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AM I HAVING A HEART ATTACK?

Chest pain -MI
When Peter  got in the car at 12.30am and drove from the house his wife looked out of the window she thought “he must be going to his mother’s and went back to bed. How wrong she was because Peter aged 65 yrs had woken with pain in the chest and recognised that this was something different and he knew he had to seek medical advice immediately. He drove himself to the nearest hospital and soon was diagnosed with a heart attack and after emergency treatment was transferred to a neighbouring hospital to have a stent inserted.
Peter is retired but a Type A personality ‘on the go’ involved in as many organisations he can fit into his life and certainly not someone to wait for things to happen!
He now puts as much energy into his Cardiac Rehabilitation as he puts into chairing a meeting.

Similarly, when Lucy 39 yrs a research biologist, pregnant with her third child telephoned me one evening and described her heavy central chest pain and how she felt very anxious, sweaty and was short of breath my reaction was to tell her to go straight to A&E and she was also diagnosed with a heart attack and subsequently went on to have a stent inserted. A surprising diagnosis as she was slim, a non smoker and young but nevertheless the presenting symptoms raised the alarm bells.

Likewise, when Dai 56 yrs came to the surgery with the story of increasing heaviness in the chest with breathlessness a week ago after rolling a barrel of beer up to ‘the Club’ as the Brewery lorry had broken down on the hill. He was revived with a glass of brandy but an ECG later demonstrated that he had suffered a heart attack.

In the same way, Bill who was a 60 yrs old bo’sun on a sailing ship and described severe indigestion when at sea, worse on exercise and again on investigation shown to have had a heart attack and subsequently had a quadruple bypass and in due course went back to sea.
In all these cases the patient had that feeling that their pain was different and overwhelmed with anxiety and fear that it may be cardiac.

Even if the pain is not assumed to be cardiac pain initially if other risk factors are taken into account such as in the case of Mrs.Patel, a 65yr old diabetic who had developed some vague chest pain on exercise and was worried, on further investigation was found to have had a ‘silent’ heart attack and subsequently followed up by a triple bypass.

As a medical student we are also told of the unpredictability of the heart and my first tutorial with a cardiologist was that of his examining a patient, reassuring them that there heart was in good order and the patient dying at the bus stop with a heart attack. Most of us are aware of this by hearing of a friend, relative or celebrity dying in the same way, but for the most part there is adequate warning.

All these stories remind us that coronary artery disease is out there and can strike at anytime in many different forms and often the chest pain is not the main feature and can be in different parts of the upper body.
Heart attack

It is for this reasons that doctors have joined together to formulate a scoring system of chest which is based on signs and symptoms which are relatively easy to recognise and can dictate how urgently action should be taken. In all the examples of the above patients presenting with chest pain each person would have scored at least 3 points.

 Components of the Marburg Heart Score
Score component Assigned points

  • Age/gender (female ≥ 65, male ≥ 55). 1
  • Known clinical vascular disease 1
  • Patient assumes cardiac origin of pain 1
  • Pain worse with exercise. 1
  • Pain not reproducible by palpation. 1

1 point is assigned for each score variable. 3 different risk categories are derived:
low risk = 0–2 points; intermediate risk = 3 points; high risk 4–5 points.

If you or someone with you scores >3 points and you strongly suspect they are having a heart attack it is important to act immediately:-

    • Dial 999 and ask for an ambulance if you suspect that you or someone you know is having a heart attack.
    • If the casualty is not allergic to aspirin and it’s easily available, give them a tablet (ideally 300mg) to slowly chew and then swallow while waiting for the ambulance to arrive

The aspirin will help to thin the blood and restore blood supply to the heart.In my early career this life threatening pain could only be treated with very strong painkillers such as diamorphine commonly known as heroin (an important component of my doctors bag at the beginning of my career) and bed-rest and watchful waiting preferably at home.Now for treating Heart attacks there are two main treatment options for people with the most serious form of heart attack; an ST segment elevation myocardial infarction (STEMI):

  • a combination of medication to dissolve the blood clot and restore the flow of blood to the heart (this is known as thrombolysis)
  • surgery to widen the coronary artery, which is usually done using a technique called coronary angioplasty.

