Heart Disease UK

Heart disease is the leading cause of death. There are many factors which may put you in a high-risk group for heart disease. If you have a family history of heart disease, have been diagnosed with high cholesterol, or have high blood pressure, you may be at risk to develop heart disease. A heart scan can reveal even minor problems, which could not be detected by physical examination, EKG, or stress test, giving you the foresight to take the necessary steps to maintain your health.
The heart scan, captures detailed, cross-sectional images of your heart, revealing the presence of coronary artery calcification, a key factor in determining your risk of heart disease. The overall condition of your heart health is based on this "calcium scoring."
Since most people have no warning of an impending heart attack, a heart scan can give you the foresight to take the necessary steps to maintain your good health.

Most people who die from a heart attack had no previous symptoms. Knowing the physical condition of your heart could save your life. A quick and easy procedure, the Preventive Heart Scan tests men and women who may be at risk, even though they may be symptom-free. All you're required to do is hold your breath for about 30 seconds while the GE Light Speed CT scanner slides over your chest area as you're lying on your back, resting comfortably. You could be just a breath away from breathing easier about your heart health with this heart scan, which provides you and your physician with valuable information about the physical condition of your heart.
A PHS exam is an excellent tool for helping your doctor get the specific information needed to make a well-informed, accurate diagnosis, so he or she can provide you with the very best care. Your PHS exam will be a big comfort to your family, too. Since the scan is quick and easy, both you and your family -- as well as your doctor -- will get the answers you're looking for.

What's a cardiac score?
The CT images provide precise, high-resolution pictures of your heart's vessels. These images are evaluated to measure the calcium and plaque build-up that leads to heart disease. A board-certified radiologist reviews your test results and a cardiac score report is provided to you and your physician. Early warning signs of heart disease can assist your physician in recommending treatment or lifestyle changes that can slow, stabilize, or even reverse heart disease

The facts about computerized tomography (CT) and heart scans
• A computerized tomography (CT) scan is a valuable diagnostic medical tool combining X-rays and computer images.
• CT scans have been used successfully in diagnostic medicine for almost 30 years.
• CT scans are non-invasive, meaning that there is no penetration of the body, either by injection or incision.
• CT scans can be put together in a computer imaging program that shows a three-dimensional image of the heart for in-depth clinical evaluations.

Constantinos Anagnostopoulos and Richard Underwood

Despite major advances in prevention and treatment of coronary atherosclerosis, coronary heart disease (CHD) remains a major cause of mortality and morbidity in the western world. Its management consumes a large proportion of national health care budgets, a significant part of which is spent in imaging technologies. Amongst them, myocardial perfusion imaging (MPI) is an established technique with important applications in the overall management of CHD, including, diagnosis, prognostication, selection for revascularisation and assessment of acute coronary syndromes.
This supplement covers the current applications of MPI and also its cost effectiveness and use in clinical practice in the UK. In the first article, Loong and Anagnostopoulos perform a systematic review of the existing literature on the diagnosis of heart disease by radionuclide MPI. The message is that MPI possesses a high overall diagnostic accuracy and remains the standard technique for assessing myocardial perfusion in the everyday clinical practice.
The assessment of myocardial viability and hibernation in patients with cardiac failure is another area where MPI also plays an important role because it can assist in the differentiation of ischaemic and non-ischaemic aetiology and it is an optimal technique for management and assessment of prognosis.
Evidence from modelling and observational studies supports the enhanced cost effectiveness associated with MPI use. In patients presenting with stable or acute chest pain, strategies of investigation involving MPI are more cost effective than those not using the technique. Despite this and the fact that MPI is an integral part of many clinical guidelines for the investigation and management of angina and myocardial infarction, the technique is under-utilised in the UK as judged by the inappropriately long waiting times and by comparison with the numbers of revascularisations and coronary angiogram performed. In view of the publication of the UK National Institute of Clinical Excellence, guidance on the role of MPI in the diagnosis and management of patients with angina and myocardial infarction, we believe that the current supplement will be a valuable source of information for both providers and users of the technique.

