In today's society, people are gaining medical knowledge at quite a fast pace.
Treatments, cures, and vaccines for various diseases and disorders are being
developed constantly, and yet, coronary heart disease remains the number one
killer in the world. The media today concentrates intensely on drug and alcohol
abuse, homicides, AIDS and so on. What a lot of people are not realizing is that
coronary heart disease actually accounts for about 80% of all sudden deaths. In
fact, the number of deaths from heart disease approximately equals to the number
of deaths from cancer, accidents, chronic lung disease, pneumonia and influenza,
and others, COMBINED. One of the symptoms of coronary heart disease is angina
pectoris. Unfortunately, a lot of people do not take it seriously, and thus not
realizing that it may lead to other complications, and even death. THE HUMAN
HEART In order to understand angina, one must know about our own heart. The
human heart is a powerful muscle in the body which is worked the hardest. A
double pump system, the heart consists of two pumps side by side, which pump
blood to all parts of the body. Its steady beating maintains the flow of blood
through the body day and night, year after year, non-stop from birth until
death. The heart is a hollow, muscular organ slightly bigger than a person's
clenched fist. It is located in the centre of the chest, under the breastbone
above the sternum, but it is slanted slightly to the left, giving people the
impression that their heart is on the left side of their chest. The heart is
divided into two halves, which are further divided into four chambers: the left
atrium and ventricle, and the right atrium and ventricle. Each chamber on one
side is separated from the other by a valve, and it is the closure of these
valves that produce the "lubb-dubb" sound so familiar to us. Like any
other organs in our body, the heart needs a supply of blood and oxygen, and
coronary arteries supply them. There are two main coronary arteries, the left
coronary artery, and the right coronary artery. They branch off the main artery
of the body, the aorta. The right coronary artery circles the right side and
goes to the back of the heart. The left coronary artery further divides into the
left circumflex and the left anterior descending artery. These two left arteries
feed the front and the left side of the heart. The division of the left coronary
artery is the reason why doctors usually refer to three main coronary arteries.
SYMPTOMS OF CORONARY HEART DISEASE There are three main symptoms of coronary
heart disease: Heart Attack, Sudden Death, and Angina. Heart Attack Heart attack
occurs when a blood clot suddenly and completely blocks a diseased coronary
artery, resulting in the death of the heart muscle cells supplied by that
artery. Coronary and Coronary Thrombosis are terms that can refer to a heart
attack. Another term, Acute myocardial infarction, means death of heart muscle
due to an inadequate blood supply. Sudden Death Sudden death occurs due to
cardiac arrest. Cardiac arrest may be the first symptom of coronary artery
disease and may occur without any symptoms or warning signs. Other causes of
sudden deaths include drowning, suffocation, electrocution, drug overdose,
trauma (such as automobile accidents), and stroke. Drowning, suffocation, and
drug overdose usually cause respiratory arrest which in turn cause cardiac
arrest. Trauma may cause sudden death by severe injury to the heart or brain, or
by severe blood loss. Stroke causes damage to the brain which can cause
respiratory arrest and/or cardiac arrest. Angina People with coronary artery
disease, whether or not they have had a heart attack, may experience
intermittent chest pain, pressure, or discomforts. This situation is known as
angina pectoris. It occurs when the narrowing of the coronary arteries
temporarily prevents an adequate supply of blood and oxygen to meet the demands
of working heart muscles. ANGINA PECTORIS Angina Pectoris (from angina meaning
strangling, and pectoris meaning breast) is commonly known simply as angina and
means pain in the chest. The term "angina" was first used during a
lecture in 1768 by Dr. William Heberden. The word was not intended to indicate
"pain," but rather "strangling," with a secondary sensation
of fear. Victims suffering from angina may experience pressure, discomfort, or a
squeezing sensation in the centre of the chest behind the breastbone. The pain
may radiate to the arms, the neck, even the upper back, and the pain may come
and go. It occurs when the heart is not receiving enough oxygen to meet an
increased demand. Angina, as mentioned before, is only temporarily, and it does
not cause any permanent damage to the heart muscle. The underlying coronary
heart disease, however, continues to progress unless actions are taken to
prevent it from becoming worse. Signs and Symptoms Angina does not necessarily
involve pain. The feeling varies from individuals. In fact, some people
described it as "chest pressure," "chest distress,"
