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Title: Blog by Novelist William S. Frankl, MD

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A Few Brief Notes About Heart Attacks For a Lay Audience

Monday, December 12th, 2016

When I was first in the practice of cardiology, a heart attack was a fearsome problem. Our tools for handling it were primitive especially in light of what we know about the process and its management with today’s technology. Over the years, the understanding of coronary artery disease, coronary thrombosis, lipids, etc. have blossomed along with a greater and greater sophistication in dealing with a heart attack. In addition, with time, research, and the burgeoning of our tools, the understanding of the variability in the presentation of heart attacks have led to an increased capability in handling such cases.

Despite our new technology, a major element in cardiac diagnosis for over a century has been, and still is, the electrocardiogram invented in 1903 by Willem Einthoven, a Dutch physiologist. It remains today a critical tool in much of cardiology, including in the diagnosis and management of heart attacks. The alterations in the EKG during a heart attack can help assess the possible severity of the attack and possibly the prognosis.

What exactly is a STEMI Heart Attack?

A STEMI is a full-blown heart attack caused by the complete blockage of a heart artery. A STEMI heart attack is taken very seriously and is a medical emergency that needs immediate attention. STEMI stands for ST elevation myocardial infarction. “ST elevation” refers to a particular pattern on an EKG heart tracing and “myocardial infarction” is the medical term for a heart attack. So STEMI is basically a heart attack with a particular EKG heart-tracing pattern.

When someone is being evaluated for chest pain the EKG tracing is done as soon as possible to help see if it’s the heart. An ST-elevation myocardial infarction (STEMI) is a combination of symptoms of chest pain and a specific STEMI EKG heart tracing. The EKG has to meet what is called STEMI criteria to make a correct diagnosis, just like an NSTEMI will provide another set of specific diagnostic criteria. The EKG also provides information as to which part of the heart the blocked artery is supplying, for example an anterior vs. a posterior STEMI vs. an inferior STEMI. An anterior STEMI is the front wall of the heart, and the most serious. A posterior STEMI is the back wall of the heart. An inferior STEMI is the bottom wall of the heart.

What Happens to the Heart?

In a heart attack there is sudden rupture of an unstable part of the wall in a heart artery (coronary artery). This leads to a build up of clot in an attempt to heal it. However this clot formation results in total blockage of the artery. Unfortunately, this total blockage leads to loss of blood supply to the heart beyond that point. The heart muscle stops working within minutes of this and dies within minutes to hours unless the artery can be opened up and illustrates what is the primary goal in tratment –––– to rescue as much heart muscle as possible. For this reason every minute from the onset of a heart attack is absolutely critical. Often the patient doesn’t make it to the hospital due to sudden death due to a malignant heart rhythm. For those that leave it too long to get help or for those in whom the heart attack isn’t treated, the heart muscle dies and is replaced by a non beating scar.

Treatment

The most important part of any STEMI treatment protocol is to get to the hospital as quickly as possible, so basically to call 911 immediately!!! In a STEMI, an artery is blocked and treatment centers on opening this up as quickly as possible. The preferred way to do this is by performing something known as an angioplasty and stent placement. In this procedure the artery is opened up working through a small tube passed into the heart either from the wrist or the groin. In some cases this cannot be performed quickly enough (less than 90-120 minutes) because of being too far away from a hospital equipped to do these things, and in order to avoid a significant delay in any treatment, clot busting drugs are used. Unfortunately these clot busters are not as good since they are less likely to open the artery and are also associated with bleeding complications. However, they are better than no treatment at all. So sometimes we have to use them.

In addition to this, a number of other treatments are used. Painkillers such as morphine are required to settle down pain and reduce anxiety. Oxygen is administered to those who are breathless or have heart failure. EKG monitors are attached so that potentially lethal arrhythmias such as ventricular fibrillation or even less dangerous but still significant arrhythmias such as inappropriate sinus tachycardia or atrial fibrillation with a rapid heart rate can be identified and treated. Blood thinners such as heparin, aspirin and other platelet inhibitors (clopidogrel/ticagrelor) are used to improve outcomes and prevent more heart attacks.

