Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Heart
attack is the number one killer of both men and
women in the U.S. Each year, about 1.1 million Americans suffer a heart attack,
and 460,000 of these are fatal. Most of the deaths from heart attacks are caused
by ventricular fibrillation of the heart that occurs before the victim of the
heart attack can reach an emergency room. Those who reach the emergency room
have an excellent prognosis; survival from a heart attack with modern treatment should exceed 90%.
The 1% to 10% of heart attack victims who die later include those victims who
suffer major damage to the heart muscle initially
or who suffer additional damage at a later time. Fortunately, procedures such as
coronary angiogram and
PTCA (coronary balloon angioplasty), and clot dissolving drugs are available that can quickly open
blocked arteries in order to restore circulation to the heart and limit heart
muscle damage. In order to optimally benefit heart attack victims and limit the
extent of heart damage, these treatments to open blocked arteries should be
given early during a heart attack.
Knowing the early warning signs of heart attack is critical for prompt
recognition and treatment. Many heart attacks start slowly, unlike the dramatic
portrayal often seen in the movies. A person experiencing a heart attack may not
even be sure of what is happening. Heart attack symptoms vary among individuals,
and even a person who has had a previous heart attack may have different
symptoms in a subsequent heart attack. Although chest pain or pressure
is the most common symptom of a heart attack, heart attack victims may experience a
diversity of symptoms that include:
Pain, fullness, and/or squeezing sensation of the
chest
A heart attack (also known as a myocardial infarction) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen. Blockage of a coronary artery deprives the heart muscle of blood and oxygen,causing injury to the heart muscle. Injury to the heart muscle causes chest pain
and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to
die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue.
Approximately one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack.
What causes a heart attack?
Atherosclerosis
Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery. Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain normal function of the parts of the body they supply. For
example, atherosclerosis of the arteries in the legs causes reduced blood flow to the legs. Reduced blood flow to the legs can lead to pain in the legs while walking or exercising, leg ulcers, or a delay in the healing of wounds to the legs. Atherosclerosis of the arteries that furnish blood to the brain can lead to vascular dementia (mental deterioration due to gradual death of brain tissue over many years) or stroke (sudden death of brain tissue).
In many people, atherosclerosis can remain silent (causing no symptoms or
health problems) for years or decades. Atherosclerosis can begin as early as the
teenage years, but symptoms or health problems usually do not arise until later
in adulthood when the arterial narrowing becomes severe. Smoking cigarettes,
high blood pressure,
elevated cholesterol, and diabetes mellitus can accelerate
atherosclerosis and lead to the earlier onset of symptoms and complications,
particularly in those people who have a family history of early atherosclerosis.
Coronary atherosclerosis (or coronary artery disease) refers to the
atherosclerosis that causes hardening and narrowing of the coronary arteries.
Diseases caused by the reduced blood supply to the heart muscle from coronary
atherosclerosis are called coronary heart diseases (CHD). Coronary heart
diseases include heart attacks, sudden unexpected death, chest pain (angina),
abnormal heart rhythms, and heart failure due to weakening of the heart muscle.
Atherosclerosis and angina pectoris
Angina pectoris (also referred to as angina) is chest pain or pressure that
occurs when the blood and oxygen supply to the heart muscle cannot keep up with
the needs of the muscle. When coronary arteries are narrowed by more than 50 to
70 percent, the arteries may not be able to increase the supply of blood to the heart muscle during
exercise or other periods of high demand for oxygen. An insufficient supply of
oxygen to the heart muscle causes angina. Angina that occurs with exercise or
exertion is called exertional angina. In some patients, especially diabetics,
the progressive decrease in blood flow to the heart may occur without any pain
or with just shortness of breath or unusually early fatigue.
Exertional angina usually feels like a pressure, heaviness, squeezing, or
aching across the chest. This pain may travel to the neck, jaw, arms, back, or
even the teeth, and may be accompanied by shortness of breath, nausea, or a cold
sweat. Exertional angina typically lasts from one to 15 minutes and is relieved by
rest or by taking nitroglycerin
by placing a tablet under the tongue. Both resting and
nitroglycerin decrease the heart muscle's demand for oxygen, thus relieving
angina. Exertional angina may be the first warning sign of advanced coronary
artery disease. Chest pains that just last a few seconds rarely are due to
coronary artery disease.
Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery
has narrowed to such a critical degree that the heart is not
receiving enough oxygen even at rest. Angina at rest infrequently may be due
to spasm of a coronary artery (a condition called Prinzmetal's or variant angina).
Unlike a heart attack, there is no permanent muscle damage with either
exertional or rest angina.
Atherosclerosis and heart attack
Occasionally the surface of a cholesterol plaque in a coronary artery may
rupture, and a blood clot forms on the surface of the plaque. The clot blocks
the flow of blood through the artery and results in a heart attack (see
picture below). The cause of rupture that leads to the formation of a clot is largely
unknown, but contributing factors may include
cigarette smoking or other
nicotine exposure, elevated LDL cholesterol, elevated levels of blood
catecholamines (adrenaline), high blood pressure, and other mechanical and
biochemical forces.
Unlike exertional or rest angina, heart muscle dies during a heart attack
and loss of the muscle is permanent, unless blood flow can be promptly restored,
usually within one to six hours.
