Are we going to have a second wave of Covid?

I was asked this by one of my patients last night.

Simple question, difficult to answer.

We are all seeing in the media that the number of infections is rising steadily, but overall numbers are much lower than earlier in the pandemic. They also seem to be geographically concentrated in the north west, north east and the midlands. Infections in London and Kent are still low, and there aren’t many suspected cases in the hospitals.

It seems obvious that as children return to school, parents will return to work and fatigue about social distancing sets in, numbers of infections will go up.

We seem to be entering an endemic phase – we’re going to have to learn to live with this, and I think life is going to change. It’s quite possible that “Christmas will be cancelled” and holidays abroad next year may well be disrupted.

What does this mean for Cardiology services? I think remote visits are here to stay, and there’s going to be a much greater focus on patient self monitoring. Already we’re seeing patients being asked to check their own blood pressure and weight. Self-recorded ECG’s are becoming indispensable in the treatment of patients with rhythm problems. In terms of procedures, we are having to be much more organised than before to ensure that elective wards are Covid free. This means patients needing to self isolate for 14 days before major procedures, and 3 days before minor procedures and Covid testing all patients 3 days beforehand.

The focus has to be on delivering safe services for those who need them, but clearly capacity is down because of the extra cleaning and social distancing required between patients.

I think we will see a second wave, but this isn’t going to be tsunami of the first wave, and we are in a much better place to cope with it second time round.

Ever wondered what all those letters after a doctors name mean?

Here’s a potted guide. The letters themselves are called postnomials. They are qualifications and can indicate membership or fellowship of an organisation that can award them.

MBBS – Bachelor of Medicine, Bachelor of Surgery. This is the degree issued by most medical schools in the UK after 5 years of medical training at University.

MBChB – Bachelor of Medicine, Bachelor of Chirugery (another term for surgery). Some medical schools in the UK issue this degree.

BSc – Bachelor of Science. This is a undergraduate degree (meaning that you do not need a degree already before you can enrol) which takes 3 years at University. A BSc in certain subjects can be obtained by an additional year taken half way through medical school training.

MD – Doctor of Medicine. In Britain this is a postgraduate research degree (meaning you need to already have a degree before you can enrol) which requires 2 years of full time study and the writing of a thesis. In the USA, this is the basic degree in medicine. In India, this is a postgraduate taught degree, rather than a research degree.

PhD – Doctor of Philosophy. Some doctors undertake a PhD, usually a 3 year research degree.

MRCP – Member of the Royal College of Physicians. Membership is awarded after passing a postgraduate exam. All doctors specialising in internal medicine must pass this exam before entering subspecialty training eg in Cardiology.

FRCP – Fellow of the Royal College of Physicians. Members of the Royal College of Physicians can be elected to become a fellow if they have distinguished themselves in the field of medicine. Not all Consultants are invited to become fellows.

FHRS – Fellow of the Heart Rhythm Society. Fellowship of this US based organisation is offered to those who have extensive training and specialise in heart rhythm disorders.

CCDSCertified Cardiac Device Specialist. This is a qualification offered by the International Board of Heart Rhythm Examiners. This requires evidence of completing training in pacemaker and defibrillator therapies, followed by a 5 hour exam, which is valid for 10 years. I recertified in 2019.

CEPS-AC. Certified Electrophysiology Specialist in Adult Cardiology. This qualification is awarded by the International Board of Heart Rhythm Examiners and again lasts 10 years.

CCT – Certificate of completion of training. This is awarded to doctors when they have completed their training and are eligible to enter the GMC Specialist register or the GP register. All permanent Consultant appointments require entry on the GMC Specialist register, though locum Consultants may not be on the Specialist register. The letters CCT are not recognised as a postnomial and are therefore not usually used.

There are a whole host of other qualifications for doctors in different fields. 

Surgeons for example have MRCS and FRCS, Membership and Fellowship of the Royal College of Surgeons, which is awarded after passing a postgraduate exam. For some reason in the UK this means that they are addressed as Mister / Miss / Mrs rather than Doctor. They don’t do this in other countries.

