Am I Having a Heart Attack? Part-2

"Health Watch"

Am I Having a Heart Attack?
Part 2

*Dr. Anu Munshi-Khandhar, MD

Dr. Sameer Khandhar, MD

Last month we discussed how and why a heart attack happens. This month, we’ll focus on how we can prevent one from taking place. The major cause of heart attacks is coronary atherosclerosis - build up of cholesterol that causes hardening and narrowing of the arteries that feed the heart. This atherosclerosis, for the most part, can be prevented. Although we cannot change our genetics, we can definitely identify multiple risk factors that can be altered thereby preventing atherosclerosis.

The blockages that develop in the coronary arteries around the heart (atherosclerosis) that lead to heart attacks take over twenty years to develop. They are due to things like high blood pressure, high cholesterol, smoking, not exercising and the genes that we are born with. We are now learning also that the atherosclerosis (blockages) that develops in the arteries are made up of cholesterol, calcium, white blood cells and lots of inflammation. Preventing atherosclerosis is the key because once it develops (and this starts in our late 20s and 30s) it is nearly impossible to make it go away. All we can do at that time is to try to stabilize it and prevent it from getting worse. I’ll explain below how a new type of CT scan is a good way to measure for early signs and amount of atherosclerosis in people that are at higher risk.

We now know that Indians are at higher risk for heart disease compared to whites and blacks in this country. That is due to several factors. First, our coronary arteries are smaller and more prone to developing blockages. Second, the cholesterol make up in our bodies is very different than that of white Americans. When we get our blood tested we have to keep this in mind, because the way we define whether our cholesterol is normal or not is based on averages of white Americans. Our bad cholesterol (LDL) is much smaller and more dense, our good cholesterol (HDL) tends be lower (when it should be higher), and triglycerides (also bad) tend to be higher compared to white Americans. The importance of this is that since our LDL is smaller and denser it leads to blockages and atherosclerosis even when the number doesn’t seem to be very high.

Nearly 50% of Indians (both men and women) suffer from an illness called metabolic syndrome. This is a growing problem, and unfortunately people and a lot of their physicians are not recognizing it. This syndrome is a group of findings that include increased waist circumference (Indians often aren’t overweight, but have a large belly which is just as dangerous as being overweight!!!!), elevated glucose in the blood (over 100), high triglycerides (over 150), low HDL (under 40) and blood pressure greater than 135/85. We should all measure our waist and use the following numbers for being too large: waist circumference ≥ 38 inches (male), and 36 inches (female). This group of findings (when you have most or all of the above) makes people at even higher risk of developing a heart attack. They need to be very aggressive at improving their health and numbers and most likely will need medications to prevent things from getting worse.

So, what should we all do next?

I really encourage everyone (starting at the age of 20) to have their blood pressure, fasting sugar, and fasting cholesterol/lipid panel checked. Most American doctors are not aware of the differences between the cholesterol make up of Indians and non-Indian Americans, so I want you all to review the actual numbers, and not just stop if the doctor says “everything looks good”.

The few important numbers that we should pay attention to are as follows:

We should all strive for a LDL (bad cholesterol) of less than 100 and the lower the better (ideally near 70). The fasting sugar should be less than 100 and if it’s above that (even though you may not have diabetes yet) this needs to be improved now. Triglycerides should be less than 150 and ideally, under 100. Blood pressure should be less than 135/85 and ideally, less than 125/85.

If you get your blood work and BP checked and they are normal (based on values mentioned above), then you should have your BP checked at least once a year and your cholesterol every 3 years at a minimum. Even though we are all very busy, I can’t stress the importance of trying to do some exercising on a regular basis (which can be as simple as a 20-30 minute brisk walk or job 3-4 days a week).

But if the values are abnormal, then instead of ignoring them I would recommend that you get a special type of CT scan of the heart called an EBCT/Coronary calcium score CT as one option. Of course, you must discuss the pros and cons of getting this test with your own physician. Most American insurance companies are not paying for this test yet, and one option would be to get this done in India. The CT scan should not be done if you are younger than 35-40.

Most people think of a stress test as the best test, but unless there is a 70% blockage, the stress test will be negative. A cardiac catheterization (described in last month’s Shehjar edition) is an invasive procedure and only detects the amount of buildup inside the artery, but not the amount within the wall or outside of the artery. This CT scan will tell you the amount of calcium in the walls and outside of the coronary arteries (arteries around the heart). If this is zero (meaning no calcium buildup) then we should still try to watch what we eat, exercise and keep getting our BP and cholesterol checked regularly to make sure they do not get any worse. There is not need to repeat the CT scan then.

If the calcium score is not zero, then we have to use this as proof that there is atherosclerosis in the arteries and motivation to really change our habits, lose weight, exercise. This is also probably the time to start taking medications (aspirin, cholesterol lowering drugs and maybe even diabetes medications) on a regular basis before a heart attack happens. Again, please make sure you see your physician and go over the benefits and risks of all these tests and medications before starting anything.

Am I Having a Heart Attack? Part-1, Please click here

We welcome any questions regarding this article or any other medical concerns. If there are any physicians who would like to contribute to our future editions, please email us at

Contributing author - Dr. Sameer Khandar is a second year cardiology fellow at University of Pittsburgh Medical Center.
*Anu Munshi-Khandhar was born and partly raised in Kashmir. She moved with her family to the USA during the mass exodus of Kashmiris in 1990. She currently lives in Pittsburgh with her husband and works at the Critical Care Department at University of Pittsburgh Medical Center.

She is very passionate about social service, global health and preventive medicine. Her other interests are hindi music, writing and pencil sketching.

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