What You Must Know About Your Heart Before It's Too Late

By Jay A. Levine M.D.

In this volume, Dr. Jay Levine takes the reader on a guided tour of the mysteries of the cardiovascular system, how it functions in health and in sickness, and what the reader must be aware of to improve his or her chances of ongoing good health. Problems are identified, and treatment options are discussed simply and easily without resorting to medically complex jargon in order to alert the reader to what could go wrong and what can be done to correct the problems. In the current era of internet medicine and television and cell phone medical examinations, it has never been more important for the patient to learn what could possibly go wrong with the body.
Using easily understood lay terminology, this book describes how the anatomy, normal function, disease abnormalities, and therapeutic approaches are all interrelated in this magnificent machine called the heart. The volume reads like a novel with one chapter gliding smoothly into the next so that the reader gains a deep understanding of a process that has fascinated and confounded physicians for ages. Welcome aboard your trip through the cardiovascular system.

• Language: English
• Publisher: Xlibris US
• Release date: Oct 6, 2021
• ISBN: 9781664110441

Jay A. Levine M.D.

Dr. Jay A. Levine received his M.D. degree from New York University School of Medicine in 1966. After training in cardiology in New York and Boston he moved to the greater Miami, Florida area where he practiced adult cardiovascular medicine for over forty years. He is board certified in medicine and cardiology and has fellowships in the American College of Physicians, FACP, the American College of Cardiology, FACC, American College of Chest Physicians, FACC, and was awarded fellowship in the American Heart Association, FAHA. Besides maintaining an active clinical practice, he was Clinical Professor of Cardiology and then Voluntary Clinical Professor of Cardiology at the University of Miami School of Medicine where he instructed three generations of students and house officers. He was Co-Director of Clinical Cardiology at the Mount Sinai Medical Center in Miami. He is on the Board of Governors of the Alumni Association of the NYU School of Medicine.

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Copyright © 2021 by Jay A. Levine, M.D.

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Rev. date: 10/06/2021

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CONTENTS

Introduction

Chapter 1 The Heart of the Matter

Chapter 2 The Delivery System

Chapter 3 This Is Your Cardiovascular System

Chapter 4 How Do You Feel?

Chapter 5 What Makes You Feel Badly?

Chapter 6 Diabetes and Cholesterol

Chapter 7 The Brain Problem

Chapter 8 Getting the Heartbeat Going

Chapter 9 Are We Regular or Not?

Chapter 10 The Beat is Too Fast

Chapter 11 How The Beat Begins

Chapter 12 The How and Why of Arrhythmia

Chapter 13 Too Fast is Too Fast

Chapter 14 Help!

Chapter 15 How Does The Help Work?

Chapter 16 The Rhythm and The EKG

Chapter 17 Valve Jobs

Chapter 18 Infected Valves

Chapter 19 Valve Abnormalities

Chapter 20 Heart Valve Replacements

Chapter 21 How Plaques and Stenoses Form in Arteries

Chapter 22 How to Determine Location and Severity of Stenoses

Chapter 23 Therapeutic Approaches: Medication and Drug Therapy

Chapter 24 Surgical Approaches to Therapy

Chapter 25 Angioplasty Considerations

Chapter 26 Congenital Heart Defects

Chapter 27 Cardiomyopathy or Primary Heart Muscle Disease

Chapter 28 Heart Failure

Chapter 29 Clots, Thrombi, and Emboli

Chapter 30 Hypertension

Chapter 31 Cardiovascular Aspects of Stroke Disease

Chapter 32 Pericardial Disease

Chapter 33 Aortic and Peripheral Arterial Diseases

Chapter 34 Unstable Coronary Syndromes, Acute Myocardial Infarction, and Alternative Diagnoses

Chapter 35 Ischemic Heart Disease

Chapter 36 Acute Myocardial Infarction

Chapter 37 Treatment of Acute Coronary Syndromes

Chapter 38 Summary

Glossary

This book is dedicated to the many patients who over the

years had confidence in my medical abilities and entrusted

me with the privilege of being their physician.