To read more about heart attack:-
http://www.nhs.uk/conditions/heart-attack/Pages/Introduction.aspx

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Posted by on February 15, 2014 in Training and Advice

 

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Vascular scaffolds

During the heavy snow in 1980’s I was working as a GP in South Wales and after heavy blizzards I had woken up to find that I was literally trapped in the snow . When I opened the door to go to the coal house to get fuel for my central heating boiler there was a wall of snow blocking my exit and I had to dig a tunnel along the short path to the shed. Having dug myself out the only way I could get to the surgery was by walking up the disused railway line.
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During that time it was challenging in that the only way patients could get to hospital was being airlifted by helicopter. We soon set up an emergency plan to manage our patients. We spoke to patients on the phone and then if appropriate we arranged delivery of medication. Local young men rallied together with their motorbikes and set up a courier service and prided themselves by getting medication delivered in record time whilst able residents cleared paths and roads. At the time there was great enthusiasm regarding CBR(Citizens Band Radio) and they facilitated communication between couriers as well as helping those people who had no telephone or connection. It was interesting because most calls were about getting their sick certificates or their Valium prescriptions!!
When the snow cleared surgeries were busy and I particularly remember one consultation about 2 weeks later.
“Dr when we were cut off the Brains (beer) lorry couldn’t get up the hill to the club and I had to help by pushing a barrel by hand and during that time I had an awful pull”. (A common description which could mean anything) “What do you mean by that?” I asked. He responded immediately with a distorted facial expression,”I had an awful gripping feeling across my chest”,he said, clenching his fist and pressing on the middle of his chest. I don’t know how I got the barrel through the door, good job someone was there to help and I came over very cold and sweaty so Dai, the bar man had to pour me a stiff brandy”.
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( the resounding, stuttering words of Dr Byron Evans, consultant physician & medical tutor in medical school whilst on a ward round came to me, “Listen here,good boys, if ever you hear a man describe a gripping chest pain and he clenches his fist and draws it to the centre of his chest it has to be cardiac” and he repeated it in Welsh with even greater gusto).
I gently explained that to  that he had probably had a heart attack and prescribed some GTN tablets to put under the tongue if the pain should recur as there was no other specific treatment and getting an ECG was not easy to arrange. At that time a study had been shown that a patients survival rate was greater if they stayed at home especially as ambulances were minimally equipped and the nearest hospital was 20miles away and coronary care units had not evolved generally.
If the pain did recur these patients often became more and more incapacitated to the point that they became bed bound and were called ‘cardiac cripples’ I remember one such patient that I visited frequently and every time a new drug appeared in the form of slow release GTN he was willing to be the ‘guinea pig’ I got to know him very well and on the visits we used to discuss the many photos of pigeons he had decorating his living room and talk about the ins and outs of rearing racing pigeons and where he used to ‘toss’ them.
It was about this time that cardiologists were beginning to perform angioplasties far away in London and if I wanted to refer a patient for an angiogram and or angioplasty they had to travel to London. Many people were fearful of going as several had not come back or returned having had a stroke.

It was not until 1986 that bare metal stents(BMS)were implanted into the coronary arteries.
Since that time preventative measures and treatment has evolved so that peoples lives have been extended and the quality of life improved. Patients at risk are now actively encouraged to change their lifestyle – smoking cessation, low fat diets and regular exercise and medicines such as statins and beta-blockers have decreased mortality by as much as 25%. Investigation by angiogram has led to better understanding of coronary artery disease.
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From 1994 implantation of stents has become common place and several generations of bare metal stents (BMS) have been developed often using cobalt chrome alloy.
The permanence of these metallic stents is not considered ideal as they can induce late clotting (thrombosis).
Also, although these stents are highly successful and most people have had significant improvement of symptoms the rate of restenosis (re-narrowing of the treated artery) causes limitation and often results in having to repeat the procedure.

This has led to the development of the DES (drug-routing stents) in 2003. These stents are coated with a special material that release (elutes) a drug(such as paclitaxel, sirolimus or tacrolimus) over a period of 30-90 days in order to reduce restenosis. The polymer coating degrades by the time the drug has been released and the metallic structure remains. DES are more expensive than BMS and are not necessarily superior in terms of reducing death, heart attack or thrombosis. According to NICE, the decision to use either a BMS or a DES should be based on the anatomy of the target vessel and the symptoms and mode of the disease.

