BRITISH BROADCASTING CORPORATION 听
RADIO SCIENCE UNIT听
CHECK UP 6. - Angina听
RADIO 4听
THURSDAY 09/09/04 1500-1530听
PRESENTER:
BARBARA MYERS听
CONTRIBUTORS:
SIMON DAVIES听
PRODUCER:
PAULA MCGRATH听听听
NOT CHECKED AS BROADCAST
MYERS
Hello. To use the cliche - it is one of the triumphs of modern medicine - clogged up arteries miraculously unblocked using minimally invasive surgery or replaced altogether by nice clean smooth blood vessels in a coronary by-pass operation. Well both these procedures have excellent results and have been an absolute life-saver for hundreds of thousands of people - former American presidents included. But if you have symptoms of hardening of the arteries, angina is the catch-all word we're using here, there are all sorts of treatments to consider - you can reduce the risks of further narrowing and blocking the arteries, which could cause a heart attack, by lifestyle changes, that would reduce cholesterol and blood pressure. There's a whole range of drugs which will do exactly the same thing. But before you start on any medical treatment you need to be diagnosed - so what tests can you have? Is it enough to take up the invitation to go to the local chemist for a blood test, for example?听
Well, call us now to put your questions to Dr Simon Davies, who's a consultant cardiologist from the Brompton Hospital in London.听
Simon, just help us to start with, a bit of clarification here on the terms we're using. Is angina a symptom or is angina the disease?听
DAVIES
Well you're quite right Barbara, I think we in the medical profession often slightly blur the meanings. Strictly angina means the symptom that comes from the heart when the heart itself doesn't have enough blood supply. And the symptom is classically pain in the front of the chest, which may go down the left arm. But because this is almost always due to furring up of the coronary arteries we tend to use angina as a short-hand for cholesterol furrings in the arteries.
MYERS
Alright, that's very clear to me, thank you very much. Let's move to our first caller who, I guess, has symptoms or has some concern about the state of his arteries, he's Mr Edwards, he's in Newcastle. Hello Mr Edwards.
EDWARDS
Hello, thank you. I've had a problem for approximately 15 years and I've been on the Suscard Buccal, having the one under the lip - GNT under the tongue. It didn't do anything and then they put me on to the longer term one after increasing the [indistinct word] on the Suscard Buccal. I'm on the 5 milligram and I take it - literally have it around the clock. If I wake up on a morning I'm okay, half an hour later it starts and then I have it right the way through until I go to sleep, sometimes I wake up through the night and have a problem then. I'm being treated for diabetes for 10 years and they're more concerned about that side of it because I've problems with liver gallstones as well and possibly the right hand kidney. But they put me, in addition to that, they've put me on the Diltiazem - supplementing the Suscard Buccal. Again I appreciate that once you're on medication long term the effects start to wear off and that. But two years ago the diabetic consultant had me for a heart scan and they just said your heart's fine, end of story, all the doctor's done has increased the strength of the medication saying [indistinct words] ischaemic heart disease, so I'm rather confused, particularly after hearing about Bill Clinton.
MYERS
Oh yes a lot of people ...
EDWARDS
I've got arthritis in all of the joints as well.
MYERS
Okay quite a complex story, can you pick out of that Simon what perhaps would be helpful for Mr Edwards and in fact for other listeners to hear about angina and what can be done?
DAVIES
Well I'm really sorry to hear you're having quite so much trouble with the angina. I'm afraid it is one of the problems with diabetes - diabetes tends to make the cholesterol levels in the blood high and the sugar also tends to make the cholesterol more sticky, literally chemically more sticky and more likely to fur up the arteries. So I'm afraid this isn't an unusual story. But the level of angina you're having and pain on and off all day is a bit unusual. The nitrates - and you mentioned Buccal Suscard - are very old fashioned tablets but very powerful - they open up the arteries and they literally make the arteries bigger and let the blood go down. And the Diltiazem - which is a group of drugs called calcium blockers - they also slow and steady the heart rate and open up. And often these and other tablets are sufficient. There's a minority of cases in whom the narrowings are just so bad that either an angioplasty with a balloon or a full by-pass is needed. But if you've had a heart scan I would hope that would have picked it up.