Introduction

Why are you reading this book? What about heart disease is of interest to you? Do you or any of your loved ones, relatives, or friends have a heart ailment? Is someone that you know taking a heart medicine, or are you in need of heart medicine or a heart procedure that you don’t understand? Don’t understand what is involved or even why it is needed? What is it? What is it all about? Even the answers to these simple questions use words that are foreign, that are difficult to understand. The issues are complicated and confusing. A basic understanding of what is going on is critical in the current era of internet medical care. HERE IS HELP!

This book is intended to explain, in language you can understand, the very complex manner in which the body functions and also what can go wrong when the body does not behave in a normal fashion. When visiting a city for the first time, you may purchase a guide book or even take a guided tour of the city highlights and main attractions. This is your tourist guide book to the important structures and byways of your cardiovascular system, how it works, and what can go wrong with its functions. This volume represents a condensation of thousands of scientific reports; hundreds of textbooks, some of which are over 3,500 pages in length; and a compendium of general medical knowledge gained over a century. In order to compensate for the occasional needed use of what seems to be complex medical terminology, this book is written to present information in a simple, sometimes folksy style to lighten the mood and enhance understanding of some very serious subject matter by the non–medically trained reader.

With over fifty years involved in the hands-on care of patients, listening to their stories, diagnosing their ailments, and trying to correct their medical problems, I have tried to explain some of the most complicated issues in layperson terminology, using words patients can understand and recognize, words concerning the necessary actions and treatments indicated for their ongoing care and well-being. The wording and terminology used throughout this book is as simple as I can make it. Many systems and structures of the body have unique names, most of which have been in use for hundreds of years. Some names are in English, but others are derived from the German, Latin, or Greek languages. In years gone by, these terms often caused confusion, and even dismay, on the part of the patient and family. Unfortunately, in order to understand what something is, where it is, and whether it is normal or abnormal, it is necessary to know some medical terminology. The use of nonmeaningful terms is hopefully avoided. It is my intention to explain this material in a language that you can understand, but not in the form of a comic book or a graphic novel. The discussions are presented in a simplified manner, which has afforded my patients an understanding of complicated situations that have taken physicians more than a century to unravel.

This book should not be used as a textbook of cardiac diseases or as a dictionary of cardiac terminology. It is not an internet article that provides information, which may or may not be related to your own particular medical situation. The book is not like a cookbook for the lay public, filled with recipes for the self-diagnosis and treatment of heart ailments. These decisions should be made only by the patient and his or her designated health care provider. The book is best used as a simple exercise in reading, much as one would read a novel. One segment flows easily into the next since so many of the problems involving cardiovascular disease are clearly interconnected and are without any major separations. This book is intended to be a guided tour through the circulation. And since I am the designated guide, some of the opinions expressed are entirely mine, but are expressed only for explanatory purposes. The information presented reflects what is generally accepted by the community of cardiac medical specialists.

In the current practice of medicine, doctors are extremely hard pressed for time. This never happened before, and certainly not to this degree. Medical problems are often complicated and complex. The potentially dangerous circumstances of many medical conditions require a full explanation and a full understanding of the situation by the patient and their loved ones. The patients have the right to ask questions and to receive understandable answers to their questions. Unfortunately, many doctors may not have the time and may not have even the willingness to explain over and over again, to patient after patient, the same answers to the same questions about the same ailments. It is not unreasonable to understand that if you must explain the same thing to ten or twenty patients every day, day after day, it can become difficult and tiresome. And it becomes worse when friends and caring relatives ask the same questions as well. So it has become much easier for the physician, and unfortunately is now common practice, to give the patient a printed handout that contains a description of some ailment, as well as a list of multiple questions that the patient must answer: Do you have any medical conditions? Do you smoke, and if so, how much? Have you had any previous surgery? Do you have any allergies? Etc.! It is even simpler to have the patient watch a video presentation of what is to be done and what is to be expected. But this only leads to a partial understanding of the patient’s problem. Many unanswered questions remain. And the printed questionnaire, or the video tape, or internet interview may not meet the patient’s psychological or social needs. Do you have difficulty reaching your physician or your physician’s staff to get an answer to a single question after completing your internet reading or finishing your Zoom or Facebook interview?

