Health-related Topics : Sudden Cardiac Death Prevention

Dr. James Manos (MD)

January 22, 2016

Prevention of sudden cardiac death (SCD)

‘Prevention is better than cure’ (Hippocrates, ancient Greek doctor – the father of Western medicine, 460 – 370 B.C.)

Note: in this text, the writer expresses his point of view. Some advice is empirical, so you should consult your family doctor beforehand.

Prevention of sudden cardiac arrest (SDA) – sudden cardiac death (SCD)

· Sudden cardiac death (SCD) from cardiac arrest is the most common cause of death worldwide, accounting for more than 50% of all deaths from cardiovascular disease. SCD results in about 250,000 to 300,000 deaths annually in the USA. SCD is characterized by unexpected cardiovascular collapse due to an underlying cardiovascular cause. Most episodes occur in people without a previously known cardiac disease. As most individuals experiencing SCD currently are not identified as being at high risk, community-based public access to defibrillation programs is essential to save lives and improve neurological and functional outcomes for cardiac arrest victims. Although there has been a recent decline in the incidence of SCD, paralleling the decline in the decrease in cardiovascular mortality, the burden of SCD remains substantial. On average, only 8% of those receiving community-based resuscitation are discharged from the hospital alive.

· Ventricular fibrillation (VF) is the mechanism underlying most sudden cardiac arrest episodes. VF is a chaotic heart rhythm that results in a loss of circulation and oxygen delivery to the body tissues. The only effective treatment to reverse VF to a normal heart rhythm is defibrillation (electric shock to the heart). However, defibrillation must be provided early. If left untreated for approximately 10 minutes, this condition will result in irreversible brain death. Survival declined by about 10% per minute for patients in ventricular fibrillation. This underscores the critical importance of early and definitive intervention with defibrillation. Other cardiac tachycardias (including pulseless VT (ventricular tachycardia), bradycardias, or pulseless electric activity can also result in cessation of cardiac mechanical activity with the absence of signs of circulation (cardiac arrest). Other causes of SCD include stroke, pulmonary embolism, aortic rupture, and other non-cardiac causes.

· Cardiac arrest typically arises suddenly in an individual with the appropriate anatomic or electrophysiological substrate without an identifiable trigger. The pathophysiology of SCD includes an abnormal myocardial substrate and transient factors that trigger cardiac arrest. However, in most instances, a clinical trigger cannot be identified. There has been a notable decrease in the incidence of cardiac arrest from ventricular fibrillation recently. Multiple factors likely contribute to this decline, including improvements in preventing sudden death and cardiovascular disease and community approaches to resuscitation and care after an out-of-hospital cardiac arrest.

· Most of these deaths are caused by initiating an abnormal heart rhythm called ventricular fibrillation. Sudden cardiac arrest is indiscriminate as to age, race, or gender. Victims of SCA may never experience any warning signs. A sudden cardiac arrest is not to be mistaken for a heart attack (myocardial infarction) that occurs when a blockage in a blood vessel interrupts the flow of oxygen-rich blood to the heart, causing the heart muscle to die. With a heart attack, the heart usually does not suddenly stop beating, although a heart attack can lead to a sudden cardiac arrest.

Symptoms of sudden cardiac arrest (SCA)

· Sudden cardiac arrest typically occurs without warning. Signs of SCA include sudden collapse, loss of consciousness, cessation of normal breathing, and loss of pulse and blood pressure.