MYERS
Okay, I'm not sure we can say much more at the moment to Mr Edwards on that but let's move to another caller, if we may, and all of these calls of course going to be around this concern about whether there's further treatment. And Andy Hanratty in Chester is interested in treatment. Because you need treatment or you're concerned you should have treatment - what's the story Andy?
HANRATTY
No it's really - I'm 39 years old and as we hurtle towards middle age I'm interested in any of the investigative techniques or diagnosing avenues which you can have from the GP - just to say whether you do have any form of furring or whether you do have any decreased coronary function. It's particularly relevant for me because I had a good old dose of pericarditis about seven years ago and whilst I was being diagnosed with that I noticed they had some fabulous diagnostic equipment there - sort of dopplersonographs [phon.] etc. to detect blood flow and blood moving in the heart etc. And I wondered as prevention is the better part of cure if there was any form of diagnosis technique that is made available to people from their GPs, just to see what their current state of play is with their heart - some form of coronary MOT as it were?
DAVIES
Well Andy I'm sorry to hear about the pericarditis because I know from my own experience that can be really excruciating. But fortunately a viral infection in the membranes round the heart, which is pericarditis, doesn't put you at any increased risk of coronary artery disease. And what that really depends on is your family and your lifestyle and your age. So if you were in your 50s and 60s and lots of close relatives had heart disease around the same age and above all if you were a smoker or a diabetic then it would be really worth looking into it with tests. Whereas if you're a clean living 39 year old, and I know what you mean about hurtling towards middle age, but 39 isn't bad, then your risks are low and it probably isn't worth a test. The tests that there are, are things like running on a treadmill and recording an ECG and you know the spiky pattern of an electrical ECG that you see. The ECG when you're standing still is often normal, it's when you exercise and you push yourself by running fast on a treadmill that the abnormality comes to the surface. So that's quite a standard test. But again I'd emphasise if you're 39 and you don't have any risk factors for coronary disease - you're not a smoker, you don't have a family riddled with it - I'm actually not sure that this is a very helpful test for you because it's so likely to be normal anyway.
MYERS
It's interesting though you mentioned a function test, but I wonder and I wonder if Andy was perhaps driving at that, that these angiograms are an example where you can see the fatty build up in the arteries. I mean shouldn't we all perhaps have an opportunity, at whatever age, perhaps just to see what our arteries look like? I mean after all if you're getting a build up wouldn't you want to know?
DAVIES
I guess so. But it's not just a resource or an availability issue. The gold standard still is an angiogram. Now this is a very old fashioned test of feeding a very fine tube along the blood vessels actually into the heart and taking pictures with the patient under local anaesthetic. This was first done in about 1929 - it's not a new test. And at a big hospital like the Royal Brompton we would do five to five and a half thousand of these every year, we'll be doing 20 or 30, perhaps 35, people today. But it is an invasive test - tubes are fed - and there is a chance of complications and the complications - the serious complications - about one person in a thousand but that makes you hold off doing it to a 39 year old in whom the arteries are almost certainly going to be normal anyway and that's why we use the running on the treadmill to try and filter people out.
MYERS
Andy I hope that helps you, has that given the answer you were expecting?
HANRATTY
That's great.
MYERS
Okay, thank you very much. Alan Goodridge is in Watford and he does feel he's in the high risk bracket for angina, what's the story Alan?
GOODRIDGE
Yes I'm quite at risk - I've got high cholesterol, overweight, although I don't smoke, but I've got a family history of heart disease. And I want to ask about the role that statins might play in a preventative regime. I've raised it with my GP and he doesn't feel that it's worthwhile but when they become available over-the-counter should I be buying them - some authorities seem to be suggesting that we should all be taking them?
MYERS
Simon, fill us in on the back story here of statins.
DAVIES
Yeah. Well there's no doubt that the higher your cholesterol the more your risk of heart disease. What we don't quite know, going the other way, is how low it should be - in other words if you have an almost normal cholesterol does it help to make it yet lower. Now there is some interesting work done from the people in Oxford, particularly, where they've done surveys and big trials and it looks as though the lower the cholesterol the better. Most of us in this country have a cholesterol of four or five, when you say you've got a high cholesterol it might well be six or seven. But if you go to rural China or South America people have cholesterols of about two. So the first point is perhaps almost all of us have a cholesterol that's higher than we necessarily should have, it's usual in our population but it's not normal. Now on that background the statins are very, very powerful at reducing cholesterol. But of course they have side effects and very occasionally they interact badly to cause inflammation in the muscles and that's my only slight concern about putting statins in the drinking water or allowing people to get statins without a prescription.
