Heart Health In Bali


As the candles on our birthday cakes multiply to alarming numbers, we wonder from time to time how our hearts are doing.  We can’t see what’s going on in there and it’s a bit of a worry.

Cardiologist Dr Putra Antara of Ubud Care Clinic recently gave an excellent presentation on heart disease, followed by an intense hour of Q&A.  Here are the highlights.

By the age of 70, our heart will have logged about 2 billion beats. That’s a lot of wear and tear. Just think about how often we have to replace our pond pumps.   But records between 1900 and 2010 show that coronary artery disease (CAD) in the west peaked in the 1960s and 1970s then decreased because of improved medical care and education.  People from high income countries are more likely to die of cancer these days, and those from middle and low income countries of CAD. In Indonesia, about half of the cost of the national health care plan BPJS is paid out for heart issues.

Risk factors include high cholesterol/blood pressure, diabetes, smoking, family history and obesity. In Indonesia smoking is the highest risk factor; Dr Putra recently treated a 22 year old heavy smoker for a heart attack.

Prevention of CAD should start in our thirties.   We all know the rules of a healthy heart: stay active, have a good diet, lose weight, control cholesterol and blood pressure, reduce blood sugar and stop smoking.  But no matter how virtuous our lifestyle, the build-up of plaque in the coronary arteries is inevitable; almost everyone will experience it over time.  Plaque eventually narrows the arteries, limiting blood flow. 

The progression, over many years, is the gradual narrowing of the coronary arteries due to plaque.  This can lead to angina, the pain caused by narrowed arteries which is usually triggered by stress or exertion.  Typically angina pain occurs in a larger area of the chest and is relieved with nitroglycerin or rest. (By the way, gentlemen, don’t take nitroglycerin with Viagra; they both open the blood vessels and may cause a blackout due to a dangerous drop in blood pressure.) 

“A heart attack occurs when a coronary artery gets completely blocked; stress or physical exertion may trigger a rupture of the plaque that leads to a sudden blockage,” explains Dr Putra.  “An electrocardiogram during an attack is the basic diagnostic tool. Treatment includes immediate oxygen and blood thinners, and nitroglycerin to reduce any artery spasm.  One or more stents may be inserted to keep the blocked artery open. In cases of severe blockage, a coronary bypass (open heart surgery) literally bypasses the blockage with a grafted vein or redirected artery.  Meanwhile, in those with only narrowing of the arteries, stents generally won’t prolong life, but may improve quality of life by reducing angina.”

It shouldn’t surprise us that all the old heart attack trials were done on Caucasian males. Only recently has it been recognized that women, Asians and Africans may have different symptoms from the ‘norm’ of chest pain radiating to the left arm.

A classic heart attack is harder to diagnose in women, especially if they are over 65 and/or diabetic. Heart attack symptoms in women can be any combination of the following, bearing in mind that symptoms may be more vague and atypical:

–     Chest pain (the pain may be dull, hard to pinpoint the exact location, it may be in the back or may radiate to the left/centre of chest) that generally goes on for more than a few minutes

–     Nausea, vomiting

–     Anxiety

–     Stomach pain

–     Pain in arm/leg/jaw

–     Shortness of breath

–     Sudden cold sweat

–     Feeling light headed or dizzy

–     Sudden exhaustion

–     Palpitations

In the United States, women coming to an Emergency Room with heart attack symptoms are much more likely to be dismissed than men. Dr Putra suggests that anyone experiencing a possible heart attack should immediately tell the doctor they have never felt anything like this before, which should be a red flag.

Heart attacks are somewhat more common in the small hours of the night. For this reason, Dr Putra suggests that blood pressure and blood thinning medications should be taken at night, while beta blockers be taken in the morning.

What about the demon cholesterol? High cholesterol alone does not necessarily turn into plaque, in fact about half of all heart attack victims don’t have high cholesterol. Around 20-30% of our total cholesterol level is determined by diet, the balance is genetic. Science now sees the obesity epidemic, fueled by sugar, salt, and refined flour, as a more serious threat to heart health than ‘fat’ or cholesterol.

I’ve always had high cholesterol, and a few years ago during a check up in Bangkok asked to have a CT coronary angiogram which was the only test I was aware of to visualize coronary plaque. Dr Putra explained that there were risks associated with this test, and it was also expensive.  In Bali we can get a Coronary Calcium Scoring CT Scan at Siloam, Kasih Ibu and other hospitals which costs only Rp 700,000 to Rp 1,500,000.  Even if we have no symptoms, it might be a good idea to see what’s going on in there and give us a baseline. By the way, although I’ve always had high cholesterol including the ‘bad’ or LDL cholesterol, I had no evidence of significant arterial plaque.

That’s the tradeoff to the lifestyle we’ve chosen.  So we need to take more responsibility.

If you think you may be having a heart attack and are not already on blood thinners, Dr Putra suggests immediately chewing 160-320 mg of aspirin/aspilet (in a pinch, it’s fine to take a full tablet of 500 mg) and 180 mg ticagrelol or 300 mg clopidogrel with a full glass of water. I had to order both of these through the clinic as they don’t seem to be available in pharmacies in Ubud.  Have someone drive you to Siloam, Kasih Ibu or Sanglah.  Sanglah has a special cardiac unit called ‘Ruang Emergency PJT’ (be sure to use this one and not the ordinary emergency entrance) and, because it’s a teaching hospital, always has a cardiology resident on duty.  The next best option would be the Siloam Hospital Emergency as they have the most cardiologists of the private hospitals.  Bear in mind that Sanglah can be slow and bureaucratic. Ubud Care Clinic in Teges has an emergency ward where heart attacks can be stabilized before the journey to hospital in their ambulance.

According to Dr Putra, forced coughing is used only for certain heart rhythm problems, but definitely not for heart attacks (chest pain). It could even make things worse and trigger a blackout.

This hasn’t been a very cheerful read, but forewarned is forearmed. I don’t know about you, but I’ll be preparing a small container with aspirin and ticagrelol to carry at all times. I personally believe than being happy and positive is a big part of mental and physical health, so take a big dose of that too.  All bright blessings for 2020.

By Ibu Kat

The Boomer Corner is a column dedicated to people over  60 living in Bali.  Its mandate is to cover topics, practicalities, activities, issues, concerns and events related to senior life in Bali. We welcome suggestions from readers.

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