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Tuesday 4 May 2004 9.00-9.30pm
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CASE NOTES 5. - Heart Attacks


TUESDAY 04/05/04 2100-2130




Someone, somewhere in the UK, has a heart attack every two minutes. Heart attacks kill twice as many women as breast cancer, and three times as many men as lung cancer.

We are winning the battle - the number of people dying from heart attacks has halved in the last 20 years - but the war may never end. The UK has one of the worst records for heart disease in the developed world - a middle aged man living in London is four times more likely to die from a heart attack than his equivalent in Paris.

I'll be finding out what it's like to have a heart attack.

In the gym that particular morning I felt fairly rough and I'd actually finished on the treadmill, I only do a small programme and then I felt that rough - heavy pain, like a JCB crushing your chest, yeah, and sweating like there's no tomorrow.

I'll be following a typical heart attack victim to hospital and back again, to discover the latest treatments on offer.

As well as finding out what you should do if you suspect that you, or someone with you, is having a heart attack - including putting my own resuscitation skills to the test.

My guests today are Dr Katherine Henderson a consultant in emergency medicine from the Homerton Hospital and Tom Quinn, professor of cardiac nursing at Coventry.

Katherine, what actually happens to someone who's having a heart attack?

What is happening is there's an already diseased and narrowed blood vessel suddenly blocks off so that the bit of heart beyond that blood vessel - the muscle wall of the heart which is doing the pumping - is no longer getting the oxygen and the nutrients that it needs and is running the risk of dying - that bit of muscle actually dying.

And this is the coronary arteries we're talking about - a lot of people think blood circulates through the heart and that's where it gets its nutrients but it has its own blood supply does it?

That's right, the heart is the pump that pumps blood round the body but it itself obviously needs to have oxygen and nutrients going to it and it has its own blood vessels and these blood vessels run over the heart and we know their anatomy very well, we know when they've become narrowed - narrowings in them. And when the heart attack actually happens they actually block off.

Tom, why is it such a problem in the UK?

I don't think we're quite clear why but there are several risk factors that are well recognised - smoking, a key one - a quarter of adults in this country smoke, according to the latest figures - diabetes, really important and we're hearing …

That's because we're getting overweight presumably as well.

We're hearing about increased incidents of diabetes because people aren't getting enough exercise, they're eating the wrong diet, we're certainly seeing obesity coming - there's been a lot in the news recently about obesity. Family history's a big one and if you've got a first degree relative who's had a heart attack then you're probably at increased risk of having one yourself.

Well how important is our diet - is it the saturated fats, the animal fats, that we're eating in our diet, is that one of the main reasons?

It's a very important reason and the proportion of the population with elevated cholesterol levels in the blood is pretty high in this country compared to other countries we think.

And Katherine, it can be even more of a problem in some ethnic minorities can't it.

Certainly that's the case and the area that I work has a very high South Asian population and that population we see has a really increased risk of having a heart attack and indeed an increased risk of not doing very well when they have had a heart attack, so the end result is less good for that population as well. Now some of that is to do with accessing care - so actually getting in touch with people when they're running into problems - but some of it is genetic, some of it is the effect of that diet within this country's setting.

In a nutshell how do you know if someone's having a heart attack - what makes you suspect they're having a heart attack?

The most common symptom reported seems to be chest pain or a heavy feeling in the chest - that's the cardinal symptom. People look very, very ill when they're having a heart attack - they look grey, they'll be sweating, they may feel dizzy, they may actually have this feeling they're about to die - that's very common, it's terrifying. And an experienced coronary care nurse or doctor will probably spot a heart attack patient coming in on the stretcher. But there are various tests we would do to confirm the diagnosis - a heart tracing for instance.

Katherine, what should someone do if they think they're having a heart attack, if they get this sort of chest pain?

If somebody's got that sort of symptom the most important thing is to get themselves to help as fast as possible and that actually means practically dialling 999, calling an ambulance, getting themselves to hospital.

Well, as is often the case, 61 year old Malcolm Hawkes's heart attack came out of the blue - it was 8:30 in the morning and he'd just finished one of his regular 45 minute work outs at his local gym in Bromsgrove when he developed crushing chest pain and started sweating profusely.

