Although people may have no symptoms the main symptoms are:
– Chest pain
– Light headedness or blackouts
Whilst all of these symptoms often are caused by non cardiac conditions, it is important that they are evaluated by a clinician to see if further investigation of the heart is needed.
The heart is a muscular pump which requires a blood supply. This is provided through the coronary arteries that run around the outside of the heart. When these are narrowed or blocked the heart muscle is deprived of blood and the oxygen it carries and this causes pain.
Typical cardiac pain is felt in the centre of the chest as a discomfort or tight/squeezing pain. It may go into the jaw of arm and is associated with breathlessness and sweating. As the heart needs more blood supply when working harder the pain may only come on when the person is exercising and is relieved by resting.
Although the description above is typical the chest pain can be described in just about any other way. The longer I have been treating cardiac patients the more unusual the presentations of cardiac chest pain I have come across. It is a good idea to see a practitioner to be sure if you have been experiencing chest pain. If severe and out of the blue this should be done as an emergency by phoning for an ambulance.
This is a fluttering sensation, often felt in the chest. Most people experience this symptom at some time in their lives. People can often describe what they are feeling accurately and this helps the doctor to determine the likely cause of the palpitation. The extra beats arise from either the top (atria) or bottom (ventricle) chamber of the heart. Occasionally the fluttering can arise due to the heart missing a beat.
Occasional extra beats or jumps in the chest are usually perfectly harmless and can be ignored UNLESS they are associated with other cardiac symptoms such as light headedness or chest pain or signs of structural heart disease.
A permanently irregular beat or a fast beat should always be investigated further. If associated with symptoms it should be done as a matter of urgency.
A blackout is a lay term for loss of consciousness. Blackouts can be divided into conditions where there is loss of blood supply to the brain (syncope or fainting) and abnormal electrical discharges in the brain (fits/epilepsy).
Most people will have had the experience of fainting at some stage of their lives; given the correct combination of circumstances we will all faint. The majority of faints that occur are perfectly harmless and the person will recover quickly. If uncertain of the cause an early appointment with the a medical practitioner is needed. Emergency assessment is essential even if full recovery has occurred if there is a history of:
• heart failure (history or physical signs)
• transient loss of consciousness during exertion
• family history of sudden cardiac death in people aged younger than 40 • years and/or an inherited cardiac condition
• new or unexplained breathlessness
When seen a full clinical history is essential as is an examination for heart murmurs. An ECG is performed.
Further investigations should be tailored to the patients likely cause but will usually include a 24 hour tape where the heart beat is monitored for a day by a recording device worn around the waist and connected to the skin.
Taking a detailed history and examination will pick up a proportion of patients with heart abnormalities. Simple blood tests with also pick up abnormal cholesterol and glucose levels which are associated with a higher chance of getting heart problems and also anaemia and high thyroid activity. An ECG is a simple quick test which can show abnormalities related to heart muscle damage or problems with the wiring of then heart.
More complex cardiology tests can show even more abnormalities… but there is a trade off. The tests themselves may expose you to a risk for 3 main reasons:
1) The test maybe inconclusive or a false positive and you may need other tests to prove you are normal.
2) Some tests expose you to X rays which at higher dose increase the risk of cancer. For example it is predicted for every 800 middle aged woman who have a CT scan of the coronary arteries it will cause 1 of them to have breast cancer in later life. With the new generation scanners available the risk will reduce substantially as less radiation is needed.
3) Some tests have a small risk of causing damage directly. Even a simple exercise test can very rarely induce a heart attack. Other tests are more directly invasive. For example to clearly see the coronary arteries requires a coronary angiogram. This involves placing a fine catheter through the artery in the wrist or leg up to the heart. Dye is put into the arteries at the same time as taking X ray pictures.
Although generally safe there is a small risk of causing a heart attack.
As tests expose you to risks themselves it is important to be selective in performing further tests on patients; particularly those who have no symptoms. I was horrified to meet someone who had been advised inappropriately to have an annual coronary CT scan at a clinic in London as part of a free annual health medical that came with his job. He had no symptoms and his first scan was normal. He very sensibly asked for more information about the risk involved before agreeing to have it ever performed again – which he didn’t when he understood about the potential radiation exposure.
Undoubtedly there is increasing demand in medicine for more ‘tests’. As a clinician it is very easy to order tests often by simply ticking a box on a request card. Careful thought however should be given before ordering these.
Risk Factors and their Modification
About half of the population in Britain will develop cardiovascular disease (CVD) at some stage of their lives.
There are some risks for developing cardiovascular disease that can’t be changed such as your age, gender or family history of heart disease but there are other factors that can be modified to make it less likely:
• Hypertension (high blood pressure)
• Tobacco use
• Raised blood glucose (diabetes)
• Physical inactivity
• Unhealthy diet
• Overweight and obesity
An excellent link to the facts can be found here.
