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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 6 - Heart Attacks
RADIO 4
TX DATE: TUESDAY 3RD FEBRUARY 2009 2100-2130
PRESENTER: MARK PORTER
CONTRIBUTORS: MARTIN ROTHMAN
DUNCAN DIAMOND
STEWART GIBBONS
AKHIL KAPUR
PRODUCER:
NOT CHECKED AS BROADCAST
PORTER
Today's programme is all about heart attacks and how they're managed in the 21st Century. I'm at the London Chest Hospital in East London, one of the NHS centres that is pioneering a new form of treatment.
ACTUALITY
DOCTOR
It looks from the cardiogram Mr Gibbons as if this is an artery possibly on the right side of the heart that may have blocked off.
GIBBONS
Where that is?
DOCTOR
Yeah, that's where the acute new changes are.
And that treatment is primary angioplasty - using tiny balloons to open up the blockages in coronary arteries that cause heart attack. Part of the burgeoning speciality of interventional cardiology, which allows doctors to work on the heart, using instruments inserted through arteries in the wrist or groin. And it's a treatment that can stop a heart attack in its tracks.
ACTUALITY
DOCTOR
How that's feeling now Mr Gibbons? Pain all gone?
GIBBONS
Yeah.
DOCTOR
Brilliant.
Up until recently the gold standard for treating heart attack was to give clot busters - drugs that can dissolve blockages and restore normal blood flow to the heart muscle if given quickly enough. Something the NHS does well. Last year three quarters of heart attack victims received clot busters within 60 minutes of calling for help. But they don't work for everyone. Around a third of cases don't respond.
Primary angioplasty goes a step further. Instead of using drugs to clear the blockages doctors pass a fine wire and balloon into the coronary arteries and stretch out the narrowing by inflating the balloon. If all goes well blood flow is restored immediately, easing pain and preventing long term damage. And once the balloon is withdrawn the narrowed section is held open by a tiny mesh tube called a stent.
Primary angioplasty, to treat heart attack, may be a recent development but the underlying technique isn't new. Balloons and stents have been used to treat angina - that's chest pain caused by gradual narrowing of the coronary arteries - for more than 20 years.
Professor Martin Rothman is director of interventional cardiology at Barts and the London.
ROTHMAN
Since about 1977 the concept of balloon stretching of human coronary arteries in a conscious patient came about after a rather intrepid Swiss German did the first patient. And I have to say that I thought he was crazy when I first heard about it. But then I went off to the States to learn that in 1980. So what's happened is that over the last 25 years or so we've replaced, for a lot of patients, open chest surgery for coronary artery disease or narrowings in the coronary arteries with balloon angioplasty - a technique that is carried out from the femoral artery under local anaesthetic.
PORTER
Because listeners will probably be familiar with coronary artery bypass surgery and that would mean opening the chest up and literally replacing the damaged or blocked coronary arteries.
ROTHMAN
Yes, literally bypassing from using usually a vein from the leg or a naturally occurring artery that's inside the chest cavity and bypassing a blockage, just like you'd bypass an obstruction on a road.
PORTER
But for many people what would have been traditionally done through the chest 20 years ago is now being down through their groin or wrist.
ROTHMAN
Yes in this country we currently do about 120,000 angioplasty procedures, compared to 25,000 bypass - open chest bypass operations for coronary artery disease. So we've gone from zero to 120,000 since 1980.
PORTER
Around six years ago a handful of specialist units, like the one at the London Chest, started testing this approach to relieve the sudden blockages seen in heart attack. It's proved highly successful and the service is now being rolled out across the UK. According to the Department of Health around a quarter of heart attacks in England are now treated with primary angioplasty.
The ambulance service work closely with Professor Rothman's team and will take any patient with suspicious chest pain from the north east of the capital directly to the London Chest.
And it was only a matter of time before an ambulance brought in the first case of the day. Fifty nine year old hairdresser Stewart Gibbons. He's already had one heart attack, so was understandably concerned when he developed chest pains again.
GIBBONS
I had my chiropodist come to me this morning about 10 o'clock, he done my feet and when I was sat there I kept getting chest pains and he'd often joked about not another heart attack. And then when he left I sort of made a cup of tea and I sat there and I thought hang on a minute this is the heart attack, because I had one three years ago, and I thought no, I'm going to go back to bed, I'll sleep this one off. And it's burning, it aches, the chest is like it's being trodden on, pain up the arm, feel sick, you sweat and then you still say no this is not a heart attack, I'm going to get on with my job - because I'm a hairdresser. And anyway I thought no, you know I couldn't find the number for the - I know you can dial 999 but I thought I'm just going to get out of this house because I'm going to die. So I ran literally to the corner, which is my GP, because I still had said to myself no this is not a heart attack, I didn't want to go through all this again, you understand what I mean, I thought I'd go up to the GP and he'd give me something and I'd come back and do my work. I mean it's all inconvenience isn't it, terrible today.