And they were mopping me down and sending for towels, I didn't think I'd got that much in me. So I'll do what the doctor says - if you ever get a problem ring 999. And they were there in four minutes. They gave me aspirin and laid me down in reception, which was a good advert for the gym. I mean they were brilliant, I was in hospital within sort of 20 minutes, bells ringing and yeah.

Katherine, talk me through the ideal management of someone who is having a heart attack. They arrive at your A&E department, hopefully quickly.

Yes this gentleman seems to have got in very fast. The main thing to do when the patient arrives is to make sure you get the diagnosis - you want to get a diagnosis very quickly by doing a tracing of the patient's heart. Now as in this earlier piece the gentleman had been given aspirin, so that's absolutely the right thing to do.

And what's the aspirin doing?

The aspirin is actually helping unblock the artery we were talking about that's blocked. You have platelets in your blood that can get quite sticky and they add to the clot that's forming in the patient's blood vessel. So aspirin helps unblock that. You want to get rid of pain because pain makes the patient's heart rate quite high and that's given increased work to the heart, let alone being an unpleasant symptom for the patient. But the main thing is to be moving towards can I get this blood vessel that's blocked unblocked? So can I get either the patient into a catheter lab and have an angioplasty or can I get clot busting drugs into that patient?

Now an angioplasty basically is inserting a little balloon isn't it into the narrowed area and stretching the coronary artery back up.

That's right yes, but the alternative is to give a drug method of unblocking the artery and for that we use a number of clot busting drugs.

Well we'll come back to the clot busting drugs a little bit later. I want to go back to aspirin. Tom, there has been some coverage in the press suggesting that we should all be carrying an aspirin around with us, just in case we get chest pain, what do you think of that?

I think it's important, I carry aspirin for that reason, just in case someone falls over when I'm on the train or something. Aspirin alone is as effective as one of the clot buster drugs, alone at saving lives, solving heart attacks, it's very important. Given in combination with one of these clot buster drugs it's even more powerful. And as an emergency first aid measure for suspected heart attack it's a pretty good thing.

Well let's assume we get the patient in, they're stabilised, they have whatever treatment's required - how long are they likely to be in hospital for?

The average stay in hospital for someone who doesn't have complications is five to seven days in England at the moment.

And once they get home, how long before they go back to work or something like that or I mean get back to a normal life?

I think that depends on the severity of the attack in the first place and how well the patient is supported in terms of family and their GP and things at getting them back to the road to recovery. Six weeks sounds about right in terms of most people who've had a full blown heart attack, if you like, getting back to work.

Well thank you both for now.

Most people who die from a heart attack do so before they get to hospital, but an even quite basic resuscitation can keep someone going until expert help arrives, or they get to an A&E department like Katherine's. I have been trained in advanced life support techniques, but as a GP I don't get to use them as often as I did when I worked in hospital, so am I still up to scratch?

Well Dr Andrew McIndoe is a consultant anaesthetist and the Chairman of the Bristol Simulation Centre - it's a training centre full of computerised patients who can be set up to mimic a range of medical emergencies, including heart attack. Andrew, with the help of SIM MAN - a complex and very realistic dummy - decided to see how well I could cope with an emergency in my surgery.

OK we're in the Bristol Simulation Centre and we've set it up to look like Mark's surgery. There's a man who's just come into the waiting room clutching his chest and saying he's got very severe central crushing chest pain and he's suddenly keeled over and collapsed and Mark's been called through to see him.

Right he's obviously not breathing, he's obviously unconscious. The first thing I do is I'm just going to see if I can find a pulse on him and I'll feel at the neck.

MCINDOESo Mark is …

PORTERAnd at the wrist.

Feeling for up to 10 seconds for a pulse and he's also feeling and looking for any signs of chest movement and breathing.

Right, so he's not breathing, he's unconscious and he hasn't got a pulse. So the first thing I'm going do is going to give him a couple of breaths.

And the man's had a cardiac arrest.