General Practitioners also have the MRCGP (Membership of the Royal College of General Practitioners) exam and can do other qualifications in many specialties, for example Obstetrics and Gynaecology (DRCOG).

Universities also have titles such as Professor / Reader / Senior Lecturer and these reflect teaching or research roles.

My qualifications include MBBS(Hons). Hons is short for honours. These were awarded because I graduated in the top 10% of my year at Medical school. I also did an additional Bachelors of science degree (BSc) in Neuroscience. After qualifying I passed the MRCP exam in 2003. I was awarded an MD(Res) in 2016 with King’s College London for echo imaging to research the effect of pacing on heart function. I also passed both the IBHRE exams in pacing and electrophysiology. I retook the pacing exam in 2019 after 10 years, I scored in the top 1% so have been invited to be an IBHRE ambassador and mentor for other candidates. I was elected a Fellow of the Royal College of Physicians in 2018 as recognition of my research, teaching and my work on College committees. I was elected a Fellow of the Heart Rhythm Society as I have exemplified my commitment to Cardiac Electrophysiology.

Chest pain – is it my heart?

Chest pain

It may be nothing, but it may not be…

I’m not trying to scare you, but heart attacks are deservedly scary.

The standard advice is if you have chest tightness that lasts for more than 15 minutes is to call an ambulance.  Particularly if the pain goes to your arms or neck, if you feel hot and sweaty, or if you feel dizzy.  The pain may be in the upper abdomen and be confused with indigestion, or go through to the back.  These are all worrying symptoms.

Heart attacks are due to a blockage of the heart arteries usually due to the lining of the artery breaking open and a clot forming.  How severe the heart attack depends on the location of the clot (at the beginning of a large artery = large heart attack, at the end of a small distal branch artery = small heart attack), and on whether your body dissolves the clot by itself, or if it is unblocked by drugs or an angioplasty.

But the people I tend to see in clinic as opposed to the Emergency department are those who have less severe symptoms or have been to hospital and had a heart attack excluded.

Here there is time to take a proper story of the pain as this gives the answer in most people.  The characteristics of pain due to heart artery narrowing are a dull heavy feeling in the centre of the chest, that can go up to the neck, jaw or left arm.  It reliably comes on with exercise and goes away with rest.  This classical history is almost certainly  due to the heart, and is known as angina.

Obviously many people don’t have a classical history.  Symptoms are often different in women, and in patients with diabetes.

In cases of clear angina it is sensible to do an angiogram to have a look at the arteries and identify narrowing.  In cases where it is not clear it may be worth doing non-invasive tests to look for artery narrowing or the functional effect of narrowing.  These investigations can determine if further medication, stents, or surgery is needed.

Other causes of chest pain include musculoskeletal problems, acid reflux or lung problems such as pleurisy pneumonia or clots.

If you are worried about chest pain, it is worth getting a specialist opinion.  Feel free to contact me to arrange an appointment where we can spend some time going through your symptoms and deciding if you need any tests.

Can I use an induction hob if I have a pacemaker?

It is not uncommon for patients to ask me ‘what if I get too close to an induction hob if I have a pacemaker?’

If you haven’t got a pacemaker, then you may think this is strange because induction hobs are so commonplace.

Surely it is safe for anyone with a pacemaker to use an induction hob.

Well, the answer is that ‘it is safe’,

…but there are things to know about.

Induction hobs are very popular

  • they look clean
  • the hob doesn’t get very hot
  • and there are fewer indoor pollutants from burning gas

They work by using powerful magnetic fields to heat the pan directly

…and magnetic fields can interfere with pacemakers.

They can cause electrical currents in the pacemaker leads.

These currents won’t damage your heart but they will be sensed by the pacemaker.

  • The first thing is not to get too close. Most manufacturers recommend the pacemaker is  at least 60cm away from the hob. This minimises the chance that any currents are induced in the pacemaker leads.

But what if you get too close to an induction hob if I have a pacemaker?

Well the pacemaker may sense electrical currents and therefore not deliver any pacing therapy.

If you are dependent on the pacemaker

This may be a problem and you might feel dizzy.

