The cardiovascular system comprises all blood vessels. These are basically made up of arteries – which pump blood that has oxygen to your body, and veins which return blood depleted of oxygen from your body. The heart is a pump that sends the blood returned from your veins to your lungs, where it absorbs oxygen. The blood from your lungs, rich in oxygen then goes back to your heart where it gets finally pumped out to the rest of your body via your arteries. This combined system of circulating blood around your body including the pump mechanism of your heart is described as the cardiovascular system.
Chest Pain
We begin this section by talking about chest pain. It can be a common symptom and can much anxiety for the sufferer or carer.
The heart has always got to be at least considered to be the potential cause of any chest pain or upper abdominal symptoms. This is due to the potential life threatening nature of a heart attack (myocardial infarction). However, many other causes of chest pain do exist. Here are a few more common causes to consider:
- The joints between your sternum and the actual ribs can get sore. Pain due to a joint this way is called arthritis. Alternatively, ribs themselves can get inflamed. This is called costochondritis. Note that costochondritis can be brought on by a virus, so it may be the case that you recently had a “cold”. It can particularly be sore when you breathe in. The other reason people can get chest pain is from coughing too much and spraining a joint. Muscles themselves can be torn from coughing too much. In the process of coughing, you can even break a rib. The nature of this pain will be such that when you cough, it hurts.
In general, musculoskeletal chest pain will reveal itself if a person gets the pain on movement. Furthermore, when you touch the area the pain is occurring, it may be sore, or tender to touch.
- When acid from the stomach moves in the wrong direction and goes back up the gullet (oesophagus) a person can experience a quite severe chest pain that is typically sharp in nature. Relief could come from taking an antacid tablet or solution.
- Stomach acid. Even if acid doesn’t go in the wrong direction causing sharp chest pain, the presence of any stomach problem including increased acid, once again, or an ulcer, can sometimes cause chest pain. Again, taking an antacid tablet may help.
- Lung problems. Any problem with your lungs or the lining around your lungs, called the pleura, can cause chest pain. Usually, when the pain originates from the lung or lining, it especially hurts when you breath in. This pain is then described as “pleuritic pain”.
How to recognise a heart attack in the elderly
Firstly, what is a heart attack? This is the common description given to the situation where a blood vessel supplying the heart itself with blood to nourish the heart muscle (myocardium) gets blocked, usually by a clot, and the heart muscle no longer being nourished with blood, dies. The technical name for a heart attack logically becomes acute (sudden) myocardial (heart muscle) infarction (death), often shorted to an “AMI”.
The fact is, when an elderly person is having a heart attack, they may or may not report having chest pain. This is really important to remember, that they may not tell you they have chest pain. The reason for this is because pain is actually a sensation reliant on our nervous system reporting things to us, accurately. However, as we age, some of these mechanisms can diminish. This is especially true of people with diabetes. They may not have chest pain, rather, they may feel short of breath or just very tired. There at times may be related sweating or clamminess. This is a sign from your body, that something is wrong. What I mentioned at the start of this chapter is also worthwhile considering. That is, when you have a heart problem, sometimes you may breathe too much and accidentally swallow air. This can lead to burping or belching at the same time.
If you do get chest pain, it is typically on the left side of the chest, at the front. However, it could be anywhere. The pain may go into your back and travel down your arms or into your neck. You may or may not have a racing heart.
The conclusion of this discussion about chest pain would be that if chest pain occurs, and despite our attempts at trying to decide on the origin of the pain, if the origin does not become clear pretty quickly, then you should call 000 and get an emergency ambulance, in case the pain is from a heart attack. In this case, time does matter, and the faster any blockage can be fixed, the less damage to the body occurs.
A few tips:
- Always keep aspirin at home. Aspirin thins the blood. And, in the case of a heart attack, the thinner your blood, the less likely it is to get stuck and cause a blockage somewhere. Therefore, aspirin, by thinning your blood, will help. However, this should not be taken without the advice of a professional. Usually, when you ring 000 and report chest pain, the call centre operator will ask you a few questions. If it is thought that the person could be having a heart attack, they will ask you to give 300mg of aspirin (this is a usual tablet size). Having this handy, will help.