While heart attacks can occur at any time, more heart attacks occur between
4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released
from the adrenal glands during the morning hours. Increased adrenaline, as
previously discussed, may contribute to rupture of cholesterol plaques.
Approximately 50% of patients who develop heart attacks have warning symptoms
such as exertional angina or rest angina prior to their heart attacks, but these
symptoms may be mild and discounted.
Heart attack - Symptoms at Onset of DiseaseQuestion: The symptoms of heart attack can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Panic attacks are sudden feelings of terror that strike without warning. These episodes can occur at any time, even during sleep. A person experiencing a panic attack may believe that he or she is having a heart attack or that death is imminent. The fear and terror that a person experiences during a panic attack are not in proportion to the true situation and may be unrelated to what is happening around them. Most people with panic attacks experience several of the following symptoms: racing heartbeat, faintness, dizzyness, numbness or tingling in the hands and fingers, chills, chest pains, difficulty breathing, and a feeling of loss or control. There are several treatments for panic attacks.
Diabetes mellitus is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
An arrhythmia is an abnormal heart rhythm. With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too early. When a single heartbeat occurs earlier than normal, it is called a prmature contraction.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Angina is chest pain that is due to an inadequate supply of oxygen to the heart muscle.
Angina can be caused by coronary artery disease or spasm of the coronary
arteries. EKG, exercise treadmill, stress echocardiography, stress thallium, and cardiac
catheterization are important tests used in the diagnosis of angina.
Palpitations are unpleasant sensations of irregular and/or forceful beating of the heart. Palpitations can be relieved in many patients by stress reduction, stopping cigarettes, and reduction of caffeine and alcohol.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Dementia is a significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning. There are different criteria classification schemes for dementias such as cortical, subcortical, progressive, primary, and secondary dementias. Other conditions and medication reactions can also cause dementia. Dementia is diagnosed based on a certain set of criteria. Treatment for dementia is generally focused on the symptoms of the disease.
Fainting, also referred to as blacking out, syncope, or temporary loss of consciousness has many causes. Often a person will have signs or symptoms prior to the fainting episode. Diagnosis and treatment depends upon the cause of the fainting or syncope episode.
Depression is an illness that involves the body, mood, and thoughts and affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. The principal types of depression are major depression, dysthymia, and bipolar disease (also called manic-depressive disease).
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Toothache usually refers to pain around the teeth or jaws. In most instances, toothaches are caused by tooth or jaw problems, such as a dental cavity, a cracked tooth, an exposed tooth root, gum disease, disease of the jaw joint (TMJ), or spasms of the muscles used for chewing. A toothache can also be caused by a problem that does not originate from a tooth or the jaw, like diseases of the heart (angina or heart attack), ear infections, and sinus infections. A thorough oral examination, which includes dental X-rays, can help determine the cause.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Epilepsy is a brain disorder in which the person has seizures. There are two kinds of seizures, focal and generalized. There are many causes of epilepsy. Treatment of epilepsy (seizures) depends upon the cause and type of seizures experienced.
Premature ventricular contractions (PVCs) are premature heartbeats originating from the ventricles of the heart. PVCs are premature because they occur before the regular heartbeat. There are many causes of premature ventricular contractions to include: heart attack, high blood pressure, congestive heart failure, mitral valve prolapse, hypokalemia, hypoxia, medications, excess caffeine, drug abuse, and myocarditis.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Myofascial pain syndrome is muscle pain in the body's soft tissues due to injury or strain. Symptoms include muscle pain with tender points and fatigue. Treatment usually involves physical therapy, massage therapy, or trigger point injection.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
High blood pressure (hypertension) means high pressure (tension) in the arteries. Treatment for high blood pressure include lifestyle modifications (alcohol, smoking, coffee, salt, diet, exercise), drugs and medications such as ACE inhibitors, angiotensin receptor blockers, beta blockers, diuretics, calcium channel blockers (CCBs), alpha blockers, clonidine, minoxidil, and Exforge.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
Smoking is an addiction. More than 430,000 deaths occur each year in the U.S. from smoking related illnesses. Secondhand smoke or "passive smoke" also harm family members, coworkers, and others around smokers. There are a number of techniques available to assist people who want to quit smoking.
A heart murmur is the sound generated when blood flow within the heart is not smooth. Causes of heart murmurs can be functional, congenital, or caused heart valve conditions. Symptoms of a heart murmur may be none, or may include chest pain, shortness of breath, and arm, leg, and ankle swelling. Treatment of a heart murmur depends on the cause.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Routine screening tests are part of basic prevention medicine. All of the
following screening tests are commonly available through your doctor. Take an active role
in your own health care and discuss screening tests with your doctor early in
life. Following is a list of diseases for which screening is recommended along
with mention of the commonly used screening tests, which usually are safe and
simple and can help detect many diseases before they become harmful.
High blood pressure (hypertension)
About one-sixth of all Americans have
high blood pressure and the incidence
of this disease increases with age. African-Americans are more likely than other
races to have high blood pressure.
High blood pressure can cause arterial disease (atherosclerosis) that can
lead to heart attack, congestive heart failure, stroke, and kidney failure.
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