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by Dr. Don Michael

It is the nature of our human condition that certain inevitables exist. These are part of our experiential evaluation and are attributed to misfortune to ill-fated time and to acts of God. While we all accept the limitations of existing on this planet, as exemplified by death and taxes for example, the human mind seeks to unravel the mysteries behind biological processes, which lead to catastrophes. In this constant endeavour a light has shone on the prevention of heart attacks and strokes, which had been unwelcome visitations to us and have led to suffering, unhappiness, economic consequences and tragedy.

It has recently become apparent that the fundamental basis for these events for the most part resides in the rupture of plaque like materials, which lie within the arteries of our bodies. These plaques are of different sizes, shapes but fundamentally are covered by fibrous caps, which enclose calcium, cholesterol and a variety of cells existing either as solid or liquid material. The undermining of the fibrous caps aforementioned, would appear to be the single important cause of a catastrophic heart attack or stroke.

In attempting to understand what are causative factors that can erode and destroy these caps and expose the blood vessel to commence evolving towards a stroke or a heart attack. We have begun to understand that a number of important enzymes called Metalloproteinases have a profound effect in undermining the fibrous caps, which normally protect us. It has also become clear that pools of cholesterol subjacent to the points of rupture are important aggravating factors in the genesis of heart attack and stroke.

In attempting to prevent the best our ability what were previously regarded as inevitable events, much information has been gained into understanding the factors that lead to the disruption of plaques some of these are quite mundane and need to be distinguished from factors that cause heart disease. One of the primary aims of this talk is to uncover the differences between heart disease and Atherosclerosis on the one hand with catastrophic clinical events, on the other and to emphasize that the two do not, by any means, mean the same thing or coincide, although there may be areas of overlap. To choose a mundane example, the inhalations of particulate materials under 10 microns, carbon monoxide, cigarette smoke , colds and pneumonia are potent causes of plaque instability and strategies to prevent these events from leading to heart disease need to be developed in treating patients. To add to this, is the interesting discovery that a single blood test can predict a catastrophic vascular event such as a heart attack.

In this context it is important, in the course of this discourse, to turn our minds to what we regard as the routine physical examination and what, if anything, it accomplishes in the prevention of heart attacks. Anecdotes of the physician telling the patient that he is fit for the next 30 years have sometimes been followed by a totally unexpected sudden heart attack or death. We will try to stress how the healers of today need to approach, not only the substrate of blocks in blood vessels by the treatment and amelioration of well-known factors such as smoking, obesity, cholesterol, triglycerides, high blood pressure, but that they probably should consider ways and means of preventing the acute events.

In addition, techniques have evolved to actually look at the coronary arteries without an angiogram, to evaluate these arteries for so-called "vulnerable plaque" to study the neck of the brain for early signs of stroke and cause thereof and to recognize less commonly understood information concerning the size of the pulse and its temporal variation as strong factors in the genesis of heart attack and stroke. By the end of the talk, it is hoped that the attendees will have achieved the following objectives:

* The vulnerable plaque

* The causes of its rupture

* The day to day events that predispose to heart attack and stroke

* Advances in the detection of proclivity to sudden death, heart attacks and strokes.

* The formulation of a healthy plan of eating, exercise, wellness, which will in combination with the appropriate treatment of heart disease and stroke ameliorate the underlying processes.

Summary: While heart disease and heart attacks need to be differentiated from the standpoint of prevention, a recognition of similarities and differences between these conditions and its relevance to day to day living will be the central topic of this discourse.

Brief introduction to the writer and article

The writer is based in California and is one of he world's foremost cardiologists. He was in Sri Lanka on a brief visit, and spoke recently at a presentation sponsored by Union Assurance, in keeping with UAL's commitment to preventive healthcare. Statistics confirm that sudden heart attacks are the No. 1 killer in Sri Lanka.

Dr. Don Michael bears the distinction of having been commissioned by McGraw-Hill to co-author a book on clinical cardiology in addition to having written several chapters in textbooks and edited many publications on cardiology. He was recently elected a Fellow of the European Society of Cardiology, the only Sri Lankan to be accorded this distinction. He is also a Fellow of the American Heart Association. 

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