A Heart Case

In most heart-attack cases the first ‘golden hour’ is lost in chaos, traffic, or wrong diagnosis. In last two decades Kashmir has seen a surge in such cases. Saima Bhat reports how the norm is shifting as almost all cases fall under 45 years age now

Cath Lab at Khyber Medical Institute, Khayam Srinagar

On February 21, Tariq Ahmad Dar, 27, who was working in Goa as salesman died of cardiac arrest. It was shocking for his friends in Goa and family back in Kashmir as he had never complained of any health problems.

“He was too young to die of a heart attack,” says Mohammad Ra-fiq, the owner of handicrafts shop, who is still in shock and was not able to share further details.

Rafiq’s cousin Kaiser Ahmad told Kashmir Life that Dar had no health problems neither he used to smoke nor drink.

“He had talked to some of his friends before sleeping but no one among them said if Dar had complained of anything.”

But in case of Nisar Ahmad Wani, 39, a police official, he complained of pain in his shoulders before he died of heart attack. Otherwise he had no health ailments, says his wife.

A day before his death, Wani had gone to attend his school friend’s funeral in Batamaloo, who died of kidney failure. His sudden death had turned Wani sad.

“He came late that day. Once home he preferred to sleep,” says Wani’s wife. Wani is survived by his wife, a son, who recently passed his Class 10 exams and a daughter who is in Class 7.

Next day Wani woke up as per his normal schedule and went for fajar prayers. But that day he didn’t get the bread from a local baker. “Once home he complained of pain in his shoulders. I thought it must be because of cold so I wrapped his neck and shoulders in a blanket. Within five minutes, he started sweating and I called a neighbour for help who took him to SMHS hospital. But doctor’s declared him brought dead,” says Wani’s wife. “He died of heart attack.”

As per the details available at SMHS hospital, since December-January 2017, the hospital has received at least 12 heart attack patients in every 24 hour. And in the month of February they re-ceived 7 patients in every 24 hour.

Five percent of the patients could not be saved because of late presentation at hospital.

Dr Irfan Ahmad Bhat, a DM in cardiology, who is presently work-ing at SMHS, says ‘earlier they used to receive heart attack pa-tient of above 45 years age, but now all of them are below 45.

As per inter-heart study done worldwide, researchers have found factors that could lead to cardiac arrests were elderly age, family history, smoking, bad cholesterol or diabetes or hypertension, al-coholic, less physical activities, psychosocial effects and people taking less fruits and vegetables.

But now the age group has shifted to below 45 with many pa-tients having coronary problems by birth, high cholesterol and thrombosis (formation of blood clots inside blood vessels).

Other than these genetic problems, Dr Irfan blames sedentary life style, excessive smoking, psycho-social stress (which is maximum in Kashmir) and unemployment for the heart attack in young generation.

The symptoms of heart attack are severe chest pain, shortness of breath, unconsciousness, with sweating, and sensation of doom. Diabetes patients don’t get severe heart pain in heart attack but they have shortness of breath, or abnormal pulse rate.

“In Kashmir, 90 percent of heart attacks happen because of stress. First it happened because of floods, earthquakes, strikes and then because of demonetisation,” says Dr Irfan, who treated most of the patients brought to SMHS hospital.

Rehana Begum, 60, a housewife from Banihal was lucky to sur-vive a cardiac arrest in 2015. Apart from being hypertensive pa-tient for which she took medication, there was no other medical issue.

That night, Rehana says, pain started at 8:30 pm, when she was alone in her room. Her husband and two sons were watching TV in other room. “Pain was scattered in chest and in left arm but exactly after an hour, I was unconscious. My husband came in room and switched off lights. I couldn’t tell him anything but I was sensing everything. I was sweating,” says Rehana.

Her husband Mohammad Asgar Mir, who is a retired headmaster, woke up before fajar prayers and found his wife missing. “When I found her in attic, she was crying and said it could be heart attack because her father also died of same problem,” says Mir, who without giving it a second thought reached Islamabad where his family doctor was waiting for them. And it is around 100 kms away from Srinagar.

After ECG, doctors advised them to straightaway drive to SKIMS hospital but Mir was reluctant to go there. He was not sure if government hospitals could save his wife so he decided to go for a private hospital.

“Whosoever taken to government hospitals in Srinagar from Ba-nihal never returned home alive. One of our relative was just 35, doctors couldn’t diagnose that it was a heart attack and he too died.”

Mir says on way to the private hospital, his doctor was conti-nuously on call. He had given them three tablets just precautio-nary, if they get stuck in a traffic jam.

At hospital, after 45 minutes, at around 10 am, Mir was called and shown the pre and post angioplasty-primary PCI, condition of Rehana’s heart. Primary PCI consists of urgent balloon angioplasty (with or without stenting) and Rehana survived. But she needed two stents.

Primary angioplasty is life saving, which means opening of artery to remove the block. If it is not opened in time then the patient can die. As per studies done worldwide, in acute Myocardial in-farction (MI), commonly known as a heart attack 25 percent die at home, out of those who reach hospitals, 10 percent die be-cause of no treatment or delayed diagnosis in the hospitals.

With medical therapy, thrombolysis, all patients cannot do well. But primary angioplasty does save hearts and lives as well.

At SKIMS, primary PCIs are done during ‘day time’ only. “No PCIs are done during night at SKIMS. And at SMHS, despite having a lab, it is not done at all,” says Dr Syed Maqbool, a cardiologist, who has worked at both SKIMS and SHMS hospitals.

In 2014, after completing his DM from Delhi, Dr Maqbool came back to Kashmir “to serve his people”. He joined SKIMS, where he started primary PCIs at night. “Doctors are always willing to work but it depends on people who deal with equipments if they are available during night time and the lab staff.”

And Dr Maqbool fondly recalls that during first month they did 60-70 angioplasty surgeries during night time only. He says, oth-erwise patients received in emergency ward were first treated with thrombolysis: treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs.

“If a patient improves, he is discharged, if not then, he is taken for surgery after 24 hours. But I made it a point that such patients should be taken for angioplasty the moment they report to hos-pital,” says Dr Maqbool.

The first hour, ‘golden hour’ is important in medical terminology. And in cardiology ‘time is muscle’ more time a patient takes to reach hospital it means more damage to the muscle of heart. The time from 3 to 6 hours is termed ‘best’ but Dr Maqbool says time up to 12 hours is also beneficial for patients whose pain has not subsided.

“There is subset of patients who can be done later as well, some patient who comes in cardiogenic shock, when heart suddenly can’t pump enough blood to meet body needs. Then pulse rate and blood pressure levels go down and primary angioplasty be-comes needful for such patients to keep them alive,” says Dr Maqbool.

But a medico himself, Dr Riyaz Mohiuddin Wani, who was barely 40, died of heart attack recently. “It happened all of a sudden. Before we could have done anything, he was no more,” says one of his friends.

Despite high prevalence in Kashmir, where stress levels are high-er, the state hospital, SMHS hospital, despite having Cathlab since last seven years now, “Angioplasty is not done. We just go for rescue PCIs. No surgical backup is available so we can’t take risk,” says a post graduate doctor, wishing anonymity, who has worked at SMHS hospital.

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