MYERS
So otherwise you're saying these are really a very good thing indeed?
DAVIES
They are and our target for cholesterol 10 years ago was we only treated the cholesterol when it was higher than about seven and then we treated when it was higher than six and then five and each year the goal posts move, so that the tide is to be much more aggressive with treating cholesterol.
MYERS
Well you say that but obviously Alan's making the point that his GP doesn't want to recommend statins and I have to say there's an e-mail here from Christine who says that her cholesterol was 7.2, which is high, she's got it down with various dietary changes but she feels it should be lower still and her doctor said well yes she could start taking stains but then she's not sure would it make a difference, is there anything more she can do without taking medication - people don't like to be on medication and this is lifelong medication isn't it.
DAVIES
Well I think she's right that lifestyle measures come first and there are several things - the diet isn't just a matter of having a low fat diet, it's a matter of having - and this is much more painful - a sufficient restriction on calories that you are the right weight for your height and sometimes I think people concentrate very much on low fat foods and they're still half a stone, a stone, overweight. And it's really important to get your weight down because most of the cholesterol that's flying around in your blood stream is not cholesterol you swallowed in that chemical form, it's reconverted from all the spare calories that you're carrying around your midriff. So diet isn't just restricting dairy products, it's getting your weight right. And exercise is part of that too.
MYERS
So Alan where does that leave you? Have you got lifestyle changes you can make or would you want to perhaps get a prescription for statins after all?
GOODRIDGE
Well I feel that it's important to lower risks on all fronts wherever possible and when my doctor says to me well you are at risk but it's a low risk - it's only 15% - that's fine for him, he's not running that risk, I am and I think that's an unacceptable level of risk and if statins are available over-the-counter I'm inclined to think I ought to be buying them, despite what he says.
DAVIES
I take your point exactly and I think a 15% risk over 10 years is quite a high risk for the person who's got it. My only note of caution about the statins is there are a few basic blood tests you should have first. For example, having an under-active thyroid is quite a powerful cause of a high cholesterol but having an under-thyroid exposes you particularly to this muscular side effect of statins, so we would always check the thyroid for example, a very simple blood test, before prescribing a statin. Now that's my only caution about them being available over-the-counter.
MYERS
If you found those side effects would you perhaps just stop taking the statins and would they go?
DAVIES
They should do, they should do and most people are perfectly fine to take statins anyway and if they get some aches and pains they can be stopped but very, very occasionally there can be a serious side effect that doesn't get better and that is to do with the low thyroid. So that's the reason for having some very simple blood tests before swallowing them.
MYERS
Okay, hope that's been helpful Alan, we'll have to move on, if we may, to Alison, who's waiting patiently in Glasgow. Alison, your question please for Simon Davies our cardiologist today.
ALISON
Hello. I'm actually calling about my father. He's otherwise a very fit healthy 68 year old, he does have a family history of heart disease, like many people in the West of Scotland and three years ago he was diagnosed with angina. He had an angiogram and that revealed that one artery to his heart is completely blocked but apparently the others are quite unaffected - they have very good blood flow. His consultant recommended that there was really no further intervention required. But I was wondering why - why is he not a candidate for angioplasty because it does seem [beep] his quality of life, he is a very active person and it does restrict him.
MYERS
Yes, if it's good enough for Bill Clinton why not for Alison's father?
DAVIES
Absolutely. Well I think the key is you said it restricts his quality of life then I think there is a good case for angioplasty. There are in most people three coronary arteries - roughly [indistinct word] size and importance supplying the heart. And what determines the future is how many of the three are narrowed or blocked and if all three are badly narrowed or in fact blocked that's a situation where by-pass surgery is excellent. But surprisingly if only one or two are narrowed, as long as a third artery is normal it often compensates for the fact the others are narrowed and many, in fact most people, with single vessel disease or double vessel disease will get along perfectly well on tablets.
MYERS
But Alison, I think you're saying, your dad's not getting on so well.