"heaviness," "burning feeling," "constriction,"
"tightness," and many more. A person with angina may feel discomforts
that fit one or several of the following descriptions: Mild, vague discomfort in
the centre of the chest, which may radiate to the left shoulder or arm Dull
ache, pins and needles, heaviness or pains in the arms, usually more severe in
the left arm Pain that feels like severe indigestion Heaviness, tightness,
fullness, dull ache, intense pressure, a burning, vice-like, constriction,
squeezing sensation in the chest, throat or upper abdomen Extreme tiredness,
exhaustion of a feeling of collapse Shortness of breath, choking sensation A
sense of foreboding or impending death accompanying chest discomfort Pains in
the jaw, gums, teeth, throat or ear lobe Pains in the back or between the
shoulder blades Angina can be so severe that a person may feel frightened, or so
mild that it might be ignored. Angina attacks are usually short, from one or two
minutes to a maximum of about four to five. It usually goes away with rest,
within a couple of minutes, or ten minutes at the most. Different Forms of
Angina There are several known forms of angina. Brief pain that comes on
exertion and leave fairly quickly on rest is known as stable angina. When angina
pain occurs during rest, it is called unstable angina. The symptoms are usually
severe and the coronary arteries are badly narrowed. If a person suffers from
unstable angina, there is a higher risk for that person to develop heart
attacks. The pain may come up to 20 times a day, and it can wake a person up,
especially after a disturbing dream. Another type of angina is called atypical
or variant angina. In this type of angina, pain occurs only when a person is
resting or asleep rather than from exertion. It is thought to be the result of
coronary artery spasm, a sort of cramp that narrows the arteries. Causes of
Angina The main cause of angina is the narrowing of the coronary arteries. In a
normal person, the inner walls of the coronary arteries are smooth and elastic,
allowing them to constrict and expand. This flexibility permits varying amounts
of oxygenated blood, appropriate to the demand at the time, to flow through the
coronary arteries. As a person grows older, fatty deposits will accumulate on
the artery walls, especially if the linings of the arteries are damaged due to
cigarette smoking or high blood pressure. As more and more fatty materials build
up, they form plaques which causes the arteries to narrow and thus restricting
the flow of blood. This process is known as atherosclerosis. However, angina
usually does not occur until about two-thirds of the artery's diameter is
blocked. Besides atherosclerosis, there are other heart conditions resulting in
the starvation of oxygen of the heart, which also causes angina. The nerve
factor - The arteries are supplied with nerves, which allow them to be
controlled directly by the brain, especially the hypothalamus - an area at the
centre of the brain which regulates the emotions. The brain controls the
expanding and narrowing of the arteries when necessary. The pressures of modern
life: aggression, hostility, never-ending deadlines, remorseless, competition,
unrest, insecurity and so on, can trigger this control mechanism. When you
become emotional, the chemicals that are released, such as adrenaline,
noradrenaline, and serotonin, can cause a further constriction of the coronary
arteries. The pituitary gland, a small gland at the base of the brain, under the
control of the hypothalamus, can signal the adrenal glands to increase the
production of stress hormones such as cortisol and adrenaline even further.
Coronary spasm - Sudden constrictions of the muscle layer in an artery can cause
platelets to stick together, temporarily restricting the flow of flow. This is
known as coronary spasm. Platelets are minute particles in the blood, which play
an essential role both in the clotting process and in repairing any damaged
arterial walls. They tend to clump together more easily when the blood is full
of chemicals released during arousal, such as cortisol and others. Coronary
spasm causes the platelets to stick together and to the wall of the artery,
while substances released by the platelets as they stick together further
constrict the blood vessels. If the artery is already narrowed, this can have a
devastating effect as it drastically reduces the blood flow. When people are
very tense, they usually overbreathe or hold their breath altogether. Shallow,
irregular but rapid breathing washes out carbon dioxide from the system and the
blood will become over-oxygenated. One might think that the more oxygen in the
blood the better, but overloaded blood actually does not give up oxygen as
easily, therefore the amount of oxygen available to the heart is reduced. Carbon
dioxide is present in the blood in the form of carbonic acid, when there is a
loss in carbonic acid, the blood becomes more basic, or alkaline, which leads to
spasm of blood vessels, almost certainly in the brain but also in the heart.