Risk Factors for sudden cardiac arrest (SCA)

· Early detection is crucial for children and adults. It is essential to be aware of the risk factors for SCA, which include:

A family history of coronary artery disease (CAD)
Smoking
Hypertension (high blood pressure)
Dyslipidemia (high blood cholesterol)
Obesity
Diabetes mellitus
A sedentary lifestyle/ lack of exercise
Drinking too much alcohol (more than one to two drinks a day)
A previous episode of cardiac arrest or a family history of cardiac arrest
A previous myocardial infarction (heart attack)
A personal or family history of other forms of heart disease, such as heart rhythm disorders, congenital heart defects, heart failure, and cardiomyopathy
Age: the incidence of sudden cardiac arrest increases with age, especially after age 45 for men and age 55 for women
Being male: men are two to three times more likely to experience sudden cardiac arrest.
Drug abuse
Early Diagnosis and Screening

People at risk for sudden cardiac arrest (SCA), including SCA survivors, may benefit from the following tests:

Electrocardiogram (ECG)
Blood tests (e.g., cardiac enzyme, electrolyte, drug, hormone)
Imaging tests (e.g., chest X-ray, nuclear scan, echocardiogram)
Electrophysiological (EP) testing and mapping
Ejection fraction (EF) testing using magnetic resonance imaging (MRI), a nuclear medicine scan, or a computerized tomography (CT) scan
Coronary catheterization or angiogram.

Recommendations for dealing with emergencies, including cardiac arrest, in the hospital (blue code & Emergency Medical Team (EMT)) and in the community (Emergency Medical Service (EMS)

· Basic life support (BLS) courses in hospitals and in the community on CPR (Cardiopulmonary resuscitation) and the use of an AEA (automated external defibrillator) for a cardiac arrest & the Heimlich maneuver for choking

· Also, the ambulance system (EMS) should organize seminars/ courses for citizens in - BLS (Basic Life Support) that involve cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED) on a cardiac arrest, as well as dealing with choking in adults (Heimlich maneuver) and in infants. In these seminars, dummies are used.

Automated external defibrillator (AED)

A way to prevent sudden cardiac death is by using an automated external defibrillator (AED). AEDs are often found in public places and places of business, such as sports arenas, airports, and grocery stores. These are extremely useful for individuals with sudden cardiac arrest. If a person suffers a sudden cardiac arrest, a quick-acting good Samaritan could use one of these devices to rapidly restore a heartbeat. AEDs are designed for use by laypeople and have been credited with saving thousands of lives.
In the community, at crucial points, i.e. that are crowded, e.g., in museums, airports, shopping centers, and other crowded places, automated external defibrillators (AEDs) need to be placed.

Basic life support (BLS) courses in hospitals and in the community on CPR (Cardiopulmonary resuscitation) and the use of an AEA (automated external defibrillator) for a cardiac arrest & the Heimlich maneuver for choking

The ambulance system (EMS) should organize seminars/ courses for citizens in - BLS (Basic Life Support) that involve cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED) on a cardiac arrest, as well as dealing with choking in adults (Heimlich maneuver) and in infants. In these seminars, dummies are used.

Emergency medicine seminars/ courses for doctors and nurses working in a hospital

It is necessary to train all medical and nursing hospital personnel and health centers in BLS (Basic Life Support), including cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED), as well as the treatment of choking in adults (Heimlich maneuver) and infants. In all hospital clinics, an automated external defibrillator and type 'Ambu' mask (bag mask) with reservoir should be available in an emergency, including a cardiac arrest. Health professionals (including doctors and nurses) must know how to use them. The training with courses and seminars can be organized by the ambulance system (EMS) and/or the hospital's anesthesiology department.
The basic life support (BLS) seminar should strictly be mandatory for all hospitals and health centers' medical and nursing staff.
All medical and nursing staff should do at least annual seminars on Basic Life Support (BLS) and become familiar with the use of an automated external defibrillator (AED; heart ‘shock’ device) to know how to deal with a cardiac arrest in or out of the hospital until the Emergency Medical Team (EMT) arrives to perform advanced life support (ALS).
Hospitals and health centers should organize these annual seminars and courses for all medical and nursing staff. The medical and nursing staff should also be able to provide rescue breaths with an ‘Ambu’ type bag valve mask (for bag-mask ventilation, BMV) with a reservoir (which may be connected with oxygen supply) or a simple face mask. The oropharyngeal airway may prevent the tongue from obstructing the airway and keep the airway patient. The immobilization of the neck is required for suspected cervical injuries. Also, emergency oxygen needs to be given with a special mask with a reservoir bag (to give more than 30% oxygen, which gives a simple mask). The ‘Venturi-type oxygen mask is used for administrating a specific percentage of oxygen.
Courses and seminars on emergencies are necessary for staff (doctors and nurses) working in the emergency department (ED) in hospitals and district health centers to become familiar with resuscitation equipment and medications and know all the algorithms for resuscitation.

