The Heart

Angina Pectoris
 
In today's society, people are gaining medical knowledge at
quite a fast pace. Treatments, cures, and vaccines for
various diseases and disorders are being developed
constantly, and yet, coronary heart disease remains the
number one killer in the world. The media today
concentrates intensely on drug and alcohol abuse,
homicides, AIDS and so on. What a lot of people are not
realizing is that coronary heart disease actually accounts
for about 80% of all sudden deaths. In fact, the number of
deaths from heart disease approximately equals to the
number of deaths from cancer, accidents, chronic lung
disease, pneumonia and influenza, and others, combined.
 
One of the symptoms of coronary heart disease is angina
pectoris. Unfortunately, a lot of people do not take it
seriously, and thus not realizing that it may lead to other
complications, and even death. 

The human heart is a powerful muscle in the body, which is
worked the hardest. It is a double pump system, two pumps
side by side, which pumps blood to all parts of the body.
Its steady beating maintains the flow of blood throughout
the body day and night, year after year, non-stop from
birth until death. The heart is a hollow, muscular organ
slightly bigger than a person's clenched fist. It is
located in the center of the chest, under the breastbone
above the sternum, but it is slanted slightly to the left,
giving people the impression that their heart is on the
left side of their chest. 

The heart is divided into two halves, which are further
divided into four chambers: the left atrium and ventricle,
and the right atrium and ventricle. Each chamber on one
side is separated from the other by a valve, and it is the
closure of these valves that produce the "lubb-dubb" sound
so familiar to us. Like any other organs in our body, the
heart needs a supply of blood and oxygen, and coronary
arteries supply them. There are two main coronary arteries,
the left coronary artery, and the right coronary artery.
They branch off the main artery of the body, the aorta. The
right coronary artery circles the right side and goes to
the back of the heart. The left coronary artery further
divides into the left circumflex and the left anterior
descending artery. These two left arteries feed the front
and the left side of the heart. The division of the left
coronary artery is the reason why doctors usually refer to
three main coronary arteries. 

There are three main symptoms of coronary heart disease:
Heart Attack, Sudden Death, and Angina. 

1. Heart attack occurs when a blood clot suddenly and
completely blocks a diseased coronary artery, resulting in
the death of the heart muscle cells supplied by that
artery. Coronary and Coronary Thromboses are terms that can
refer to a heart attack. Another term, Acute myocardial
infarction, means death of heart muscle due to an
inadequate blood supply. 

2. Sudden death occurs due to cardiac arrest. Cardiac
arrest may be the first symptom of coronary artery disease
and may occur without any symptoms or warning signs. Other
causes of sudden deaths include drowning, suffocation,
electrocution, drug overdose, trauma (such as automobile
accidents), and stroke. Drowning, suffocation, and drug
overdose usually cause respiratory arrest which in turn
cause cardiac arrest. Trauma may cause sudden death by
severe injury to the heart or brain, or by severe blood
loss. Stroke causes damage to the brain which can cause
respiratory arrest and/or cardiac arrest. 

3. People with coronary artery disease, whether or not they
have had a heart attack, may experience intermittent chest
pain, pressure, or discomforts. This situation is known as
angina pectoris. It occurs when the narrowing of the
coronary arteries temporarily prevents an adequate supply
of blood and oxygen to meet the demands of working heart
muscles. 

Angina Pectoris (from angina meaning strangling, and
pectoris meaning breast) is commonly known simply as angina
and means pain in the chest. The term "angina" was first
used during a lecture in 1768 by Dr. William Heberden. The
word was not intended to indicate "pain," but rather
"strangling," with a secondary sensation of fear. Victims
suffering from angina may experience pressure, discomfort,
or a squeezing sensation in the center of the chest behind
the breastbone. The pain may radiate to the arms, the neck,
even the upper back, and the pain may come and go. It
occurs when the heart is not receiving enough oxygen to
meet an increased demand. Angina, as mentioned before, is
only temporary, and it does not cause any permanent damage
to the heart muscle. The underlying coronary heart disease,
however, continues to progress unless actions are taken to
prevent it from becoming worse. 