ATHEROSCLEROSIS The coronary arteries may be clogged with atherosclerotic
plaques, thus narrowing the diameter. Plaques are usually collections of
connection tissue, fats, and smooth muscle cells. The plaque project into the
lumen, the passageway of the artery, and interfere with the flow of blood. In a
normal artery, the smooth muscle cells are in the middle layer of the arterial
wall; in atherosclerosis they migrate into the inner layer. The reason behind
their migration could hold the answers to explain the existence of
atherosclerosis. Two theories have been developed for the cause of
atherosclerosis. The first theory was suggested by German pathologist Rudolf
Virchow over 100 years ago. He proposed that the passage of fatty material into
the arterial wall is the initial cause of atherosclerosis. The fatty material,
especially cholesterol, acts as an irritant, and the arterial wall respond with
an outpouring of cells, creating atherosclerotic plaque. The second theory was
developed by Austrian pathologist Karl von Rokitansky in 1852. He suggested that
atherosclerotic plaques are aftereffects of blood-clot organization
(thrombosis). The clot adheres to the intima and is gradually converted to a
mass of tissue, which evolves into a plaque. There are evidences to support the
latter theory. It has been found that platelets and fibrin (a protein, the final
product in thrombosis) are often found in atherosclerotic plaques, also found
are cholesterol crystals and cells which are rich in lipid. The evidence
suggests that thrombosis may play a role in atherosclerosis, and in the
development of the more complicated atherosclerotic plaque. Though thrombosis
may be important in initiating the plaque, an elevated blood lipid level may
accelerate arterial narrowing. Plaque Inside the plaque is a yellow,
porridge-like substance, consisting of blood lipids, cholesterol and
triglycerides. These lipids are found in the bloodstream, they combine with
specific proteins to form lipoproteins. All lipoprotein particles contain
cholesterol, triglycerides, phospholipids, and proteins, but the proportion
varies in different particles. Lipoproteins Lipoproteins all vary in size. The
largest lipoproteins are called Chylomicra, and consist mostly of triglycerides.
The next in size are the pre-beta-lipoproteins, then the beta lipoproteins. As
their size decreases, so do their concentration of triglycerides, but the
smaller they are, the more cholesterol they contain. Pre-beta-lipoproteins are
also known as low density lipoproteins (LDL), and beta lipoproteins are also
called very low density lipoproteins (VLDL). They are most significant in the
development of atheroma. The smallest lipoprotein particles, the alpha
lipoproteins, contain a low concentration of cholesterol and triglycerides, but
a high level of proteins, and are also known as high density lipoproteins (HDL).
They are thought to be protective against the development of atherosclerotic
plaque. In fact, they are transported to the liver rather than to the blood
vessels. Lipoproteins and Atheroma The theory is that lipoproteins pass between
the lining cells of the arteries and some of them accumulate underneath. All
except the chylomicra, which are too big, have a chance to accumulate. The
protein in the lipoproteins are broken down by enzymes, leaving behind the
cholesterol and triglycerides. These fats are trapped and set up a small
inflammatory reaction. The alpha particles do not react with the enzymes are
returned to the circulation. RISK FACTORS There are several risk factors that
contribute to the development of atherosclerosis and angina: Family history,
Diabetes, Hypertension, Cholesterol, and Smoking. Family History We all carry
approximately 50 genes that affect the function and structure of the heart and
blood vessels. Genetics can determine one's risk of having heart disease. There
are many cases today where heart disease runs in a family, for many generations.
Diabetes Diabetics are at least twice as likely to develop angina than
nondiabetics, and the risk is higher in women than in men. Diabetes causes
metabolic injury to the lining of arteries, as a result, the tiny blood vessels
that nourish the walls of medium-size arteries throughout the body, including
the coronary arteries, become defective. These microscopic vessels become
blocked, impeding the delivery of blood to the lining of the larger arteries,
causing them to deteriorate, and artherosclerosis results. Hypertension High
blood pressure directly injures the artery lining by several mechanisms. The
increased pressure compresses the tiny vessels that feed the artery wall,
causing structural changes in these tiny arteries. Microscopic fracture lines
then develop in the arterial wall. The cells lining the arteries are compressed
and injured, and can no longer act as an adequate barrier to cholesterol and
other substances collecting in the inner walls of the blood vessels. Cholesterol
Cholesterol has become one of the most important issues in the last decade.