Emergency medicine seminars/ courses for emergency department (ED) doctors and nurses

The ER (emergency room) of hospitals and health centers should regularly organize seminars for resuscitation of emergencies such as endotracheal (ET) intubation, laryngeal mask placement, ventilation with bag-mask with reservoir, defibrillation in arrest, cardioversion of life-threatening tachyarrhythmias, treatment of severe bradycardia, heart attack, and stroke diagnosis, immobilization of injured, ABCDEs assessment on trauma, etc. The emergency seminars should involve adults (seminars ALS, ACLS), children (seminars APLS, EPLS), and trauma (seminars ATLS, PHTLS, and ATCN for nurses). The training may include all of these, and not only, for example, adults.

Emergency medicine seminars list

The official emergency medicine courses are:

• BLS (Basic Life Support) for all doctors and nurses. This seminar also applies to the public. It includes cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED), as well as the treatment of choking in adults (Heimlich maneuver) and infants.

• ALS (Advanced Life Support) / ACLS (Advanced Cardiac Life Support) and AMLS (Advanced Medical Life Support) for doctors dealing with emergencies (such as emergency and acute medicine doctors) and nurses involved in emergencies.
• Airway, ECG (electrocardiogram) & pharmacology (drug administration) courses are additional courses for emergencies.

• GEMS (Geriatric Education for Emergency Medical Services) for geriatric (elderly) patients (most of the patients in hospitals).

• APLS (Advanced Pediatric Life Support) / EPLS (European Pediatric Life Support), NLS (Neonatal / Newborn Life Support) for emergency medicine doctors, pediatricians, and nurses involved in emergencies on children. Notably, in many medical facilities, there are no specialized emergency rooms and specialists, emergency pediatricians, for children, but an emergency medicine doctor treats pediatric cases in addition to adults. There is also a course called ALS (Advanced Life Support) – PEPP (Pediatric Education for Pre-hospital Professionals) for prehospital professionals.

• ATLS (Advanced Trauma Life Support), ETC (European Trauma Course), and ATT (Assessment & Treatment of Trauma) for those dealing with trauma.

• ATCN (advanced trauma care for nurses) for nurses occupied with trauma.

• PHTLS (Pre-Hospital Trauma Life Support) for ambulance rescuers (paramedics).

• ALSO (Advanced Life Support in Obstetrics) for obstetricians and those involved in emergencies that may face obstetric emergencies.

As mentioned, hospitals and health centers' ED (emergency department) should regularly organize seminars/ courses for resuscitation in emergencies based on the above seminars.

These seminars must be repeated after at least four years (but can be repeated earlier). However, lessons based on these seminars may be organized frequently in the hospital. The medical and nursing staff involved in the emergencies should be familiar with all the emergency seminars.
Courses and seminars on emergency medicine must be held in all hospitals and health centers regularly by senior doctors in the form of practical workshops (rather than theoretical courses) that can be based on the seminars mentioned above (BLS, ALS / ACLS, ATLS, PHTLS, APLS, EPLS, ALSO, NLS), and various emergency scenarios with models and monitors, so emergencies to be taught practically (intubation, defibrillation, immobilization of injured on board, etc.).
The basic life support (BLS) seminar should strictly be mandatory for all hospitals and health centers' medical and nursing staff.