Two breaths. And the next thing I'm going to do is I'm going to give him a little firm strike just here and I'm going to start CPR. And the paramedics have come in, thankfully, so if you could take the top end and do that.

At this point Mark is attempting to hold the man's circulation by giving him external cardiac compressions at a rate of about a hundred per minute.

…7, 8, 9, 10, 11, 12, 13, 14, 15.

And one of the paramedics is doing mouth-to-mouth resuscitation and giving two breaths for every 15 compressions that Mark gives to the chest.

…3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15.

And this is very tiring and essentially it's a holding manoeuvre, these basic life support measures buy time so that we can get a defibrillator and attempt to …

Right, we've got the …

… put the patient back into a normal rhythm. Now the patient's in ventricular fibrillation, this means that the heart's contracting in a very uncoordinating way and there's no blood being ejected.

Okay? Stand clear. And he's still in ventricular fibrillation, so I'm going to do it again.

Mark's giving a shock of 200 Jules across the man's chest with two defibrillator paddles.

Okay stand clear.

Now this is quite a dangerous procedure because if he shocks anybody else inadvertently then he could very easily put them into ventricular fibrillation. So everybody's standing well clear at the moment.

Okay stand clear. Okay.

Now he's given three shocks in quick succession. Now if these shocks are given quickly it is possible to put somebody back into a normal heart rhythm. And as time goes by it becomes less and less successful, so it's important now that we try to get some oxygen circulating to the patient's brain, so they've gone back to basic life support measures. And they're giving mouth-to-mouth resuscitation and Mark's resumed chest compressions.

And he's applied another shock of 360 Jules. And he's seen a change in the heart rhythm now.

And we've got a normal rhythm, let's just see if we can feel …

Instead of the irregular kind of zig zag appearance …

Okay, can you give him a couple of breaths?

…of ventricular fibrillation he's now got a rhythm that looks like a normal sinus rhythm.

No output so I carry on CPR.

Okay and a minute's gone by now, so he's just stopped and he's feeling a pulse.

Yeah we've got a pulse. It's a weak one.

And he just needs to check now whether the patient has actually started breathing.

Breathing on his own?

…oxygen mask.

Good so that means that they no longer need to actually give mouth-to-mouth resuscitation, they no longer need to give cardiac compressions. So the safest position for the patient now is instead of being flat on his back is actually to turn him over into the recovery position so that if he vomits - which patients quite often do after a cardiac arrest like this - then he's not going to suffocate on his own vomit. And we can hear the beep rising, the pitch is rising, so that means that his oxygen saturations in his blood are improving, which means that he's actually circulating oxygenated blood to at least to his finger where the pulse oximeter is. That's a very good sign.

Right, let's get him into hospital.

Well done.

And mop my brow please.

Being put through my paces there by Dr Andrew McIndoe from the Bristol Simulation Centre. You are a listening to Case Notes, I'm Dr Mark Porter, and I'm discussing heart attacks with my guests A&E consultant Katherine Henderson and Tom Quinn.

SIM MAN pulled through there Tom but what sort of success rates would you expect following cardiac arrest after a heart attack?

Well your patient there Mark was lucky, he had a very treatable rhythm in a medical establishment with skilled people on hand.

Very skilled.

In those circumstances we're looking at around 40% survival for that group of patients. For the group of patients who've had their cardiac arrest before the ambulance is summoned we're looking at one or two per cent survival in this country, so what we're trying to do is to encourage people to call for help when they get their symptoms so that if they do have a cardiac arrest the ambulance is nearer to them, the defibrillator is nearer to them. And in those circumstances up to 40% of patients can survive.

Katherine, we mentioned earlier clot busters, they really have revolutionised the treatment of heart attacks haven't they and I remember them coming in in the mid-'80s really, they were coming into widespread practice, just remind us how they work.

Clot busters are marvellous because the blocked artery has to be unblocked, so you need something that can actually dissolve the clot and let blood flow back through. And what they can do is not only make the patient survive but they can in a surviving patient reduce the amount of damage that's done to the heart so that the patient has a better outcome even if they survive.

Because presumably if that blood supply is not restored then that part of the heart dies?

