БРОНХИАЛЬНАЯ АСТМА – BRONCHIAL ASTHMA

The three main classes of drug used are nitrates, beta-blockers, and calcium antagonists:

Nitrates

The main effect of nitrates is on the large veins, causing blood to pool in them. Less blood returns to the heart at one time so the pressure created inside the heart as it fills is less. This reduces wall tension in the heart, lowering the «preload.» The muscle does less work and therefore needs less oxygen.

Nitrates also open up the smaller arteries in the periphery of the body, the arms and legs for instance; the heart muscles can pump blood more easily through wider bore vessels. By decreasing the «afterload,» the heart muscle again does less work and needs less oxygen.

By dilating collateral channels, nitrates appear to distribute the blood that enters the coronary circulation to areas that may have been deprived during angina attacks. In all three ways, these medicines help return the supply-demand equation normal.

Nitrates can be fast-acting or long-acting. Fast-acting ones such as sublingual nitroglycerine are used to stop angina attacks once they have begun. As soon as the attack begins, stop what you’re doing, sit down, place one fresh tablet under your tongue, and allow it to dissolve unswallowed. If the pain is not relieved in three to five minutes, repeat the medicine. The strength of the tablets and the number used before seeking medical help is determined by your doctor. Your doctor might order the medicine in the form of a spray rather than a tablet.

If you are able to anticipate an angina attack because you know that a particular level of activity leads to pain, you may be able to premedicate yourself with a tablet or spray before you start and avoid an attack altogether. You can make such a plan with your doctor.

Long-acting nitrates are used to prevent attacks throughout the day. These include isosorbide dinitrate, isosorbide mononitrate, and sustained-release nitroglycerine preparations in the form of an ointment or a transdermal patch. These avoid the side effects of headache, dizziness, or nausea that you might encounter with short-acting nitrates, but they also can lead to reduction of the beneficial effects as well. A period of eight to ten hours a day without these medicines is necessary to maintain their effectiveness. Remember that if you begin to need more and more nitrates to control your angina, your condition may be getting worse and you need to consult your doctor.

You will probably want to change the location of ointment or patch each day to avoid skin irritation. The medicine works just as well on hairless skin of the arm, side, or abdomen as it does on the chest.

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If you don’t want to stop, and you have angina, then you may as well give this book away and put your affairs in order. If you continue to smoke, your chances of surviving for any length of time are reduced. No matter what else you do to protect your heart, it is being overwhelmed by your suicidal habit of smoking.

If you could invent something that in every way was guaranteed to give you angina and a heart attack, then smoking would be it. It reduces the oxygen levels in your blood, it narrows further your already narrowed coronary arteries, it poisons your heart muscle with carbon monoxide and your brain with nicotine, it makes your blood much more likely to clot, and it directly damages your most delicate blood vessels.

Yet I have known many patients who continue to smoke after a coronary bypass or a heart attack. I’m sure that they do not wish to kill themselves, but that is exactly what they are doing. It is so unfair to their families, and even to nonsmokers who are waiting for their own bypass operations, and who will benefit far more from the skill and devotion of their surgeons.

Smoking gives people a sallow, unhealthy look, and wrinkles. By the time they are forty, women smokers look ten years older than their nonsmoking counterparts. By the time they are sixty, many of them are already dead. Cancer of the lung and heart attacks, both of them directly due to smoking, cause far more early deaths in women than anything else.

Most smokers lit their first cigarette as teenagers, when they were far too immature to think about the long-term risk. If you are a non-smoker at twenty, it is odds on that you will remain so for the rest of your life. By this time, most people have learned sense!

If you have angina and still smoke, it is not too late to learn sense. To a doctor like myself, who has had to comfort so many families in which smoking has directly led to the deaths of men and women in their forties and fifties, it is frankly incredible that anyone should ever wish to light up a single cigarette. For a smoker who mulls over the facts about his or her habit, continuing to smoke means that cigarettes are worth more than life itself, yet 25 percent of the population continue to smoke them.

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Your heart’s efficacy will improve if you can keep your coronary arteries as wide open as possible. Crucial to that aim is to avoid cigarette smoke—your own and other people’s. Exposure to cigarette smoke narrows all the small arteries in the skin, pushing up the blood pressure, and causing the coronary arteries to shut down. If they are already narrowed as a result of atheroma, then narrowing them further at the same time as increasing the work of the heart is both insane and suicidal.