· The emergency medical team (EMT) in the hospital and the blue code for calling them

· The resuscitation team is essential for immediately treating a cardiac arrest in the hospital. But its role is also preventive by resuscitating the acute exacerbation of a patient before this end in cardiac arrest. The team consists of doctors and nurses and has at least 5-members: the 1^st is the team – leader and coordinates the rest; the 2^nd performs defibrillation; the 3^rd deals with intravenous (IV) access and administers IV medicines; the 4^th person performs heart compressions; finally, the 5^th one conducts intubation (usually endotracheal, but if not experienced then he/she may use a laryngeal mask) and gives rescue breaths with bag-mask ventilation connected with the endotracheal tube.

· The person doing chest compressions should be changed every 2 minutes to achieve superior quality chest compressions (which are not performed correctly if the rescuer gets tired). The role of the team leader is essential. If there is no team leader, everyone does whatever he/she wants, and there is a mess (as occurs in developing countries). The resuscitation team acts as the word says, as a group (teamwork).

· At the same time, a reversible cause of arrest should often be addressed. Otherwise, the patient may lose his/her life from reversible causes such as the 6 ‘T’s [Tension pneumothorax, cardiac Tamponade, poisoning - Toxins/tablets, coronary Thrombosis (myocardial infarction, i.e., heart attack), pulmonary Thrombosis/ thromboembolism (pulmonary embolism) and Trauma] and the 6 ‘H’s [Hypoxia, Hydrogen ion (acidosis), Hypovolemia (including bleeding & severe dehydration), Hyper/hypokalemia, Hypoglycemia, and Hypothermia (also other metabolic causes such as hypomagnesemia that may lead to Torsades de pointes, a severe dysrhythmia, need to be excluded)].

· In the emergency department and wards, there must be a special alarm button and a loudspeaker in case of an emergency (such as a cardiac arrest) for the resuscitation emergency medical team (EMT) to be alerted and summoned to the scene of the emergency. This is the ‘blue code.’ When the loudspeaker announces the blue code in a particular room of the chamber or in the emergency department, the resuscitation team (which every day must be specific, ‘on call,’ and immediately ready if called) should be gathered quickly at the point of the emergency. For an immediate emergency call, all the doctors in the country's hospitals should have pagers (beepers) to be immediately summoned.

· The preventive role of the emergency medical team (EMT)

· As mentioned above, the role of the Emergency Medical Team (EMT) may also be preventive by resuscitating the acute exacerbation of a patient before this ends in a cardiac arrest.

· Rapid sequence induction & intubation in the hospital & medical center

· Emergency intubation with induction medications should be taught to those involved in emergencies with seminars, such as ALS (advanced life support) that the hospital needs to organize for the health professionals dealing with emergencies, particularly in the emergency department, but also on the medical and nursing personnel in wards where a cardiac arrest is possible, e.g., at a general medicine or surgical ward. The anesthesiology team of the hospital may also hold rapid sequence induction & intubation courses.

· Emergencies in the district or rural medical centers

· All rural or district or rural medical centers' emergency departments (EDs) should occupy emergency medicine doctors and trauma surgeons. They should be covered 24/7 by senior doctors and an adequate number of nurses experienced in emergency medicine. Of course, the ED must have all the necessary resuscitation equipment and medications.

· Organizing the emergency rooms (ERs) of the hospitals and medical centers with skilled emergency medicine doctors & trauma surgeons

· Skilled emergency medicine doctors in the ERs

· Junior and unskilled specializing/ resident/ intern doctors and rural doctors should not cover the emergency department without supervision. Junior doctors do not have the skills to deal with emergencies but need a senior doctor (registrar, consultant) to guide them. In the community, the GPs (General Practitioners) deal with outpatient cases and relieve the emergency department (ED) from congestion.