DAVIES
So absolutely ...
ALISON
Well he has - he has one of those GTN sprays but he does find that he uses it a fair bit. It's clearly balancing up the risks versus the potential advantage of getting it sorted out once and for all. But I think it's something he himself, if there was a procedure that was on offer, he says he would be keen to go through with it in order to restore his previous level of fitness.
DAVIES
Well that's why I think when we diagnose somebody on an angiogram as having single vessel disease we treat them medically "in the first instance". The let out is that if they have symptoms that are intrusive, what ever it is they want to do they can't do, then absolutely some kind of revascularisation is needed. Now revascularisation - improving the blood supply physically - could either be a by-pass or an angioplasty and with luck when just one is blocked your father would be suitable for an angioplasty. Now to know that depends on the site of the actual x-rays themselves because if it's blocked over a very long length or it's blocked round several sharp bends it may not be physically possible to open it. But we can open most of these now with balloons and drills.
MYERS
Thank you very much, I hope that's helpful Alison. Just give us a little bit of a picture there - you say you can open these, I mean I've got this image of some sort of rod going into the drains, as it were, up the pipes, just what is involved, I mean for a start it's minuscule stuff isn't it?
DAVIES
Well it's a bit like Dynarodding but possibly more fun. This was first done by ...
MYERS
For you or the patient?
DAVIES
Well both I hope. This was something first done by a Swiss doctor in about 1977-1978, so this isn't a particularly new technique. And he had the smart idea that when we feed tubes under local anaesthetics of the heart and inject dye then instead of just taking the pictures and packing up and going home you could down the same tube feed a little balloon - an elongated sausage shaped balloon - that is then deflated and you gently feed it down the artery into the narrowing or blockage and then inflate it and it pushes the stuff out of the way. The bid advance came from carrying on the balloon a little cylindrical sleeve, called a stent, which is generally a metal structure that is expanded and it's forced into the wall of the artery and it stays there and it keeps the artery open and that greatly improves the results of angioplasty. Now there are lots of other tricks - lasers, drills etc. - but 99% of the time a conventional balloon and a little metal stent will do the job.
MYERS
And this is a procedure you do on a daily basis then?
DAVIES
Yeah, and at a centre like the Royal Brompton where we're doing, shall we say, five and a half thousand angiograms and other procedures, about a thousand of those will be angioplasties.
MYERS
We've got a call now, John Carmichael is waiting and I don't know whether we pre-empted his call by talking about the angioplasty procedure. Something that interests you - is it something some thing that you've had?
CARMICHAEL
Yes I had two angioplasties and the first one was seemingly very successful, lasted for six years, but when I had the second one, which only lasted six months, one of the doctors said sort of casually - You'll be back for a by-pass very shortly - and I was in fact back for one six months later. And I just wondered whether angioplasty is really a permanent solution or if everyone is really heading for a by-pass?
DAVIES
I think it depends a great deal on how aggressive the underlying disease is. Now some people will have one or two localised narrowings, the angioplasty for those narrowings could last indefinitely, particularly with stents and particularly with the very modern drug coated stents - which I haven't mentioned - but in the last two years the technology's moved on by another leap and bound. Especially they might manage if they were doing something wrong before - like maybe smoking - and then stop smoking, so you've done something to stop the disease going on. However, there will be patients who carry on smoking or patients whose cholesterol doesn't come down as low as we'd like or people who are just plain unlucky. And then the disease will progress. And it usually isn't that the angioplasty hasn't worked, it's that they then grow a new narrowing further down the same artery. Now that of course can also mean that a by-pass operation won't last indefinitely. So the key thing here is having done an angioplasty or having done a by-pass get the cholesterol down and a good lifestyle.
MYERS
And this picks up on another e-mail, if I can just go to that, from Audrey who says that her husband has just undergone one of these angioplasty's in the last two weeks and she's concerned to know what the prognosis is long term. To an extent you've rather answered that but she's rather shocked because her husband is 57, a non-smoker, he's a regular gym user, he's slim, he has a good diet, his cholesterol level was 5.9 - high average, so called. But what she points out is: "Our experience has shocked us and our friends, we should all be less complacent." We're talking about a disease that actually without the obvious risk factors still can strike.