Almost all pacemakers eventually realise that there is electrical noise so revert to a non-sensing mode where the pacemaker continues to deliver pacing treatment.

This is usually quite quick so any dizzy spells will pass without resulting in a fainting episode.

If you are not pacing dependent

It is highly unlikely that you will notice anything if you get too close.

Get in touch

If you want to discuss your personal situation and risk then please email me and we can make an appointment.

I can review your device, indication for pacing and what the risks are to you.

51.506327-0.0858931

Are Heart Rate Monitors Accurate?

Wearable heart rate monitors used to be reserved for the serious sportsman, but they are becoming more commonplace and we use them to monitor our health, but are heart rate monitors accurate?

Lots of people come and see me because they are worried about their heart rate.

They may have had palpitations, which is feeling their heart racing, or they may have noted that their heart rate monitor says they have got a very fast or very slow heart rate.

It is understandable to be concerned if your heart rate registers an abnormal reading, but the question is ‘are heart rate monitors accurate?’

The answer is ’yes and no’.

It depends on the actual device used. There are thousands of different ones on the market, which can use many different ways of measuring the heart rate.

A recent study has compared the effectiveness of wrist monitors.

They found the Apple watch and Polar monitors were pretty accurate at detecting abnormal fast rhythms – supraventricular tachycardias (SVT’s). For episodes over a minute, the Apple watch detected them all.

The Polar monitor got most of them, but the Garmin and Fitbit devices were much worse, detecting less than half of these episodes of SVT.

The accuracy for shorter episodes was less good for all, but the Apple and Polar devices picked up about 2/3rds of 15-60 second episodes.

The take home message is that the Apple and Polar monitors are excellent to pick up this problem.

However, if you have had palpitations and think your heart is going fast, don’t be reassured by a Garmin or Fitbit.

Also, these devices are not substitutes for medical grade monitoring with a device such as a Bardy Carnation or Zio patch, let alone an implanted Reveal LinQ monitor.

The other thing to consider, is that your heart rate is just one measure of how healthy your heart is. There can be quite a wide range of what is normal depending on your age, sex and general levels of fitness.

If you are having any symptoms, such as palpitations, chest pain or breathlessness, then it is important to get checked out and don’t rely on home testing kits.

You should contact your GP, or you can arrange a consultation directly with me either in person or by video call. I am happy to talk to patients without a GP referral and also work with all of the major insurance providers.

The small print – the devices used in this study were the Apple Watch, Fitbit Charge HR, Garmin Vivosmart HR and the Polar A360. All these devices use a technique called photoplethysmography. This uses a green led light. It measures the reflections of the light. The reflected light changes with blood flow which can allow the device to calculate the pulse rate. This study applies to SVT’s, and refers to their ability to detect the fast heart rate. The devices may have algorithms to detect other abnormal rhythms such as atrial fibrillation – these were not tested in this study.

51.506327-0.0858931

High Cholesterol, now what?