· The necessary medical equipment for dealing with emergencies

· It is also necessary for the emergency room (ER) of hospitals and health centers to be equipped with modern equipment, such as emergency ultrasound (FAST, which helps quickly diagnose internal bleeding and also helps to illustrate the pericardiocentesis in case of cardiac tamponade), portable radiology machines (e.g., for X – Rays), modern heart monitors, defibrillators capable also for transcutaneous pacing, specific kits for thoracotomy/thoracostomy (with chest tubes) pericardiocentesis kit, cricothyroidotomy kit, tracheostomy kit, vascular access with the Seldinger method (which can be assisted by ultrasound imaging, e.g., on jugular vein), etc.

· Furthermore, especially in trauma and other surgical emergencies, emergency surgery should be performed (but it should be better not to be delayed more than 30 min after the trauma patient’s arrival).

· ‘On call’ doctors

· All doctors in the hospitals, especially the ‘on call’ doctors, need beepers (pagers) to be notified immediately in case of an emergency. For this purpose, the doctors can also be called by loudspeakers (in many hospitals, there are no loudspeakers). In all hospital wards, there should be a specific alarm button (blue code) to call and gather the resuscitation team in case of a medical emergency.

Prevention of Sudden Cardiac Arrest (SCA)

Recommendations for people who have survived Sudden Cardiac Arrest (SCA)

People who have already had an SCA are at elevated risk of having it again. Research shows that an implantable cardioverter-defibrillator (ICD) reduces the chances of dying from a second SCA. An ICD is surgically placed under the skin in the chest or abdomen. The device has wires with electrodes on the ends that connect to the heart's chambers (ventricles). The ICD monitors the heartbeat. If the ICD detects a dangerous heart rhythm, it gives an electric shock to restore the heart's normal rhythm. A doctor may prescribe a medicine to limit irregular heartbeats that can trigger an ICD. They're often used to treat less dangerous heart rhythms, such as those in the heart's upper chambers. Most new ICDs work as both pacemakers and ICDs.

People at High Risk for a First Sudden Cardiac Arrest

People with severe coronary heart disease (CHD) are at increased risk for SCA. This is especially true if someone recently suffered a myocardial infarction (MI; heart attack). A doctor may prescribe an antiarrhythmic medicine called a beta-blocker to help lower the risk for SCA. The doctor also may discuss beginning statin treatment if someone has an elevated risk of developing heart disease or having a stroke. Doctors usually prescribe statins (cholesterol-lowering agents) for people who have diabetes mellitus (elevated blood sugar), heart disease or had a prior stroke, and high LDL-cholesterol (also known as bad cholesterol) levels. A doctor also may prescribe other medications to decrease your chance of having a heart attack or dying suddenly, lower blood pressure (BP), prevent blood clots, which can lead to heart attack or stroke, avoid or delay the need for a procedure or surgery, such as angioplasty or coronary artery bypass grafting; reduce the heart’s workload and relieve coronary heart disease symptoms. Other treatments for coronary heart disease, such as percutaneous coronary intervention (PCI, also known as coronary angioplasty) or coronary artery bypass grafting (CABG), may also lower the risk for SCA. A doctor also may recommend an implantable cardioverter-defibrillator (ICD) if someone is at elevated risk for SCA.

Radiofrequency ablation

In some cases of sudden cardiac arrest, complete heart stoppage is preceded by a dangerous arrhythmia or abnormal heartbeating. With electrophysiology studies, cardiologists can sometimes identify an abnormal electrical pathway in the heart and burn the heart tissue in that area by radiofrequency catheter ablation (RFA). This prevents the abnormal electrical pathway from causing arrhythmias and reduces the risk of sudden cardiac death. This treatment involves the insertion of a catheter through the venous system into the right ventricle. Then, the pathway causing arrhythmias can be identified by electrical mapping. Finally, this aberrant electrical pathway is zapped, reducing the risk of future arrhythmias. This has successfully treated Wolf – Parkinson – White (WPW) disease and many other arrhythmias.

