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Thursday 1 March 2007, 3.00-3.30pm
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BRITISH BROADCASTING CORPORATION



RADIO SCIENCE UNIT



CHECK UP

Programme 1. - Heart Attacks



RADIO 4



THURSDAY 01/03/07 1500-1530



PRESENTER:

BARBARA MYERS



CONTRIBUTORS:

KEITH CHANNON



PRODUCER:

PAMELA RUTHERFORD



NOT CHECKED AS BROADCAST




MYERS


Hello. It's good to be back. Now here's a thought though to start our new series: In the time we're on air this afternoon 15 people in this country will have a heart attack, five of them will die before they get into hospital. None of them, I hope, our listeners. Yet with modern preventive medicine most people need never have a heart attack and with the best medical treatment those who do might expect to make a full recovery. So there's a lot of good news today, if you want to know how to avoid a heart attack, and if you've already had one there's a lot that you can do to make sure it doesn't happen again. So do call us with your questions about prevention and treatment of heart attacks and if you are a heart attack survivor we'd very much like to hear how you were helped by medical interventions. The number to ring is 08700 100 444 or you can e-mail checkup@bbc.co.uk to put your points, your questions, to Professor Keith Channon, he's a heart specialist from John Radcliffe Hospital at the University of Oxford.



Our first caller is indeed on the line. We've got Chris Croden who's in Bradford in Yorkshire, Chris your question or your comment please for our programme today.



CRODEN

Hi, good afternoon. My comment was really just some advice for patients following on from what was on the British Heart Foundation adverts that people might have seen before Christmas. And it's about making sure they make the call early when they get the symptoms of chest pain and all the associated symptoms that go with that, if they make the call early the paramedics can get to them quickly and we're now able to give early thrombolytic treatment to some patients, we're also in some areas of the country able to get patients directly in for a procedure called primary angioplasty but it means taking them to a specialist unit.



MYERS

Well I know what you've said is going to be music to Keith Channon ear, I mean it's really important isn't it, it's the one thing, if you get nothing else across today, you hope to inform people about the importance of getting early treatment for their heart attack for any pain they may be having. Let's - and you say - you mentioned getting them in for angioplasty, do you want to pick this up Keith and tell us a little bit more about what can happen, if indeed you do get to hospital in that very short timeframe so that there isn't any damage done?



CHANNON

I think those are some of the biggest points Chris that you've brought out here and that is that when the heart attack first happens the clock starts ticking and from that time onwards heart muscles start to be damaged irreversibly and ultimately die. And in fact the studies show that it's the first one or two hours that's the critical time window and if treatment can be given to the patient to reopen the blocked artery then the hart muscle that's threatened by the heart attack can be rescued. And the two big treatments are blood clot dissolving drugs that dissolve away the blood clot that blocked the artery or as you mentioned in many centres now what's called primary angioplasty which is a special almost surgical treatment to open up the artery directly and then put in some type of stent to hold the blocked artery open.



MYERS

And these really are life savers aren't they.



CHANNON

They are. Thrombolytic or blood clot dissolving treatment has been around for more than 15 or 20 years now and I think really revolutionised the way we treat heart attacks worldwide. And more recently primary angioplasty has made us realised that if we can open arteries more effectively and more rapidly there may be even more to gain for patients coming into hospital with a heart attack.



MYERS

Chris, do you find a lot of patients when you get to them they really have been hanging around wondering what they should do, whether they should call the ambulance and they are leaving it much too late?



CRODEN

Occasionally, I mean there are people who do call inappropriately but if they recognise the classic symptoms - the central chest pain radiating into the arms, the neck, sometimes associated with nausea and dizziness - the classic ones, especially people in the age range - in the zone for having those kind of heart attacks, need to call early and if when the ambulance crew get there they will generally do a 12 lead ECG, check the history, check the clinical signs and act appropriately, whether that be with pre-hospital thrombolytics or going directly to a catheter lab, it's all around teamwork between the professionals.