PORTER
By lunchtime Stewart was being wheeled into the operating theatre where cardiologist Duncan Diamond was waiting for him.
ACTUALITY
DIAMOND
Now what we're going to do first is take some pictures of the left side of the artery Mr Gibbons, okay if you hear the x-ray machine whirring .... nice breath in Mr Gibbons, hold your breath. Breathe away. Breathe normally.
Stewart is lying on his back and will remain fully conscious while Dr Diamond inserts a small hollow tube into the artery in his wrist, through which he'll pass the long wire carrying the balloon and stent. The progress of the tip of the wire, as it heads towards the heart, is monitored by an x-ray machine and the trouble spot in the coronaries is identified by a puff of radio opaque dye that shows up white on the x-ray. It flows rapidly through normal vessels but outlines the cul-de-sac of a blocked one, as Duncan Diamond explained when he went over the images afterwards.
DIAMOND
The first thing we've done - we've gone in through Mr Gibbons's wrist, the right radial artery, which is an artery just below the thumb. And this is a picture of Mr Gibbons's left coronary artery, you see all these branches here, out of interest this is not the artery that causes heart attack, what we normally do is we look at the ECG, the heartbeat trace, identify which artery we think is blocked and when we start we take a picture of the other artery on the other side. And also because this gentleman has had a stent put in previously, he had a procedure done here I think about two years ago, and you can see that here - that's the artery down the front of the heart and if you look carefully can you see that little outline of metal there, that's actually his stent that was placed. Unfortunately he's got a degree of re-narrowing in that stent - you can see it comes down like an hourglass there - but that's not actually the cause of today's problem. He may well need some treatment that on another occasion but you can see the artery isn't blocked, you can see this grey little road kind of all the way down there, that's called the left anterior descending, is the artery that supplies the front of the heart. And as I say he's got a stent in there and unfortunately he's gone on smoking, which is one of the main reasons why he's got recurrent problems. But you can see all these branches here, there's no narrowings or blockages, they look like a spider or an octopus with branches supplying part of the heart muscle.
ACTUALITY
DIAMOND
Now Mr Gibbons we're just changing the catheter round to take a picture of the right sided artery now, which we think is the one that's going to be blocked. Are you okay there?
GIBBONS
Yeah. Shivering - I'm still getting pain.
DIAMOND
Yeah you will do until we get the artery open, it's what you said was indigestion, a lot of people think it's indigestion but it's not, it's heart pain.
So what we'll do is we'll go on to the - where the business end is today and this is now a different catheter placed in the right coronary artery. You can see its shape there coming round, and this dye is travelling down, there's quite a nasty degree of narrowing in the middle part of the artery but if you look carefully you can see there a stump and that's where a blood clot has formed very suddenly and cut off the blood supply to part of the inferior wall, which is the back wall of the heart. And of course what's happening is he's got terrible chest pain because that part of the heart is screaming out for blood, it's short of blood and it hurts, just like cramp really.
ACTUALITY
DIAMOND
Right, the situation Mr Gibbons is that there's the right sided artery divides into two big branches about halfway down and one of the branches is blocked off completely and that's the one we're going to try and reopen, that's what's giving you your pain and causing ECG changes. So I'm going to try and put a wire through that now.
GIBBONS
What a stent?
DIAMOND
Well we put - the stent will hopefully go in eventually. The first thing you do is put a wire through it, get the artery open and then put a stent in.
The treatment of choice is to open the artery, pass the wire, under x-ray control, this wire is very floppy, very fine, it's 14 thousandth of an inch in diameter and we've managed to just turn the artery and guide it with very fine hand movements through the blockage and even without putting the balloon in, just the act of getting the wire has created enough hole in the blood clot that now we can see that artery, that you couldn't see on the previous films but you can see there's a very tight narrowing there.
ACTUALITY
DIAMOND
We'll take a picture there because I think we've actually - I think that's gone through now. Take a picture. Good. The wire's gone through the blockage now, it's a nice big artery there. Your pain should actually start to improve pretty quickly.