Antiarrhythmic drugs

Numerous pharmaceutical drugs have proven benefits against arrhythmias that can lead to sudden cardiac death. These drugs regulate ion channels or nerve stimulation of the heart. Precisely, they control sodium, potassium, and calcium channels and block sympathetic heart stimulation. Different medications work better for distinct types of arrhythmias. A cardiologist can only determine the right medication based on an individual's unique risk factors.

Prevention of sudden cardiac arrest (SCA)

For people who have no Known risk factors for Sudden Cardiac Arrest

CAD (coronary artery disease) causes most SCAs in adults. CHD is also a significant risk factor for angina pectoris (chest pain or discomfort) and heart attack, contributing to other heart problems.

A healthy lifestyle can help lower the risk of CAD, SCA, and other heart problems. A heart-healthy lifestyle includes heart-healthy eating, maintaining a healthy weight, managing stress, physical activity, and quitting smoking.

Heart-healthy eating

Heart-healthy eating is an essential part of a heart-healthy lifestyle. Heart-healthy eating should include the following:

· Fat-free or low-fat dairy products, such as skim milk

· Fish high in omega-3 fatty acids, such as salmon, tuna, and trout, about twice a week

· Fruits, such as apples, bananas, oranges, pears, and prunes

· Legumes, such as kidney beans, lentils, chickpeas, black-eyed peas, and lima beans

· Vegetables, such as broccoli, cabbage, and carrots

· Whole grains, such as oatmeal, brown rice, and corn tortillas

For a heart-healthy diet, people should avoid eating the following:

· A lot of red meat

· Palm and coconut oils

· Sugary foods and beverages

Diets that make blood cholesterol levels rise and should be avoided are:

Saturated fat (found mostly in foods that come from animals).

Trans fat (trans fatty acids) is found in foods made with hydrogenated oils and fats, such as stick margarine; baked goods, such as cookies, cakes, and pies; crackers; frostings; and coffee creamers. Some trans fats also occur naturally in animal fats and meats.

Saturated fat raises blood cholesterol more than anything else in the diet. When someone follows a heart-healthy eating plan, only 5% to 6% of their daily calories should come from saturated fat. Food labels list the amounts of saturated fat. Some advice includes:

Monounsaturated and polyunsaturated fats help lower blood cholesterol levels. Some sources of monounsaturated and polyunsaturated fats are avocados, corn, sunflower oil, soybean oil, nuts, and seeds (such as walnuts), olive, canola, peanut, safflower, and sesame oils, salmon and trout, and tofu.

Low sodium (Na⁺) diet

People should limit the amount of sodium they eat, choosing and preparing foods that are lower in salt and sodium. Using low-sodium and avoid salt foods and seasonings at the table or while cooking is advised. Food labels tell what someone needs to know about choosing lower-sodium foods. People should try to eat no more than 1,500 milligrams of sodium daily. If someone has hypertension (high blood pressure), he/she may need to restrict sodium intake even more.

Hypertensive people should have a low-sodium diet and avoid salt. They should remember that all processed & restaurant food has salt (and sugar) added! This accounts for 75% of our sodium intake!

Excessive salt also increases blood pressure, so a restricted salt intake applies to everyone, not only the hypertensive.

A low-sodium diet is especially important for salt-sensitive hypertension.

People should eat less than half a teaspoon of salt daily and do not forget that salt (and sugar) is added to all processed and restaurant food.

Primary hypertension (formerly called "essential" hypertension) is seen primarily in societies with average sodium intakes above 100 meq/day (2.3 g sodium); however, it is rare in societies with average sodium intakes of less than 50 meq/day (1.2 g sodium). Reducing salt intake from 170 to 100 meq/day lowers the mean blood pressure (BP) in normotensive (with normal blood pressure) adults by approximately 2/1 mmHg and in hypertensive adults by 5/3 mmHg. However, over the course of 30 years, the fall in BP may be more significant, in part because salt restriction minimizes the expected rise in BP associated with aging (because of arteriosclerosis (hardening of the arteries)) (1).

