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A quarterly spotlight on the big questions for your health Part 1 Healthy Hearts

Fixing broken hearts Treatment for heart problems is much less scary than it used to be, says Sophia Martelli

Let’s face it, your heart is pretty important.

Treat it right and your cardiac muscle will expand and contract more than two billion times in your three-score-and-ten lifetime — for humans are outliers of Kleiber’s Law, the ‘golden ratio’ that dictates mammals, birds and amphibians cluster around the billion-heartbeats-per-lifetime mark. But, if you look at the statistics, the human heart might seem the most illtreated organ in the body. Cardiovascular disease, including heart failure, stroke and other life-threatening conditions, causes more than a quarter of deaths in the UK. Coronary heart disease is the country’s single biggest killer, at 74,000 deaths a year: that’s one in six men, and one in ten women.

Part of the reason the figures are so high is because people ignore warning signs. Episodes of chest pain are put down to anything but the heart, because no one wants to go through what they may have seen one or both of their parents go through: invasive, scary surgery (or indeed a strict diet and health regime). ‘Well, things have moved on,’ says Dr Clifford Bucknall of the London Bridge Hospital.

Of the non-emergency patients who visit a cardiologist because of mysterious chest pain, the vast majority will respond well to medication — aspirins, beta blockers, statins or nitrates — or relatively minor interventions such as angioplasty and stenting (about which more later). Most of the time, says Dr Bucknall, ‘these will resolve the whole thing, and a big heart operation won’t be necessary. So the fear factor is inappropriate.’

Initial investigation of most heart issues is a simple matter of an ultrasound, or transthoracic echocardiogram (TTE); sometimes patients will be asked to

run on a treadmill before another TTE is performed for comparison. Similar echocardiograms indicate a clean bill of health, while mismatching ones suggest part or parts of the heart are not receiving enough blood. This requires further inquiry. Thankfully, the introduction of the CT coronary angiography over the past five years has ‘revolutionised’ this process, says Dr Bucknall: in 30 minutes, you can have an X-ray that is effectively a ‘road map’ of the six main arteries and their smaller branches. The angiogram will indicate what interventions will be most appropriate — and the earlier an individual goes to the cardiologist, the

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more chance there is of these interventions being minor.

The most common heart condition is coronary artery disease (CAD), when arteries ‘fur up’. Sufferers can experience angina (heart cramp) or a heart attack.

If CAD is too far advanced to treat with medication, coronary angioplasty and stenting (also known as PCI or PTCA) is the next treatment level up. This procedure is done under local anaesthetic and takes 30 minutes to two hours. A tiny catheter, tipped with an uninflated

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Experts’ tips for a healthy heart

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balloon, is inserted into an artery. At the narrowed or blocked part, the balloon is inflated, squashing the fatty tissue and widening the artery. The balloon also places the stent, a small mesh tube that keeps the artery open. This is made of fabric, metal or a ‘scaffold’ that dissolves when it’s no longer needed, as some stitches do. Patients getting this procedure generally have to take aspirin or another blood-thinning drug for up to a year afterwards, although drugeluting stents release medication into the bloodstream that prevent further blockages or obstructions. The PCI restores blood flow to the heart, relieving angina chest pain; it can also improve the prognosis of patients with unstable angina and can minimise or stop a heart attack (and is a lot less faff than a coronary artery bypass graft).

Ah yes, the coronary artery bypass graft.

You probably know enough about bypass operations to know you want to avoid having one of those. But if arteries are too blocked or damaged, this is what will be recommended: grafting a blood vessel (or two, three or four) from elsewhere in your body to the heart, to improve blood flow. ‘Traditionally, this surgery is performed through the breastbone,’ says Mr Inderpaul Birdi of The Keyhole Heart Clinic. This is a sternotomy, and it involves the breastbone being broken and 12 weeks’ recovery — not to mention your heart being temporarily stopped while a heart-lung machine takes over your vital operations. However, today, some patients can undergo keyhole CABG, where ‘the aim is to provide a perfect heart operation through a smaller incision, which often avoids breaking any bones at all. This allows complete healing in seven days.’

A minithoractomy, for example, accesses the heart through a small incision in the chest to perform hybrid revascularisation (a combination of bypass and stenting procedures); it heals in ten days and leaves a discreet, non-Frankenstein-esque scar. It’s not just for private patients, either: through NHS Choices, you can refer yourself to specialist centres such as the Orwell Suite at the Essex Cardiothoracic Centre, the

Exercise Activity is vital. Build 10,000 steps (or another form of daily physical exercise) into your daily routine.

