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Cardiology News, Views and Comments
Valentine interview for Sale & Altrincham and Stretford & Urmston Advertiser:
Dr Petr Ruzicka, cardiology consultant at Trafford General Hospital, advises on how to keep your heart healthy
This Valentine’s Day, when you’re busy making sure your sweetheart feels loved, remember it’s just as important to look after the heart closest to you – your own.
What kind of lifestyle changes can I make to keep my heart healthy?
Stop smoking. The tar and chemicals in cigarettes damage the lining in coronary arteries, make the blood more susceptible to clotting and increase blood pressure and heart rate which puts extra strain on the heart. Smokers are twice as likely to suffer a heart attack than non-smokers. Make sure you get at least 30 minutes exercise a day – even a brisk walk is better than nothing. One small change is always to climb the stairs instead of taking the lift. Eat a healthy and nutritious diet that is low in fat, cholesterol and salt and high in fruit, vegetables and whole-grains.
What are the risks associated with poor heart health?
Smoking, high blood pressure, cholesterol, stress and lack of physical activity may lead to narrowing of coronary arteries which impairs blood supply to the heart and causes chest pain called angina . Everybody should also have their blood pressure and cholesterol checked at least once very five years.
What is a heart attack and what are the symptoms?
A heart attack is a sudden blockage of the blood supply to the heart muscle. Look out for a pressure-like discomfort, heaviness or tightness in the check which may radiate to the neck, jaw and arm. Sudden breathlessness, sweating, anxiety, and light-headedness are also symptoms. But no two heart attacks are the same and symptoms can vary from person to person.
What if I’m not sure if this is a heart attack or not?
If you’re ever in doubt or suspicious, don’t delay in calling 999. A heart attack is a medical emergency and every second counts – the sooner you seek medical help the greater your chance of survival.
Article for Sale & Altrincham and Stretford & Urmston Advertiser:
Trafford General's cardiology team is asking you to check your pulse as part of national Heart Rhythm Week.
Atrial fibrillation is a heart condition that causes a fast and irregular heartbeat. It's the most common heart rhythm disturbance in the UK and is more common as people get older, affecting 10 per cent of the over 65s. The condition can increase the chance of suffering a stroke by five times but once recognised it can be effectively managed and the risk of stroke can be greatly reduced.
The best way to detect an irregular heartbeat is just by checking your pulse. You can do this yourself by placing two fingers of your left hand on your right wrist, just below the base of your thumb and pressing lightly until you feel a pulse. If your heartbeat is fast and irregular (usually well above 100 beats per minute) book an appointment with your GP who will investigate this further and refer you if required.
Dr Petr Ruzicka is a consultant cardiologist at Trafford General with a special interest in heart rhythm problems. He advises that people shouldn't panic if their pulse feels irregular. He said: "This can be down to many factors such as tiredness or stress but it's so important to have this checked out so that you can get the right support and treatment if needed. It's a very treatable condition."
Heart Rhythm week runs to Sunday, June 9. To find out more about the week and other heart rhythm disorders, go to www.aaaw.org.uk.
Mitral Valve Prolapse Controversy
The mitral valve separates the upper left heart chamber (left atrium) and lower left chamber (left ventricle). Mitral valve allows only blood flow from the left atrium to left ventricle, and prevents the blood from going in the opposite direction. Mitral valve prolapse (MVP) occurs when one part of the mitral valve slips into the left atrium during the heart muscle contraction (systole). It is often an incidental finding during routine medical examination, as it produces a characteristic murmur.
Is mitral valve prolapse dangerous? Some old textbooks and patient blogs on internet paint a grave picture of debilitating consequences of MVP including intractable palpitations, dangerous heart rhythm problems, infective endocarditis (infection of the heart valves), chest pain and even sudden death.
The truth however is that most people with MVP are not even aware of its existence and will never have any symptoms or complications. The confusion stems from the pioneer era of echocardiography (heart ultrasound) with massive overdiagnosis of MVP on background of limited diagnostic accuracy and no reliable diagnostic criteria. People who have been labeled with the condition a long time ago may now be reluctant to accept that anxiety, awareness of heart beat or non-specific chest discomfort have nothing to do with any heart problem.