So with the development of modern, efficient, and accurate computer-based institutionalized medical care and internet medical diagnoses, the patient who is not medically sophisticated is lost in a strange world. And in this new world, the patient may not even know what questions to ask, if he or she is even given the chance to ask anything. This book will hopefully provide you with what you need to know about your cardiovascular health before it’s too late.

Recent statistical analysis suggests that approximately 50% of adult Americans suffer at least one form of cardiovascular disease. From time to time, each and every one of us will have an illness of some type. Most of the time it will be mild, not dangerous, and of short duration. Generally, there will be no long-term effects of the illness, and life will be able to go on without interruption. But occasionally, an illness turns out to be more serious, last longer, and may even have long-term effects that can be troublesome, or even devastating. This is especially true if the ailment is not correctly recognized and identified early on, such that proper care and treatment can be started promptly.

A delay in the identification of an ailment and the start of treatment can, at times, cause severe consequences. For example, a small crack in a bridge or a tiny leak in a dam across a large river could deteriorate with catastrophic results. The bridge could collapse with multiple deaths, or the dam could burst with serious downstream flooding, causing loss of life and property. The human body acts as a machine, much like a bridge or a dam. Individual parts that we call body organs have specific jobs to do and functions to perform. It is the job of engineers and survey inspectors to discover problems with their machinery and to make sure their machines are in working order. If not in working order, they must make prompt corrections to ensure the continued working of their equipment.

When dealing with the human body, the job of inspection, identification, and repair of problems is the responsibility of professionals whom we call physicians. It is the physician’s responsibility to check out the body’s machinery and to make corrections as necessary. Some corrective actions may involve various types of therapy, medication, or even surgery. But unlike the bridge or the dam where the inspectors or engineers visit the site to check on the function and the health of their machines, the human has to go to the physician to get checked out. For proper maintenance, bridges and dams should be evaluated from time to time, even if nothing is known to be wrong. If a defect is found, even at a tiny beginning stage, quick corrective action can often avert tragedy. This requires a constant surveillance program, which is mostly ordered by state or local governmental agencies. And as we all know, and unfortunately have seen, failure to follow these procedures can lead to tragedy.

But people are different. Most people do not get periodic medical checkups, especially if they don’t feel ill. There has always been a general reluctance to go to a physician. There is nothing wrong with me! I feel OK! I am not sick! I don’t have the time! I don’t want to take any medicines! I don’t have the money to pay for doctor visits, medicines, or treatments! I don’t want anybody touching my body! I have religious convictions against medicines, medical practitioners, and the lot! And so since I am not sick, I don’t want to waste my time, spend my money, or do something that is annoying! I feel OK! Instead of seeing a doctor, I could be doing something else that I really want to do or that I must do!

Truth be told, all the above is correct, as long as nothing is wrong or until something crops up that is wrong. Unfortunately, by the time a person comes to realize something is not quite right, a serious problem might have developed. If identified early enough, a baby-sized problem could be corrected with baby-sized actions. But delay often makes things worse. Babies grow up. If not attended to, small-sized problems grow into large-sized problems. And the consequences of delay might turn out to be disastrous. And even a visit to a health care practitioner may not identify a small or silent problem early enough.

The average patient visiting a doctor’s office is presented with a computer printout of 50 to 100 questions about possible conditions and symptoms, which often confuse and confound the issue. Some patients are even prepared for their doctor visit by an e-mail questionnaire. Are you this? Do you have that? What do you have? Do you have anything? There are no fine-line options between a yes and a no answer. I might have this! Perhaps I did have that, but it went away some time ago, and I don’t have it anymore. Or I have it so rarely that I don’t think it is important! And I forgot all about it. What does all this mean to a person who is not particularly medically aware? Are these real complaints, real aches, real pains, real feelings, real sensations, real discomforts, or am I just a neurotic?