Reducing cholesterol intake can directly decrease one's risk of developing heart
disease, and people today are more conscious of what they eat, and how much
cholesterol their foods contain. Cholesterol causes atherosclerosis by
progressively narrowing the arteries and reduces blood flow. The building up of
fatty deposits actually begins at an early age, and the process progresses
slowly. By the time the person reaches middle-age, a high cholesterol level can
be expected. Smoking It has been proven that about the only thing smoking do is
shorten a person's life. Despite all the warnings by the surgeon general, people
still manage to find an excuse to quit smoking. Cigarette smoke contains carbon
monoxide, radioactive polonium, nicotine, arsenious oxide, benzopyrene, and
levels of radon and molybdenum that are TWENTY times the allowable limit for
ambient factory air. The two agents that have the most significant effect on the
cardiovascular system are carbon monoxide and nicotine. Nicotine has no direct
effect on the heart or the blood vessels, but it stimulates the nerves on these
structures to cause the secretion of adrenaline. The increase of adrenaline and
noradrenaline increases blood pressure and heart rate by about 10% for an hour
per cigarette. In simpler words, nicotine causes the heart to beat more
vigorously. Carbon monoxide, on the other hand, poisons the normal transport
systems of cell membranes lining the coronary arteries. This protective lining
breaks down, exposing the undersurface to the ravages of the passing blood, with
all its clotting factors as well as cholesterol. Multiple Risk Factors The five
major risk factors described above do more than just add to one another. There
is a virtual multiplication effect in victims with more than one risk factor.
(Chart: Risk Factors) DIAGNOSIS It is very important for patients to tell their
doctors of the symptoms as honestly and accurately as possible. The doctor will
need to know about other symptoms that may distinguish angina from other
conditions, such as esophagitis, pleurisy, costochondritis, pericarditis, a
broken rib, a pinched nerve, a ruptured aorta, a lung tumour, gallstones,
ulcers, pancreatitis, a collapsed lung or just be nervous. Each of the above
mentioned is capable of causing chest pain. A patient may take a physical
examination, which includes taking the pulse and blood pressure, listening to
the heart and lung with a stethoscope, and checking weight. Usually an
experienced cardiologist can distinguish it as a cardiac or noncardiac situation
within minutes. There are also routine tests, such as urine and blood tests,
which can be used to determine body fat level. Blood test can also tests for:
Anemia - where the level of haemogoblin is too low, and can restrict the supply
of blood to the heart. Kidney function - levels of various salts, and waste
products, mainly urea and creatinine in the blood. Normally these levels should
be quite low. There are other factors which can be tested such as salt level,
blood fat and sugar levels. A chest x-ray provides the doctor with information
about the size of the heart. Like any other muscles in the body, if the heart
works too hard for a period of time, it develops, or enlarges. An
electrocardiogram (ECG) is the tracing of the electrical activity of the heart.
As the heart beats and relaxes, the signals of the heart's electrical activities
are picked up and the pattern is recorded. The pattern consists of a series of
alternating plateaus and sharp peaks. ECG can indicate if high blood pressure
has produced any strain on the heart. It can tell if the heart is beating
regularly or irregularly, fast or slow. It can also pick up unnoticed heart
attacks. A variation of the ECG is the veterocardiogram (VCG). It performs
exactly like the ECG except the electrical activity is shown in the form of
loops, or vectors, which can be watched on a screen, printed on paper, or
photographed. What makes VCG superior to ECG is that VCG provides a
three-dimensional view of a single heart beat. DRUG TREATMENT Angina patients
are usually prescribed at least one drug. Some of the drugs prescribed improve
blood flow, while others reduce the strain on the heart. Commonly prescribed
drugs are nitrates, beta-blockers, and Calcium antagonists. It should be noted
that drugs for angina only relief the pain, it does nothing to correct the
underlying disorder. Nitrates Nitroglycerine, which is the basis of dynamite,
relaxes the smooth fibres of the blood vessels, allowing the arteries to dilate.