Angina does not necessarily involve pain. The feeling
varies from individuals. In fact, some people described it
as "chest pressure," "chest distress," "heaviness,"
"burning feeling," "constriction," "tightness," and many
more. A person with angina may feel discomforts that fit
one or several of the following descriptions: 

1. Mild, vague discomfort in the center of the chest, which
may radiate to the left shoulder or arm,
 2. Dull ache, pins and needles, heaviness or pains in the
arms, usually more severe in the left arm, 
3. Pain that feels like severe indigestion,
 4. Heaviness, tightness, fullness, dull ache, intense
pressure, a burning, vice-like, constriction, squeezing
sensation in the chest, throat or upper abdomen, 
5. Extreme tiredness, exhaustion of a feeling of collapse, 
6. A shortness of breath or choking sensation,
 7. A sense of foreboding or impending death accompanying
chest discomfort, 
8. Pains in the jaw, gums, teeth, throat or ear lobe, .
 9. Pains in the back or between the shoulder blades. 

Angina can be so severe that a person may feel frightened,
or so mild that it might be ignored. Angina attacks are
usually short, from one or two minutes to a maximum of
about four to five. It usually goes away with rest, within
a couple of minutes, or ten minutes at the most. 

There are several known forms of angina. Brief pain that
comes on exertion and leaves fairly quickly after rest, is
known as stable angina. When angina pain occurs during
rest, it is called unstable angina. The symptoms are
usually severe and the coronary arteries are badly
narrowed. If a person suffers from unstable angina, there
is a higher risk for that person to develop heart attacks.
The pain may come up to 20 times a day, and it can wake a
person up, especially after a disturbing dream. 

Another type of angina is called atypical or variant
angina. In this type of angina, pain occurs only when a
person is resting or asleep rather than from exertion. It
is thought to be the result of coronary artery spasm, a
sort of cramp that narrows the arteries. 

The main cause of angina is the narrowing of the coronary
arteries. In a normal person, the inner walls of the
coronary arteries are smooth and elastic, allowing them to
constrict and expand. This flexibility permits varying
amounts of oxygenated blood, appropriate to the demand at
the time, to flow through the coronary arteries. As a
person grows older, fatty deposits will accumulate on the
artery walls, especially if the linings of the arteries are
damaged due to cigarette smoking or high blood pressure. As
more and more fatty materials build up, they form plaques
which causes the arteries to narrow and thus restricting
the flow of blood. This process is known as
atherosclerosis. However, angina usually does not occur
until about two-thirds of the artery's diameter is blocked. 

Besides atherosclerosis, there are other heart conditions
resulting in the starvation of oxygen of the heart, which
also causes angina. The arteries are supplied with nerves,
which allow them to be controlled directly by the brain,
especially the hypothalamus - an area at the center of the
brain which regulates the emotions. The brain controls the
expanding and narrowing of the arteries when necessary. The
pressures of modern life: aggression, hostility,
never-ending deadlines, remorseless, competition, unrest,
insecurity and so on, can trigger this control mechanism.
When you become emotional, the chemicals that are released,
such as adrenaline, noradrenaline, and serotonin, can cause
a further constriction of the coronary arteries. The
pituitary gland, a small gland at the base of the brain,
under the control of the hypothalamus, can signal the
adrenal glands to increase the production of stress
hormones such as cortisol and adrenaline even further.
Coronary spasm - Sudden constrictions of the muscle layer
in an artery can cause platelets to stick together,
temporarily restricting the flow of flow. This is known as
coronary spasm. Platelets are minute particles in the
blood, which play an essential role both in the clotting
process and in repairing any damaged arterial walls. They
tend to clump together more easily when the blood is full
of chemicals released during arousal, such as cortisol and
others. Coronary spasm causes the platelets to stick
together and to the wall of the artery, while substances
released by the platelets as they stick together further
constrict the blood vessels. If the artery is already
narrowed, this can have a devastating effect as it
drastically reduces the blood flow. 