The purpose of this book to try to educate the average non–medically trained person as to what things might mean, what to look for in feelings and symptoms, and what might go wrong. This kind of awareness could help to identify a problem before the bridge cracks or before the dam bursts and floods the countryside.

Chapter 1

THE HEART OF THE MATTER

Although no longer considered to be the seat of emotions, the heart still has a central role in the functioning of the body. The heart is the pump that causes the blood to circulate through the body. In turn, the blood delivers food stuffs and removes waste products from all cells in the body. The heart is a pump with four chambers. Two are pumping chambers, and two are basically receiving chambers. The receiving chambers are filled by veins that return blood to the heart. In turn, the two pumping chambers push the blood out of the heart and through arteries to the body. (See fig. 1).

Heart%20Book%20FINAL%20Figure_01.jpg

Figure 1

Actually, the heart has two jobs. One job is to distribute blood to the body through arteries. The other job is to bring blood into the lungs where the blood can pick up needed oxygen. The right side of the heart sends blood to the lungs while the left side sends blood to the body. The arteries take the blood away from the heart to various target organs while the veins return the blood to the heart. The veins from the body connect to the right side of the heart. The right side of the heart distributes blood to the lungs. Veins from the lungs return blood to the left side of the heart from which arteries distribute blood to the body.

The veins are like an upside-down tree. From tiny little channels, tiny capillaries and vessels join to become veins. The veins join up to become bigger vessels. This is just the opposite of what happens when you climb out on to any branch of a tree. On the tree, the further out you go on the branch, the smaller the branches become until you get to twigs. Eventually, you reach the leaves. Returning in the opposite direction toward the tree trunk, the tiny branches get larger as you approach the tree trunk. You can consider the leaves of the tree like the cells of the body. The cells of the body are at the end of the delivery route for blood. The cells are also at the beginning of the route that returns blood to the heart. Like the leaves of the trees, the cells of the body are living and breathing things that are supplied by tiny twigs, which we call capillaries.

Again, going back down the branches of the tree toward the tree trunk, you can see that after leaving the leaves, the twigs begin to get bigger and bigger as they join up with other twigs to form larger and larger branches. And in similar fashion, tiny veins that leave the cells of the body eventually join up to form enormous vessels. These huge vessels are called vena cavae. Normally, there are two large vessels called vena cavae, one from the lower part or the body and one from the upper part of the body. These two large veins join together in a mixing chamber in the right side of the heart. The mixing chamber is called the right atrium. The atrium functions like a large receiving area, or vestibule, in a house.

In the receiving chamber, the blood from the two vena cavae mixes. The blood then moves on to a pumping chamber in the right side of the heart. This pumping chamber is called the right ventricle. In order to enter the right ventricle, the blood must pass through a valve called the tricuspid valve. This is normally a one-way valve. It’s like three french doors hooked up together. Each door is called a cusp. So since the valve has three doors, it is called a tricuspid valve (See fig. 2). The blood that passes through the tricuspid valve enters a squeezing chamber called the right ventricle. This chamber squeezes down and gets smaller, rhythmically, periodically, and forces the blood out into an artery called the pulmonary artery. After the squeeze, the pumping chamber relaxes and returns to its prior larger size as it waits for more blood from the right atrium to fill it so it can squeeze again.

Heart%20Book%20FINAL%20Figure_02.jpg

Figure 2

In order for the blood to be squeezed out of the right ventricle, the blood must pass through another valve called the pulmonic valve. This is also normally a one-way valve. Passage of blood through the pulmonic valve into a large vessel called the pulmonary artery allows the blood to be delivered to the lungs. The pulmonary artery divides into two major branches, one to the right lung and one to the left lung. Each of the two major pulmonary artery branches then divide into many smaller and smaller branches as they distribute blood to the lungs. This arrangement is just like the branches of a tree, which divide into smaller and smaller branches. Finally, the lung vessels are so small that they can be seen only with a microscope. And they are then called pulmonary capillaries. These tiny vessels, pulmonary capillaries, surround tiny air sacs in the lung. You can imagine these tiny air sacs to be like a bunch of grapes. But there are millions of them. And each grape is surrounded by a mesh or network of tiny blood vessels. These tiny grapelike air sacs are called alveoli (See fig. 3).