DAVIES
I think that's right and it must seem terribly unfair when it happens to you and you've been careful about your health. But it's all a matter of probabilities, it's more likely to occur in smokers, much more likely to occur in smokers, but there will be a few people who smoke and get away with it and there'll be people, I'm afraid, who've been very careful and never smoked who run into a problem. When she's asking about the prognosis I think the good thing here is that her husband's prognosis must be excellent because he's a non-smoker, going to the gym, being careful about things. The cholesterol of 5.9 is never that high but presumably he is now on statins on things to bring it down. So I would hope that having had the immediate problem dealt with, the very bad narrowing has been stretched and stented, I would hope he wouldn't get anymore problems.
MYERS
John, thanks very much for your call. Another one - another John in fact - John Gibson who I think is on the phone from France, John hello?
GIBSON
Yes, I just - first of all - I'm 67 years of age and 12 years ago I had a triple by-pass operation and for a long time after that I felt very well but lately I've had angina pain and subsequently I've had an angiogram done here and it was discovered that one of the by-passes was blocked. And the decision was not to do anything physically, if you like, nothing invasive, but to simply add to the already wide spectrum of drugs that I already have - like statins, like erbastatin, like Lopressor - and I'm type II diabetic. Now I was - I should have asked at the time but if you - is it possible to have angioplasty done on a by-pass on the heart graft or not?
DAVIES
Indeed it is John and quite a lot of our workload is opening up by-pass grafts because even with the best care a vein graft may only last 10 or 15 years. So there is a - if you like - a cooperation between the surgeons and the interventionists, there will be times during the natural course of somebody's coronary narrowings when angioplasty's appropriate, then the narrowings may, despite all the drugs, get to the point where they need a by-pass and then 10 years later they may need angioplasty gain. So it's very possible to open vein grafts, although generally the sooner you try to open it after it's blocked, the easier it is - the longer it's been blocked the more solid it is the more difficult it is to open it.
MYERS
Now if John had that procedure would he have to take all those pills that seem to be rattling around?
DAVIES
Yeah, I'm afraid most of our patients do, by the time you've had a small dose of aspirin, which has the most enormous benefits at stopping clots, a statin or something else to lower the cholesterol, some tablets for blood pressure and some tablets like the nitrates or the Diltiazem, we had about earlier, to open up the arteries - yeah I think it's fairly common to be on five, six, seven drugs.
MYERS
But at least you're alive to be on those drugs, this is life-saving stuff isn't it.
DAVIES
I think that's right and I think that cocktail thereby reduces the need to keep coming back and having angioplasties or by-pass surgery. So it is medical treatment plus, from time to time, a bit of dynarodding.
MYERS
Okay, one last very quick call if we may and we'll go to John - another John - I think it is, quick question please.
HUSSELL
Hello?
MYERS
Hello there.
HUSSELL
Hello and good afternoon. Very briefly I'm 67 years of age and about two and half years ago I was put on to the statins by my family doctor and at that time I came across research that was carried out in the States which connected high cholesterol with heart problems and showed that homocysteine levels in those who had had heart attacks was 100%, whereas on the other hand only 20-30% of people suffering from heart attacks had high cholesterol levels. I wonder if you know - can you throw any light on this homocysteine hormone?
DAVIES
Yeah, although unfortunately the story's much less firm than it is for cholesterol. Homocysteine is an amino acid we all have in our blood stream. It tends to be at a higher level when the lining of the arteries is unhealthy, so it's a signal that there's some disease and perhaps some early furring up. Patients who take a vitamin supplement called folic acid it reduces the level of homocysteine in their blood but we don't yet know if that influences what's actually going on in the lining of the artery, in other words is the homocysteine just a signal or does it matter?
MYERS
That you very much. We will have to stop it there, time as ever has run out. My thanks to Simon Davies from the Brompton Hospitals and thanks of course to all our e-mailers and our callers today and indeed throughout the series because this is the last in this current series, we will be though in November. In the meantime there's more information on all the topics that we've dealt with - go to our website, bbc.co.uk, follow the trail to Check Up. And you can call our free and confidential help line, that's 0800 044 044. And if you want more inspiration on how to improve your lifestyle for the good of your heart tune in tonight to the launch of Fat Nation on 大象传媒 television. Bye for now.
ENDS
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