From Richard N. Fogoros, M.D.
By DrRich

In standard textbooks of cardiology, much space is devoted to a description of the symptoms that typically occur with heart disease. In most cases, these "typical" symptoms turn out to be a recitation of the symptoms men get. In women, the symptoms can be quite different, and are usually regarded by cardiologists as being "atypical." However, since more women are dying from heart disease than men these days, it may be statistically more correct to consider men's symptoms as the ones that are "atypical."

Angina in women
When women have angina, they are more likely than men to experience "atypical" symptoms. Many women report a hot or burning sensation, or even tenderness to touch, in the back, shoulders, arms or jaw; often they have no chest discomfort at all.
Any good doctor will think of angina whenever a patient describes any sort of transient, exertion-related discomfort located anywhere above the waist, and they really shouldn't be thrown off by "atypical" descriptions. However, because many doctors persist in believing that CAD is uncommon in women, they are all too likely to write such symptoms off to mere musculoskeletal pain or gastrointestinal disturbances.
Myocardial infarctions (MI, heart attacks) also tend to behave differently in women. Frequently they experience nausea, vomiting, indigestion, shortness of breath or extreme fatigue - but no chest pain. Unfortunately, these symptoms are easy to attribute to something other than the heart. Women also are more likely than men to have "silent" MIs - that is, MIs without any acute symptoms, and that are diagnosed only at a later time when subsequent cardiac symptoms occur.

Chest pain with normal coronary arteries
Furthermore, women are more likely than men to experience true angina (chest pain due to a coronary artery disease) but with "normal" coronary arteries seen on cardiac catheterization.

Women minimize their symptoms
Women tend to complain less about their cardiac symptoms than men, thus leading doctors to think they are doing better than they actually are. Now, scientific evidence exists to show that, indeed, women tend to minimize their symptoms of cardiac disease.

By DrRich

Magnetic Resonance Imaging (MRI) has long been useful for diagnosing problems of the brain, spine and joints. Over the past decade, MRI has proven useful in diagnosing certain uncommon cardiovascular problems such as aortic dissection, cardiac tumors, and congenital heart disease. And MRI has proven a valuable research tool for studying more common cardiac disorders such as ischemia and cardiomyopathy. Until recently, however, it has been impractical to use MRI where it would be the most useful – in the routine evaluation and management of patients with coronary artery disease.
All that appears about to change. New techniques are becoming available that promise to deliver the holy grail of cardiology– a means to non-invasively image the coronary arteries – and to do it with far more precision than is achieved by today’s gold standard, coronary angiography.
In December, 2001, researchers at Harvard reported in the New England Journal of Medicine that they were able to use MRI scanning of the coronary arteries to detect disease in the major branches of the coronary arteries. They reported an overall accuracy of 72% with the MRI technique, and a much higher accuracy for disease of the left main coronary artery (which, while relatively uncommon, is the most dangerous place for a person to have coronary artery disease.)

What is MRI?
MRI is an imaging technique that takes advantage of the property of certain atomic nuclei (in this case, the single proton that forms the nucleus of a hydrogen atom) to vibrate – or “resonate” – when exposed to bursts of magnetic energy. When the hydrogen nuclei resonate in response to changes in a magnetic field, they emit radiofrequency energy. The MRI machine detects this emitted energy, and converts it to an image.
The MRI offers a potential means of detecting areas of cardiac tissue that have poor blood flow (as in coronary artery disease) or that has been damaged (as in a heart attack).
However, there are many technical problems in imaging moving structures like the heart with MRI. Movement of the heart during scanning significantly distorts the image (just as taking a photo of a moving object causes a blurring of the picture), and when the structures you are trying to see are small the movement problem becomes extremely difficult to overcome. Technology is progressing rapidly, however, and commercial MRI machines that can produce high-quality heart images are already being used in many research institutions.