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Figure 3

As you breathe, air enters the body from the mouth or nose. The air then moves into the larynx in the throat, then to the trachea in the chest from which the air is distributed to progressively smaller tubes called bronchi and bronchioles. From the bronchioles, the air eventually enters the tiny grapelike sacs called alveoli.

Blood returning to the right side of the heart and lungs from the periphery of the body contains waste products. The primary waste product is carbon dioxide, CO2, and it must be eliminated from the body. The alveoli are filled with inspired air. Around the tiny alveoli, blood in the network of capillaries releases carbon dioxide into the air in the sac, much like fumes leave the exhaust pipe of an automobile. In addition, because the cells of the body have been using up oxygen in the process of living, blood returning to the lungs from the body is low in oxygen. In exchange for giving up carbon dioxide, the blood in the capillary meshwork picks up needed oxygen from air, which has been inhaled into the tiny grapelike alveoli. The oxygen is then carried in the blood until it gets to the cells of the body. Here, oxygen is taken up by the cells while the cells release carbon dioxide (CO2) into the passing blood.

But the grapes have stems. If you picture a bunch of grapes and follow the stems, the stems seem to join together and get larger, just like the branches of a tree get larger as you get closer and closer to the trunk. These stems are actually the tubes that carry air into and out of the lungs with each breath. So, when you breathe in, you suck air into these tubes. The air passes down through the tree of tubes into the lungs. The smallest of these tubes go directly to each individual grape, the alveolus. In each grapelike sac, oxygen is transferred from the air contained in the alveolus into the blood flowing in the tiny meshwork of blood vessels surrounding the grape. The blood containing fresh oxygen then passes into larger and larger lung veins. The veins which drain the lungs are called pulmonary veins. The pulmonary veins eventually reach the left atrium. From the left side of the heart, the oxygen contained in the blood is distributed to the body.

The elimination of waste carbon dioxide begins at the alveolus. After being produced by cells in distant parts of the body, carbon dioxide is carried to the tiny blood vessels surrounding the alveolus. At the grapelike alveolus, the carbon dioxide is released from the bloodstream and enters the air in the alveolus. The air in the alveolus now contains waste carbon dioxide. This air with waste carbon dioxide is exhaled, whisked up by tiny tubes into bigger and bigger tubes, until it gets to the throat and mouth. These tiny air tubes are called bronchioles. As you get farther away from the alveoli, the bronchioles change their names to bronchi. Eventually, the bronchi join to form the trachea. The trachea is the huge tube that is in the upper part of the chest and which is connected to the throat and mouth by the larynx, which is in the neck.

Although we have now described several aspects of the breathing process, we should revisit this area to clarify and further enhance our understanding of the topic. Throughout this review of cardiovascular medicine, it is necessary to revisit several topics to improve understanding of complex problems. Now, let’s get back to the grape.

The grapes have taken on a load of oxygen from the air that has been inspired, or breathed in. In the exchange process, the alveolar structures move waste carbon dioxide into air that is to be expired or breathed out. The oxygen-loaded alveoli, or grapes, transfer the oxygen to the blood, which is flowing in the tiny vessels surrounding the alveoli. These tiny vessels are lung capillaries. The capillaries around the grapes join up and start to get bigger and bigger. As the lung capillaries join together to form larger vessels, they come to be called pulmonary veins. The pulmonary veins join up to become really huge. Usually, one set of pulmonary veins comes from the lung on the left side of the body, and one set comes from the lung on the right side of the body. The pulmonary veins ultimately drain into a receiving chamber in the left side of the heart. This receiving chamber is called the left atrium. It has much the same job to do as the previously mentioned right atrium. It’s a mixing chamber. After mixing, the blood passes into the main heart-pumping chamber, which is called the left ventricle. But in order to go from the left atrium into the left ventricle, the blood must pass through yet another heart valve. This is also a one-way valve. It is called the mitral valve because it somewhat resembles the miter, the name given to the ecclesiastical hat worn by bishops. It has two doors, or leaflets, and looks like a double french door. Here, in the left ventricle, the blood is again mixed and then squeezed out in a rhythmic fashion to the rest of the body. Usually, both the right and the left ventricles have the same rhythmic activity in their contractions. Any disturbances in the regularity of this rhythm could cause major illness and will be discussed later.