MYERS

Thanks very much for making that point, that's very helpful. Of course you talked about classic symptoms there but they're not always classic. David Collins joins us now from Aberdeenshire, talking about rather non-conventional heart attack symptoms, is this something you've experienced yourself David?



COLLINS

Yes, in fact I had a heart attack about six years ago and although I'm fairly clued up on what to look out for in terms of ill health, at the time of the heart attack even though I was clued up I didn't realise for quite some time that I was actually having a heart attack. What had happened is I'd woken up in the night and I'd had some sweating and upper back pain, more muscular, it wasn't at all as though there was an elephant sat on my chest preventing me from breathing, none of the classic symptoms at all. And that sort of - because it was a non typical situation I persuaded myself not to respond to it in the way in which I would have done had I realised I was having a heart attack.



MYERS

I mean we can hear you obviously did survive to tell the tale, which is extremely good news, so you did obviously seek treatment in the end and it was in a timely sort of way I guess.



COLLINS

Yes I contacted NHS Direct and the nurse there was astute enough to advise me straightaway that any pain that a patient experiences which is above the waistline needs to be taken seriously and of course at that point I did decide to do something about it and drove myself to hospital, which apparently I shouldn't have done. But as I say I was fairly well, not experiencing any very serious symptoms at all.



MYERS

Let me ask the professor just to comment on that because in a way that suggests that some people don't have these absolutely sort of grinding heavy desperate pains, they don't have a really acute emergency but in fact, as David's been saying, something that felt like upper back pain and he managed to drive himself into hospital, so it's rather a different picture isn't it.



CHANNON

I think that's right. Many of us now know the classical features of a heart attack with central crushing chest pain and many people also realise that that pain can move elsewhere and radiate down the arms, up into the neck or the jaw or into the back. But as David has pointed out it's also possible to have a heart attack with very different symptoms - feeling unwell, nauseated, dizzy, sweaty, blackout - and these symptoms are very common in quite a large number of patients. What's worrying is that even in patients who do have the classic symptoms the average time it takes for people to call for help is in fact greater than one hour and patients are taking more than two hours to get into hospital for blood clot dissolving drug treatment. And even patients who've had a previous heart attack still tend to wait at home too long before calling the ambulance. So the message is that if there are symptoms which could be consistent with a heart attack then patients in general should call for help as soon as possible, rather than waiting until they're convinced that this is a heart attack.



MYERS

But then turn it the other way round - you do occasionally hear of someone dropping dead of a massive heart attack, as though there is no time at all to do anything, how typical would that be?



CHANNON

Unfortunately that cardiac sudden death, which is the medical term for that, is still common and it's very difficult for that type of presentation of a heart attack to be treated by calling an ambulance. Although the wider provision of automated defibrillators in many public places is of course helping patients who would have previously died of their heart attack make it into hospital to then get the treatment that they need.



MYERS

And David just to finish up there in Aberdeenshire, I guess you're okay now and getting on with life, proof - living proof that you can survive and make a good recovery?



COLLINS

Well absolutely, I'm a middle aged - mid-50s - parent of two young children and I'm a house parent of those two young children so you can imagine what a hectic life I've got. But one piece of advice to anybody who has experienced a heart attack is get out there and get some exercise done - I've a bicycle and I try and cycle 10 miles a day and I find that keeps my waistline reasonably trim and it keeps me in fairly good condition and it gives me quite a lot of optimism for the future because I remember feeling quite depressed after the heart attack but these days it's thankfully a distant memory.



MYERS

And you can say aye to that I guess Keith.



CHANNON

Absolutely and I think we'll hear again about the importance of changing lifestyle and modify what we call risk factors - the things that we know contribute to causing a heart attack in the first place, the importance of changing those after a heart attack.