Diabetes Get your glucose level tested — a simple sugar test will tell you if you have or are at risk from diabetes (which can be controlled with a good diet, exercise and medication).

Cholesterol More than half of UK adults have high cholesterol: find out if you’re one of them. If you are, ‘please attend to your diet’, says Dr Bucknall. ‘More chicken and fish, less red meat, reduce dairy and try to cut out refined sugar.’ Cut down on alcohol, too. ‘But we’re only human, so if you’re good 80% of the time, that’s great.’

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Blood pressure ‘Over a quarter of adults in the UK have high blood pressure, and nearly half of them aren’t on any medication for it,’ says Dr Bucknall. Iain Simpson adds, ‘I wish everyone knew how important is is to have their blood pressure and cholesterol checked to avoid a ticking time bomb.’ Derek Yach, director of the Vitality Institute, says, ‘We are on the cusp of being able to measure blood pressure, glucose and cholesterol levels continuously’, opening the way to much more personalised treatment and prevention.

Smoking ‘If you smoke, stop now,’ says Dr Bucknall. ‘And don’t say no one told you.’ Derek Yach of the Vitality Institute adds that even switching from cigarettes to an e-cigarette can be a good thing for the heart.

Family health Have a clear understanding of your family health history. For those with no one left to ask, science can provide an answer. StoreGene specialises in genetic profiling which will tell you whether you are predisposed to coronary artery disease.

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newest NHS and private facility in the UK, where Birdi practises.

In a very 21st-century leap, CABG can be performed with the aid of a robot.

It’s called totally endoscopic robotically assisted coronary artery bypass (TECAB) grafting, and not all surgeons think it’s a good thing. ‘We do not like the robot and have taken a policy decision not to use it presently at the Keyhole Heart Clinic,’ says Mr Birdi. ‘In the US where robotics are used, the tide has turned and there is now a multi-billion-dollar legal suit market in the area of robotic surgery.’

Coronary artery disease is not the only common problem. Aortic valves can become rigid and stenotic, or can leak.

Treatments, include surgical replacement (by breastbone division and using a heartlung machine while the new valve is positioned); sutureless valves (quicker to replace, and good for high-risk patients who want less time on the heart-lung machine); surgical repair (only available at specialist clinics); and transcatheter aortic valve replacement (TAVI), a huge leap forward in treatment. A form of keyhole surgery via the groin artery, it enables a new valve to be positioned inside the damaged valve.

Then there’s atrial fibrillation — an irregular heartbeat — which reduces heart function and is associated with the formation of clots in the heart (which in turn can cause strokes, if they fly off into the blood circulation and injure the brain).

However, ‘There has been a dramatic advancement in the use of sophisticated pacemakers,’ says Derek Yach.

Now treatments may have bounded ahead, but what would really be ideal is for heart disease not to be such a big killer in the first place. ‘We want to avoid anyone ever going near the hands of a cardiothoracic surgeon, ever needing a heart transplant,’ says Yach. ‘And this requires a greater focus on prevention.

Over the past 50 years we’ve learnt not just what works, but we’ve seen dramatic declines in heart disease death rates particularly in the developed world.’ Let’s continue that trend, shall we? All it takes is following the heartfelt advice of these top cardiologists…

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Welcome to the machine

Understanding how your cardiovascular system works can help you to keep it working well, says Dr Sarah Jarvis The eye may be the window to the soul but the heart is the engine that keeps it blinking. It is a four-chambered, ‘double circulation’ pump system. The heart, arteries and veins carries blood in a constant stream round the body, delivering oxygen to supply the needs of muscles and vital organs and removing waste products which would poison our bodies if they built up.

Blood arrives at the heart via the two vena cavas (the largest collecting veins in the body). These connect to the two chambers of the right side of the heart, from where the blood is pumped at relatively low pressure to the lungs to collect oxygen. It returns to the left side of the heart and is pumped out at high pressure into the largest artery in the body, the aorta, and on to all the body’s organs.

The system is highly efficient, allowing adaptation of blood supply in response to exercise, adrenaline and outside conditions.

But it relies on clear passage through the arteries and veins, and synchronised contraction of the heart muscles. This contraction is triggered by regular waves of electrical activity passed over the heart’s surface. Blockage of an artery supplying blood to the heart results in a heart attack; blockage of an artery supplying part of the brain is a stroke. Abnormalities of the electrical conduction system — the most common in the UK is atrial fibrillation — can cause everything from shortness of breath and palpitations to stroke.