The significance of mitral valve prolapse lies in its impact on the correct function of the mitral valve. In some patients, the prolapsed mitral valve leads to leaking of blood back to the left atrium, a condition called mitral regurgitation. As the disease progresses, the volume of blood going in the wrong direction gradually increases, and over time, the heart becomes enlarged and weak, ie heart failure develops. People with a significant mitral regurgitation may need a surgical intervention in the form of mitral valve repair or replacement.
Promising Future of Wireless Pacemaker
Pacemakers are devices which deliver electrical impulses to the heart in order to regulate its rhythm. They are used in patients with slow heart beat to speed it up and prevent tiredness, breathlessness, dizzy spells and blackouts. So far, all pacemakers had two parts: the generator with battery and clever circuitry which produces electrical signal, and wires used to connect the generator with the heart muscle. The whole device is implanted under the skin, usually under the left collar bone. If the pacemaker is needed only temporarily, an external device is used. The implantation procedure is normally straightforward but as always, there is risk of complications such as bruising, infection and damage to the wires.
Recent invention of wireless pacemaker has the potential to make things much easier. It has the size of a small battery, and is implanted by a simple puncture of the skin and delivered directly inside the heart so that no wires or leads are necessary. So far, there is only a limited experience with these new devices, but they look very promising. The advantages of wireless pacemakers include less invasive implanting procedure, reduced risk of infection and the promise to eliminate complications related to wires.
Arrhythmias in most people require the stimulation of both top and bottom right heart chamber but the current wireless pacemaker can deliver impulses only to the right ventricle. There are some other problems and wireless pacemakers will require further improvements before widespread clinical use. Nonetheless, the preliminary findings are very promising and the new technology has enormous potential.
The Total Artificial Heart
Heart failure is a common cause of mortality in developed countries. Patients suffering from this progressive condition have several treatment opportunities such as different kinds of medications, special heart failure pacemakers, surgical procedures and heart transplantation as the last resort.
The main problem with transplantation is finding the matching donor in very limited period of time, as the patients with the end stage heart failure cannot wait. Total Artificial Heart (TAH) is a possible solution for those patients. It is a device which replaces the function of both right and left ventricles of the heart, thus providing adequate blood flow and oxygen supply to the body. TAH can be implanted as a bridge to heart transplantation or as a destination therapy for patients that are not suitable for heart transplant.
There are several different types of TAH available nowadays. Some of them are using external power source, while other are placed entirely inside the chest and are powered by magnetic charger through the skin. In Britain, the first patient to leave hospital with an artificial heart was Matthew Green who received the SynCardia TAH at Papworth Hospital in Cambridge on 9 June 2011.
Although TAHs may provide lifesaving help, they are used in very limited number of patients because they are not yet perfect, can cause various complications, and the implantation procedure is very complex. The devices, operations and surrounding care are of course extremely costly. However, scientists are giving their best to improve the TAHs in order to help patients with the terminal stage of heart failure.
Obesity as a Heart Attack Risk Factor
Heart attacks occur because of the sudden obstruction of the blood flow through the coronary arteries – the blood vessels that supply the heart muscle with blood. The obstruction is caused by a blood clot on background of a ruptured atherosclerotic plaque in the wall of the coronary artery. It has been known for a long time that obesity is associated with increased cholesterol, diabetes and high blood pressure, which then affect coronary arteries causing their narrowing and thickening, and finally lead to the heart attack. But only recently it has been shown that there is a direct link and obesity itself without other risk factors.
It has been reported that obese male individuals have 60% greater risk of heart attack than non-obese individuals of the same age, even accounting for all the other risk factors included. It is interesting that the risk in obese people is increased only for heart attacks which have the fatal outcome and not for non-fatal heart attacks. The reasons for that are still unknown, but it is suggested that fat cells produce some substances which may cause such events. Increased needs of obese body may also cause worse outcome.
These findings change greatly the thinking that if we just control diabetes, cholesterol and blood pressure by taking medication, we will be fine and free of risks. In other words, obesity is just as important as the traditional risk factors and has to be tackled with healthy diet and active lifestyle. Even the slightest reduction in weight results in decreased cardiovascular risk. If you are overweight, by losing only a few pounds you will lower significantly your risk of heart attack.
Heart Failure Epidemiology and Treatment
Heart failure is a serious medical condition in which the heart is failing as a pump and is not able to provide sufficient blood supply to the organs. The heart muscle becomes weak and can no longer deliver enough oxygen to the rest of the body. The most common cause of heart failure is heart attack due to coronary artery disease and dilated cardiomyopathy (enlarged and weakly pumping heart muscle with normal coronary arteries).
