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

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.

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.

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 this 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 liver failure so it’s not so 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.

Ablation – for heart rhythm

Ablation really just means the destruction of cells. When applied to heart rhythm problems it means we can treat heart cells that are causing trouble.

It is done by using one of 2 technologies – either microwave energy to heat cells, or liquid nitrous oxide to freeze cells. These cause the proteins in the cells to change their structure and stop the cell from working.

The heating or freezing is done via catheters which are introduced to the heart via the veins (or sometimes arteries) in the groin. They are long and thin, usually about 3mm in diameter, though some can be significantly larger.

Different rhythm problems are due to different causes – either cells are over-active, so fire too much, or conduct slowly allowing electrical circuits to be set up inside the heart.

In atrial fibrillation we have learnt that dealing with the over-active cells in the veins as they enter the heart can lead to narrowing of the veins, so it is safer to electrically isolate the veins from the atria by burning or freezing around the veins. This can be known as Pulmonary Vein Isolation (PVI) or Wide Antral Circumferential Ablation (WACA). We doctors do like our acronyms!

Like any procedure, there are risks and benefits.

On the benefits side, they can cure rhythm problems, particularly supra ventricular tachycardias, or at least improve symptoms for example for atrial fibrillation. The exact benefit depends on the condition being treated.

On the risks side they can cause problems inside the heart such as destroying normal conduction tissue so a pacemaker is needed, or causing a heart attack or stroke. There can be bleeding around the heart or damage to structures near the heart such as the veins, the gullet, or the nerve to the diaphragm. There can also be problems in the groin where we access the veins such as clots in the veins or damage to the artery or nerves near the veins. The risks do depend on the condition being treated.

Hopefully that is some information for you that will help you understand what might be happening. If you want specific information, please don’t hesitate to get in touch and arrange an appointment.

Atrial Fibrillation – rhythm control, but how?

So maybe we’ve done rate control and you’re still not ok. Or perhaps the atrial fibrillation is at the stage where it comes and goes. Maybe we should try to get and keep you in a normal rhythm.

There are a few strategies to do this.

The simplest is a DC cardioversion. This uses an electric shock across the heart to reset the atrial rhythm. The good news is that this is quick, almost always works initially. The bad news is that if you’ve had atrial fibrillation for more than a day, you should be on anticoagulants to prevent blood clots from forming in the atrium. It’s also quite painful so needs to be done under deep sedation or a general anaesthetic.

The other bad news is that the atrial fibrillation can start again. Sometimes it can recur quite quickly. Medications can be used to try to keep you in a normal rhythm. In the UK, the commonly used ones are amiodarone, flecainide, sotalol and possibly dronedarone. These can successfully control the rhythm but are not perfect, but are certainly worth trying.

There is another strategy which is a procedure called ablation. Current guidelines suggest that ablation be offered if drug therapy doesn’t work, but more data is being published to say that it is a reasonable first line option in atrial fibrillation that comes and goes (paroxysmal).

Ablation refers to a procedure where we selectively treat part of the heart muscle to prevent rhythm disturbances. For atrial fibrillation, it seems that the trigger for atrial fibrillation is electrical activity coming from muscle sleeves around the veins from the lungs as they empty into the left atrium. So in ablation, we either freeze or microwave tissue around the veins to electrically isolate the veins from the atrium. The medium term success rates for ablation in patients with paroxysmal atrial fibrillation is above 70%, though some patients will need more than one procedure. For persistent atrial fibrillation (ie the heart is in atrial fibrillation for more than a week, or needed drugs or cardioversion to restore normal rhythm), the medium term success rates are more like 50%. It’s important to know that lifestyle measures such as weight loss do significantly improve the success rates so this is extremely important.

Bad news about ablation – like any procedure there are risks associated with it such as groin damage, bleeding around the heart, damage to the nerve to the diaphragm resulting in breathlessness and very rarely heart attack, stroke or damage to the gullet which can be fatal.

It’s worth speaking to a specialist to discuss the best strategy for you as it can be quite a complex decision.

Atrial fibrillation – rate or rhythm control?

So if you have atrial fibrillation what’s the first thing that needs to be sorted?

In the absence of medicines or heart disease the heart races at over 150 beats per minute. This can feel very uncomfortable – a sensation the heart is racing combined with breathlessness and fatigue. If there are other heart problems such as coronary artery disease it can make these more troublesome and cause worsening chest pains.

Surprisingly some people don’t have any symptoms and it’s picked up incidentally! If untreated this can cause the heart to wear out – the ventricles contract more weakly – a condition called tachycardia cardiomyopathy.

So the first goal is to reduce the heart rate. This can be achieved by medication – beta blockers, calcium channel blockers or digoxin. These all slow conduction in the atrioventricular node and therefore slow the ventricular rate.

But rewind a bit – if the atria are fibrillating, shouldn’t we fix it?

Well, yes, that is the logical thing to do. But being cardiologists we are not satisfied with mere logic, we want evidence.

It is relatively simple to reset the heart from atrial fibrillation to normal (sinus) rhythm. In fact in many people the fibrillation lasts less than a day, but these episodes (or paroxysms hence the term paroxysmal atrial fibrillation) have a tendency to become more frequent and last longer before becoming persistent.

At the turn of the century cardiologists performed a trial to test if patients did better with a rate control strategy or with a rhythm control strategy. This was the AFFIRM trial which published in 2002. This landmark study of 4060 patients showed that there was no benefit to a rhythm control strategy compared to a rate control strategy. In fact, there was a trend towards a lower death rate in the rate control group (but statistically this did not reach significance). Quality of life was assessed and not found to be different between the 2 groups but the method of assessing this and the results are not quoted in the original paper.

This has led to guidelines recommending rate control as the initial treatment strategy. But there are important caveats to this. The trial only enrolled patients above the age of 65, so it’s findings are not applicable to younger patients. Secondly, the use of anticoagulants to prevent stroke was a little worse in the rhythm control group at around 70%, compared to the rate control group at 83%, because the trial protocol allowed for discontinuation of anticoagulation in the rhythm control group. This may account for inferior outcomes in the rhythm control group. Finally, of course, our treatments for rhythm control have expanded since 2002 (the subject of a future post)

In the AFFIRM trial only a single patient in the rhythm control group underwent ablation of atrial fibrillation (the seminal paper which described this was only published in 1998) which has become an important tool in the intervening years.

So we know that rhythm control or rate control with medicines are equivalent options in the treatment of atrial fibrillation when it comes to hard outcomes like death rates.

But that’s not to say there aren’t symptomatic improvements with rhythm control. This is where it is important to see an expert to tailor the treatment strategy to you personally as opposed to what’s good the population. A good doctor will explain all the options for treatment strategies for rate or rhythm control, anticoagulation and the importance of lifestyle factors, discover what goals are important to you and help you achieve them.