During the past 3 yrs Bioresorbable stents (BVS), also referred to as vascular scaffolds, represent a new concept in stents for treating coronary artery disease. Stents are vascular scaffolds that are used to hold open a blocked vessel to restore blood flow to the heart.
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Bioresorbable stents are designed to slowly disappear over time, leaving patients with a treated vessel free of a permanent implant. With no material left behind, the vessel has the potential to return to a more natural state and function reducing the risk of late thrombosis. Other advantages may include:
 A reduction in the risk of bleeding complications which can be caused by anti-clotting treatments.
Anti-clotting therapy, with two anti-platelet drugs, is given after a stent is implanted, and it may be that bioresorbable stents require a shorter period of this treatment because of resorption of the device. However, some patients may still need long term anti-clotting treatments because of their underlying heart condition.
 Patient acceptability. Some patients may prefer a temporary implant rather than a permanent one.

Five bioresorbable stents are in various stages of development. So far, clinical studies are encouraging and have shown that bioresorbable stents may offer an additional option to current stents.

On September 25th 2012 Abbott announced that Absorb™, the world’s first drug eluting bioresorbable vascular scaffold (BVS), and it is now widely available across Europe and parts of Asia Pacific and Latin America. Absorb is a first-of-its-kind device for the treatment of coronary artery disease (CAD).
We are awaiting long term follow up………..

If you want to find out more patient information about angioplasty and insertion of stents use the following link:-
http://www.bhf.org.uk/heart-health/treatment/coronary-angioplasty-and-stent.aspx

 
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Posted by on October 24, 2013 in Training and Advice

 

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C-r-y

imageOne early morning in February 3 years ago the phone rang and it was the wife of our Best man at our wedding. She was letting us know that she had woken in the night to a strange sound and following attempts at resuscitation by herself and the ambulance crew he had died suddenly. He was a handsome,highly intelligent,charming doctor/dentist/medical director of a pharmoceutical company who had been negotiating with NICE to accept Aricept as a treatment for Dementia.He had also been training for his 7th full marathon which he had taken part in and raised thousands of pounds for leukaemia following the death of his son’s best friend at the age of five.It was unbelievable and a total shock to all such a loss of someone so special. The night before he had been listening to opera with friends singing along with gusto and passion as he was also a musician, a pianist with talent.The funeral was an amazing musical tribute and those who spoke talked about his life with humour and sadness. Afterwards, his friends and colleagues commented that he had seemed the healthiest of everybody and as we chatted agreed it would have been a great party but it lacked one person. He was an ordinary East End lad made good commonly known as ‘Paul boy’! His only fault was that he was a Tottenham supporter which meant many an Saturday afternoon or a Boxing Day was spent in raucous banter whilst ‘the lads’ watched their rivals play – nothing more exciting than a London Derby!
This was an adult sudden cardiac death (SCD)as there was no evidence of disease on examination of his body after death and it was presumed death was due to sudden cardiac arrest,when the heart abruptly and without warning stops pumping.
Ironically, the week after he died the drug was passed!

I was reminded of this when a young attractive 25year old lady attended surgery recently devastated as she had lost her young partner in the same way. This young man had died suddenly without warning and his young partner and family had been left devastated.
She then told me that his mother had become very keen to support the charity CRY was founded in 1995 to raise awareness of conditions that can lead to young sudden cardiac death (YSCD); sudden death syndrome (SDS); SADS. She was also taking part in the CRY Heart of London Bridges Walk 2013 on 7th July. There main reason for supporting this charity is that it funds screening of anyone who could considered at risk as shown on the link. What a brave lady, the love she had for this man was tangible and this family had also lost someone very special whose life had just begun. The family are keen to support this charity as it raises money to screen anyone at risk and support research projects aswell as support bereft families.

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http://www.c-r-y.org.uk/general_information_on_cardiac_s.htm

CRY holds ECG screening clinics for those aged 14 to 35 at a number of established locations around the UK including Belfast, Cardiff, Colchester and London.The CRY mobile screening unit facilitates various screening events at other locations in the UK – often organised by CRY supporters. Details of where these clinics are and how to book are on the website.