To see if you have some of these risk factors requires a visit to a doctor who can check the blood pressure, glucose and cholesterol. Other risk factors are all related to you! I often hear patients say that they don’t do enough exercise and are resigned to not doing it. They seem to accept a sedentary lifestyle as inevitable – it’s not! See ‘How much exercise do I need to do?’ below.
Studies show that doing more than 150 minutes (2 hours and 30 minutes) of moderate physical activity or an hour of vigorous physical activity every week will reduce your risk of coronary heart disease by about 30%. If you do not keep active, the risk to your cardiovascular health is similar to that from hypertension, abnormal blood lipids and obesity. A middle-aged woman for example doing less than one hour of exercise per week doubles her risk of dying from a cardiovascular event compared to a physically active woman of the same age.
1. No amount of exercise is too small to do. The benefits of exercise add up over time.
2. Try and introduce exercise into your normal way of life. Think:
• Are you able to leave the car behind so you walk/cycle to the shops/work?
• Can you get off the underground train or bus one stop earlier so you walk?
• Do you need to use the lift or can you use the stairs?
• Can you get a dog who will force you to take him out for a walk?
3. If you do decide to perform more strenuous sport choose something you enjoy. Swimming is a great exercise but if you don’t enjoy doing it choose something different! Ideally do this with others who will encourage you.
4. Be realistic. Do not be overambitious. You want a lifetime of healthy exercise. An exercise programme 5 times a week at the gym is unsustainable for most people. Once a week to start with may be better.
We know now that disease (atherosclerosis) in the coronary arteries is the key risk factor in being predisposed to having a heart attack in the future. We also know the major risk factors that predispose to its development. Some of these are modifiable (such as stopping smoking, losing weight , controlling high blood pressure and cholesterol) others aren’t (age, male gender!)
So to assess risk we can either look directly at how extensive any individuals coronary artery disease is or indirectly look at all the risk factors for developing the disease. The downside of looking in isolation directly at the arteries is that it involves exposure to radiation and/or an invasive procedure with its attendant risks. It also doesn’t look at modifiable risk factors.
Risk factor tables looking at the likely hood of developing disease have been developed over the last 20 years. The first of these tables was derived from the inhabitants of a small American town of Framingham situated 21 miles west of Boston.
In 1948, the Framingham Heart Study embarked on an ambitious project in health research. At the time, little was known about the general causes of heart disease and stroke, but the death rates for cardiovascular disease (CVD) had been increasing steadily since the beginning of the century and had become an American epidemic. The objective of the Framingham Heart Study was to identify the common factors or characteristics that contribute to CVD by following its development over a long period of time in a large group of participants who had not yet developed overt symptoms of CVD or suffered a heart attack or stroke.
The researchers recruited 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts, and began the first round of extensive physical examinations and lifestyle interviews that they would later analyze for common patterns related to CVD development. Since 1948, the subjects have continued to return to the study every two years for a detailed medical history, physical examination, and laboratory tests, and in 1971, the Study enrolled a second generation – 5,124 of the original participants’ adult children and their spouses – to participate in similar examinations.
Over the years, careful monitoring of the Framingham Study population has led to the identification of the major CVD risk factors – high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity – as well as a great deal of valuable information on the effects of related factors such as blood triglyceride and HDL cholesterol levels, age, gender, and psychosocial issues.
Tables have been derived to estimate individual patient’s chances of having a cardiovascular event. An example is shown opposite for non diabetic men.
Other calculating tools have been developed for other communities in particular in Britain. Here the risk of developing cardiovascular disease has been developed from the records of over 500 general practices. The QRISK calculator is thought to be the most accurate way of assessing risk. Click here for example.
The Framingham or Q risk calculator will tell you your chances of having a cardiovascular event (heart attack or stroke) and you will be compared to someone your age.
If you are at >10% risk of having a cardiovascular event over the next 10 years the government is happy for you to have a statin to lower the risk . They are even more happy if you exercise, eat healthily and don’t smoke! You can discuss statin treatment with your doctor (see comments on statins) and have some soul searching about your lack of fitness or otherwise!
As can be seen by the Framingham tables above if you are over 60 and a male you will have a risk of a cardiovascular event of greater than 10% in the next 10 years – the current treatment threshold for considering starting statins. If you are a male over 60 you may wish to consider whether you want a statin before visiting your GP next time.
A final note. The Q risk tables incorporate your post code in your overall assessment of risk. It may seem illogical that your chances of having heart disease are assessed as more or less depending if you live in one area compared to another. To a large extent this reflects poor lifestyle choices in one area compared to another. When I was in Glasgow I came to realise that the Glaswegians life expectancy was 4 years less than someone living in Edinburgh. I initially thought this maybe a reflection of the fried mars bars supplied in the fish and chip shops in Glasgow. It was probably due to the higher alcoholism/ drug abuse/ poverty rates in Glasgow. Some have argued the hardness of water or other environmental factors may be the relevant factor. Personally I do not believe that changing your post code per se is a modifiable risk factor for heart disease. So don’t move upmarket to help your heart!