How is cardiac MRI useful today?
While MRI machines abound in the United States, cardiac MRI, because of its complexity, has largely been limited to university hospitals where there is a strong research interest. Accordingly, much of the work with cardiac MRI has been done in the research setting.
Because of the difficulties in producing detailed MRI heart scans, only a few uses of cardiac MRI have become more-or-less routine. MRI has proven very useful in evaluating patients with aortic dissection prior to surgery. The detailed images offered by MRI tell the surgeon precisely where the “tear” in the wall of the aorta begins, and the full extent of the dissection. MRI can also locate and characterize the rare cardiac tumor. And in children with complex congenital heart disease, MRI can help to identify and “sort out” the various anomalies, and to plan potential surgical approaches to treatment.
While such applications of MRI are very helpful, these clinical situations are relatively rare. So cardiac MRI has yet to become a commonly used tool in clinical medicine.

What are some of the potential uses of cardiac MRI?
Once certain limitations are overcome – and that day seems to be rapidly approaching – the uses of cardiac MRI will explode.
MRI has the potential to diagnose heart attacks in patients presenting with chest pain. Not infrequently, a patient coming to the emergency room with chest pain will not have the typical ECG changes seen with myocardial infarctions, and the doctors end up waiting for an hour or two for the results of cardiac enzyme tests.
MRI can help distinguish between “stable” atherosclerotic plaques and “vulnerable” plaques. Vulnerable plaques are those that are prone to rupture, thus suddenly occluding a coronary artery and causing a myocardial infarction. If vulnerable plaques can be identified, those particular plaques can be targeted for intervention (angioplasty, stent, or bypass), while leaving the stable plaques alone.
MRI has already proven useful in the research setting for identifying restenosis after angioplasty. MRI might thus prove an accurate, noninvasive means of following patients after angioplasty.
MRI may replace the x-ray tube in both diagnostic and therapeutic situations. Research is already being done in animals using MRI to image the coronary arteries – instead of using fluoroscopy – for angioplasty procedures.

What about this week's report from Harvard on using MRI for diagnosing coronary artery disease?
Report in the New England Journal of Medicine constitutes another step forward, but MRI is still quite a ways from being ready to replace cardiac catheterization for most patients. While an accuracy of 72% is encouraging, it is certainly nowhere near the nearly 100% accuracy achieved with cardiac catheterization and coronary angiography. So, aside from the other disadvantages listed below, today the MRI is not accurate enough to substitute for coronary angiography when you really need to know the status of the coronary arteries. Indeed, while progress is ongoing, the MRI today is scarcely better in overall accuracy than the less inconvenient noninvasive tests that are used every day in cardiology.

Summary
MRI technology holds tremendous promise in the evaluation and treatment of heart disease. It is clearly technically feasible for MRI to replace – and significantly improve on – many of the sophisticated imaging techniques that are now routinely performed in cardiology. The potential for MRI to accurately diagnose and direct the treatment of coronary artery disease before it becomes clinically apparent is probably the most exciting prospect. Before this can happen, however, the amazing technology now being developed needs to be made accurate enough and inexpensive enough to achieve broad usage.

From Richard N. Fogoros, M.D.
A common congenital heart disorder
Hypertrophic cardiomyopathy (HCM), originally felt to be rare, is now known as a common congenital heart disease that causes several varieties of heart problems – not the least of which is sudden death.

What is HCM and what causes it?
HCM is a form of heart disease in which the muscular walls of the ventricles become abnormally thickened. The thickening of the heart muscle causes the muscle itself to function abnormally. The thickening can also cause the ventricles to become distorted, which can interfere with the function of the aortic valve and the mitral valve.
HCM is caused by a genetic abnormality that produces a striking disorder in the growth of the heart muscle fibers.
However, in almost half the patients with HCM, the genetic problem is not inherited at all, but occurs as a spontaneous mutation – in which case parents and siblings of the patient will not be at risk for this condition (but children of the patient can be.)