Heart attack, stroke and other diseases of the circulatory system are known collectively as ‘cardiovascular disease’.

Fifty years ago, this accounted for more than half of UK deaths; today the figure is 32 per cent. Death rates in the UK from heart attack have halved in the past decade alone. But despite all the advances we have

made, it’s still the biggest killer in the UK. In 2010, almost 180,000 people in the UK died from cardiovascular disease, about 80,000 from heart attack and 49,000 from stroke. And it doesn’t just strike the elderly and infirm — in 2010, 46,000 people died prematurely of cardiovascular disease in the UK. We need to learn the lessons of history and put them into practice to prevent ourselves from becoming victims.

Much of the progress in preventing cardiovascular disease has come from understanding of the risk factors that predispose people to it. Many of the big research findings were designed to inform public health policies, so are biased towards the general population rather than to individuals. For instance, an individual who stopped smoking might reduce their risk of heart disease by 40 per cent. Doing more exercise might cut their risk by 10 per cent. But if only 10 per cent of a population smoke, and 40 per cent don’t take enough exercise, then for the population as a whole those two changes would carry the same weight.

One of the most important international studies of risk factors for heart disease, the Interheart study, was published in 2004. The study recruited 15,000 patients admitted for a first heart attack in hospital centres in 52 countries, and matched them with controls, people who had not suffered a heart attack. Until then, the consensus was that the relative impact of risk factors for cardiovascular disease varied with country, ethnicity and gender. In fact, it emerged that just nine modifiable risk factors account for over 90 per cent of the population-level risk of having a first heart attack, across gender, geographical and ethnic boundaries.

Of these, the top five (smoking, lipids, hypertension, diabetes and obesity)

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Increase heart-protecting HDL cholesterol levels by 8%

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oss

The top nine causes of a heart attack 1. ApoB/ApoA1 (the balance of two components of cholesterol in the blood)

90%

-10 kilos

Cut blood pressure by about 10/5mmHg (about the same as a daily blood pressure lowering medication)

Cut artery-furring LDL cholesterol levels by 15%

Slice of heart disease risk in population attributed to the nine factors listed above

85%

Heart attack rates fall over 30 years from lifestyle changes in North Karelia project

accounted for about 80 per cent of the population-level risk. Since many of the same risk factors predispose to atrial fibrillation and stroke as well as to heart attack, the implications are far-reaching.

Smoking showed a ‘dose dependent’ effect on risk — for instance, smoking one to five cigarettes a day increased the risk of heart attack by 38 per cent, with a steady positive correlation between cigarettes smoked and risk, up to 900 per cent for 40 a day. Moderate alcohol consumption was found to have a protective effect, but this needs to be balanced against the harmful effects of excess alcohol on the liver and also against the risk of cancer (every two units a day of alcohol increases the risk of bowel cancer by 8 per cent and for women, every unit a day increases the risk of breast cancer by 7 to 11 per cent).

One of the major game-changers for doctors from this study was the finding that abdominal obesity correlated more closely with the risk of heart attack than body mass index, the ration of height to weight traditionally used to measure obesity. Particularly among people whose BMI would be considered normal or overweight, risk of both cardiovascular disease and type 2 diabetes is affected not just by amount of fat but by its distribution.

Intra-abdominal or visceral fat seems to affect the metabolism in a way that other, subcutaneous fat doesn’t. It increases insulin resistance (and thus the risk of type 2 diabetes); predisposes people to the clogging of arteries; and ups the level of immune system chemicals called cytokines, which further increase the risk of heart disease.

Fortunately, stomach fat responds extremely well to weight reduction.

Thus, tackling that middle-aged spread significantly reduces not just the risk of

6. Adverse psychosocial factors 7. Lack of daily consumption

38%

Increase in heart disease risk from smoking one to five cigarettes a day

of fruit and vegetables 8. Lack of daily exercise 9. Alcohol

900%

Increase in heart disease risk from smoking 40 or more cigarettes a day

heart attack and stroke but also of type 2 diabetes — with a reduction in the risk of cancer thrown in as a bonus.

The saturated fat debate has been brought into focus this year with the publication of a study suggesting that reducing saturated fat does not increase the risk of heart attack and that polyunsaturated fat does not reduce it.