The American Heart Association recommends consuming less than 1,500 mg of sodium daily. 1/4 teaspoon of salt has 575 mg of sodium; 1/2 teaspoon contains 1,150 mg of sodium; 3/4 teaspoon contains 1,725 mg of sodium; and one teaspoon of salt has 2,300 mg of sodium.

Table salt combines two minerals: sodium (Na⁺) and chloride (Cl^-). Table salt is approximately 40% sodium and 60% chloride by weight. About 90% of Americans’ sodium intake comes from sodium chloride.

Someone can find the amount of sodium in packaged food sold in stores by looking at the Nutrition Facts label. The amount of sodium per serving is listed in milligrams (mg). The sodium content of packaged and prepared foods can vary widely. Check the labels to help you achieve the American Heart Association’s recommendation of 1,500 mg a day.

Ninety percent of American adults are expected to develop high blood pressure in their lifetimes, and overeating sodium is strongly linked to the development of high blood pressure. If the U.S. population moved to an average intake of 1,500 mg/day sodium from its current level, it could result in a 25.6% overall decrease in blood pressure and an estimated $26.2 billion in health care savings. Achieving this goal would reduce deaths from CVD by anywhere from 500,000 to nearly 1.2 million over the next 10 years (2), (3).

To track the sodium in food, you may check the American Heart Association (AHA) article Sodium sources: Where does all that sodium come from?

The recommendation for less than 1,500 mg of sodium daily does not apply to people who lose significant amounts of sodium in sweat, such as competitive athletes and workers exposed to extreme heat stress (for example, foundry workers and firefighters), or to those directed otherwise by their healthcare provider (3).

During a hot day in summer or strenuous physical exercise, we need extra salt, water, and carbohydrates (sugar) to avoid dehydration and electrolyte imbalance that may be life-threatening.

Salt also has iodine as an additive necessary for the thyroid gland. Its deficiency in children may cause cretinism, a severe mental disease. We can’t live with zero salt. However, as mentioned above, salt is added to all processed food.

Dietary approaches for hypertension (high blood pressure)

See also above about salt restriction.

A doctor may recommend dietary approaches to stop hypertension (DASH) eating plans for people with high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart-healthy and low in fat, cholesterol, sodium, and salt. The DASH eating plan is an excellent heart-healthy eating plan, even for those who don’t have high blood pressure.

DASH is a flexible and balanced eating plan that helps create a heart-healthy lifestyle. This plan recommends:

· Eating vegetables, fruits, and whole grains

· Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils

· Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils

· Limiting sugar-sweetened beverages and sweets.

DASH eating plan targets a 2,000-calorie-a-day diet.

DASH diet recommends a maximum of 2,300 mg sodium daily. However, it encourages lower doses and mentions that 1,500 milligrams (mg) of sodium lowers blood pressure even further than 2,300 mg daily.

When following the DASH eating plan, it is important to choose foods that are:

· Low in saturated and trans fats

· Rich in potassium, calcium, magnesium, fiber, and protein

· Lower in sodium.

Limiting alcohol intake

People should limit their alcohol intake. Too much alcohol can raise blood pressure (BP) and triglyceride levels (fat in the blood). Alcohol also adds extra calories, which may cause weight gain. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. One drink is:

· Twelve ounces of beer

· Five ounces of wine

· 1½ ounces of liquor

· Maintaining a healthy weight

· Maintaining a healthy weight is vital for overall health and can lower the risk of sudden cardiac arrest. People should aim for a healthy weight by following a heart-healthy eating plan and keeping physically active. Knowing body mass index (BMI) helps people determine if they have a healthy weight concerning their height and gives an estimate of total body fat.

· The body mass index (BMI) is derived from an individual's mass (weight) and height. BMI is defined as the body mass divided by the square of the body height and is universally expressed in units of kg/m², resulting from the mass in kilograms and height in meters.