They have a tendency to produce flushing and headaches because the arteries in
the head and other parts of the body will also dilate. Glyceryl trinitrate is a
short-acting drug in the form of small tablets. It is taken under the tongue for
maximum and rapid absorption since that area is lined with capillaries. It
usually relieves the pain within a minute or two. One of the drawbacks of
trinitrates is that they can be exposed too long as they deteriorate in
sunlight. Trinitrates also come in the form of ointment or "transdermal"
sticky patch which can be applied to the skin. Dinitrates and mononitrates are
used for the prevention of angina attacks rather than as pain relievers. They
are slower acting than trinitrates, but they have a more prolonged effect. They
have to be taken regularly, usually three to four times a day. Dinitrates are
more common than trinitrates or tetranitrates. Beta-blockers Beta-blockers are
used to prevent angina attacks. They reduce the work of the heart by regulating
the heart beat, as well as blood pressure; the amount of oxygen required is
thereby reduced. These drugs can block the effects of the stress hormones
adrenaline and noradrenaline at sites called beta receptors in the heart and
blood vessels. These hormones increase both blood pressure and heart rate. Other
sites affected by these hormones are known as alpha receptors. There are side
effects, however, for using beta-blockers. Further reduction in the pumping
action may drive to a heart failure if the heart is strained by heart disease.
Hands and feet get cold due to the constriction of peripheral vessels.
Beta-blockers can sometimes pass into the brain fluids, and causes vivid dreams,
sleep disturbance, and depression. There is also a possibility of developing
skin rashes and dry eyes. Some beta-blockers raise the level of blood
cholesterol and triglycerides. Calcium antagonists These drugs help prevent
angina by moping up calcium in the artery walls. The arteries then become
relaxed and dilated, so reducing the resistance to blood flow, and the heart
receives more blood and oxygen. They also help the heart muscle to use the
oxygen and nutrients in the blood more efficiently. In larger dose they also
help lower the blood pressure. The drawback for calcium antagonists is that they
tend to cause dizziness and fluid retention, resulting in swollen ankles. Other
Medications There are new drugs being developed constantly. Pexid, for example,
is useful if other drugs fail in severe angina attacks. However, it produces
more side effects than others, such as pins and needles and numbness in limbs,
muscle weakness, and liver damage. It may also precipitate diabetes, and damages
to the retina. SURGERY When medications or any other means of treatment are
unable to control the pain of angina attacks, surgery is considered. There are
two types of surgical operation available: Coronary Bypass and Angioplasty. The
bypass surgery is the more common, while angioplasty is relatively new and is
also a minor operation. Surgery is only a "last resort" to provide
relief and should not be viewed as a permanent cure for the underlying disease,
which can only be controlled by changing one's lifestyle. Coronary Bypass
Surgery The bypass surgery involves extracting a vein from another part of the
body, usually the leg, and uses it to construct a detour around the diseased
coronary artery. This procedure restores the blood flow to the heart muscle.
Although this may sound risky, the death rate is actually below 3 per cent. This
risk is higher, however, if the disease is widespread and if the heart muscle is
already weakened. If the grafted artery becomes blocked, a heart attack may
occur after the operation. The number of bypasses depends on the number of
coronary arteries affected. Coronary artery disease may affect one, two, or all
three arteries. If more than one artery is affected, then several grafts will
have to be carried out during the operation. About 20 per cent of the patients
considered for surgery have only one diseased vessel. In 50 per cent of the
patients, there are two affected arteries, and in 30 per cent the disease
strikes all three arteries. These patients are known to be suffering from triple
vessel disease and require a triple-bypass. Triple vessel disease and disease of
the left main coronary artery before it divides into two branches are the most
serious conditions. The operation itself incorporates making an incision down
the length of the breastbone in order to expose the heart. The patient is
connected to a heart-lung machine, which takes over the function of the heart
and lungs during the operation and also keeps the patient alive. At the same
time, a small incision is made on the leg to remove a section of the vein. Once
the section of vein has been removed, it is attached to the heart. One end of
the vein is sewn to the aorta, while the other end is sewn into the affected
coronary artery just beyond the diseased segment. The grafted vein now becomes
the new artery through which the blood can flow freely beyond the obstruction.
The original artery is thus bypassed. The whole operation requires about four to
five hours, and may be longer if there is more than one bypass involved. After
the operation, the patient is sent to the Intensive Care Unit (ICU) for
recovery. The angina pain is usually relieved or controlled, partially or
completely, by the operation. However, the operation does not cure the
underlying disease, so the effects may begin to diminish after a while, which
may be anywhere from a few months to several years. The only way patients can
avoid this from happening is to change their lifestyles. Angioplasty This
operation is a relatively new procedure, and it is known in full as transluminal
balloon coronary angioplasty. It entails "squashing" the
atherosclerotic plaque with balloons. A very thin balloon catheter is inserted
into the artery in the arm or the leg of a patient under general anaesthetic.