That part of the heart dies and then you end up with a patient who potentially has heart failure, maybe very restricted in their activity, may become housebound because of the amount of heart muscle that has died. So there's an urgency about getting clot busting drugs into a patient.

How urgent?

We want to get it in to a patient within 30 minutes of arrival at the hospital door or within 60 minutes is the standard that we're all working to from calling for help. So once the call for an ambulance it's 60 minutes to get the clot busting drug in.

And Tom the NHS does actually quite well at that doesn't it.

Yes on both those measures on the 60 minutes from calling the NHS now about 50% of patients have started their clot busting treatment. It was 10% in 1997. In terms of hospital care the 30 minute time to treatment target - door to needle time we call it - in 2000 38% of patients started their treatment within half an hour of getting to hospital, 81% currently start their clot buster treatment within half an hour of getting to hospital.

Well until recently clot busters of course were only available in hospital meaning some delay was always inevitable, unless you had your heart attack in hospital or on hospital grounds, but a new initiative to train paramedics to give the drugs can cut that waiting time dramatically - with significant benefits - as Mark Cooke of the Ambulance Service Association explains.

A 30 minute delay in receiving thrombolysis can result in an equivalent of a year of life lost and I think that really puts it into context. Because people think oh yeah a minute delay, that's not much, but I think put that way it really is important.

So how much quicker are these injections given if the paramedics do them rather than the doctor in the hospital?

Well it can make an enormous difference and obviously as soon as somebody dials for an ambulance by 999 as soon as that ambulance arrives after a brief assessment phase this patient can be assessed, diagnosed and provided with a thrombolytic agent.

You talk about a brief assessment there - how do the paramedics actually know when they need to use these drugs?

Well the paramedics have received additional training in how to assess a patient's condition, how to acquire and how to interpret a 12-lead ECG, which is the electrical image we get of what's happening in the heart at the time and that shows us whether there's any pathological damage within the heart.

Do they liaise with doctors in hospital at the time or is this a decision that they make for themselves in the ambulance?

Yes they can do, there are a number of different systems in place at the moment and some ambulance services are working autonomously, in which case a paramedic will assess, diagnosis and provide this clot busting drug without any outside assistance and then there are decision support systems in place whereby the use of telemetry we can actually send a 12-lead ECG and speak to the coronary care staff or cardiologist and get their advice over the telephone as well.

Now these are very powerful drugs, they're obviously potentially lifesaving but potentially also very dangerous as well - if you're giving somebody something that's dissolving clots I mean there is a small risk of stroke isn't there.

There is a very small risk of stroke and from the in-hospital research trials that risk of stroke is actually less than 1%. I'm delighted to say that there are already more than 500 patients that have received pre-hospital thrombolysis and as yet we haven't had one reported incident of stroke or any other serious internal haemorrhage.

Mark Cooke of the Ambulance Service.

Well so far we have talked about treating heart attacks but, Tom, no mention of preventing them and that's important isn't it and it's all about lifestyle really.

It is, if you read some of the fairly recent research on this sort of thing the reduction in deaths from heart disease, 60% of that reduction is attributed to better lifestyle, better living conditions, healthier populations. And 40%, an important 40%, to better medical treatments and faster medical treatments, as we've been discussing.

Katherine, do you think patients - patients and the general public - see drugs as a short cut solution - I smoke but if I take a cholesterol lowering tablet or if I take a daily aspirin I'll be okay?

I think that's right, I think we need to emphasise that although lowering cholesterol is incredibly important and it can be done very successfully with medical intervention much more important would be to have people eating five bits of fruit and vegetable a day, particularly not smoking, particularly being aware of their risk of diabetes in relation to obesity and their family in fact, and doing something about those parts of their life. In a sense it's better because it's something they really have control of but they also have responsibility for and that's probably the key to it - taking responsibility for your health and avoiding the risk factors that lead to heart attack.

But we do often get criticised, don't we, for "banging on" about these things which the general public often see as a boring message but it's important to emphasise that that's because it's the most effective intervention - it's better than our treatments.

You just have to have had a relative suffer a heart attack or suffer the side effects of prolonged cardiac illness to see that they probably wished they hadn't smoked all their lives.