Heart failure can affect people of any age but it is most common in the elderly. More than 5% of individuals aged between 60 and 69 are suffering from some stage of heart failure, and in persons older than 65, it is the main cause of hospitalization. Heart failure is slightly more frequent in men than in women, mainly due to the differences in the occurrence in coronary artery disease. Survival rates depend on the severity of the heart impairment, general health and the treatment.
A plenty of treatment options for heart failure are available today. Standard medications combined with dietary and lifestyle changes give good results in early stages of the disease. Some of the drugs useful in heart failure are ACE inhibitors, beta-blockers, aldosterone antagonists, diuretics and digoxin.
Sometimes, surgical procedures are also required. Some of them are performed in order to eliminate the cause of heart muscle damage such as coronary artery bypass, CABG and heart valve surgery (valve repair or valve replacement). Some people may benefit from special heart failure pacemakers that improve the coordination of heart pumping function; they are called biventricular pacemakers or cardiac resynchronization therapy (CRT). One of the newest treatment options is the implantation of the Left Ventricular Assist Device (LVAD) which helps the function of the failing heart, thus improving the blood flow.
The ultimate resort in some patients may need to be heart transplant, which is often not available, so the efforts need to be made in order to slow the progression of the disease by using available treatment options.
Sudden Death in Athletes
Sudden death in young athletes is not frequent but there are still many high-profile tragedies occurring every year. The most commom cause of sudden death in normal population is coronary artery disease. A sudden rupture of atherosclerotic plaque inside coronary artery lead to the blockage of the artery by a blood clot. This may cause dangerous heart rhythm disturbances including ventricular fibrillation (uncoordinated contraction of the heart with no cardiac output) and death.
In athletes, the most common cardiac congenital anomaly is hypertrophic cardiomyopathy – abnormal thickening of the walls of heart muscle – which is responsible for about 50% of sudden deaths in people under 35. Other possible causes of sudden death in young people are congenital abnormalities of coronary arteries (blood vessels that feed the heart muscle), myocarditis (inflammation of the heart muscle), arrhythmogenic right ventricular cardiomyopathy (disease of the muscle of the right bottom heart chamber), dilated cardiomyopathy (enlarged and weak heart), aortic stenosis (stiff and rigid aortic valve), and channelopathies (disturbance in the function of ion channels in membranes of heart muscle cells, such as LQTS, long QT syndrome, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia (CPVT).
Studies have shown that most of the athletes, who experienced sudden death, have never had any cardiac symptoms. Only in 25% of those athletes, some kind of cardiovascular disease is suspected or diagnosed before death. A degree of controversy exists over what level of screening is appropriate before engaging in competitive sports. Routine clinical tests include physical examination, ECG, and ergometry. Early indicators that can suggest the existence of hidden cardiovascular disorders are episodes of unexplained chest pain, blackouts as well as occurrence of sudden death in the family. Athletes with such symptoms require thorough cardiovascular examination and testing.
Epidemiology and Treatment of Aortic Stenosis
Aortic stenosis is one of the most common heart valve problems. It occurs when the aortic valve gets stiff and rigid, so that the heart muscle has to make extra effort to push the blood across the diseased valve. That causes poor circulation and insufficient oxygen supply to body organs. The usual symptoms include reduced exercise tolerance, tiredness, shortness of breath, chest discomfort and finally dizziness and blackouts. The symptoms first appear only when the disease is significantly progressed and necessitate prompt treatment.
There are two types of aortic stenosis: congenital and acquired. Congenital aortic stenosis is diagnosed in young people and is relatively rare. The vast majority of cases occurs in elderly people and is of degenerative origin. The incidence of aortic stenosis increases with age. It is estimated that 29% of people older than 65 years and 37% people above 75 years have some stage of aortic stenosis. The disease is more common in men than in women.
Treatment options today include an established and time proven aortic valve replacement (AVR) and newer and less invasive Transcatheter Aortic Valve Implantation (TAVI). AVR is a first option in majority of patients. AVR is an open-heart surgery performed under general anesthesia. During the operation, the heart is stopped, and the device for artificial circulation is connected. The heart is then opened, and the old stenotic valve is replaced with new artificial valve. It is obviously a major procedure but the operation has great success rate and the risk of complications is relatively low. TAVI, on the other hand, does not require chest opening, because the artificial valve is brought to the heart through blood vessels. This technique is less invasive but it is still a substantial procedure. TAVI can be used in some patients in whom open-heart surgery is contraindicated.