Post-STEMI Recovery

Educating patients and their families is one of the most critical aspects of care after a STEMI. Several new medicines are started after a heart attack, several of which may be needed lifelong. Patients need to be sure they take the medications prescribed to have a benefit. I’ll address these briefly later. Stopping smoking is essential. It’s important patients follow up with their doctors. Drugs should be used to control blood pressure. After a STEMI patients will be enrolled in cardiac rehabilitation that is a program they should attend on a regular basis. This involves exercise, addressing questions such as time of return to physical activities and dietary concerns. Following these things after the STEMI is arguably as important as treating the STEMI itself.
What exactly is a Non-STEMI Heart Attack

As previosly indicated, ST refers to the ST segment, which is part of the EKG heart tracing used to diagnose a heart attack. NSTEMI stands for Non-ST segment-elevation myocardial infarction. Nevertheless, a NSTEMI is still a type of heart attack, although presenting in a somewhat less acute manner than a STEMI. A myocardial infarction is, of course, the medical term for a heart attack.
How is a NSTEMI diagnosed?

In addition to signs such as chest pain, a heart attack is diagnosed mainly two ways. First is a blood test that shows elevated levels of certain markers of heart damage such as cardiac troponin. Secondly is by looking at the EKG heart tracing. As we have already shown, if there is a pattern known as STsegment-elevation on the EKG, this is called a STEMI, short for ST elevation myocardial infarction. If there is elevation of the blood markers suggesting heart damage, but no ST elevation seen on the EKG tracing, this is known as a NSTEMI, a non ST segment elevation myocardial infarction. A NSTEMI may be associated with other EKG changes such as ST segment depression. Often looking at the EKG helps us to locate the area of the heart that is affected.

Treatment of Non STEMI Myocardial Infarction

In addion to the EKG, part of the way of diagnosing a NSTEMI is by a blood test called troponin that is indicative of heart damage. Although the troponin test is great in that it does not miss heart attacks, it is not specific for heart attacks alone. Once the patient’s problem is diagnosed as a NSTEMI, the treatment strategy will typically include an echocardiogram to look at heart muscle functioning. Initially, blood-thinning agents will be given such as aspirin and the blood thinner heparin. These medicines have been proven to improve outcomes in patients with NSTEMI. There may be other medicines given such as a beta-blocker or nitrates. Many patients will then go for a heart catheterization. This test involves injecting dye into the heart arteries to look for blockages. In the case of severe blockages, treatment in the form of a stent or multiple stents may be required. Sometimes there are so many blockages that bypass surgery is advised.

Prognosis after a NSTEMI

A NSTEMI IS a heart attack, so the treatment of that applies here as well. Medicines are prescribed that have been proven to save lives in the long term for heart attack sufferers. Depending on factors such as symptoms and heart function, a number of medicines may be prescribed. Lifestyle changes and modification of risk factors are key in preventing recurrence. It is important for smokers to stop smoking. Blood pressure control and control of diabetes are key. A post-heart attack exercise plan should be incorporated into a daily lifestyle if possible. Often NSTEMI patients will be sent to cardiac rehab to receive education on the important of exercise and begin a program in a supervised environment.
Common Medicines Prescribed After a Non STEMI or STEMI Myocardial Infarction
Aspirin, antiplatelet agents, Beta-Blockers, ACE-Inhibitors and Statins are often prescribed.
STEMI vs NSTEMI – Which is Worse?

The bottom line is that both are bad. STEMI is seen as more of an immediate emergency because there is a known total occlusion of a heart vessel that needs opening urgently. In terms of long-term outcomes, they have equal health implications. Patients with NSTEMI often have other illnesses such as ongoing critical illness, diabetes, kidney disease, and other that means they have a generally high risk over the long term. Both STEMI and NSTEMI need aggressive treatment over the short and long term.