The balloon catheter is guided under x-ray just beyond the narrowed coronary
artery. Once there, the balloon is inflated with fluid and the fatty deposits
are squashed against the artery walls. The balloon is then deflated and drawn
out of the body. This technique is a much simpler and more economical
alternative to the bypass surgery. The procedure itself requires less time and
the patient only remains in the hospital for a few days afterward. Exactly how
long the operation takes depends on where and in how many places the artery is
narrowed. It is most suitable when the disease is limited to the left anterior
descending artery, but sometimes the plaques are simply too hard, making them
impossible to be squashed, in which case a bypass might be necessary. SELF-HELP
The only way patients can prevent the condition of their heart from
deteriorating any further is to change their lifestyles. Although drugs and
surgery exist, if the heart is exposed to pressure continuously and it strains
any further, there will come one day when nothing works, and all that remain is
a one-way ticket to heaven. The following are some advices on how people can
change the way they live, and enjoy a lifetime with a healthy heart once more.
Work A person should limit the amount of exertions to the point where angina
might occur. This varies from person to person, some people can do just as much
work as they did before developing angina, but only at a slower pace. Try to
delegate more, reassess your priorities, and learn to pace yourself. If the rate
of work is uncontrollable, think about changing the job. Exercise Everyone
should exercise regularly to one's limits. This may sound contradictory that, on
the one hand, you are told to limit your exertion and, on the other, you are
told to exercise. It is actually better if one exercise regularly within his or
her limits. Exercises can be grouped into two categories: isotonic and
isometric. People suffering from angina should limit themselves to only isotonic
exercises. This means one group of muscle is relaxed while another group is
contracted. Examples of this type of exercise include walking, swimming
leisurely, and yoga; some harder exercises are cycling and jogging. Weight Loss
The more weight there is on the body, the more work the heart has to do.
Reducing unnecessary weight will reduce the amount of strain on the heart, and
likely lower blood pressure as well. One can lose weight by simply eating less
than their normal intake, but keep in mind that the major goal is to cut down on
fatty and sugar foods, which are low in nutrients and high in calories. Diet
What you eat can have a direct effect on the kind of condition you are in. To
stay fit and healthy, eat fewer animal fats, and foods that are high in
cholesterol. They include fatty meat, lard, sweets, butter, cream and hard
cheese, eggs, prawns, offal and so on. Also, the amount of salt intake should be
reduced. Eat more food containing a high amount of fibre, such as wholegrain
cereal products, pulses, wholemeal bread, as well as fresh fruits and
vegetables. Alcohol, tea and coffee Alcohol in moderation does no harm to the
body, but it does contain calories and may slow the weight loss progress. People
can drink as much mineral water, fruit juice and ordinary or herb tea as they
wish, but no more than two cups of coffee per day. Cigarettes It has been
medically proven that cigarettes do the body no good at all. It makes the heart
beat faster, constricts the blood vessels, and generally increases the amount of
work the heart has to do. The only right thing to do is to quit smoking, it will
not be easy, but it is worth the effort. Stress Stress can actually be
classified as a major risk factor, and it is one neglected by most people. Try
to avoid those heated arguments and emotional situations that increase blood
pressure, as well as stimulate the release of stress hormones. If they are
unavoidable, try to anticipate them and prevent the attack by sucking an angina
tablet beforehand. Relaxation Help your body to relax when feeling tense by
sitting or lying down quietly. Close your eyes, breathe slowly and deeply
through the nose, make each exhalation long, soft and steady. An adequate amount
of sleep each night is always important. CONCLUSION Angina pectoris is not a
disease which affect a person's heart permanently, but to encounter angina pain
means something is wrong. The pain is the heart's distress signal, a built-in
warning device indicating that the heart has reached its maximum workload. Upon
experiencing angina, precautions should be taken. A person's lifestyle plays a
major role in determining the chance of developing heart diseases. If people do
not learn how to prevent it themselves, coronary artery disease will remain as
the single biggest killer in the world, by far.

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