But as with so many statistics, it depends on your perspective. Replacing calories of saturated fat with the same number of calories of refined carbohydrates may well not protect you against heart disease. A heart-healthy diet which not only limits saturated fat but also red meat and cakes, pastries and carbonated drinks, and has more fruit, vegetables and fish along with regular intake of mono/polyunsaturated fat and nuts, indisputably does. During a groundbreaking project on a population group in North Karelia in Finland, levels of use of butter on bread dropped from almost 90 per cent to under 5 per cent and the use of mono/polyunsaturated cooking oils increased to 60 per cent of the group. In combination with other factors, including less salt and less smoking, the result was that over a 30-year period average cholesterol levels across the board dropped by 20 per cent and heart attack rates dropped by 85 per cent.

The overall message? Ignore the recent headlines which sought to turn traditional thinking about cardiovascular disease on its head. Exercise regularly, keep your weight down, limit intake of saturated fat and refined carbohydrates and focus on fruit, vegetables, unrefined carbohydrates and mono/polyunsaturated fat alternatives.

Alcohol in small amounts is protective, but with increasing levels the risks outweigh any benefits. As for smoking — do you need to ask?

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2. Smoking 3. Diabetes 4. Hypertension 5. Abdominal obesity

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‘Both my parents died of heart attacks when they were quite young. I am worried that the same thing might happen to me’ Dr Cliff Bucknall

Cardiology consultant, London Bridge Hospital Both my parents died of heart attacks when they were relatively young. I am worried that the same might happen to me. Is there any test that I can have to see how healthy my heart is?

My sympathies. This must be really quite concerning for you. It is certainly important for you to do the simple things like stopping smoking and ensuring that you have a sensible diet and plenty of exercise. In terms of testing, it would be important to know that your blood pressure is normal, that you are free from diabetes and that your cholesterol is low. It’s also important to look at how your weight is distributed. Your waist measurement — the circumference of your waist just above the navel — can determine fat distribution. The risk of cardiovascular disease is higher for women when it’s over 35 inches and for men at over 40 inches. In addition, it is important to be careful not to drink too much alcohol and, of course, to be aware of stress and to try to reduce it. There are also blood tests that can be performed that look at your cholesterol: Apo B and the PLAC test. These give additional information on risks that can be addressed

with diet, lifestyle and medicines. And there is also a screen being launched by Storegene that looks at the genetically transferred risk of heart attack and stroke. It is early days for that test, but it would certainly be appropriate for you to discuss with your GP whether you should take it. It might even be worth asking whether a calcium score would be an appropriate test. This is a specialised CT scan (complex X-ray) that would give a guide as to whether you have laying down of calcium in and around your coronary arteries. Not all individuals in your situation need this test but it is worth discussing.

My GP has found a ‘murmur’. It has never caused me any problems before. Is it dangerous? What should I do about it? I am 49 and otherwise in good health.

The vast majority of patients referred with a ‘murmur’ will be asked to undergo an echocardiogram, a completely painless procedure which uses sound waves to give us a picture of your heart. It uses technology rather like that which is used to look at a developing baby in the womb. Very few patients who are found to have a ‘murmur’ turn out to have anything that requires immediate treatment. Very

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occasionally the ‘murmur’, which is just a noise of blood passing through the heart, is found to be due to a valve that has a problem. This can be of significant concern. The echocardiogram will allow the doctor to either reassure you, or move on to further investigations if needed.

I have recently been to my GP and she has said that my cholesterol is high.

I’m keen to avoid taking medication, but is there a way I can reduce my cholesterol enough that I won’t have to take tablets?

The amount of cholesterol in your system is the sum of how much your body produces naturally, and how much you get from food, minus how much your body uses.

There are things that you can do to control each factor.

Smoking, high blood pressure and raised cholesterol are the big amendable causes of cardiovascular disease, so I would encourage you to stop smoking, to take care not to drink too much and make sure that you are eating healthily. It is important to reduce your intake of foods that contain saturated and trans fats, such as processed meats and processed meals generally, especially those high in sugar. Some foods contain unsaturated fats and these are actually very good for you. Furthermore, some foods, such as green leafy vegetables, can help to lower LDL cholesterol, and are therefore key in a cholesterollowering diet. It is also important to keep your salt intake to a minimum. Exercise plays its part by increasing the activity of certain enzymes in the body that help lower LDL cholesterol levels. I normally recommend that you try diet and lifestyle changes over a sixmonth period and then retest the cholesterol. This may alter things so that statins are not necessary. However, statins are being offered to many more people, and their effectiveness has been well proven, with the vast majority of patients being able to tolerate them well.

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