Tom, what cholesterol, it's the word we associate with heart disease, it's a very important risk factor but people won't know what their cholesterol level is - you can have a high cholesterol and eat a perfectly healthy diet, who do you think should ask for a test or have a test?

I think anybody who's got a family member who's had a heart attack or needed heart surgery or got angina needs to know their cholesterol, as part of a, what we call, a multi factorial risk assessment, so they need to go to their GP or the practice nurse and have that assessment. I think anybody who's had a cardiac diagnosis - so anyone who's had angina, who's - heart failure, who's had a heart attack, most people fall under that …

What about people who smoke?

Smoking on its own as an indication for having your cholesterol checked I'm not convinced, I think the key thing there is to help people to stop smoking but again it's all about a global risk assessment, if you like, on an individual basis rather than saying it's just that risk factor we're going to focus on.

Which bring us very nicely on to the statins - a family of cholesterol lowering drugs that can protect against heart disease. At the moment they are only prescribed on the NHS to people at the highest risk, but there is now good evidence that far more us could benefit them - and there are moves to make them available over-the-counter in the near future. The global prescription market for statins is already worth billions of pounds a year - could the over-the-counter market soon follow suit? Dr Tom Marshall is visiting fellow at Harvard Medical School, and Rory Collins, British Heart Foundation Professor of Medicine and Epidemilogy at Oxford. I started by asking Tom how the statins work?

Statins lower cholesterol levels and they do this by acting on an enzyme which is found in the liver which is called Hydroxy Methyl Glutaryl Coenzyme A reductase inhibitor - so it's quite a mouthful - which is responsible for producing cholesterol in the bloodstream.

Because it's possible isn't it to have a higher than ideal cholesterol level, even if you don't eat a particularly poor diet.

There's a lot of variation between individuals, so that what we find is that different individuals have different cholesterol levels. We know that whatever your cholesterol level is if you eat a diet that's more high in saturated fat your cholesterol will be higher and if you eat a diet that's less high in saturated fats - bit more polyunsaturates - you'd have a lower cholesterol. So there's variation between individuals but there's also variation caused by what people eat. Approximately what they do is whatever your chances are of getting heart disease they knock about a third off that. So if you take a statin it will reduce your risk of heart disease by about a third and probably similar for stroke.

Pretty significant given that heart disease and stroke of course are the biggest killers of Americans and British people. But it actually doesn't make an awful lot of difference what your cholesterol level is to start with does it.

Well that's the curious thing about it because originally we thought that what we were treating was high cholesterol levels and if you brought them down to a more normal sort of level that was really what the advantage was coming from. But what we're finding more and more, for example from the heart protection study, it was a very large study in the UK a couple of years back, is that it doesn't really make a lot of difference what your cholesterol level is, it still reduces your risk. So if you're at high risk, even if your cholesterol level's pretty well average you're better off having a lower cholesterol level. And so the general rule about cholesterol is lower the better.

So potentially nearly everyone could benefit from taking a statin?

Well that's an interesting question. In principle, it would be very hard to prove that you were really benefiting people who very rarely get heart disease anyway but in principle that's probably correct, that virtually everybody can reduce their risk of heart disease, their chances of getting heart disease by about a third by taking a statin. But the key question is a third of what? Because if I've got a very high chance of getting heart disease then reducing my chances by a third seems like a pretty good idea but if I'm the sort of person who is very unlikely to get heart disease it means an awful lot of people like me are going to take the tablet and very few of us are actually going to really prevent anything.

Well at the moment statin use is effectively rationed by the NHS to those who need it most - put simply, at around, I suppose, a £1 per day a person, the NHS couldn't afford to supply these drugs to everyone who, the latest evidence shows, may benefit from them. Rory, it's going to a difficult problem to solve.