- Don’t let yourself get dehydrated. When you are sick, or during the summer or if you’re not very active, it’s very easy to get dehydrated because of not drinking enough water. Once you get dehydrated, your blood literally gets thicker and as a consequence more sticky, making it far more likely to have a heart attack. Therefore, make it a habit to drink plenty of water, always. Of course, there are some situations where the amount of water you drink needs to be regulated, for example, if your body tends to accumulate water and you experience swelling of the legs or fluid in your lungs. This could be from a weak heart or having kidney troubles. If this is the case, then you need to balance things. However, for everyone else, drinking plenty of water is a good way to help avoid a heart attack.
- Take your medications. Heart attacks happen typically because of a blood clot within an artery forming and dislodging. In other words, from damaged arteries. There are different factors which contribute to arterial damage. These include high blood pressure, high cholesterol, cigarette smoking and diabetes. Often a person is meant to be on medications to control these “risk factors” for arterial disease. It’s very important to take your medications. This is especially true of blood pressure medications.
- Stay active. Your heart is an amazing organ. When you have blockages in an artery supplying the heart, which could have occurred slowly over time because of more gradual wall damage (as opposed to more suddenly with a clot), provided your active, new blood vessels and branches will grow to bypass that blockage. This is called “collateral supply”. Basically, what it represents is the fact that the heart is responding to your active lifestyle, over time, and your activity is stimulating the production of new blood vessels supplying your heart. Amazing but true. Obviously, the creation of all this “collateral” takes time. However, if you can then stay active, your in effect conditioning your heart, so that if something did go wrong all of a sudden, your heart will hopefully be less damaged. Stay active could be as simple as walking as much as you can.
Heart rate and rhythm disturbances
Your heart beat usually originates from one area in your heart, at the upper right section of it. When functioning correctly, the heart rate (speed) should be between 60 – 100. And the rhythm should be regular. However, if the heart beat occurs from somewhere else, or if your body is experiencing some stress or lack of balance from any other reason, your rate could be less than 60 (described as being bradycardic) or greater than 100 (described as being tachycardic).
When your heart is beating normally, you usually don’t feel your heart beating. However, when it beats abnormally, it may feel your heart beating. This is what we call the sensation of having “palpitations”. Of note, palpitations can tell you that there is a problem, but it may not tell you whether your heart is beating fast or slow, regularly or irregularly. You can try to tap out the rhythm however, and get a sense of that. Also, you may choose to feel the pulse on a wrist. This can help with understanding whether the rhythm is regular or irregular, and also what the rate is. If you can time how many heart beats there are in a 60 second period, this is helpful to then tell your doctor. However, sometimes, the pulse at the wrist can be unreliable and a doctor will need to assess things further to decide what sort of rhythm problem is occurring, if any.
Some common issues with the elderly, and heart rhythms are:
Atrial fibrillation.
As discussed earlier, the usual source of the heart beat is the right upper area. This area is called the sinoatrial node. The beat starts here and effectively spreads throughout the heart, starting from the top. However, sometimes the top half of the heart (atria) can beat in an uncoordinated fashion, consequently causing the top half of the heart to quiver rather than actually contract and beat. This is described as atrial fibrillation. Thankfully, in this case, blood still flows to the bottom half of the heart (the ventricles) and subsequently gets pumped out and delivered to the rest of the body. However, the output of the heart is said to be 25% less as a consequence of the atrial not contracting in a coordinated way.
Atrial fibrillation is a very common disease. It can be caused by the accumulation of several longer term stresses on the heart (lack of blood, previous heart attacks, stretching of he heart over time), or factors relating to the make up of your blood (including your thyroid function) or more immediate reasons such as drinking too much alcohol.
A person with atrial fibrillation can feel dizzy, tired or short of breath. If the heart is beating fast enough, causing stress, they may even have chest pain. Or, they may not feel abnormal at all. Atrial fibrillation increases the risk of stroke. This is because when the top half of the heart (atria) quiver, they fail to really pump out all blood. There are parts to the top heart of the heart, little nooks, where blood can then be prone to stagnate and subsequently form a clot. That clot is then liable to dislodge, find its way into the arterial system, often into the brain where it blocks a vessel causing a stroke. Therefore, in general, it is advisable to take a medication to thin your blood if you have atrial fibrillation. This needs to be balanced with the risk of having a fall, in which case, if you are someone who falls over a lot, the risk of having a bleed from falling and being on a blood thinning medication may outweigh the benefit of taking the medication. That’s a decision to discuss with your doctor. You may also take medication to control how fast your heart beats, to avoid it going too fast.