Shallow, irregular but rapid breathing washes out carbon
dioxide from the system and the blood will become
over-oxygenated. An overloaded blood actually does not give
up oxygen as easily, therefore the amount of oxygen
available to the heart is reduced. Carbon dioxide is
present in the blood in the form of carbonic acid, when
there is a loss in carbonic acid, the blood becomes more
basic, or alkaline, which leads to spasm of blood vessels,
almost certainly in the brain but also in the heart. 

Atherosclerosis is caused when the coronary arteries are
clogged with atherosclerotic plaques, thus narrowing the
diameter. Plaques are usually collections of connection
tissue, fats, and smooth muscle cells. The plaque project
into the lumen, the passageway of the artery, and interfere
with the flow of blood. In a normal artery, the smooth
muscle cells are in the middle layer of the arterial wall;
in atherosclerosis they migrate into the inner layer. 

The reason behind their migration could hold the answers to
explain the existence of atherosclerosis. Two theories have
been developed for the cause of atherosclerosis. The first
theory was suggested by German pathologist Rudolf Virchow
over 100 years ago. He proposed that the passage of fatty
material into the arterial wall is the initial cause of
atherosclerosis. The fatty material, especially
cholesterol, acts as an irritant, and the arterial wall
respond with an outpouring of cells, creating
atherosclerotic plaque. The second theory was developed by
Austrian pathologist Karl von Rokitansky in 1852. He
suggested that atherosclerotic plaques are aftereffects of
blood-clot organization (thrombosis). The clot adheres to
the intima and is gradually converted to a mass of tissue,
which evolves into a plaque. 

There are evidences to support the latter theory. It has
been found that platelets and fibrin (a protein, the final
product in thrombosis) are often found in atherosclerotic
plaques, also found are cholesterol crystals and cells
which are rich in lipid. The evidence suggests that
thrombosis may play a role in atherosclerosis, and in the
development of the more complicated atherosclerotic plaque.
Though thrombosis may be important in initiating the
plaque, an elevated blood lipid level may accelerate
arterial narrowing. 

Inside the plaque is a yellow, porridge-like substance,
consisting of blood lipids, cholesterol and triglycerides.
These lipids are found in the bloodstream and when they
combine with specific proteins, they form lipoproteins. All
lipoprotein particles contain cholesterol, triglycerides,
phospholipids, and proteins, but the proportion varies in
different particles. Lipoproteins vary in size. The largest
lipoproteins are called Chylomicra, and consist mostly of
triglycerides. The next in size are the
pre-beta-lipoproteins, and then the beta lipoproteins. 

As their size decreases, so does their concentration of
triglycerides, but the smaller they are, the more
cholesterol they contain. Pre-beta-lipoproteins are also
known as low density lipoproteins (LDL), and beta
lipoproteins are also called very low density lipoproteins
(VLDL). They are most significant in the development of
atheroma. The smallest lipoprotein particles, the alpha
lipoproteins, contain a low concentration of cholesterol
and triglycerides, but a high level of proteins, and are
also known as high density lipoproteins (HDL). They are
thought to be protective against the development of
atherosclerotic plaque. In fact, they are transported to
the liver rather than to the blood vessels. 

The theory is that lipoproteins pass between the lining
cells of the arteries and some of them accumulate
underneath. All except the chylomicra, which are too big,
have a chance to accumulate. The protein in the
lipoproteins is broken down by enzymes, leaving behind the
cholesterol and triglycerides. These fats are trapped and
set up a small inflammatory reaction. The alpha particles
that do not react with the enzymes, are returned to the
circulation. 

There are several risk factors that contribute to the
development of atherosclerosis and angina: Family history,
Diabetes, Hypertension, Cholesterol, and Smoking. We all
carry approximately 50 genes that affect the function and
structure of the heart and blood vessels. There are many
cases today where heart disease runs in a family, for many
generations. 

Diabetics are at least twice as likely to develop angina
than nondiabetics, and the risk is higher in women than in
men. Diabetes causes metabolic injury to the lining of
arteries, as a result, the tiny blood vessels that nourish
the walls of medium-size arteries throughout the body,
including the coronary arteries, become defective. These
microscopic vessels become blocked, impeding the delivery
of blood to the lining of the larger arteries, causing them
to deteriorate, and artherosclerosis results. 