In the last few weeks I’ve been asked about high cholesterol by family and fellow doctors.
Now that cholesterol checks are so easily done, the harder thing is understanding the result and what that means for you.
A bit of background – cholesterol is a fat that is necessary for the walls of all cells.  It is carried around the bloodstream in 2 different types of proteins – Low density (LDL) and High density (HDL).
High LDL levels are associated with a higher risk of heart attacks, strokes and peripheral vascular disease.
Higher HDL levels seem to be protective.
So the first thing to look at when the total cholesterol is high, is to look at the breakdown into HDL and LDL.
What to do about high LDL levels?  It depends on the overall risk of problems.
In the UK the 10 year risk is usually estimated using the Qrisk calculator. The main determinant of risk is age and you can plug your numbers into the online calculator (qrisk.org).
People in their 40’s are likely to be at lower risk, particularly if you don’t smoke, don’t have diabetes and exercise regularly.
There is good evidence that if your risk of running into problems over the next 10 years is high, then using statins can lower that risk by 20-30%.
However most trials have focussed on people with a high risk of problems.  This is obviously because these people have the most to gain, and it’s the easiest to demonstrate a difference with treatment.
For example, the WOSCOPS study in Scotland enrolled patients with an LDL > 4mM (average 5mM) and lowered it to 3.9 with 5 years of pravastatin and demonstrated a significant reduction in cardiovascularly endpoints and a nearly statistically significant reduction in mortality. (P=0.051). Benefits were maintained out to 15 years.
The Jupiter study looked at people with a mean LDL of 2.8mM and an elevated CRP (>2) suggestive of inflammation, and did find a small benefit.
Current recommendations suggest it is not worthwhile treating patients with a patient 10 yr risk <5%(European guideline), and do suggest treating if risk is >7.5% (US guideline) or >10% (NICE UK guideline)
Lowering LDL with lifestyle measures or non-statin drugs has not been proven to reduce risk. The data regarding dietary measures indicates that most people can lower their LDL by ~5%, but if you have a bad diet to start with you can see reductions of up to 30%.
There’s no real data about long term statin therapy to extrapolate results from shorter term trials. It’s also unknown if treating patients earlier is better than leaving treatment until risk increases.
So to sum up I personally wouldn’t panic if my cholesterol were high – I would consider getting a high sensitivity CRP test (one that can detect a level of <5) and check your Qrisk score.  And be sensible about lifestyle – at least half an hour of brisk walking a day, not too much salt or alcohol, and a balanced diet with plenty of vegetables and fish.

Some people find it helpful to understand their risk to a greater level by having further tests such as a CT scan to look at furring up (calcification) in the heart arteries, or indeed genetic testing. I’m happy to discuss these tests with you to see if they would help you or not. So if you want to set up a consultation email or call my secretary so we can get you booked in.

After an ablation

I’ve just done a clinic and had several patients who had their first appointment after an ablation. It got me thinking of the things that people wanted to know so I thought I’d get this information out there.

When can I drive? The DVLA have just updated their guidelines and say for most ablations that you can drive 2 days after an ablation. For a bus or lorry it’s 2 weeks

When can I exercise? We ensure you are up and walking about before you go home. Walking as exercise is not a problem. Upper body exercises can be done when you feel ready. I’d be careful about bending exercises such as sit ups or crunches, squats, and running. I’d suggest waiting a week to make sure your groin has healed well.

When will the bruising go? Not all patients have bruising, it’s much more common if you are on blood thinners. The bruise is due to blood leaking from the vein into the skin. The bruise is usually pretty well gone by 6 weeks but it can take longer if it’s a big bruise. If there’s a lump, or if it’s painful, or if it’s throbbing then you should get in touch so we can look at you.

I feel great – all the palpitations have disappeared! This is what I love to hear and is the highlight of my day!

I’m much better but I’m still getting some pounding or flutters? This is not uncommon, particularly in patients who have SVT’s (supra ventricular tachycardias). The ablation deals with an extra connection in the heart, but not with the extra beats that trigger it. So I often hear people say it feels as if it’s going to start, but it doesn’t. Many people get extra beats but I think people with SVT’s are sensitised to them because they have felt their heart race. Oftentimes the gradual realisation that it won’t set off a sustained palpitation means the bad association with the extra beats goes away and people don’t feel them as much.

Any more questions? Hopefully this has addressed the common issues, but please get in touch if you have any more questions and I’m happy to answer by email if I can or otherwise we can book you into clinic.

51.506327-0.0858931

Where have all the heart attacks gone?

During this lockdown the hospitals have been flooded with people suffering with Covid-19

The dirty secret is that no one else seems to be coming to hospital. The non – Covid bit of the emergency department and the non-Covid part of the hospital is fairly empty.

Hospital bed occupancy has never been lower in memory. Very few surgical beds are being used as planned surgery has been cancelled.

The strange thing is that the things we would expect to see happening like heart attacks and strokes have also dropped.

This is a worldwide phenomenon not just confined to the U.K.

The question is why? Nobody really knows. Of course there can only be two explanations.

Firstly people are still having heart attacks but not coming to hospital. This is a little scarey as it suggests we will see more people with complications of heart attacks such as heart failure.

The other possibility is that there are in fact fewer people experiencing heart attacks!