So the next step is to get a stent. Now a stent is a metal mesh, it's - if you like it's a high tech biro spring, tightly crimped and mounted on to a balloon. And what we have to do is judge with our eye how wide we think that artery is and what length the narrowing is and we have a whole choice of stents, some of the stents are medicated with a drug on them to prevent re-narrowing but in this situation we often don't use those, for technical reasons I won't bore you with, and also in this gentleman's case he may be facing prostate surgery, so with the bare metal stents the blood thinning tablets he'll need to be on he won't need to take for so long and then he can have his prostate sorted out. So here you can see the stent being placed across the narrowing, the black dots guide us to where we are. We have to do that really carefully, blow the stent up, as the balloon expands the stent is sunk into the wall of the artery and acts, if you like, as scaffolding to hold it open. And lo and behold we've now got a completely open artery, the narrowing has gone. What we like to do is just follow the passage of dye through there to make sure we can see the blush of the heart muscle and we can see the blood coming back through the coronary veins. That's a really good result.
ACTUALITY
DIAMOND
Right that pain should really start to go now.
GIBBONS
Yes it's gone.
DIAMOND
Yep. How's that feeling now Mr Gibbons? Pain all gone?
GIBBONS
Yeah.
DIAMOND
Brilliant.
PORTER
Stewart Gibbons is a committed smoker and this last attack didn't put him off but will this one?
ACTUALITY
GIBBONS
Thank you team, can't say thank you enough, you've saved my life yet again. I'm going to give up smoking now.
DIAMOND
You've got to do that. Have you gone on smoking since your first heart attack?
GIBBONS
I'm a [indistinct word] smoker.
DIAMOND
Well that's probably more important than stopping your aspirin, so I hope really you'll - having had this angi twice you really must, must stop smoking. I know doctors always keep on banging on about this but look what's happened to you, you know.
GIBBONS
I promise.
DIAMOND
So no more fags.
PORTER
And Stewart was back home within a couple of days and he's doing well.
In a viewing room outside the operating theatre the hospital's director of interventional cardiology, Professor Martin Rothman, went through the various options for treating heart attack.
ROTHMAN
Originally we were treating what we called fixed narrowings, which were hard craggy narrowings in coronary arteries made up of atheromatis or fatty material. But we've learned over the years that actually heart attacks, which are the sudden narrowing of a coronary artery or blockage of a coronary artery is actually caused usually by a clot formation of the artery, a blood clot formation in the artery, because of local damage in the vessel wall that's induced that sudden clotting. And originally what used to be the treatment was to be put to bed, given painkillers, given oxygen and latterly, probably in the '90s, given a clot buster drug known as thrombolysis, where you actually give the drug which tried to melt the clot and that would, in some cases, re-establish blood flow. Unfortunately with clot busters about a third of patients in who it was given it would work, about a third of the patients wouldn't get it for one reason or another - they might be elderly, they may have had an operation recently and that would be a reason for not giving clot buster - or about a third of patients would be given the drug and the problem would come back quite suddenly. And so we found with very extensive research that we could actually do an angioplasty in that same situation of clot forming in the coronary artery and using wires and balloons and so on we could actually open the artery in about 98-99% of patients and successfully maintain that opening, so that the patient's heart attack was stopped immediately. And we found that's time critical - you have to do it very quickly.
PORTER
How big is that time window?
ROTHMAN
Well for clot buster drug we maintain it really has to be effective within an hour, so you have to get your chest pain, recognise it's a heart attack, go to somewhere that confirms it's a heart attack and then they need to get the drug in your and it needs to start to work, all within an hour, which is pretty tough. We believe for angioplasty, for opening the artery mechanically, you can actually go much longer and you can go up to about a 150 minutes - two and a half hours - from the time of first onset.
PORTER
What sort of time delay do you have here in this unit, how do you manage?
ROTHMAN
Here at the London Chest Hospital we have an internal guideline which says from the moment you arrive here - and we call it wheels stop of the ambulance - from the moment the wheels stop to the moment of opening the artery has to be under 60 minutes. But actually we manage to deliver most of the time that complete process within 40 minutes and our median time is 52 minutes. So we are well within our own guideline.
PORTER
Is that 24 hours a day, seven days a week?
ROTHMAN
Yes, that's a good question, yes it is - the number I've given you of 40-52 minutes is 24 hours a day, seven days a week, bank holidays, Christmas, New Year. Now we're a 400 staff unit and a lot of people are involved, as you've said, there are usually four people who have to be in the - I'll use the word operating room, in the x-ray room at a time when you're doing the procedure. So there's a lot of staff involved and we had to get agreement for them to be able to come in in time.