Hypertension, high blood pressure, directly injures the
artery lining by several mechanisms. The increased pressure
compresses the tiny vessels that feed the artery wall,
causing structural changes in these tiny arteries.
Microscopic fracture lines then develop in the arterial
wall. The cells lining the arteries are compressed and
injured, and can no longer act as an adequate barrier to
cholesterol and other substances collecting in the inner
walls of the blood vessels.
 
Cholesterol has become one of the most important issue in
the last decade. Reducing cholesterol intake can directly
decrease one's risk of developing heart disease, and people
today are more conscious of what they eat, and how much
cholesterol their foods contain. Cholesterol causes
atherosclerosis by progressively narrowing the arteries and
reduces blood flow. The building up of fatty deposits
actually begins at an early age, and the process progresses
slowly. By the time the person reaches middle-age, a high
cholesterol level can be expected. 

A risk factor which can readily be controlled is cigarette
smoking. Cigarette smoke contains carbon monoxide,
radioactive polonium, nicotine, arsenious oxide,
benzopyrene, and levels of radon and molybdenum. The two
agents that have the most significant effect on the
cardiovascular system are carbon monoxide and nicotine.
Nicotine has no direct effect on the heart or the blood
vessels, but it stimulates the nerves on these structures
to cause the secretion of adrenaline. The increase of
adrenaline and noradrenaline increases blood pressure and
heart rate by about 10% for an hour per cigarette. In
simpler words, nicotine causes the heart to beat more
vigorously. Carbon monoxide, on the other hand, poisons the
normal transport systems of cell membranes lining the
coronary arteries. This protective lining breaks down,
exposing the undersurface to the ravages of the passing
blood, with all its clotting factors as well as
cholesterol. 

The five major risk factors described above do more than
just add to one another. There is a virtual multiplication
effect in victims with more than one risk factor. It is
very important for patients to tell their doctors of the
symptoms as honestly and accurately as possible. The doctor
will need to know about other symptoms that may distinguish
angina from other conditions, such as esophagitis,
pleurisy, costochondritis, pericarditis, a broken rib, a
pinched nerve, a ruptured aorta, a lung tumor, gallstones,
ulcers, pancreatitis, a collapsed lung or just be nervous.
Each of the above mentioned is capable of causing chest
pain. A patient may take a physical examination, which
includes taking the pulse and blood pressure, listening to
the heart and lung with a stethoscope, and checking weight.
Usually an experienced cardiologist can distinguish it as a
cardiac or noncardiac situation within minutes. There are
also routine tests, such as urine and blood tests, which
can be used to determine body fat level. Blood test can
also tests for: Anemia - where the level of haemogoblin is
too low, and can restrict the supply of blood to the heart.
Kidney function - levels of various salts, and waste
products, mainly urea and creatinine in the blood. Normally
these levels should be quite low. There are other factors
which can be tested such as salt level, blood fat and sugar
levels. A chest x-ray provides the doctor with information
about the size of the heart. Like any other muscles in the
body, if the heart works too hard for a period of time, it
develops, or enlarges. An electrocardiogram (ECG) is the
tracing of the electrical activity of the heart. As the
heart beats and relaxes, the signals of the heart's
electrical activities are picked up and the pattern is
recorded. The pattern consists of a series of alternating
plateaus and sharp peaks. ECG can indicate if high blood
pressure has produced any strain on the heart. It can tell
if the heart is beating regularly or irregularly, fast or
slow. It can also pick up unnoticed heart attacks. A
variation of the ECG is the veterocardiogram (VCG). It
performs exactly like the ECG except the electrical
activity is shown in the form of loops, or vectors, which
can be watched on a screen, printed on paper, or
photographed. What makes VCG superior to ECG is that VCG
provides a three-dimensional view of a single heart beat. 

Angina patients are usually prescribed at least one drug.
Some of the drugs prescribed improve blood flow, while
others reduce the strain on the heart. Commonly prescribed
drugs are nitrates, beta- blockers, and Calcium
antagonists. It should be noted that drugs for angina only
relief the pain, it does nothing to correct the underlying
disorder. 