What happens when sudden cardiac death(SCD) occurs
When SCD occurs, no blood can be pumped to the rest of the body. It is responsible for half of all heart disease deaths.
Sudden cardiac death occurs when the heart’s electrical system malfunctions. It is not a heart attack (also known as a myocardial infarcation). A heart attack is when a blockage in a blood vessel interrupts the flow of oxygen-rich blood to the heart, causing heart muscle to die. So if the heart can be compared to a house, SCD occurs when there is an electrical problem and a heart attack when there is a plumbing problem.
The most common cause of cardiac arrest is a heart rhythm disorder or arrhythmia called ventricular fibrillation (VF). The heart has a built-in electrical system. In a healthy heart, the sinoatrial node, the heart’s natural “pacemaker” triggers the heartbeat, then electrical impulses run along pathways in the heart, causing it to contract in a regular,rhythmic way. When a contraction happens, blood is pumped.
But in ventricular fibrillation, the electrical signals that control the pumping of the heart suddenly become rapid and chaotic. As a result, the lower chambers of the heart, the ventricles, quiver or fibrillate instead of contracting, and they can no longer pump blood from the heart to the rest of the body. If blood cannot flow to the brain, the brain becomes starved of oxygen, and the person loses consciousness in seconds. Unless an emergency shock is delivered to the heart to restore its regular rhythm using a machine called a defibrillator, death occurs within minutes. It’s estimated that more than 70 percent of ventricular fibrillation victims die before reaching the hospital.
When CPR and an AED (automated external defibrillator) are used together, the chance of survival following a cardiac arrest goes up to 50%, a ten-fold increase over CPR alone.

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This is why you may see Automated External Defibrillator (AED) machines are being hung on walls in supermarkets or other public places. I have frequently seen them in French supermarkets and hyper stores.
It is amazing that the nearest limited access AED is in Twickenham in a fitness club and the nearest 24 hr public access AED machine is outside an accountants office. To see the location of AED machines click on the link below:-
http://www.aedlocator.org/AEDLocations.php
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Who should be screened?
It is recommended that screening is requested via your GP if there have been any young sudden deaths in the family. Or if there are symptoms of:

Chest Pain (exercise related)
Severe Breathlessness
Palpitations
Prolonged Dizziness
Fainting/Blackouts

This checklist has been designed to help you determine whether you have a heart rhythm problem. If you have more than one of the symptoms below, see your GP.

    • Have you fainted or passed out during exercise, while emotional or when startled?
    • Have you ever fainted or passed out after exercise?
    • Have you ever had extreme shortness of breath during exercise?
    • Have you ever had extreme fatigue associated with exercise (much more so than others of your age and level of fitness)?
    • Have you ever had discomfort, pain or pressure in your chest during exercise?
    • Has a doctor ever ordered a test for your heart?
    • Have you ever been diagnosed with an unexplained seizure or fit?
    • Have you been diagnosed with epilepsy that fails to respond to medication?
    • Have you ever had exercise-induced asthma that medication didn’t control well?
    • Are there any family members who had a sudden, unexpected, unexplained death before age 50 (including cot death, car accident or drowning)?
    • Are there any family members who died suddenly of heart problems before they were 50?
    • Are there any family members who have had unexplained fainting or seizures?
      Do you have any relatives with the following conditions:
      Hypertrophic cardiomyopathy: thickening of the heart muscles.
      Long QT syndrome: a condition that results in a very fast, abnormal heart rhythm, which can cause fainting.

What is happening by way of research?

VeniceArrhythmias, a biannual meeting started in 1989 and, year after year, has become one of the most important international congresses in the field of arrhythmology with almost 3000 attendees and with more than 400 invited speakers.
As you read many cardiologists and electrophysiologists are preparing their abstracts to be presented at the Venicearrythmia conference next held in October 2013
VeniceArrhythmias, a biannual meeting started in 1989 and, year after year, has become one of the most important international congresses in the field of arrhythmology with almost 3000 attendees and with more than 400 invited speakers.image
At other venues and during the year there will be similar events. It is through these events that there have been major breakthroughs in screening and prevention of sudden death.Research in the channelopathies and cardiomyopathies is progressing rapidly and in the future it is expected that the majority of the genes involved will be discovered.
In the future, it may also be possible to diagnose all carriers easily – even in those people who have a normal ECG reading. It may also be possible to choose the best treatment based on the type of mutations involved, and the treatment may even be designed based on this knowledge.
In the meantime, better understanding of these conditions and improvements in methods for diagnosis should still result in better management. It is crucial that, when a heart disease such as a channelopathy or cardiomyopathy is diagnosed, all immediate blood relatives should be evaluated by a specialist cardiologist to find out if they have an inherited heart disease.

IMPORTANT
It needs to be considered in sudden death in especially younger adults where the post Mortem fails to provide a cause of death, it is important to send the heart to a pathologist who specialises in this field of medicine and this may be a relative, friend or attending doctor who makes that request.
However, to help this research and appreciate the true incidence there must be a change in the Law.
In the UK, unexplained sudden death is frequently recorded as due to death from natural causes. Until the law is changed and coroners have to refer hearts on to specialists we will not know the true figures. CRY’s fast track coroner / pathology service enables the cause of death in a sudden death case to be established more quickly and accurately than might otherwise happen if left to a local coroner lacking expertise in cardiac pathology.

