Fixing broken hearts

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 ill-treated 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 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 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 drug-eluting 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 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 heart-lung 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…

Exercise

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

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.

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.’

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).