Nitrates Nitroglycerine, which is the basis of dynamite,
relaxes the smooth fibers of the blood vessels, allowing
the arteries to dilate. They have a tendency to produce
flushing and headaches because the arteries in the head and
other parts of the body will also dilate. 

Glyceryl trinitrate is a short-acting drug in the form of
small tablets. It is taken under the tongue for maximum and
rapid absorption since that area is lined with capillaries.
It usually relieves the pain within a minute or two. One of
the drawbacks of trinitrates is that if they are exposed
too long, they can deteriorate in sunlight. Trinitrates
also come in the form of ointment or "transdermal" sticky
patch which can be applied to the skin. 

Dinitrates and mononitrates are used for the prevention of
angina attacks rather than as pain relievers. They are
slower acting than trinitrates, but they have a more
prolonged effect. They have to be taken regularly, usually
three to four times a day. Dinitrates are more common than
trinitrates or tetranitrates. 

Beta-blockers are used to prevent angina attacks. They
reduce the work of the heart by regulating the heart beat,
as well as blood pressure; the amount of oxygen required is
thereby reduced. These drugs can block the effects of the
stress hormones adrenaline and noradrenaline at sites
called beta receptors in the heart and blood vessels. These
hormones increase both blood pressure and heart rate. Other
sites affected by these hormones are known as alpha
receptors. There are side effects, however, for using
beta-blockers. Further reduction in the pumping action may
drive to a heart failure if the heart is strained by heart
disease. Hands and feet get cold due to the constriction of
peripheral vessels. Beta- blockers can sometimes pass into
the brain fluids, and cause vivid dreams, sleep
disturbance, and depression. There is also a possibility of
developing skin rashes and dry eyes. Some beta- blockers
raise the level of blood cholesterol and triglycerides. 

The drug, Calcium antagonists, helps prevent angina by
mopping up calcium in the artery walls. The arteries then
become relaxed and dilated, so reducing the resistance to
blood flow, and the heart receives more blood and oxygen.
They also help the heart muscle to use the oxygen and
nutrients in the blood more efficiently. In larger dose
they also help lower the blood pressure. The drawback for
calcium antagonists is that they tend to cause dizziness
and fluid retention, resulting in swollen ankles. 

There are new drugs being developed constantly. Pexid, for
example, is useful if other drugs fail in severe angina
attacks. However, it produces more side effects than
others, such as pins and needles and numbness in limbs,
muscle weakness, and liver damage. It may also precipitate
diabetes, and damages to the retina. 

When medications or any other means of treatment are unable
to control the pain of angina attacks, surgery is
considered. There are two types of surgical operation
available: Coronary Bypass and Angioplasty. The bypass
surgery is the more common, while angioplasty is relatively
new and is also a minor operation. Surgery is only a "last
resort" to provide relief and should not be viewed as a
permanent cure for the underlying disease, which can only
be controlled by changing one's lifestyle. 

Coronary Bypass Surgery involves extracting a vein from
another part of the body, usually the leg, and using it to
construct a detour around the diseased coronary artery.
This procedure restores the blood flow to the heart muscle.
Although this may sound risky, the death rate is actually
below 3 per cent. This risk is higher, however, if the
disease is widespread and if the heart muscle is already
weakened. If the grafted artery becomes blocked, a heart
attack may occur after the operation. The number of
bypasses depends on the number of coronary arteries
affected. 

Coronary artery disease may affect one, two, or all three
arteries. If more than one artery is affected, then several
grafts will have to be carried out during the operation.
About 20 per cent of the patients considered for surgery
have only one diseased vessel. In 50 per cent of the
patients, there are two affected arteries, and in 30 per
cent the disease strikes all three arteries. These patients
are known to be suffering from triple vessel disease and
require a triple-bypass. 