PORTER
Because a 400 staff unit, working 24/7, 365 days of the year and you're doing a very good job here but what's happening nationally? If I was to develop my chest pain in the middle of Yorkshire or Cornwall or even in the Midlands am I going to get that sort of service?
ROTHMAN
It's patchy, it's patchy because you're actually in a period of change. The process change started when - I think when we started in 2002 with the pilot and we had to prove the service, others have to recognise the value of the service and now the Department of Health has taken up the call and have recommended that the majority of people with a heart attack should be treated in this way. The benefit for me is that I'm in a big inner city environment in London, I have a population that we serve of 2.2 million and we have an ambulance service that is second to none in the world, that is resourced to deal with a massive number of patients. Now that can't be true if you're in the middle of the countryside, 70 miles from Cambridge, for example, Cambridge is a great centre but you've got to get there. And so the next two or three years will be spent with people overcoming the problems locally to deliver that service for the majority of patients.
PORTER
What are the advantages to the patients and what are the advantages to the NHS?
ROTHMAN
Very good question. The advantage to the patient is that they have their heart attack stopped immediately the wire goes down the coronary artery because we re-establish blood flow. So they may have only had loss of blood flow to the muscle of the heart for 60 minutes or 90 minutes. And stopping the damage to the heart muscle is very important because you're ultimate survival - the length of time you'll live after your heart attack - is actually governed by how much muscle damage is done at the heart attack - the more damage the shorter you live. So cutting the heart attack time and the treatment time, making it very short, re-establishing blood flow, reduces the amount of damage, you live longer. And of course with that also is associated with reducing the side effects of the heart attack - people getting heart failure, more renal failure and kidney problems and so on - are all reduced.
From an economic point of view, which we have to bear in mind today, the normal process for a patient is to come either directly to a major centre where they manage heart attacks, in the way that I've just described with balloons and so on, but more often the patient goes to a local hospital where these services aren't available and in the past a patient would have been admitted to that hospital, got clot buster drug, may or may not have got an open artery at that process and then would have eventually be transferred to a specialist centre for investigation of their heart disease and the decision as to whether they needed an angioplasty or surgery. So the wastage in economic terms of the patient would go to another hospital, be admitted, have cost, wait, wait for a transfer, usually wait longer and wait longer until a bed was available at a specialist centre. We have found that we are saving probably in our own catchment in excess of 拢3 million we understand from establishing this service because all of the district general hospitals, of which there are six in my area, that normally admit these patients no longer admit them, they transfer them directly to us within 20 or 30 minutes.
PORTER
Meanwhile in the operating theatre consultant cardiologist Akhil Kapur was on hand to deal with the next emergency - and it wasn't straightforward.
ACTUALITY
KAPUR
This gentleman had chest pain on Monday, two days ago, am I right in thinking that you thought that that was indigestion? So that's somewhat unusual, it's what we call a stuttering heart attack. Usually the patients that we receive have had their chest pain maybe sometimes as short as an hour or two ago and then we're opening up their arteries within a couple of hours.
PORTER
Another factor that made this case unusual was that the patient - Marco Diaz - was just 27 years old.
ACTUALITY
KAPUR
How you doing Marco?
DIAZ
I'm alright.
KAPUR
Any pain in the chest at all?
DIAZ
Not chest [indistinct words]...
KAPUR
We've found the problem - one of your main arteries has blocked, that was probably the cause of the heart attack. So now that we have the wire down the affected artery we are going to pass a special piece of equipment which can suck out the clot that exists in the artery. We have already given some treatment which is that as we speak hopefully dissolving some of that clot but on its own it may not be completely effective, so we'll use this device to suck the clot out. Then we'll be able to see if there's a narrowing underneath and we will fix that by maybe ballooning it but certainly putting in a metal tube to fix the artery.
KAPUR
So the case that you've just witnessed now was a 27-year-old gentleman, this is very unusual for our heart attack centre, although we do have young people who we need to operate on with primary angioplasty occasionally, it's fairly unusual to have anyone under the age of 40, we obviously see people in their 30s but 20s is very unusual, fortunately. The big lesson here though is this gentleman - and at the age of 27 you'd think well why would he think he was having a heart attack - but he had indigestion on Monday, two days ago, although it was a severe pain he ignored it, he thought it was heartburn and I think there's a big lesson here that that kind of chest pain you should not ignore. Although we have been successful in opening up his artery it was a little bit more difficult than normal, I guess it took us about 30 minutes, sometimes we can do this in 10 or 15 minutes and that was all really related to the gap between his chest pain and his probable - the start of his heart attack two days ago - and now.
