Blocked arteries: role of life-style
Dr J.D. Wig

Blocked arteries can be a serious health problem. Blood vessel disorders that cause blockage or narrowing are usually acquired diseases. Atherosclerosis is the most common arterial disease and a common clinical challenge. Atherosclerosis is derived from Greek "athere", meaning porridge or gruel, and "sclerosis" meaning hardening. It is a diffuse disease characterised by a plaque formation as a result of disruption of the innermost layer of the artery. Plaque is a combination of changes in the wall of the artery consisting of focal accumulation of lipids, blood and blood products, complex carbohydrates, fibrous tissue and calcium deposits.

Plaque often forms in the arteries of lower abdomen (iliac) and in the lower limb (femoral, popliteal). As the thickening of plaque increases, the blood supply to the target regions decreases progressively. There occurs deficiency of oxygen-rich blood in the areas supplied by diseased arteries. Atherosclerosis is responsible for mini-strokes, heart attack, and pain on walking and eventual gangrene of the limbs.

Risk factors include smoking, high blood pressure, high level of blood cholesterol, obesity, diabetes and a family history. Clinical efforts to control the risk factors have been shown to be effective in limiting the morbidity and mortality. Complete and permanent cessation of smoking is by far the single most important factor determining the outcome of the treatment efforts.

Lower limb artery problems is a common disease and occurs when blood vessels in the groin or legs are narrowed or blocked. Blood flow to the leg and foot is reduced.

The patients have pain while walking, change in skin colour, and slow healing sores on the foot. The pain is called intermittent claudication. Even though the symptoms are frequently unilateral, most people have bilateral disease. Revascularising one leg often simply serves to unmask the hitherto asymptomatic contralateral disease.

Selective X-ray study (angiography) permits the study of a particular segment of the vascular system using X-rays and a special dye to locate the site of blockage. X-ray images show how much dye gets through the blocked arteries.

The blockage in the main artery does not ever clear itself. To correct ischaemia to the limbs, the most common procedure performed is to revascularise. Vascular reconstruction is performed in an attempt to restore circulation in longer blockage. Drugs do not unblock the artery. The longer blocked segment is bypassed by interposing a prosthetic graft between a patent artery above and the patent artery distal to the block — a bypass procedure.

The patients who have predominantly aortoiliac disease (suprainguinal) are best dealt by aortoiliac reconstruction as it deals with both legs at the same time. Another method is to use a vein from inner thigh to link the arteries and this link provides a new path for blood to flow to the lower leg and foot.

The alternatives to surgery are balloon angioplasty and stenting. Lesions that respond best to balloon angioplasty are of shorter length.

If the predisposing insult is not taken care of, other arteries in the body can also get involved subsequently. Even the sites of bypass can get affected by the progress of the disease, leading to late graft failure.

Graft failure is most often caused by fibrointimal hyperplasia at distal anastomoses. Late graft failure is most frequently caused by recurrent atherosclerosis. In the event of a graft failure, the most durable alternative is replacing with a new bypass. Young patients who have atherosclerosis are heavy smokers and frequently progress to limb loss despite attempts at revascularisation. Reconstructive procedures require frequent revision in this segment of the population.

The appropriate management of patients with chronic lower limb ischaemia is a complex clinical issue. Much needs to be done regarding education and risk factor modification. The most important thing is to improve life-style — stop smoking, lose weight and take regular exercise. If blood cholesterol is high, a low fat diet is advised and cholesterol lowering drugs may be needed. Tobacco is harmful — it speeds up the hardening of arteries, and clamps down the small collateral vessels, resulting in the diminution of the amount of blood and oxygen to the muscles.

It is not unusual for a woman to gain weight in due course of pregnancy, and is equally true that most of them struggle to shed that weight post-delivery. There is no doubt that during pregnancy the female does require more calories to meet the needs of the growing child within, but it is ideal to consume more vegetables and fruits rather than ghee and fried food (the usual culprits leading to obesity).

Today the public in general is more aware of the importance of exercise during pregnancy, but it would still take a long time to make this into a universal phenomenon. It is also common for pregnant females to exercise during the last three months and therefore experience difficulty due to increased abdominal girth and body-weight.