Tests That Predict Risk

There are a number of tests that can be performed to determine if some- one is in a group that is at high risk for cardiac arrest. These include:
Echocardiogram – a painless test in which ultrasound waves are used to create a moving picture of the heart. The test can measure the strength of the heart’s pumping function (ejection fraction) and identify other problems that may increase a person’s risk for SCD.

Electrocardiogram – A painless test in which electrodes are attached to the patient’s chest to record the electrical activity of the heart in order to identify abnormal heart rhythms. Certain arrhythmias could point to an increased risk of SCD.imageHolter monitor – A cell phone-size recorder that patients attach to their chest for one to two days, recording a longer sampling of their heart rhythm. After the recorder is removed, the tape is analyzed for signs of arrhythmia.
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Event recorder – a pager-sized de- vice that also records the electrical activity of the heart over a longer period of time. Unlike a holter moni- tor, it does not operate continuously. Instead, patients activate the de- vice whenever they feel their heart beating too quickly or chaotically.
Electrophysiology study (EPS) – This test is performed in a hospital. A local anesthetic is used to numb areas in the groin or neck and thin flexible wires called catheters are
advanced through veins into the heart under x-ray to record its electrical signals. During the study, the electrophysiologist studies the speed and flow of electrical sig- nals through the heart and paces the heart to see if arrhythmias can be induced. The physician can also determine if a patient has had a prior heart attack or evidence of prior heart damage without know- ing it. All of this information can help determine whether the patient is in a group at higher risk for SCD.There is another interesting device
The AliveCor Heart Monitor app is designed for medical professionals, patients and health conscious individuals to record, display, store and transfer accurate single-channel electrocardiogram (ECG) rhythms. These recordings could be saved on the mobile phone or shared with others (such as your doctor) via email. The app is CE-mark approved.
imageThe Heart Monitor snaps onto your iPhone 4 or 4S like a case and wirelessly communicates with the app on your phone. No pairing between your iPhone and the Heart Monitor is required. The free AliveECG app will be available for download from the Apple App Store when you receive your Heart Monitor. Once in the app, create a free account and you’re ready to begin recording ECGs. It’s that easy to get started. http://www.AliveCor.com provides you with anytime, anywhere, fully secure, online access to all of your ECGs. Once you have the Heart Monitor and the AliveECG app you can create an account that gives you access to your ECG data.

Prevention

There are a number of things people can do to decrease the likelihood of becoming a victim of sudden cardiac death. To begin with, living a “heart healthy” life can help reduce the chances of dying of cardiac arrest or other heart conditions. This includes ex- ercising regularly, eating healthful foods, maintaining a reasonable weight, and avoiding smoking.
Treating and monitoring diseases and conditions that can contribute to heart problems, including high blood pressure, high cholesterol, and diabetes, is also important.
Finally, for some patients, preventing sudden cardiac death means controlling or stopping the abnormal heart rhythms that may trigger ventricular fibrillation.

Treating arrhythmias is done in three ways:

Medications – Medications, includ- ing ACE inhibitors, beta blockers, calcium channel blockers, and antiarrhythmics, can control abnormal heart rhythms or treat other conditions that may contribute to heart disease or SCD. But taking medication alone has not proved to be very effective in reducing cardiac arrest. These medications are sometimes taken by patients who also have an ICD, in order to reduce how often it fires.

Implantable cardioverter defibrillators (ICDs) – These devices have been very successful in preventing sudden cardiac death in high-risk patients. Like a pacemaker, ICDs are implanted under the skin. Wires called leads run from the ICD to the heart, and the device monitors the heart to detect any abnormal rhythms. If a dangerous arrhythmia is detected, the ICD delivers an electrical shock to re- store the heart’s normal rhythm and prevent sudden cardiac death. The ICD can also act like a pacemaker if the heart is beating too slowly.

Catheter Ablation – In this technique, radiofrequency energy (heat), cryotherapy (freezing), or other energy forms are used to destroy small areas of heart muscle that cause the dangerous, rapid heart rhythms. The energy is delivered through catheters that are positioned through the veins or arteries to the heart. Catheter ablation is sometimes done in patients who have an ICD to decrease the frequency arrhythmias the number of ICD shocks.
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If anyone has any particular concerns Dr Livingston has a special interest in this condition and is very knowledgable and would be pleased to discuss any related problem.

Posted by Dr Bayer

 
 

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