I VIVIDLY remember one morning  when I was in Standard Three, my teacher, the late Mrs Wong, walked into the classroom. Looking distraught, she broke the news that Elvis, the King of Rock and Roll, had died at the tender age of 42. The class went silent not knowing how to react to what she said as most of us didn't know who Elvis was at that time.

I was reminded of that incident when I heard of Michael Jackson's death. The King of Pop was planning a mega comeback in Britain beginning next month. His sad death at the age of 50 was shocking and has provoked an outpouring of emotion around the whole world.

Both Elvis and Michael were the undisputed kings of music of their generation. They were legends. But the similarities do not end there. Both were very young when found collapsed in their homes suspected of having a cardiac arrest due to a heart attack.

Cardiac arrest leading to sudden cardiac death (SCD) is a major mode of death in the United States, the home country of Elvis and Michael, with more than 300,000 deaths annually according to the American Heart Association (AHA). As in Malaysia and many other countries, the pattern of disease has changed significantly over the past couple of decades to resemble that of the United States with cardiovascular disease causing about a quarter of all deaths.

By far, the most common cause of SCD is a heart attack where one of the coronary arteries becomes blocked. This causes the heart to suddenly fibrillate very fast (ventricular fibrillation) or stop beating altogether (asystole).

Another important cause, especially in fit young individuals, is hypertrophic cardiomyopathy, an inherited disorder causing abnormal thickening of the heart muscle. Other causes are electrical problems of the  heart predisposing these individuals to abnormal heart rhythms and SCD such as the Long QT and Wolff-Parkinson-White syndromes.

Recreational drugs and ironically, prescription cardiac drugs may also be associated with SCD.

Do you know what to do if someone shows symptoms of a heart attack?

If the person is known to have CHD:

1. Sit the person up and ask if he carries glyceryl trinitrate (GTN) tablets with him. Put one under the tongue. This acts to dilate the artery. Give another tablet after five minutes if he is still in pain.

2. If the symptom does not subside, make the person chew one full-strength aspirin and swallow it with a glass of water.

3. Call 999 to get an ambulance to bring the person to the nearest hospital (not clinic) because emergency medical facilities and treatment are available only at a hospital. Stay until help arrives in case cardiopulmonary resuscitation (CPR) is needed

4. If there is going to be a delay, bring the person in a car to the hospital as time is of the essence.

5. Upon arrival at the hospital, insist on immediate attention by the medical personnel. Tell them of the suspected heart attack so that the person will be placed in a monitored bay and seen by a doctor straight away.

If the person is not known to have a heart disease:

Start with step 3 (above). It is useful to have aspirin at home for this unexpected need. Remember to be with the person at all times until help arrives.

If you are the person suffering the heart attack:

Follow steps 1 to 5. Get someone to be with you all the time.

Did you know that about 80 per cent of all cardiac arrests or SCDs occur at home and are witnessed by family members? Someone close to you may collapse suddenly after having a meal. A colleague may clutch his chest while playing badminton before dropping to the floor.

What do you do if you witness a cardiac arrest?

● Call out the person's name and check for breathing. If there is no response or breathing, immediately
call 999 for an ambulance.

● Start CPR and continue non-stop until help arrives. Get another person to assist you. Do two mouth-to mouth (MTM) respirations for every 30 chest compressions. If you are alone, just do chest compressions without MTM respirations.

The most important thing is to restore and maintain circulation throughout the body. Although CPR does not directly get the heart rhythm back to normal, without this immediate intervention, permanent brain damage may occur after four to six minutes and death will soon follow.

● The use of an automated external defibrillator (AED), a device to deliver electrical shocks, may restore normal heart rhythm and save lives. AEDs have been placed in aircrafts and other public places for this purpose.

As the world continues to mourn the loss of arguably the greatest performer to have ever lived, let us also learn about the manner of his death and the steps we can adopt to overcome the problem. Let's equip ourselves with the knowledge of basic emergency care and how to handle cardiac arrest if we happen to be the bystander witnessing it one day.

The Ministry of Health through its many hospitals and also non- governmental organisations such as The National Heart Foundation, are actively running courses for the public. Grab this opportunity and don't wait.

Remember that the person who collapses could be someone you know or someone you love. Share your thoughts and 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 a man, in my mid 40s. I am grateful that I am relatively healthy. So far, I have only gone for blood screening tests every year. I would like to go for a more comprehensive health check, including
tests for heart disease. There seem to be many types of health screening tests in the market. I would appreciate your advice as to the “must have” tests for heart disease which I should undergo at my age.
Thank you.

Wong
Petaling Jaya

Answer:
There are two main objectives of a heart-specific medical check-up. The first is to detect the presence of heart disease and the second is to look for the presence of risk factors causing heart disease.

A comprehensive heart assessment requires a good history-taking by the doctor followed by a thorough examination which includes taking blood pressure and listening to the heart. Symptoms such as chest pain and breathlessness are suggestive of heart disease. Swelling of the legs may indicate heart failure.

The presence of a heart murmur may point towards heart valve problems.

Once done, appropriate investigations are ordered to support the clinical findings. They are summarised  as follows:

1. Blood tests:
● Lipid profile. This is to look for the presence of abnormal lipid profile, ie. high LDL-cholesterol,
low HDL-cholesterol and high triglyceride which may predispose a person to getting coronary heart disease (CHD).
● Blood glucose. This is to detect diabetes, an important cause of CHD. Ideally, a fasting sample is taken where normal is less than 5.6 mmol/L. An oral glucose tolerance test (OGTT) may be done if diagnosis is in doubt.
● hs-CRP and homocysteine. Both are relatively new risk factors for CHD and not done routinely.

2. Electrocardiogram (ECG):
This is surface electrical recording of the heart. It can detect conditions such as CHD, left ventricular hypertrophy (abnormal thickening of the heart muscle due to hypertension, for example) and abnormal heart rhythm.

3. Exercise stress test:
Many patients with CHD have normal ECG at rest but the ECG becomes abnormal when the heart works harder. An exercise stress test involves walking on a treadmill machine which is programmed to be faster and steeper in stages. As the heart works harder, the ECGs may become abnormal indicating the presence of CHD.

4. Chest X-ray:
It may show changes consistent with heart failure (enlarged heart shadow and congested lung fields).

These are the usual tests ordered  for a basic heart screening. However, further tests may be considered if there is doubt about any of the basic heart tests. They include:

5. Echocardiogram.
This is an ultrasound scan of the heart looking at the structure and function of the heart.

6. CT coronary angiogram.
If an exercise stress test is equivocal, the doctor may order this test. It is a non-invasive method of visualising the coronary arteries by injecting an iodine-based solution into the vein and then doing CT scan. It involves high X-ray radiation and injection of radioactive contrast.

Therefore, it should not be done as a routine screening.