It is a misconception that exercise during pregnancy causes problems. The truth is that exercises done correctly remarkably reduce some common discomfort associated with pregnancy such as backache, constipation, fatigue, edema, etc. Exercise also alleviates mood, energy level and self-image.

Regular exercises strengthen muscles, improve blood circulation and reduce tiredness. Strengthening of abdominal, pelvic muscles helps in easy delivery of the child and in avoiding the strain of pregnancy on the lower back.

In fact, there is no reason why women in good health should not follow a regular exercise regimen during pregnancy. However, in certain obstetric complications like hypertension/toxemia, etc, one should avoid vigorous physical activity. Contra-indications to exercise are hypertension, history of pre-term labour, history of abortions, rupture of membranes, etc.

A number of exercises are safe which pregnant females at any stage can do but certain guidelines, if followed, can avoid complications:

• Women who have been undertaking exercises regularly prior to pregnancy can continue with the same programme but with minor adjustment.

• Regular exercise for at least thrice a week should be undertaken.

• It is ideal to avoid exercise during hot and humid weather conditions. Never exercise to the point of exhaustion or breathlessness. It is better to do exercise early morning or evening when it is cooler.

• Frequent breaks and drinking plenty of water are advisable.

• Pulse should remain below 140 beats/minute while exercising.

• Avoid lying flat on the back after the fourth month of pregnancy for more than five minutes as this position decreases the blood flow to the heart and the uterus.

There are certain aerobic exercises that can be performed during pregnancy. These include walking and cycling (stationary recumbent cycle is safer than riding a bike on the road as the sense of balance decreases during pregnancy). One should stop exercising in case there is pain, bleeding, fainting, rapid heart beat, etc.

The schedule should comprise five to 10 minutes’ warm-up followed by 20 to 30 minutes of walking/cycling and cooling down with gentle stretching, relaxation and breathing exercises.

The following exercises are advisable:

Pelvic muscle exercises are also called kegel exercises. These help in improving bladder and bowel control. These can be done anywhere, anytime and in any position — lying down, sitting or standing. Tighten and then release muscles around the vagina as if trying to stop the flow of urine. Similarly, tighten up the back passage as if trying to prevent bowel movement. Tighten up the muscles for a count of six and relax for a count of four.

Knee press: Keeping the back straight, press the knees slowly and gently to the floor. Hold the knees in this position for a count of three. Repeat three to five times and repeat it two to three times per day.

Pelvic rock: Kneel on the hands and the knees like a four-legged animal. Keeping the hands and the knees straight, tighten up the abdominal muscles by inhaling deeply. Breathe out to relax. Repeat it two to three times and twice a day throughout pregnancy.

In addition to this, abdominal strengthening exercises and neck, chest, hamstring and quadriceps stretching can be done throughout pregnancy. Exercises during pregnancy should be planned with the consultation of a specialist. Yoga exercises like Ardha Titali asana(half butterfly), Poorna Titali asana (full butterfly) are also very helpful.

Eating healthy and exercising in moderation make pregnancy more comfortable. It can shorten the labour period and reduce the need for obstetric interventions.

Surgery often avoidable for men with hernias

NEW YORK: Men who experience few or no symptoms from an inguinal hernia do not requite immediate surgery: instead, they can be safely followed and treated if symptoms worsen, new research shows.

If this approach catches on with surgeons throughout the US, it could markedly reduce the number of hernia repairs performed.

Inguinal hernias, the most common type, occur in the groin when tissue that normally resides in the abdomen pushes through a weak area in the abdominal wall. This bulging mass of tissue, which may contain intestine, can cause pain, but usually can be pushed back into the abdomen without difficulty. In some cases, however, it may become stuck, a potentially life-threatening complication called incarceration.

Out of fear that incarceration and other problems may occur, "surgeons are generally taught that all hernias should be repaired at diagnosis," lead author Dr Robert J. Fitzgibbons, from Creighton University in Omaha, Nebraska, said. — Reuters