Well you call it a problem, I call it a solution. The fact is that the statins and cholesterol lowering therapy are much more effective than we had realised - they're more effective for a much wider range of individuals at high risk, they're effective for people at high risk not just of heart attacks or strokes, they're protective for people throughout the cholesterol levels that we see in Western populations. So we can produce benefits for a very much wider range of people who are otherwise going to have a heart attack, stroke and die - or be disabled by those conditions. So I see it as solution. And you say it's an expensive treatment but you know so too is being hospitalised with a heart attack, so too is being disabled with a stroke. And in fact when we do analyses of the benefits in terms of cost terms - leaving aside the human benefits - actually these treatments turn out to be cost effective for a much wider range of individuals than have previously been thought to be the case. And of course now that sinvastatin is no longer protected by patent and is available as a generic drug, as the cost of the drug falls the cost effectiveness of the treatment increases and it will become cost effective, cost saving, for a very much wider range of patients.

So what are the downsides Tom?

Statins do have side effects. There are some that are considered relatively minor and seem to be reversible when you stop them like sometimes people have suffered a little bit of hair loss and things like that. But the most important kind of side effect is a type of muscle damage which can be sort of mild, in the sense that people get some muscle pain and some blood tests show that there's some evidence of muscle damage and they can stop the treatment or in its more severe form can actually be quite a serious problem where there's breakdown of the muscles and this is referred to as rhabdomyolysis.

Are there doubts about the current statins that we're using, because this is quite an unusual side effect isn't it?

It's a very - yeah it's a very unusual thing and when it happens in its full blown form it's pretty serious - people can die from it. In its very serious form it's quite infrequent - it's in the region of 1 in 10,000 or even less frequent than that, so it's really quite infrequent.

Rory, what impact do you think deregulation of statins is going to have?

I think number one, the fact it's going over-the-counter emphasises our very good evidence about the safety of this treatment. I think the other thing is that it will bring to the attention, not just of the people that the over-the-counter is targeted at, but also the higher risk patients, the possibility that there are ways of lowering their risk and it may, I hope, encourage them to go and talk to their family doctors to get on to prescribed statin for people with vasc disease or diabetes or hypertension.

PORTERTom, Katherine - do either of you take a statin?

I don't but I measure my cholesterol and I know that I don't need to.

What about you Tom?

I did, my cholesterol was a little bit high, as was my blood pressure, but the statins didn't agree with me so I've now bought a bicycle and try and cycle more and eat less but I don't take a statin.

What about low dose aspirin - a daily half or quarter of an aspirin?

Yes I think the current guidance on this is that if you've got a cardiac diagnosis you should have been prescribed low dose aspiring almost ad infinitum but if you haven't had a diagnosis then it's probably best to discuss with your GP or practice nurse before starting to take that treatment because even low dose aspirin isn't totally without risk.

Lifestyle changes, Katherine, remain the key, don't they, to preventing heart problems?

Absolutely, if we could reduce the number of people smoking, if we could get everybody doing a decent amount of exercise per day and if we could make sure that people are having a reasonably healthy diet we would make huge strides in reducing the number of deaths from heart attack and cardiac disease. But if the problem arises the next most important thing is for people to get in touch with help as fast as they can because it's quite clear that the sooner we treat these people the better they do.

And just to remind them that means - if they have chest pain?

And that means that they phone 999, they get an ambulance and they get themselves to an accident and emergency department.

Katherine Henderson, Tom Quinn thank you very much.

Well Malcolm Hawkes is now back working out at the gym where he had his heart attack and doing his utmost to lead a health lifestyle as Helen Sharp discovered.

The wife's been good on the food side, not fatty, not red meat particularly, I have a lot of chicken, a lot of fish, cabbage, porridge, carrots, broccoli, a lot of fruit in the mornings. I'm like a rabbit really I suppose.

And how much exercise do you do a week?

Twice to the gym at 6 o'clock in the morning and I walk for a mile every other day fast and get into a bit of a sweat and I've got a heart monitor I bought myself and I watch so I can keep a check on what I'm doing basically. Well I've asked the girls at the gym whether I could have a kiss to see if my heart rate goes up but none of them have volunteered, so perhaps that's a little bit too much to ask for!

Nothing ventured nothing gained Malcolm.

Next week's programme is all about blood - why doctors tend to worry more about anaemia in men, and how the blood service is under more pressure than ever, and what you and I can do to help.

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