attack but they only come to hospital three days later. It's too late. That bit of that tissue, that bit of that heart has already gone. There's no point putting stents in at that point. Where as soon as you have those symptoms, you're in the hospital and you can get straight into the cath lab and we can put that stent in within an hour of you having those symptoms. That maximizes your chance of us being able to save the heart and therefore the survival and prognosis afterwards.

SPEAKER_01:

And of course, capacity... is one of the key issues with this getting a patient to hospital fast enough and getting them treated fast enough, which is one of the reasons we're doing this podcast is basically to help people prevent rather than having to go through this and rely on the health system, which is often overburdened, especially for things like this, right? Yeah. Jaspal, thanks so much for joining us and walking us through that. Everyone, please join us for our next episode with Dr. Jaspal Gill, where we'll be talking about stroke.

SPEAKER_00:

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