MYERS

Indeed. Well we have Joe on the line, who is asking precisely about the prevention of heart attacks. In his case I think he's worried about what he knows to have been a bad diet for probably a length of time, what's making you now wonder whether you're doing the right thing by your heart Joe?



FARRELL

Well now I've - I'm trying to look after things a bit better - I'm eating better; lots of fruit and vegetables and so forth. But I worry that I've got a legacy of damage in my arteries and I wonder whether there's some kind of check that I can have done that would assess the damage so that I could take appropriate measures to prevent any problems, like statins or something like, I just wondered what was available?



MYERS

Well we all know about the value of prevention but you make an interesting point there - when do you go and have a test which says yes now is the time that I really have to get really quite proactive about prevention, including taking drugs if necessary. Is there a simple test any of us could do at this point?



CHANNON

I think the more important point is that it's not simple tests that are really telling us how we should be altering lifestyle. If someone has had a heart attack in the past that tells them that they are at risk and they absolutely need to take major lifestyle measures and possibly or very likely drug treatments to alter their future risk of another heart attack. So although it seems simple to want a quick easy test we already know that patients who've had a heart attack are at risk of further cardiovascular events in the future and these are the people who should be - we should be concentrating on altering their risk factor profile and their lifestyle and giving them drugs, such as statins, to reduce their risk of further heart problems.



MYERS

I can see that but take Joe's case and I would join him, if you're worried but well and want to do the right thing, is there something that will measure, if you like, the urgency or the importance of doing the right thing and making some quite substantial changes in some cases to lifestyle?



CHANNON

I think the things to measure are the risk factors that predict future risk of a heart attack. So those are things like bodyweight, blood glucose levels, screening for diabetes, screening cholesterol levels, screening for blood pressure and also trying to get some measure of your overall health of your lifestyle through both diet and exercise. And it's those factors that are the most important in giving us an idea of how likely that person is to have a heart attack in the future, as opposed to one single medical test which could be reassuring today but falsely so, so that a patient may have a heart attack in six months time. Whereas the lifestyle changes they act over the whole of our life and so have a much longer impact over the years.



MYERS

I suppose you could take the bet of that policy which is it's a very good idea to have as low cholesterol as is reasonably possible and a reasonable blood pressure and you should do the exercise and the diet accordingly and you don't really need a test to tell you whether you should do it, you should just do it. But I mean that's a counsel of perfection isn't it for people?



CHANNON

To some extent it is but in patients who are at risk on the basis of those simple measures such as bodyweight, amount of exercise, blood pressure, cholesterol and glucose level - all of which can be done very readily at your local GP - we can get a very accurate picture of the cardiovascular risk of that individual person. And secondly, all of those factors that I've mentioned are modifiable, even now through both the patient or simple medical treatments, all of those factors can be altered.



MYERS

Joe, is any of this making any sense?



FARRELL

Yes indeed, in fact your specialist there I mean makes perfect sense, what he's saying, I can understand if there is no test and all of these indicators are really the things I should be focusing on and I will do. I just wondered whether there was some kind of magic bullet, as it were, that would give me some peace of mind because it is something I do worry about because I frequently get strange sensations in my chest - not pain at all - but what feels like a slight tightening and I just wonder - given my history of bad diet - maybe I've got some kind of a problem which even if I change my lifestyle now that I may suffer from and not be able to do anything to change, that was really the point.



MYERS

Indeed, last word of advice back to Joe?



CHANNON

There are tests that can be done to screen for coronary artery disease but really what matters is to alter the causes of the coronary artery disease which is the points we've just been talking about. And so rather than looking for the presence of coronary artery disease we should be screening for the risk factors and treating those as best as possible.



MYERS

Thanks very much for that call Joe. We'll go to Matthew Johnson in Devon who is well aware of one risk factor which is what's happened in the past to family members. Sadly lost two generations I think to heart attacks, is that right Matthew?