The Impact of Salt Intake on High Blood Pressure
Essential hypertension is the most common type of hypertension as it is present in more than 95% of patients with elevated blood pressure, and it is by far the most common cardiovascular disorder in general population. The prevalence of hypertension increases with age and the registries show that 90% of people develop essential hypertension over their lifetime. The exact cause of essential hypertension is still unknown, and that is why it is also called idiopathic or primary hypertension. However, there is a good evidence that multiple factors – genetic and environmental are causing this disorder.
It seems that one of the main causes of essential hypertension might be the increased salt intake. Several studies and registries have found that daily salt intake greater than 100 mmol is crucial factor for the development of hypertension. The problem is that nowadays, most people exceed that limit, thus increasing the risk of elevated blood pressure.
The explanation of the effect of salt on blood pressure is simple. The concentration of salt, or more precisely sodium, is constantly regulated by kidneys, until the capacity of this organ is exceeded. Excess sodium holds water in the circulatory system, thus increasing the blood pressure.
World Health Organization (WHO), in its guideline “Sodium Intake for adults and Children”, strongly recommended the daily salt intake for adults to be less than 5 g.
Estimated salt intake in Europe (1990 – 2009) is 8-12 g/day, which is a very high amount. Although various programs have been applied across the European Union in order to lower the intake of salt, they resulted in very limited improvements, because of technological and economic barriers.
NSAIDs and Increased Cardiovascular Risk
Non-steroidal anti-inflammatory drugs (NSAID) are among the most commonly prescribed medications for the treatment of many medical conditions. They are prescribed for arthritis in order to decrease inflammation, for pain relief in numerous conditions such as headache, and in the management of fever.
Despite their widespread use, these drugs have recently been proven to have a harmful effect on cardiovascular system. In 2011, Hull York Medical School has published a paper with results of an international study which investigated the effects of NSAID on cardiovascular system. They found that some of these drugs such as diclofenac and indomethacin significantly increased the risk of stroke and heart attack. On the other hand, naproxen and ibuprofen in recommended doses did not elevate the risk of cardiovascular events. Dr Patricia McGettigan from Hull York Medical School pointed out that much more attention has to be paid when it comes to prescribing NSAIDs to patients with increased cardiovascular risk. She also said that choosing the less harmful NSAIDs – ibuprofen and naproxen is crucial in order to reduce the incidence of stroke and heart attack in population with higher risk.
Despite similar concerns were first raised a decade ago, clinical practice has not changed much. Recent study conducted in 15 countries showed that diclofenac was the most commonly prescribed NSAID, while naproxen was prescribed in only 10% of patients receiving NSAID.
To really understand the importance of NSAIDs’ harmful effects on cardiovascular system, we should have in mind that diclofenac increases the cardiovascular risk to a similar extent as rofecoxib, the drug which has been withdrawn from the market because of high prevalence of strokes and heart attacks in treated patients.
The Role of Aspirin in the Prevention and Treatment of Cardiovascular Disorders
Until 1970s, aspirin was mainly used as analgesic, but today, it is considered one of the most important drugs used in patients with cardiovascular diseases. Aspirin lowers the production of substances called prostaglandins, thus affecting various functions of vital organs and tissues.
Prostaglandins make the platelets clump together and create a blood clot. This is obviously very useful in injury to stop bleeding but blood clots are also responsible for heart attacks and strokes by obstructing arteries and blocking blood supply to a part of heart or brain. Aspirin, by blocking the production of prostaglandings, therefore reduces the risk of excessive clotting and subsequently risk of heart and brain infarct.
Aspirin can cause damage to the lining of stomach and guts. Susceptible patients may require the use of drugs called proton pump inhibitors (PPI) such as omeprazole or lansoprazole to prevent this. Aspirin also prolongs bleeding time, so people undergoing any invasive procedure or people with increased risk of bleeding should only use aspirin when recommended by their GP or Consultant.
News, comments and opinion from the world of cardiology.
The opinions expressed in this blog are strictly those of the author and should not be construed as the opinions of the BMI Alexandra Hospital or Central Manchester University Hospitals NHS Foundation Trust, nor recommendations for personal medical care. Blog users should contact Dr Ruzicka or seek other professional opinion for advice regarding specific cardiology problems.