In order for the blood to be pumped out of the left ventricle, the blood must pass through the fourth and final heart valve. This valve is called the aortic valve because it connects to the major arterial blood vessel, which is called the aorta. The aortic valve is normally a one-way valve and has three cusps. It generally requires a lot of squeeze power to open the valve and to force blood across the valve. If the valve is too tight or narrow, it will not allow blood to pass easily. If the aortic valve leaks when it should be closed, blood can flow back into the left ventricular chamber. A tight valve is called a stenotic valve. A leaking valve is called a regurgitant valve. If either of these abnormalities were to occur, it could cause serious problems.

Blood that successfully passes through the aortic valve and enters the aorta is now on its way to provide oxygen and food materials necessary for the proper function of the body. This huge vessel, the aorta, branches into smaller and smaller arteries, again like the branches of a tree. It divides into special arteries that supply the needs of various organs of the body, such as the brain, kidney, gut, lungs and muscles. All the while, as they course through the body, these arterial vessels get progressively smaller until they reach the size of the microscopic arteries and capillaries, which surround individual cells. And now the journey is complete.

Chapter 2

THE DELIVERY SYSTEM

The simplest way to look at heart damage and its consequences is from the viewpoint of the muscle cell. The muscle cell is called a myocyte. It is not the only cell type in the heart, but from the point of view of damage, this cell is the most important cell. It is critical for small arteries and tiny capillaries to bring food, fuel, and oxygen to the myocyte and for tiny capillaries and small veins to remove poisonous waste products from the cell and its surrounding vicinity. Failure to receive adequate delivery of oxygen and food will cause the cell to weaken, function poorly, slow down its activities, and even die if the situation is not corrected. The buildup of waste products, which have not been removed, can irritate neighboring cells, such as nerve cell, and cause them to function poorly as well. If enough nerve cells are irritated, they will send a message, an impulse of this distress, up the nerve trunks into the brain. In the brain, this message is recognized as abnormal and is processed into a feeling or a sensation, which we call a symptom.

Symptoms are abnormal feelings recognized by the brain. The more severely the heart muscle cells are distressed, the greater the intensity and the frequency of abnormal impulses transmitted to the brain and the more intense may be the sensations or feelings, which we call symptoms. (Symptoms of heart ailments will be discussed later.) But if the supply of fuel and foodstuffs is improved and the waste material is removed, the cells may not die. The cells may recuperate and begin to function appropriately, but often in a weaker condition. The abnormalities may be only partially reversible or may be fully reversible. Again, the number of cells involved and the area and location within the heart structure will determine the final outcome of the injury.

So what kind of conditions can cause a cell or a group of cells to undergo such stress? The first and most important answer is that the cells are starved for oxygen and fuel. One way or another, inadequate fuel delivery can cause the oil-burning furnace in your home to fail during the winter months. Your car can run out of gas on the highway. Electric lights will fail in a community experiencing a blackout. And with excessive exertion, your body will fatigue.

So let’s look at the delivery system for the cells. Blood is delivered to the cells by vessels, tubes that we call arteries and capillaries. If the tubes are partly or completely blocked, delivery of foodstuffs is partly or completely stopped. How can this happen? Like a cork in a wine bottle, the cork may completely prevent the exit of wine from the bottle or may allow a small leak to occur through a partly plugged-up hole. The arteries that supply the cells are not lead pipes or