JOHNSON

That's right yeah. I lost my father at 51 and he lost his father in his early 50s as well. And you've talked a little bit about lifestyle, well my father had a very fit and healthy and active lifestyle, very good diet, he cycled to work regularly and that was a 30 mile round trip, he swam a mile in the pool every week, had a mild heart attack at 45 and then died of a major heart attack at 51.



MYERS

And what age are you now?



JOHNSON

Thirty six. There's a big part of me that thinks am I two thirds of the way through my life, am I nine years off my first heart attack.



MYERS

Oh that's a terrible thought isn't it.



JOHNSON

It is and what can I do about it. I have a good diet, lots of exercise, all the right things but that sort of didn't work for him, which flies in the face of the advice for the previous caller.



MYERS

Well you've done one good thing which is to phone our programme and speak to Professor Channon, so let's see what advice you've got then for Matthew.



CHANNON

Well Matthew raises a critical point and that is that family history is one of the recognised factors in modulating a person's individual risk for a heart attack in the future. Cholesterol is the single biggest factor that's currently known to run in families. There are some uncommon or even rare conditions where a very high cholesterol level can be passed on from parent to children or more commonly just the general tendency to have quite a high cholesterol is also - tends to run within families. So in fact between your father's generation and the present generation Matthew there are things that can be done and cholesterol should be measured in your bloodstream and there are now drugs that can be used to bring down a very high cholesterol.



JOHNSON

So your advice then is for me to get a cholesterol test and if necessary take drugs to control it?



CHANNON

I think you should get that checked yes.



MYERS

I mean it's quite interesting that you haven't because a lot of people do - we were talking earlier about the worried well - do now go along to their doctor and ask for a cholesterol test in the full knowledge that there are drugs that can bring it down.



JOHNSON

I guess I feel - I feel really healthy and appear healthy and I feel kind of slightly fraudulent going to the - to see my GP about something that ...



CHANNON

It sounds as if you're very healthy and of course when other patients ask me about family history my first answer is to say you need to make doubly sure that you don't smoke and you don't exposure yourself to the other lifestyle risk factors because the underlying tendency that your family seems to have to have heart attacks you've got to be even more careful not to expose yourself to those risks. But if you think that your lifestyle is very healthy and you don't smoke and you exercise and the one other thing that you could check up on would be to get that blood test from your GP to check cholesterol.



JOHNSON

Right and how regularly should I do that?



CHANNON

It really depends on what the result of the blood test is, if it were elevated then it may be something that would need to be monitored. If it is in fact quite low then you may not need to have it checked quite so frequently.



MYERS

Please do that - I think that was well worth getting that information Matthew. And if I can just take it on for those who may not have a risk factor in the family history but have a cholesterol level that may be concerning, is there a magic number, because targets are often changing and what is the story - what is that sort of lipid level, that level of cholesterol in the blood that we should be looking for?



CHANNON

Well currently the guidelines and the targets if you like for blood cholesterol level vary depending on what risk you're at of coronary artery disease. If you're known to have coronary artery disease or have had a heart attack in the past or have diabetes then the current guidelines suggest a total blood level of 5 milimolar or even more stringently 4 milimolar total cholesterol level. And so those are the levels which we should be getting cholesterols down to in patients who we know or think have got an underlying coronary artery disease problem.



MYERS

And if you can't do it by lifestyle changes, although that helps, then you're talking about statins, using those drugs?



CHANNON

Yes. And in fact now statins are almost universally used in patients who have had a heart attack or are at high risk of having a heart attack because we know that the benefit of diet alone is not adequate to bring cholesterol down sufficiently to give us the long term benefits in lowering the risk of future heart attacks.



MYERS

Well David Jones joins us from Edinburgh and he's got a question about the use of statins. Are you on statins yourself David?