Stopping smoking completely is essential; it is no use «cutting down» or «trying to stop.» The only answer, if you are a smoker, is to say to yourself that you are, from this moment on, a nonsmoker. If you can’t do that, then it doesn’t matter how good you are at taking the rest of the advice—you are lost.

Keeping away from other people’s smoke is vital, too. Despite the claims of the tobacco companies to the contrary, there is plenty of evidence that other people’s smoking gets nicotine into the bloodstream of nonsmokers. Nicotine breaks down in the body to a poisonous substance called cotinine. The measuring of cotinine in the blood helps researchers judge the level of exposure, since people inhale cigarette smoke differently, making the number of cigarettes smoked per day an inaccurate measure. Nonsmokers who work in smoky atmospheres have measurable levels of cotinine in their blood. The more their colleagues or customers smoke, the higher their own blood cotinine levels are. The same applies to your home. The babies of parents who smoke have cotinine in their blood; and the higher the level, the more likely they are to be admitted to hospital with lung disease. For every twenty cigarettes smoked around them, non-smokers passively smoke the equivalent of one cigarette.

So if you have angina, avoid cigarette smoke at all costs. In today’s social climate, you shouldn’t feel embarrassed to ask smokers nearby to stop smoking or to go elsewhere to do so. In your home, a small, discreet nonsmoking sign on the window can deter visitors from lighting up, but if they know you have angina, then a quiet word of explanation why they should not smoke in the house should be perfectly acceptable.

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The British had been aware of their problem for more than a century. In 1871, a Dr. Haviland alluded to big differences in the numbers of deaths from heart disease in different regions of England and Wales. To the north of a line from the Severn River to the Wash bay, he wrote, people were especially prone to heart disease. South of the line, they seemed to be protected against it.

That line divided the prosperous south from the poorer north in Victorian Britain, but the differences were still there in 1978, the year of the start of the British Regional Heart Study. The Scottish towns had twice the heart attack rates of towns on the English south coast and there was a gradient from low to high in the towns in between, so that each town had a higher heart attack rate than its neighbor to the south, and a lower rate than its neighbor to the north.

The British Regional Heart Study divided the subjects into risk groups—according to age, smoking habit, Body Mass Index (BMI) (a measure of obesity), blood pressure, and blood cholesterol levels. It also divided them on whether they had signs of heart disease before entering the study. The results have painted an accurate picture of who is at highest risk of angina and heart attacks, and why.

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Three women make up my last three examples of angina. The first, Jane, is sixty years old. She has been well all her life, and sailed through menopause with no difficulty. In fact, she prided herself on having done so without the need for hormone replacement therapy. However, now that her children were grown up and moved away, and she and her now-retired husband had bought a smaller house near the sea, her life had become much less active. She took the occasional walk, but the garden took only a few minutes a day, and she was becoming a couch potato. A nonsmoker and nondrinker, she ate well, and was steadily putting on weight.

Jane’s extra weight was the main reason for her visit to the doctor. She was becoming breathless and a little tight-chested when walking up the steps to her front door, or walking over the dunes to and from the beach. She was less able than before to keep up with her husband, and this irked her. So Jane asked her doctor for a diet plan so that she could lose weight.

The tight-chested feeling worried her doctor, who ordered an EKG and various blood tests. Jane’s blood pressure was normal, but her blood cholesterol level was over 350mg/dl—well above the average—and her EKG showed changes suspicious of ischemia, the medical term for a lack of blood supply. A treadmill test confirmed that the tightness in the chest was linked to further EKG changes that showed that one of the coronary arteries was not delivering enough oxygen to the left side of the heart.

Jane was surprised to find that this tightness was, in fact, angina. The subsequent angiogram showed that she had one narrowed area in the main left coronary artery, and that the area beyond it was now being served by new collateral arteries that had grown in from another coronary artery. In fact, her heart was trying to deal with the problem in its own way—by producing a natural bypass.

The surgeon and cardiologist agreed that with medical treatment to keep the coronaries as open as possible, and a program of judicious exercise and weight reduction, Jane might well get away without having surgery.

She is now eating and exercising better, has lost over 28 pounds, no longer .experiences her attacks of tightness, and is feeling much better. Her cholesterol level is down to 270mg/ dl—still relatively high, but not dangerous for a woman of her age. Jane has to visit her doctor every month or so, but there is every chance she will be able to avoid surgery.

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