Triple vessel disease and disease of the left main coronary
artery before it divides into two branches are the most
serious conditions. The operation itself incorporates
making an incision down the length of the breastbone in
order to expose the heart. The patient is connected to a
heart-lung machine, which takes over the function of the
heart and lungs during the operation and also keeps the
patient alive. At the same time, a small incision is made
on the leg to remove a section of the vein. Once the
section of vein has been removed, it is attached to the
heart. One end of the vein is sewn to the aorta, while the
other end is sewn into the affected coronary artery just
beyond the diseased segment. The grafted vein now becomes
the new artery through which the blood can flow freely
beyond the obstruction. The original artery is thus
bypassed. 

The whole operation requires about four to five hours, and
may be longer if there is more than one bypass involved.
After the operation, the patient is sent to the Intensive
Care Unit (ICU) for recovery. The angina pain is usually
relieved or controlled, partially or completely, by the
operation. However, the operation does not cure the
underlying disease, so the effects may begin to diminish
after a while, which may be anywhere from a few months to
several years. The only way patients can avoid this from
happening is to change their lifestyles.
 
Angionplasty, another type of operation, is a relatively
new procedure, and is known in full as transluminal balloon
coronary angioplasty. It entails "squashing" the
atherosclerotic plaque with balloons. A very thin balloon
catheter is inserted into the artery in the arm or the leg
of a patient under general anesthetic. The balloon catheter
is guided under x-ray just beyond the narrowed coronary
artery. Once there, the balloon is inflated with fluid and
the fatty deposits are squashed against the artery walls.
The balloon is then deflated and drawn out of the body. 

This technique is a much simpler and a more economical
alternative to the bypass surgery. The procedure itself
requires less time and the patient only remains in the
hospital for a few days afterward. Exactly how long the
operation takes depends on where and in how many places the
artery is narrowed. It is most suitable when the disease is
limited to the left anterior descending artery, but
sometimes the plaques are simply too hard, making them
impossible to be squashed, in which case a bypass might be
necessary.
 
The only way patients can prevent the condition of their
heart from deteriorating any further is to change their
lifestyles. The following are some advice on how people can
change the way they live, and enjoy a lifetime with a
healthy heart. 

1. A person should limit the amount of exertions. 

2. Exercise regularly to one's limits. This may sound
contradictory that, on the one hand, you are told to limit
your exertion and, on the other, you are told to exercise.
It is actually better if one exercise regularly within his
or her limits. Exercises can be grouped into two
categories: isotonic and isometric. People suffering from
angina should limit themselves to only isotonic exercises.
This means one group of muscle is relaxed while another
group is contracted. Examples of this type of exercise
include walking, swimming leisurely, and yoga; some harder
exercises are cycling and jogging. 

3. Reducing unnecessary weight will reduce the amount of
strain on the heart, and likely lower blood pressure as
well. One can lose weight by simply eating less than their
normal intake, but keep in mind that the major goal is to
cut down on fatty and sugar foods, which are low in
nutrients and high in calories. What you eat can have a
direct effect on the kind of condition you are in. 

To stay fit and healthy, eat fewer animal fats, and foods
that are high in cholesterol. They include fatty meat,
lard, butter, cream and hard cheese, eggs, and so on. Also,
the amount of salt intake should be reduced. Eat more food
containing a high amount of fiber, such as wholegrain
cereal products, wholemeal bread, as well as fresh fruits
and vegetables. 

Alcohol in moderation does no harm to the body, but it does
contain calories and may slow the weight loss progress.
People can drink as much mineral water, fruit juice and
ordinary or herb tea as they wish, but no more than two
cups of coffee per day. 

Cigarettes It has been medically proven that cigarettes do
the body no good at all. It makes the heart beat faster,
constricts the blood vessels, and generally increases the
amount of work the heart has to do. 

Stress can actually be classified as a major risk factor,
and it is one neglected by most people. Try to avoid those
heated arguments and emotional situations that increase
blood pressure, as well as stimulate the release of stress
hormones. If they are unavoidable, try to anticipate them
and prevent the attack by sucking an angina tablet
beforehand.
 
Help your body to relax when feeling tense by sitting or
lying down quietly. Close your eyes, breathe slowly and
deeply through the nose, make each exhalation long, soft
and steady. An adequate amount of sleep each night is
always important. 