The Political Follies Continue

Monday, December 12th, 2016

As I and many others predicted, the election of either Trump or Clinton would produce chaos in our country. Well, here are a few present and future issues to provide headaches and headlines over the next four years.
After President Obama and Hillary Clinton definitively stated that the election was fair and absent of any significant corruption in November, the administration, the New York Times, Washington Post, and all the other left wing media outlets are indicating that the Russians intervened in the 2016 election to help Donald Trump win the presidency, rather than just undermine the confidence in the electoral system. The CIA is indicating that the Russians provided Wikileaks with thousands of hacked e-mails from the Democratic National Committee and others, and further alleged that this was part of a wider Russian operation to boost Trump and hurt Clinton’s chances.
So, could all this proceed in the following manner: Democrats declare the election should be nullified, putting pressure on the Electors to change their votes and deny Trump the 270 electoral votes required to win, throwing the election into the House of Representatives where either the Republican House votes to elect Trump (thus allowing Democrats to proclaim that the Republicans have elected an illegitimate president) or with enough votes from Republicans abandoning Trump in the House giving the election to Hillary. Well, folks, is that enough chaos for you? I hope my predictions are wrong. But hold on, the voyage might be rough in the next few months.
/But, in the meantime, I am going to add a few posts, which are not political, but might be interesting to some of the very few who visit my site.

Mea Culpa

Saturday, November 12th, 2016

Well, the election is over, and I stand up as stupid, the dummy of the year.

1. Hillary Clinton did not win as I was convinced she would.

2. Trump was obviously not a “Trojan Horse” for Hillary as I kept insisting.

3. I did not at all understand what was going on during this election –– the immense number of disaffected Americans who voted for Trump no matter how the media slammed him.

4. It is not the Republican Party that I said was torn asunder by Trump. It turned out to be the Democrat’s who lost so hugely –––  national, statewide, local. So now we have a Republican President, a Republican Senate, a Republican House, and an overwhelming number of Republican governors and Republican state legislatures.

Wow! How could anyone be so wrong?

How Far We Have Fallen

Sunday, October 9th, 2016

I refuse to tell you how old I am, but you can guess when I tell you I knew who Franklin Roosevelt, Harry Truman, Dwight Eisenhower, and John Kennedy were when they came close to where I lived when they ran for President. Were they perfect? Certainly not. Roosevelt, Eisenhower, and Kennedy were known for their personal peccadilloes ––– not Truman, of course ––– honest, trustworthy, attached forever to his Bess. But even he had a checkered past as regards his biases. But, all loved this country of ours. They worked to do the very best for us. They were not habitual liars. They were not traitors, allowing our national secrets to be stolen; they did not patronize and look down on the people they led; they did not demean women; they were not vulgar (at least not in public); they did not cause the FBI and the Department of Justice to deteriorate in an effort to deceive the people about their crimes; they lied sometimes, as all politicians do, but were mostly truthful with the American people. They were men who guys like us wanted to grow up and be like. They cared primarily about the people, not primarily about themselves. They worked with Congress and did not throw the Constitution down the toilet. They were human, like us, and did foolish things. But, never bent on hurting the country they loved.
And what do we have now? Who will we see tonight in the second Presidential Debate? I’ll tell you who: the most despicable, lascivious, lying, traitorous, ignorant, self-centered, dangerous, money mad, disreputable pair that ever ran for the Office of the Presidency. Whoever is ultimately elected will bring down our nation further down the road to socialism or into abysmal chaos and confusion.
I will watch them tonight with the empty hope of hearing something from their lying lips that might, even marginally be positive and substantive.
Please pray for our nation.

Krauthammer on the “New” Trump

Sunday, September 18th, 2016

This is an interesting article by Charles Krauthammer who apparently prefers Trump to Clinton. Apparently, even brilliant individuals do not understand that either as President will be destructive to the USA. Nothing either says can be believed. Both are psychologically damanged and dangerous. Dr. Krauthammer is a psychiatrist! Can’t he see that! Don’t indicate that anything either one says or does should be lauded.