JONES

Yes I am, I'm taking 40 milligrams of Simvastatin every day and it's agreeing with me very well but my question was that I had what's called a silent heart attack or one without any symptoms whatever. The first time I actually had any symptoms I was just running for a bus and I suddenly felt angina, I thought there was something wrong with my lungs. So I went alone to my GP and he sent me along to a cardiac clinic and they sort of diagnosed this silent heart attack. And then when I went for the angiogram about two or three months later it showed that there had been a blockage in one of the arteries but that happily the vessels had grown around the blockage and had started supplying the heart again. So I'm taking treatment for blood pressure, the statins and aspirin as well. But I'd heard this asteroid study that was done last year in Edinburgh, here in Edinburgh, and they're looking at one particular statin that seemed to even reverse the fatty build up in the artery walls and I thought - I just wanted to ask if that was going to come on stream for everybody or what?



MYERS

A very good question, what's the view on that?



CHANNON

Well the first thing to say David is that statin treatment has really revolutionised the outlook for patients with coronary artery disease because lowering cholesterol leads to very major long term benefits. And what the many different studies show over the last 10 years or so is that lowering cholesterol to even lower levels than we thought before seems to produce additional benefits in terms of lowering people's risk of a future heart attack or indeed other adverse cardiovascular events like stroke, for example. And so it seems to be that if we could use statins at either higher doses or more powerful statins it might be possible to prevent the progression of coronary artery disease or even start to turn it back and if you like to undo some of the furring up of the artery. And the asteroid study was just one example of one of the very recent studies that showed some indication that using the latest most powerful statins at the highest possible dose may indeed be able to do that. But I think I would warn that those studies are relatively preliminary and that we should be concentrating, like you, on getting everyone who's at risk of a heart attack or who has had a heart attack on a statin drug at a proper dose to get their cholesterol down below 4 milimolar.



MYERS

Thank you very much for that and just to add into that - to what extent will it reduce your risk, it's quite powerful stuff isn't it?



CHANNON

Yes, so the studies show that lowering - that a typical statin such as Simvastatin 40 milligrams daily, which is what our last caller David was taking, will lower your cholesterol by about 25-30% and in the long term that can reduce your risk of a heart attack by as much as 15 or 20%, so it's a big reduction.



MYERS

Thank you very much. We've got a caller from Surrey, Simon Dalton, interested in more information about angioplasty, we were talking about that earlier, that's the opening up of the coronary arteries. Is this something you've had experience of Simon?



DALTON

Oh hello, yes and good afternoon Barbara and Dr Channon. Yes indeed, well three years ago I was diagnosed with 95% blocked main circumflex and despite having a relatively healthy lifestyle, in my job as an airline pilot I had a medical every six months, I was quite surprised by this and had a couple of angiograms and eventually they said well you're going to have to come in for an angioplasty. I went in and the first one was partially successful only - for those who don't know the angioplasty is the insertion of a small metal stent around the area of the build up and so I had a second angioplasty. And what I'd like to know is, is there any research on how long these stents will last and how effective they will continue to be in the life - in my lifetime?



CHANNON

Well the good news Simon is that if the angioplasty or stent procedure is successful at the time and then goes out more than six months or one year afterwards and things still look good then the likelihood is that the result of that stent will be very good in the long term. And I think that the message is that the problem is more likely to be new furring up or blockages in other areas, hence the importance of all the lifestyle measures that Barbara and I have been talking about earlier in the programme.



DALTON

I hope that's helpful, thank you very much indeed. We're pretty much out of time but just if you had to give one last warning to people if they perhaps wanted to take some of this information forward what would you say - lifestyle changes, look out for symptoms, make sure you get treatment if you need it, anything else?



CHANNON

No I think for those people who are not at risk of a heart attack: change lifestyle, measure cholesterol and get it down. And if you think you're having a heart attack with typical or worrying symptoms call an ambulance without delay.



MYERS

Thank you very much indeed to Professor Keith Channon. Thank you for all your calls and e-mails today. More information, as always, if you go to our free and confidential helpline, that's 0800 044 044 or to our website, follow the prompts to Check Up. And Next week we'll be back and the subject will be food allergies.




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