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.

51.32789320.5265284

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

Coronavirus & the heart

There’s lots of information out there, and lots more uncertainty.

The good news is that most people experience mild symptoms if any and recover. But the elderly and people with pre-existing medical conditions, particularly heart conditions, are at higher risk of adverse outcomes.

The American College of Cardiology has just released a bulletin on the cardiac effects of coronavirus.

In a study of 138 patients hospitalised due to coronavirus, 17% experienced rhythm problems, and 7% experienced injury to the heart muscle.

Anecdotal reports include patients experiencing acute onset heart failure, heart attack (myocardial infarction) and inflammation of the heart (myocarditis)

We need to be aware of these and open to other rare issues that may arise with this new disease.

Stay well everyone, and wash your hands!

Can exercise cause trouble for my heart?

Everyone thinks exercise is good for you. It certainly is! Being fit does reduce the chance of health problems including heart attacks strokes and diabetes.

But it becomes more complex if you have heart problems. People who have had heart attacks are offered cardiac rehab to put them through a graded exercise program to get them back into safe levels of exercise.

Some people have inherited problems such as hypertrophic cardiomyopathy which can increase the risk of heart rhythm problems with exercise.

Very rarely, these can result in cardiac arrest with dramatic examples such as Fabrice Muamba collapsing on the football pitch during a premier league match.

To combat this professional athletes undergo screening for cardiac disorders.

Last month Professor Sanjay Sharma published the results of his experience screening adolescent footballers. This study was funded by the English football association and its great to see them taking this issue seriously and perhaps more so than the US national (American) football league and their ongoing problems with chronic brain injuries.

I have worked with Prof Sharma previously on similar screening events of England cricketers and Manchester City football club, so I know how much work is involved as well as the worry it brings when something abnormal is found.

But this study has covered many more people to give us much better data. They looked at 11,148 players with an average age of 16 over a 20 year period. 95% of these were male. 42 players were found to have a cardiac disorder with a risk of sudden cardiac death. A further 225 had other cardiac problems that were picked up.

The players were all youth players at English professional football clubs. The 42 players who were found to have cardiac disorders associated with sudden cardiac death were advised not to compete.

After follow up (obviously of varying durations – 20 years for those screened at the beginning, down to 2 years for those at the end), 23 people had died, 8 of which from Cardiac causes.

Clearly the risk of cardiac problems is small but not zero in these players, with 0.38% if screened players having a Cardiac disorder associated with sudden cardiac death, and 2% having some form of cardiac problem.

We don’t know how effective screening is at preventing problems – this study doesn’t address that as there is no control group, but it does tell us that screening is not perfect at preventing sudden Cardiac death and some problems are not detected at the point of screening.

Nevertheless the absolute risk is small.

The big gap now in my mind is the risk in veteran athletes – the MAMIL’s or middle aged man in Lycra – or people like me!

There is a growing trend for fitness and certainly there are far more middle aged people cycling / doing triathlons / marathons and so on.

Every year there seems to be a death in the ride London event. There’s no data to show that screening in this population picks up treatable conditions but I would certainly want to think about it before I took on a big race or competition.

 

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.

 

Medicines for rhythm problems

There are lots of medicines out there for heart rhythm issues.

The first line that are beta blockers (eg bisoprolol) or calcium channel antagonists (eg diltiazem).  These generally slow the heart and can reduce extra beats, but aren’t very good at keeping you in a normal rhythm.

Anti-arrhythmic drugs can keep you in a normal rhythm. The most effective is a drug called amiodarone. This is a very powerful anti-arrhythmic, but it’s by no means perfect. It increases the time to recurrence of atrial fibrillation, reduces recurrent symptoms but doesn’t abolish them (ie it’s not 100% efficacious – probably more like 60%).  It does reduce ventricular tachycardia episodes.  It is overkill for supraventricular tachycardias and hangs around for ages so is generally avoided in this situation.

It also has lots of potentially nasty and lethal side effects. Most of these only occur after prolonged exposure after many years or decades but some can occur early. Initially the drug was used at doses of 400mg a day, but now we commonly use it at 200mg or even 100mg a day. The commonest side effects include problems with the thyroid gland but it can also cause grey discolouration of the skin, sensitivity to the sun, deposits on the surface of the eye causing issues with glare of vision particularly at night, taste problems, lung fibrosis, liver problems, damage to the peripheral nerves.

There are alternatives. The great hope for atrial fibrillation was dronedarone which was supposed to be as good as amiodarone but safer. It actually has the best evidence base of any antiarrhythmic ever but is probably as it is the latest drug. Unfortunately it doesn’t seem to be as good as amiodarone and is dangerous in people with impaired heart function and has a warning against it that it can cause fulminant liver failure so it’s not popular with doctors.

Flecainide or propafenone are pretty good in patients without heart disease and are pretty safe. In fact flecainide is my go to antiarrhythmic in pregnant patients. Sotalol is another option but isn’t particularly effective.

It can be quite complex choosing the right medication for yourself so it’s always helpful to see a specialist to discuss options and come up with a tailored personalised management plan.  Feel free to get in touch and make an appointment

Atrial fibrillation – rate control, but how?

So we’ve decided that rate control is the best way forward for you – but how do we achieve it?

The mainstay is medication and there are different types that can be used.

First line are beta blockers such as bisoprolol.  These are usually very safe and well tolerated.  They can be taken safely for many years.  They can even be used in pregnancy!  The most frequent side effects that people complain to me about is feeling cold, and the second is that they can make some people feel tired.  Some people complain about vivid dreams.  There are of course other side effects noted in the sheet you get with the medicines, but these are the ones I hear about in the real world!

If these don’t suit a calcium channel antagonist such as diltiazem can be helpful.  Again, usually well tolerated and safe.

If these don’t do the trick or can’t be used because of low blood pressure then digoxin is a reasonable choice.  This is a drug that is made from the foxglove and has been known about for centuries.  It is quite effective, but oftentimes doesn’t control the heart rate on exercise so isn’t so suitable for active people.  I’ve linked a short film made a long time ago by one of my mentors Dr Holman for the Wellcome foundation.

Occasionally of course combination of these medications need to be used.  The alternative is a “pace and ablate” strategy where a pacemaker is implanted and the electrical connection between the atria and the ventricles is ablated thus making the ventricular rate controlled by the pacemaker.  This can be very effective in dealing with symptoms because it results in a regular pulse as well as a normal heart rate.