Hillary Sharpens, Trump Softens. He’s Rising, She’s Falling
By Charles Krauthammer
September 16, 2016, 7:14 am

WASHINGTON — If you are the status quo candidate in a change election in which the national mood is sour and two-thirds of the electorate think the country is on the wrong track, what do you do? Attack. Relentlessly. Paint your opponent as extremist, volatile, clueless, unfit, dangerous. Indeed, Hillary Clinton’s latest national ad, featuring major Republican politicians echoing that indictment of Donald Trump, ends thus: “Unfit. Dangerous. Even for Republicans.”

That was the theme of Clinton’s famous open “alt-right” speech and of much of her $100 million worth of ads.

Problem is, it’s not working.

Over the last month, Trump’s new team, led by Kellyanne Conway, has worked single-mindedly to blunt that line of attack on the theory that if he can just cross the threshold of acceptability, he wins. In an act of brazen rebranding, they set out to endow him with stature and empathy.

Stature was acquired in Mexico whose president inexplicably gave Trump the opportunity to stand on the world stage with a national leader and more than hold his own. It’s the same stature booster Sen. Barack Obama pulled off when he stood with the French president at a news conference in Paris in 2008.

That was part one: Trump the statesman. Part two: the kinder gentler Trump.

Nervy. Can you really repackage the boasting, bullying, bombastic, insulting, insensitive Trump into a mellow and caring version? With two months to go? In a digital age in which every past outrage is preserved on imperishable video?

Turns out, yes. How? Deflect and deny — and pretend it never happened. Where are they now — the birtherism, the deportation force, the scorn for teleprompters, the mocking of candidates who take outside money? Down the memory hole.

Orwell was wrong. You don’t need repression. You need only the sensory overload of an age of numbingly ephemeral social media. In this surreal election season, there is no past.

Clinton ads keep showing actual Trump sound bites meant to shock. Yet her numbers are dropping, his rising.

How? Trump never goes on the defensive. He merely creates new Trumps. Hence:

(1) The African-American blitz. It’s a new pose and the novelty shows. Trump is not very familiar with the language. He occasionally slips, for example, into referring to “the blacks.” And his argument that African-Americans inhabit a living hell and therefore have nothing to lose by voting for him hovers somewhere between condescension and insult.

But, as every living commentator has noted, the foray into African-American precincts was not aimed at winning black votes but at countering Trump’s general image as the bigoted candidate of white people.

Result? A curious dynamic in which Clinton keeps upping the accusatory ante just as Trump keeps softening his tone — until she finds herself way over the top, landing in a basket of deplorables, a phrase that will haunt her until Election Day. (Politics 101: Never attack the voter.)

(2) The immigration wobble. A week of nonstop word salad about illegal immigration left everyone confused about what Trump really believes. Genius. The only message to emerge from the rhetorical fog is that he is done talking about deportation and/or legalization. The very discussion is off the table until years down the road.

Case closed. Toxic issue detoxified.

Again, that’s not going to win him the Hispanic vote. But that wasn’t the point. The point was to soften his image in the Philadelphia suburbs, pundit shorthand for white college-educated women that Republicans have to win (and where Trump trails Romney 2012 by 10 points). Which brings us to:

(3) The blockbuster childcare proposal. Unveiled Tuesday, it is liberalism at its best, Big Government at its biggest: tax deductions, tax rebates (i.e. cash), and a federal mandate of six weeks of paid maternity leave. The biggest entitlement since, well, Obamacare.

But wait. Didn’t Trump’s acolytes assure us that he spoke for those betrayed by the sold-out, elitist, GOP establishment that for years refused to stand up to Obama’s overweening mandates, Big Government profligacy and budget-busting entitlements?

No matter. That was yesterday. There is no past. Nor a future — at least for Ivanka-care. It would never get through the GOP House.

Nor is it meant to. It is meant to signal what George H. W. Bush once memorably read off a cue card. “Message: I care.”

And where do you think Trump gave this dish-the-Whigs cradle-to-college entitlement speech? Why, the Philadelphia suburbs!

Can’t get more transparent than that. Or shameless. Or brilliant.

And it’s working.


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