This would be fantastic if it were true.

But why could it be true?

Well social distancing is having an effect on Corona virus transmission; it’s probably affecting all the other viruses we get too. We know that infections can trigger heart attacks so it’s possible fewer infections mean fewer heart attacks

I’ve also noticed on my cycle to work is that there are a lot of people out there exercising. I wonder if there’s more exercise that’s having an effect.

Maybe more home cooking is having an effect too?

Maybe people are sleeping more, are less stressed, or spending more time with your family at home are all protective?

It’s impossible to say at the moment but I’m sure we will learn a lot about this phenomenon in the months to come and hopefully if we can take the lessons this pandemic will have resulted in something good

51.28665490.5561078

Driving and the heart

I thought I’d write this as the DVLA have updated their rules on driving and medical conditions.

They have made it clearer, particularly around ablation, pacemakers and defibrillators, but also for heart attacks

Ablation. For most ablations you can drive after 2 days and you don’t need to let the DVLA know you’ve had an ablation. It is different for VT ablations.

Pacemaker implants. You must let the DVLA know you have a pacemaker and you can drive a week after the procedure.

Defibrillators. You must let the DVLA know. For patients having as a preventative option, you can drive a month after the procedure. For other circumstances, talk to your cardiologist.

Heart attacks. You don’t need to let the DVLA know. If you have had stents, don’t need more stents within a month and your heart function (ejection fraction) is more than 40% then you can drive after a week. If these conditions don’t apply, for example you haven’t had stents, you can drive a month after your heart attack. This advice also applies to patients who have had a type 2 heart attack (there’s a post coming on that!)

Fainting. Also known as transient loss of consciousness (TLOC). This is a really tricky area and it’s important to get advice from your doctor. For common faints such as vasovagal syncope, driving is not restricted. However, if there are unexplained episodes of transient loss of consciousness you must let the DVLA know and your licence will be refused or revoked for 6 months.

Personal advice. It can be tricky to know what to do, particularly if your job depends on driving. I’m always happy to see people and discuss their condition and the driving regulations. Call my secretary on 020 3369 6521 to book in or drop us an email.

The comments above are for ordinary car licenses only. This is uptodate at the time of writing, but it’s always good to check the definitive version on the Government website in case there’s been any change. This summary only includes some of the most common conditions, there is more detail in the rules themselves.

The rules are different for ordinary car licenses and for bus and lorry drivers who are held to a higher standard. These higher bus and lorry standards are often applied to Taxi or minibus drivers but this is determined by Transport for London or the local council. Other occupational drivers may have these higher standards applied at the discretion of their employer.

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Healthcare & Covid-19

This lockdown has certainly changed all our lives, and has completely changed healthcare.  As you can tell from the news, Covid patients have become the bread and butter of NHS hospitals.  To deal with this all elective surgery has stopped in most NHS hospitals to clear theatres and intensive care unit beds for Covid patients.  NHS hospitals have managed to quadruple or quintuple the number of ventilator beds available.  

The private sector including HCA, Spire group and Kims have all given their beds and theatre capacity to the NHS to deal with time-critical patients requiring procedures – mostly cancer patients.

Outpatient clinics have been reduced in the NHS and converted to telephone clinics.

My service

In the private sector, we too are converting clinics to Video or telephone consultations, and these are now covered by all major insurers.

Appointments are available Monday morning, Wednesday and Thursday evenings.  Just reply to this email and we can book you in, or call 01634510521.

I can call using FaceTime / Skype / WhatsApp as these are secure platforms.  Consultations are not recorded, but a clinic letter will be generated as usual.

Tests can be performed now via post for ECG and blood pressure monitoring, or for tests such as echo scans, at a dedicated clean outpatient diagnostic facility with full PPE for patients and staff.  This is at One Welbeck Street in Marylebone, London.

The current information is that private Hospitals in Kent and London are closed to usual activity until at least mid July to allow them to focus on helping the NHS deal with time-critical patients.  

If you need a procedure that can be safely deferred, this will be scheduled once normal service resumes. 

Stay safe,

Shaumik