· For a BMI calculator, go to http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm

· A BMI:

· Below 18.5 is a sign that someone is underweight

· Between 18.5 and 24.9 is in the normal range

· Between 25.0 and 29.9 is considered overweight

· Of 30.0 or higher is deemed to be obese

· A general goal is a BMI of less than 25.

· Measuring waist circumference helps screen for health risks. If most of the fat is around the waist rather than at the hips, then the person is at a higher risk for heart disease and type 2 diabetes mellitus. This risk may be higher with a waist size greater than thirty-five inches (88.9 cm) for women or greater than forty inches (101.6 cm) for men.

· If someone is overweight or obese, he/she should try to lose weight. Losing just 3 – 5 % of someone’s current weight can lower his triglycerides (fats in the blood), blood glucose, and the risk of developing type 2 diabetes mellitus. Higher amounts of weight loss can improve blood pressure (BP) readings, lower LDL – cholesterol (‘bad’ cholesterol) and increase HDL (‘good’) cholesterol.

· Managing Stress

· Managing stress, relaxing, and coping effectively with problems can improve emotional and physical health. Healthy stress-reducing activities, such as:

· A stress management program

· Meditation

· Physical activity

· Relaxation therapy

· Hanging out with friends or family

· Regular physical activity

· Regular physical activity can lower the risk of coronary heart disease (CHD), sudden cardiac arrest (SCA), and other health problems. Everyone should try to participate in moderate-intensity aerobic exercise for at least 2 hours and 30 minutes per week or vigorous aerobic exercise for 1 hour and 15 minutes per week. Aerobic exercise, such as brisk walking, is when the heart beats faster, and the body uses more oxygen than usual. The more active someone is, the more he/she will benefit. People should participate in aerobic exercise for at least 10 minutes at a time spread throughout the week.

· People should talk to their doctor before starting a new exercise plan and ask their doctor how much and what kinds of physical activity are safe for them.

· Quit Smoking

· People who smoke are more likely to have a heart attack than people who don’t smoke. The risk of a heart attack increases with the number of daily cigarettes. Smoking also raises your risk for stroke and lung diseases, such as chronic obstructive pulmonary disease (COPD) and lung cancer.

· Quitting smoking can significantly reduce the risk of heart and lung diseases. Smokers should ask their doctor about programs and products to help them quit smoking. Also, they should try to avoid secondhand smoke. If someone has trouble quitting smoking on his/her own, he/she may consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking.

Thanks for reading!

Reference

Bibliography & External Links

Bibliography

· Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

· Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.

· Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

· Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw–Hill LANGE, 6th edition, 2008.

· Disease prevention & health maintenance, p. 1103 – 1130, Harrison’s Manual of Medicine, Fauci A.S., Braunwald E.B., Kasper D.L., Hauser S.L., Longo D.L., Jameson J.L., Loscalzo J., 17th edition, Mc Graw Hill Medical, 2009.
McGraw-hillmedical.com

· Screening in the future, p. 160 – 161, Oxford Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick, 2nd edition, Oxford University Press,2005.
www.oup.com

Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J.L., Loscalzo J.L., Harrison’s Manual of Medicine, 18^th edition, McGraw–Hill, 2013.

Longmore M., Wilkinson I.B., Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, 8^th edition, Oxford University Press, 2010.

Ahmed N., Clinical Biochemistry, Oxford University Press, 2010.

Reference – Links

(Retrieved: January 20, 2016):

· http://www.nhlbi.nih.gov/health/health-topics/topics/scda/prevention

· http://www.webmd.com/men/guide/heart-attack-cardiac-arrest

· http://circ.ahajournals.org/content/124/5/651.full

· http://www.la12.org/AboutUs/SuddenCardiacArrest/PreventionOfSuddenCardiacArrestSca.aspx

· http://www.tn.gov/health/topic/sudden-cardiac-arrest-prevention-act

· http://www.chp.edu/our-services/heart/health-care-professionals/sudden-cardiac-arrest-prevention-act

· http://www.la12.org/AboutUs/SuddenCardiacArrest.aspx