Sometimes your heart may beat so fast or slow, despite medications, that you need a pacemaker. A pacemaker is a mechanical device which sends an electrical impulse to your heart, dictating its rate and rhythm of beating.
In summary, heart rhythm disturbances are very important to understand and be aware of in the elderly. They can be the origin of many symptoms including dizziness, tiredness and chest pain. And, most importantly, they can be the cause of person blacking out and falling.
A few tips:
- Drink plenty of water. Once again, dehydration can affect your body and contribute to your heart rhythm becoming irregular. It’s really important to stay well hydrated. This is especially true of times when you are unwell. For example, if you have diarrhoea, influenza, a urinary infection or skin infection. All of these times in life put a stress on your heart, and that stress is increased by dehydration.
- Report palpitations. Sometimes the heart rhythm and rate can drift between being normal and abnormal. If you have experienced times when you thought, I could feel my heart beating, and it didn’t feel quite right, don’t ignore it. Rather, let you GP know. It can be investigated, and it’s really very important to know that you may be having an irregular heart rhythm and or heart rate, every now and then. The risk of stroke is actually said to be greater when your heart drifts between being normal and abnormal this way. Your doctor may advise you to wear a monitor which records your heart activity over 24 hours. This is called a holter monitor. This is a simple, pain free investigation and worthwhile doing if you can find the cause of your palpitation.
- Look after your heart. In general, as aforementioned, stress on your heart will increase the chance of the rhythm becoming irregular. Stress can come in the form of high blood pressure, smoking, a lack of exercise. Care for your heart, and it is more likely to stay on track. A special note here – alcohol. If you drink too much alcohol, it’s more likely you’ll have a heart rhythm problem. Drink in moderation and your heart will thank you.
Blocked arteries
Earlier, I mentioned that a heart attack is typically caused by a blood vessel which supplies blood to the heart, getting blocked. Well, this same thing, could really happen to any blood vessel throughout your body. And, like the heart with chest pain, the usual consequence is that we feel pain in area of the body which is lacking blood. This may be pain in your feet, particularly at night or pain in your abdomen after meals (when your bowels need more blood). Remember a blockage to an artery can be longstanding or sudden and dramatic. This will affect the way it presents. But pain will likely be a feature. A good way to consider whether a hand or foot has enough blood is to look at it’s colour and feel the temperature and note the fullness of any veins. A warm, pink hand or foot, with bulging veins, likely has blood. A cool, pale or blueish hand or foot, with flattened, spidery veins, is likely lacking in blood.
Varicose Veins
This is a problem usually encountered in the legs. It is a very common problem of the elderly. Veins usually only allow blood to travel in one direction. This is because they have special one way valves. However, over time, these valves can become faulty and allow blood to travel in either direction. In the case of blood within the veins of your legs, it need to overcome gravity to be returned to the heart. And that’s not easy. So much so, that the force of gravity, can lead to the valves within your legs losing their one way functioning, allowing blood to pool within the veins, causing “varicose” veins. It goes further because all the pressure of blood in the veins, causing an increasing pressure in the surrounding tissues, and the return of others fluids (via what is called the lymphatic system) is also compromised. The leg is now swollen. Added to this, iron from the stagnant blood, leaches out, discolouring the overlying skin. The skin itself can get painful, itchy and red or purple. This is called, venous eczema. Sometimes, the stagnant venous blood and resultant pressure is so irritating to the skin, that an ulcer is formed. This typically occurs on the inner aspect of the ankle.
In the case of varicose veins and such venous congestion, the problem gets worse as the day progresses. This is because of the cumulative effect of gravity, since during the day, the legs are usually more upright. The legs then improve overnight, whilst horizontal, the force of gravity now largely absent. The problem can then be lessened during the day by elevating the legs. If a person is sitting, then they should put their feet up on a foot stool, and recline the chair a bit, if this is able to be done.
