Sunday evening, November 15, and it was a night of celebration.

More than 700 former SRK Sri Petaling pupils and teachers had gathered in KL to commemorate the 40th year of the primary school’s existence. Old friendships were rekindled and fond memories were shared. It was a night to remember. Well, it certainly was for my ex-classmate, Ibrahim (not his real name).

I was just outside the hall when a close friend grabbed my arms and hurried me back into the hall. With a serious tone in his voice, he said, “Ibrahim has collapsed on stage!” By the time I arrived, Ibrahim was already on the floor, thankfully awake but clutching his chest. He was having chest pains. With a frightened look he asked, “Is it my heart, doc?”

A series of questions from me followed. My initial hunch is that the pain was not coming from the heart — a bad case of indigestion as he had just had a heavy dinner.

Muscular pain is also a possibility. Of course, I was not able to prove or disprove any of these without appropriate tests which I was not able to carry out. As the pain persisted, we decided to call 999 and before long he was at the Accident and Emergency unit of a nearby hospital.

Three doctors attended to Ibrahim that night. By 3am, he was admitted to the Coronary Care Unit. He was given aspirin and clopidogrel (both act to thin the blood) and morphine (for pain-relief). Ibrahim was being treated for suspected heart attack. I left the hospital still wondering if my initial impression was wrong. I had missed an appendicitis before but I can’t remember the last time I wrongly diagnosed a heart attack.

Further tests ensued in the morning and fortunately, all proved to be negative for heart attack or heart-related
conditions. He was discharged in the evening.

So why am I sharing this with you? I feel there are a few important points that we can learn from this incident:

1. Severe chest pain should always make us think of the heart. We have discussed in past articles the importance of seeking help urgently especially if someone has a heart attack as usually it is a case of life and death.

2. It is often not possible to be certain that a chest pain is not due to the heart. We should always seek appropriate medical attention if unsure as there is a lot to lose if the assumption is wrong. In Ibrahim’s case, I was not sure of the nature of the pain and so off he went to the hospital

3. Even doctors can be uncertain about the diagnosis of chest pains. Despite repeated ECG recordings, Ibrahim’s cause of chest pain was inconclusive but it was treated as a heart disease case as it was safer to do so than to assume otherwise.

4. More tests are sometimes needed to establish or exclude a diagnosis of heart attack or other heart conditions.

In a heart attack, the initial ECGs or blood tests can be normal. The abnormalities are more apparent with time and therefore the same tests may need to be repeated after some time. Other investigations like echocardiogram which allows for visualisation of the heart can identify the presence of any heart muscle damage and support the diagnosis of the heart attack.

5. Not all chest pains are due to the heart. brief list of causes other than the heart includes the following:

• Gastrointestinal tract: Peptic ulcer and gastro-oesophageal reflux disease (causing heartburn)
• Lung: Pleurisy (inflammation of the covering of the lung), pneumothorax (lung collapse due to air in the space between lung and thoracic wall), pulmonary embolism (blood clot in the pulmonary artery) and pneumonia
• Muscle and bone: Costochondritis (inflammation of the joint between sternum and ribs), chest trauma
• Vascular: Aortic dissection (sudden tear in the inner layer of the aorta often related to hypertension and atherosclerosis)

Remember to have a cool head and seek help in any case of emergency. Attend to the person who is unwell
and in a serious case get someone to call 999 for ambulance assistance to get to the hospital. Equipping yourself now with a basic knowledge of CPR (cardiopulmonary resuscitation) is useful as you won’t know how important it is until you are required to perform it.

For many that night, the joyous occasion lasted until way past midnight. For Ibrahim, it was one of the most frightful experiences of his life. One thing for sure, although the pain that brought him to the hospital was not heart-related, I know that from that night onwards, he would give his heart and health due care and attention… and so should all of us.

If you have any questions or comments, please write to me at haizal@tropicanamedicalcentre.com. See you next Monday.

Dr Haizal Haron Kamar
Consultant Cardiologist
Tropicana Medical Centre

Dear Dr Haizal

I am 25-years-old and consider myself quite fit and healthy. I recently went for a medical check-up and was told that my blood homocysteine level was high. The doctor told me that I have an increased risk of getting heart disease in the future.

This has caused me to be worried. What can I do to reduce the homocysteine level in me? Jane

Dear Jane

Although there has been a lot of talk lately about homocysteine and its role in heart disease, research into this area is really almost as old as I am. It has been said that as high as 10 per cent of deaths from heart disease are attributable to high homocysteine level in the blood.

However, the debate remains over whether raised serum homocysteine concentrations actually cause heart disease and stroke.

Homocysteine is a common amino acid (one of the building blocks that make up proteins) found in the blood and is acquired mostly from eating meat. High homocysteine is associated with low levels of vitamin B6, B12, and folate.

Doctors are still not sure how homocysteine increases the risk of heart disease and stroke. Some even say that the high level is a result of heart disease rather than the cause, but there is increasing evidence linking high homocysteine levels and damage to the arteries, causing atherosclerosis (hardening of the arteries), and the formation of blood clots.

Some even regard it as an independent risk factor for cardiovascular disease (CVD) like hypertension and abnormal cholesterol level. So far, no definitive controlled treatment study has shown that folic acid supplements reduce the risk of atherosclerosis or that taking these vitamins affect the development or recurrence of CVD.

Researchers are still trying to find out how much folic acid, B-6 and B-12 are needed to lower homocysteine levels. Having said that, I believe homocysteine has an important role to play in CVD although at the moment the jury is still out as to the best way to handle a high homocysteine level. I also believe that our attention should not be swayed away from dealing with the traditional risk factors for CVD such as smoking, hypertension, obesity, abnormal cholesterol levels and diabetes.

If a person has proven heart disease and high homocysteine level, it would make sense to take folic acid supplements. The same may also be for those at high risk of getting CVD such as those with diabetes.

However, for others like yourself, if you don’t have any risk factors for getting CVD, getting enough folic acid and vitamins B-6 and B-12 in your diet is all you’d need. These can be found in a wide variety of fruits, green, leafy vegetables, and grain products fortified with folic acid. Meat and eggs have high levels of the B vitamins too but should be eaten in moderation as they can also raise your cholesterol level.

So Jane, do not be worried. Continue to be fit and healthy and eat the right food.

Can aspirin cause stomach upset?

Dear Dr Haizal

My father had two stents inserted five years ago and had been taking aspirin ever since. Lately, he has been experiencing pain in his stomach.

I wonder if it is due to the aspirin? If so, is it safe for him to stop taking it?

Ahmad
Kelana Jaya

Dear Ahmad
Your father has coronary heart disease (CHD) and had coronary angioplasty with the insertion of two stents.

When your father had the procedure, it was never meant to cure him of the disease. In fact, CHD is for life.

The angioplasty and stents only ‘modified’ the disease. Therefore, taking appropriate medicines and leading a heart-healthy lifestyle is absolutely essential.
Aspirin acts to thin the blood by inhibiting the action of platelets, thereby reducing the risk of heart attack. It
very important component the management of anyone with CHD. However, I understand that your father is experiencing the unwanted effect of aspirin. There are options. The first is to take medicine to counter this
effect, such as a proton-pump inhibitor, omeprazole, or that belongs to this family of drugs. The other option
to stop aspirin and replace with a different but effective anti-platelet drug such clopidogrel or ticlopidine.

In any case, please consult your father’s doctor who would be the best person advise on which option
take. He may even recommend that your father undergo a certain investigation called gastroscopy. It involves passing a tube with an attached camera at the end look inside the stomach duodenum for the presence of erosions or ulcers.