Sexual activity may bring on an angina attack, but the
chronic frustration of abstinence may cause more tension.
If intercourse precipitates angina, either suck on an
angina tablet a few minutes beforehand or let your partner
assume the more active role.
 
There is a marked increase of coronary heart disease in
most industrialized societies in the twentieth century.
This may have resulted, in part, because these societies
reward those who performed more quickly, aggressively, and
competitively. Type-A individuals of both sexes were
considered to have the following characteristics: 
 1. An intense, sustained drive to achieve self- selected
but often poorly defined goals. 
 2. A profound inclination and eagerness to compete. 
 3. A persistent desire for recognition and advancement. 
 4. A continuous involvement in multiple and diverse
functions subject to time restrictions. 
 5. Habitual propensity to accelerate the rate of
execution of most physical and mental functions. 
 6. Extraordinary mental and physical alertness. 
The enhanced competitiveness of type-A persons leads to an
aggressive and ambitious achievement orientation, increased
mental and physical alertness, muscular tension, and an
explosive and rapid style of speech. A sense of time
urgency leads to restlessness, impatience, and acceleration
of most activities. This in turn may result in irritability
and the enhanced potential for type-A hostility and anger.
Type-A individuals are thus at an increased risk of
developing coronary heart disease. The type-A behavior
pattern is defined as an action-emotion complex involving
the following: 

(1) behavioral dispositions (e.g., ambitiousness,
aggressiveness, competitiveness, and impatience). 
(2) specific behaviors (e.g., muscle tenseness, alertness,
rapid and emphatic speech stylistics, and accelerated pace
of most activities).
 (3) emotional responses (e.g., irritation, hostility, and
anger). 

Comparatively, type-A persons are more risky to develop
coronary heart disease than type-B individuals, whose
manners and behaviors are relaxed. The risk, however, is
independent of the risk factors. Not all physicians are
convinced that type-A behavior pattern is a risk factor,
and thousands of studies and researches are currently being
done by experts on this topic. 

The Cardiac Rehab Program at the Credit Valley Hospital is
designed to help patients with coronary artery disease
lower their overall risk, and to prevent any further
attacks. It provides rehabilitation for patients who are
likely to have heart attacks, have had heart attacks, or
had a recent surgery. Most patients come to this one-hour
class two nights a week, which takes place outside the
physiotherapy department. The class is conducted by
volunteers, and is usually supervised by a kinesiologist.
The patients come in a little before 6:00 PM, and have
their blood pressure taken. At six o'clock, volunteers will
take the patients through a fifteen-minute warm-up. After
the warm-up, the patients will go on with their exercise
for half an hour. The patients can choose from walking,
rowing machines, stationary bicycles, and arm ergometer, or
a combination of two or more as their exercise. Each
patient is reassessed once a month, in order to keep track
of their progress. Volunteers will ask the patient being
reassessed a series of questions, which include frequency
of exercise, type of exercise program, problems with
exercise, etc. At about 6:30, when the patients are near
the peak of their exercise, the ones being reassessed will
have to have their pulse and blood pressure measured to see
if they have reached their "target heart rate" and to see
if their blood pressure goes up as expected. At about 6:45,
the patients end their exercise and cool-down begins.
Cool-down is in a way similar to warm-up, only this helps
the patients to relax their hearts, as well as their body
after a half-hour workout. After cool-down, most patients
have their blood pressure taken again just to make sure
nothing unusual occurs. 
 
Angina pectoris is not a disease which affects a person's
heart permanently, but to encounter angina pain means
something is wrong. The pain is the heart's distress
signal, a built-in warning device indicating that the heart
has reached its maximum workload. Upon experiencing angina,
precautions should be taken. A person's lifestyle plays a
major role in determining the chance of developing heart
diseases. If people do not learn how to prevent it
themselves, coronary artery disease will remain as the
single biggest killer in the world, by far. 

Bibliography:
 
Amsterdam, Ezra A. and Ann M. Holms. Take Care Of Your
Heart. New York: Facts on File, 1984. 
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