On the 5th of June 2015, Malaysia experienced a magnitude 6.0 earthquake, centred in Ranau, Sabah. It was the strongest earthquake in Malaysia since 1976. This tragedy resulted in the death of 18 people on Mount Kinabalu, most of whom were on a school trip from Singapore. Earthquakes are very rare in our country. Malaysians don’t spend the day wondering and worrying about them, and so the 5th June earthquake caught us unawares. In the aftermath of this tragedy the newly opened Gleneagles Kota Kinabalu Hospital became the custodian for the injured visitors from Mount Kinabalu. Several had major injuries and required urgent surgery. Thankfully all the injured who came to Gleneagles survived and were returned home.
Seeing the effects up close, it struck me how similar earthquakes are to heart attacks. No one anticipates a heart attack. They often occur without warning.
They are devastating to families and loved ones. They result in long term injury to a person. And they require prompt, urgent medical care. There are important differences. Heart attacks are common. They are by far the leading cause of death worldwide. Every year in Malaysia, about 29000 people will die from heart disease. Those who survive may have further heart problems as a result of the heart attack. And yet, most people don’t spend the day worrying about heart attacks. Even when a person starts having chest pain or difficulty breathing, the idea that this could be heart related is too frightening to consider. It is only when the pain or breathing problems become unbearable, do people come to hospital. The average time it takes for a Malaysian to come to a hospital after a heart attack is between 4 to 5 hours. 20% of heart attacks victims come in more than 8 hours after the attack. This is a shame, as the sooner you come to a hospital with a heart attack, the more effective the treatment and the higher the chance of surviving.
What is a heart attack? Most heart attacks occur when a blood clot forms inside the arteries of the heart. These clots are more likely to happen if you have cardiovascular risk factors. This includes being male, smoking, high blood pressure, high cholesterol, diabetes or if a close family member has heart trouble. Once the clot blocks the blood flow, that part of the heart begins to die. This usually causes chest pain, but sometimes (especially if you have diabetes) you may only have difficulty breathing. The part of the heart that is dying will be unable to work as well as the rest of the heart. Patients complain of dizziness, weakness, heavy sweating, heart racing and fainting. Walking or doing normal activity becomes difficult. If the blocked artery is not reopened, that part of the heart will become permanently damaged. This usually happens within 6 to 8 hours. From the moment the artery is blocked, it becomes a race against time to reopen the blockage.
How can you treat a heart attack? In the first 2 hours, the clot is soft like toothpaste. When it is soft, a drug can be injected to dissolve the clot. This is called “thrombolysis”. If given in the first two hours, thrombolysis works very well. One drawback is that the effect occurs throughout the entire body. Sometimes, this can result in bleeding complications, the worst of which is bleeding into the brain. After 2 hours, the clot begins to harden. At this point, thrombolysis is no longer as effective. Studies show that if given after 2 hours, the clot has only dissolved in 50% of people given the drug. The other 50% will have a full blown heart attack. In Malaysia, thrombolysis is the main method of treating heart attacks. The best treatment for unblocking the clot is actually doing primary coronary angioplasty. This involves using specialized tubes which are passed up to the arteries of the heart and inflating balloons to “squash” the clot and reopen the artery. If a narrowing remains, a stainless steel metal scaffold (called a stent) can be inserted into the artery to restore normal blood flow. In comparison to thrombolysis, emergency angioplasty results in successful removal of the clot in 98% of cases. Another advantage of angioplasty is the risk of bleeding into the brain is extremely low.
If primary angioplasty is so good, then why isn’t it performed for all heart attacks? Angioplasty requires a special X-ray facility, a trained interventional cardiologist, experienced cardiac team and nursing staff. This is not widely available in Malaysia. In countries where these facilities are available, primary angioplasty is the treatment of choice. In the Greater Kuala Lumpur area (population of 1.6 million), 21 facilities are available. Of those, 17 offer primary angioplasty. In comparison, Sabah (population 3.54 million), only has 3 such facilities; Queen Elizabeth 2, Gleneagles Kota Kinabalu and KPJ Sabah Specialist Hospital; all of which are in Kota Kinabalu. In Gleneagles, we offer primary angioplasty as the treatment of choice for heart attacks.
What happens after a heart attack? If the blocked artery is opened quickly enough, the amount of damage to the heart will be small. This is the best outcome, and most people in this group will resume their lives as normal. If the artery is blocked for too long, the damage will be extensive. The heart becomes very weak. Fluid builds up in the lungs and the legs. The likelihood of dying is high. For those who recover, they are usually limited in their day to day activities by breathlessness. All persons who suffer a heart attack will be on life-long medication, regardless of the treatment they receive. Almost all will be on a blood thinning medication, a cholesterol medication, and usually 2 other medications to lower the risk of further heart attacks from occurring. For most, some lifestyle changes will be required. Those who smoke should stop. Regular exercise is recommended, at least 3 sessions of running, jogging or cycling a week for 40 minutes. Cardiac rehabilitation is available in some hospitals, and is strongly advised.
“An ounce of prevention is worth a pound of cure” Perhaps the best way to treat a heart attack is to ensure you never have one in the first place. Identification and treatment of cardiovascular risk factors have been shown to be very effective in preventing heart attacks from occurring. Many studies have confirmed that strict control of high blood pressure, diabetes and cholesterol will significantly reduce the risk of cardiac events by as much as 40%. Of course, identifying and treating these risks requires a visit to a doctor; which requires time and the enthusiasm to do so! Most hospitals and medical centres offer screening services which can measure cholesterol, glucose and blood pressure. Other tests such as ECG, treadmill test, echocardiography and Cardiac CT may be performed as necessary. The death of 18 people on Mount Kinabalu was a terrible tragedy. It captured the minds and attention of all Malaysians. Every day in Malaysia, 80 people die from heart disease. The fact that this is considered “normal” and not newsworthy is also a terrible tragedy. Don’t wait until it’s too late.
Dr Ahmad Ashraf Zaini, Consultant Interventional Cardiologist & Physician
Gleneagles Kota Kinabalu Hospital