What we would always advise anyone who has pain that they cannot identify, that's chest pain, and it presents in all sorts of ways - it can be crushing, gripping, you can feel like you have a heavy pressure on your chest - is if there's any doubt at all you must call an ambulance and you will certainly in London hopefully be presented to a heart attack centre where we can at least make that diagnosis and if you are having a heart attack then we will be able to open up your arteries and limit any damage to the heart.
We're going to do a test now, a scan of the heart, to find out if he has any damage to the heart muscle. I suspect there will be a degree of damage, hopefully we've limited it to a certain extent, but usually to limit that damage fully we have to have the patients with us within six hours really.
PORTER
As Dr Kapur pointed out this type of treatment needs to be offered promptly to have the best chance of success. Meaning people must know what to look out for. Hence recent campaigns encouraging anyone with suspicious chest pains to dial 999. And that's chest pain that's normally felt in the centre of the chest, though it may spread to the neck, jaw, shoulders or arms, is often described as a tightness or heavy pressure, typically lasts more than 10 to 15 minutes and may be accompanied by feeling faint or sick, sweating and difficulty breathing. But have such campaigns meant that hospitals have been swamped with other less sinister causes of chest pain like indigestion? Professor Martin Rothman.
ROTHMAN
In the development of the service we are allow for about a 12-15% of activations, as we would call them, to not be a heart attack. And that's about what we're getting. Now the peculiar thing is that the majority of those patients who come to us who are not having a heart attack are actually having some sort of cardiac problem and would benefit from being seen by a cardiac specialist. And what this service does is it actually means that anybody with a heart attack or suspected of a heart attack gets to a see a consultant cardiologist immediately because one of the rules of service in our institution and everywhere doing angioplasty for heart attack is that the angioplasty is led by a consultant day or night. Now if you went with a heart attack to another hospital and were admitted to the ward you are unlikely to see a consultant cardiologist and you're, if I'm fair, unlikely to see a consultant physician. So this is a, if you like, providing the best care possible to a patient immediately when they need it.
PORTER
Can you demonstrate differences not only in quality of life but in overall survival too? If I was to have my heart attack 10 minutes away from your doorstep compared to let's say a typical district general management in the rest of the country what might the difference of my chance of pulling through be?
ROTHMAN
If we look at the overall survival say at one year, let's make it easy, let's start with the initial survival from the heart attack, so the in hospital survival. You will probably have a significant reduction, that is a halving, of the death rate from this process. If you look at that at six months, a one year, those numbers seem to be consistent. So your chances from having successful angioplasty compared with the old fashioned process, and I call it old fashioned carefully, the old fashioned process of giving clot bluster drug is a halving of the mortality rate - so one in two people will be better off from having this process. Which we need to be careful about knocking thrombolysis or clot bluster therapy because I'm talking about the older process by which clot buster drug was given in an accident and emergency department on recognition. There are situations today where the ambulance when they come to you in your home will recognise a heart attack and give you clot buster drug there and then. Now that is associated with better outcomes than waiting till you get to hospital. So that, for some areas of the country where delivery of care is going to be difficult, difficult to get a patient to a heart attack centre that can do an angioplasty, then the choice will be to use clot buster drug locally for the patient at their home.
PORTER
Can you have both - could you have clot buster at home and then come in for a primary angioplasty?
ROTHMAN
Certainly you can do that but of course you had clot buster drug so you're more at risk of bleeding during the procedure but for those patients for whom clot buster drug doesn't work and you won't know that for 20, 30, 60 minutes you could be in an ambulance on your way to a centre so that when you arrive a decision can be made that oh you know the shake up in the ambulance, the cocktail shaker of the ambulance ride, has helped the clot buster drug to work and so you don't need an angioplasty at the moment versus or it hasn't worked let's go straight and fix it.
PORTER
Martin Rothman, whose team at the Barts and London NHS Trust have been at the forefront of developing a primary angioplasty service that should be rolled out across the UK over the next two to three years. And it's already up and running in many parts of the country, albeit often not always a 24 hour a day, seven days a week service offered by the London Chest. Luckily 27-year-old Marco Diaz lives close by.
DIAZ
The procedure itself wasn't that bad. I felt more pain when they were pushing it further and further and further in, I could really feel it, it went up my arm and into my chest and that's when I said [indistinct words] morphine, then I was fine. The chest pain relief was gone already, so I didn't feel any chest pains when I went in fortunately, obviously the gentleman cleared it up, so it's a lot easier now. I'm going to stay here for four or five days because obviously I'm a young patient, normally most people tend to live after two days, just to keep an eye on me and make sure I'm okay and then hopefully I can go home.
ENDS
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