A few tips:
- Maintain some musculature within in your legs. Blood tends to collect in the legs in the case of varicose veins, as discussed. However, leg muscles help literally push the blood back out of the legs, back up to the heart. Therefore, maintaining and using your leg muscles, helps to keep blood moving, pumping it back out of your legs. Some simple exercises could include calf raises. However, the best way to maintain your leg muscles, is going for a walk. Don’t sit down all day if you can avoid it.
- Keep your legs elevated. If you do have to sit down for a long period during the day, try to keep your legs up on a foot stool.
- Moisturise your skin. The congestion caused by the accumulation of blood can cause venous eczema, causing your legs to ache or feel itchy. The skin can get dry along the way. Moisturiser helps keep your skin strong and less itchy. There are many products to choose from, but I think that simple vitamin E cream or Nivea is fine. The main thing is to alternate products being used here and there. If you keep using the same product forever, your skin may develop an allergy to it. Of course, everyone’s different as well. So what works for one person, may not work for another. One point to note when discussing the use of any cream (which is water based) is not to allow it to be coated between your toes. Sometimes, patients put creams between their toes, in such quantity that the water content itself, of the cream, causes the webspace of their toes to crack as it becomes macerated. Rub a cream (moisturiser in this case) in, so that it’s gone.
- Compression stockings. If you do get swollen legs, you can use stockings to reduce the amount o
- Be vigilant for leg cellulitis.
Deep Vein Thrombosis
This is a more serious medial condition. It describes the situation when a deeper vein in your body (typically your lower limb) gets blocked. If this happens, then that limb, usually the leg, starts to swell, get warm and tender. The problem with having a DVT is that the clot inside your deep vein may flick off and travel in your veins to your heart, from where it gets pumped into your lungs, finally blocking a large blood vessel there. The blood clot, now in your lung, is called a pulmonary embolus. When that blood vessel in your lungs gets blocked, a portion of your lung itself may suffer and collapse, leaving you unable to breath. If the clot is very large blocking off a sufficient part of your lung, it could kill you.
A DVT can be classified as “provoked” – meaning that there was a particular reason, why, at this time, a person had a DVT. For example, after an operation. Or, unprovoked, meaning that no such “special” circumstantial reason exists. In this case, you may have an underlying medical condition which causes your blood to be sticky and therefore clot more easily.
A few tips:
- The blood will block in your legs more easily if your legs aren’t moving, so keep those legs moving. This is true particularly of your ankle and calf muscle. When your calf muscle contracts, it actually pumps the blood in the veins of your legs back up towards your heart. Therefore, you should exercise your leg to encourage this to happen. The best exercise is of course walking.
- Elevate your legs. If you cannot walk either temporarily or permanently, consider elevating your legs. This will reduce the effect of gravity, which will tend to cause blood to collect and pool in your legs.
- Compression stockings. These can help prevent blood from pooling in your legs. It is ideal that you put these on whilst you have been laying down, horizontal for a while, that is, before blood has had the chance to pool in your legs. First thing in the morning, before you get up, may be suitable. Otherwise, lay in bed for a few moments, before you put any compression stockings on.
- Stay well hydrated. Dehydration is a reason for your blood to become more sticky. Therefore, always try to stay well hydrated by drinking plenty of water or other fluids. Tea or coffee is still better than nothing. This is especially true if you have been ill, for example with an infection or diarrhoea. Another very vulnerable time is after an operation, particularly one on your knee or hip. After such a procedure, you may well find that your surgeon has prescribed for you a medication to keep your blood thin. Still, you do your bit, by staying well hydrated.
- Know the signs of a DVT. As described, a DVT can be a medical emergency, so you should get help if you experience:
- A sudden swelling, tenderness, warmth and redness to your leg
- Shortness of breath that you cannot explain. This may come on quickly, but in some instances, can come on more gradually over some weeks.
- Coughing up blood. This generally is a worrying sign and you should see a doctor.
- Chest pain. The type of chest pain experienced with a DVT may be sharp and particularly present when you breathe in.
- Your heart racing. This can also be a sign of a pulmonary embolus.