What problems does HCM cause?
There are four kinds of cardiac problems caused by HCM:
1) HCM can cause diastolic dysfunction. "Diastolic dysfunction" refers to the fact that thickened ventricles become stiff, making it more difficult for the ventricles to fill with blood. This stiffness causes the blood to "back up" into the lungs, causing shortness of breath – usually with exertion. The diastolic dysfunction also makes it more difficult for patients with HCM to tolerate arrhythmias, especially atrial fibrillation.
2) HCM can cause systolic dysfunction. "Systolic dysfunction" means that the heart's pumping action is not normal - that is, when the heart beats, an unsufficient volume of blood is ejected. In HCM, systolic dysfunction is usually caused by abnormal functioning of the mitral or aortic valves, which, in turn, is caused by distortion of the ventricles resulting from the abnormal thickening of muscle.
3) HCM can cause dilated cardiomyopathy. This condition leads to heart attack, and is caused by an eventual “burning out” of the thickened heart muscle. Dilated cardiomyopathy occurs late in the course of the disease.
4) Finally, HCM can cause sudden death. The sudden death in HCM is usually due to ventricular tachycardia or ventricular fibrillation. While many of these sudden deaths occur during vigorous exertion, it can also occur during minimal exertion or at rest, with no warning whatsoever. The risk of sudden death has been estimated being as high as 5% per year in patients in their teens and 20s, though it drops off somewhat after that.

How is HCM diagnosed?
In general, the echocardiogram is the best method of diagnosing HCM. The echocardiogram allows accurate measurement of the thickness of the ventricular walls, and can detect abnormal heart valve function as well. The electrocardiogram (ECG) also can give important clues as to the presence of HCM.
Both an ECG and echocardiogram should be performed in close relatives of a patient diagnosed with HCM, and an echocardiogram should be performed in any person in whom the ECG or the physical examination suggests ventricular hypertrophy.

How is HCM treated?
HCM cannot be cured, but it can be managed. Beta blockers and calcium blockers can help reduce the "stiffness" in the thickened heart muscle. In some patients - especially those who have significant heart valve dysfunction - surgery to remove portions of the thickened heart muscle is necessary. Atrial fibrillation, if it occurs, often causes severe symptoms and needs to be managed more aggressively in patients with HCM than in the general population.

How can sudden death be prevented?
Sudden death in HCM is often seen in younger patients – often before symptoms have occurred, or even before a diagnosis has been made. While sudden death is always a devastating problem, it is particularly so when it occurs in young people.
Many methods have been tried for reducing the risk of sudden death in patients with HCM - including avoiding exercise, using beta blockers and calcium blockers, and using antiarrhythmic drugs - these methods unfortunately met with mixed results. In recent years it has become apparent that in patients whose risk of sudden death appears high, an implantable defibrillator should be used. The implantable defibrillator is a pacemaker-like device that is implanted under the skin, monitors the heart rhythm continuously, and automatically delivers a shock to the heart to restore a normal rhythm should a dangerous ventricular arrhythmia occur. While it sometimes seems a drastic step, it is much less drastic than allowing a young individual to die suddenly.

By DrRich
EECP may help in heart failure
Enhanced External Counterpulsation (EECP) is a procedure that has proven beneficial in patients with angina. Some have long speculated that the cardiovascular effects induced by EECP might also be useful for patients with heart attack.

What is EECP?
EECP is a mechanical procedure in which long inflatable cuffs (like blood pressure cuffs) are wrapped around both of the patient’s legs. While the patient lies on a bed, the leg cuffs are inflated and deflated with each heartbeat. This is accomplished by means of a computer, which triggers off the patient’s ECG so that the cuffs deflate just as each heartbeat begins, and inflate just as each heartbeat ends. When the cuffs inflate they do so in a sequential fashion, so that the blood in the legs is “milked” upwards, toward the heart.

EECP has two potentially beneficial actions on the heart. First, the milking action of the leg cuffs increases the blood flow to the coronary arteries. (The coronary arteries, unlike other arteries in the body, receive their blood flow after each heartbeat instead of during each heartbeat. EECP, effectively, “pumps” blood into the coronary arteries.) Second, by its deflating action just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries, which reduces the work of the heart muscle in pumping blood into the arteries.

EECP in heart failure
In a study, 26 patients with stable congestive heart attack were enrolled to receive a standard, 35 session course of EECP. 19 patients completed the EECP sessions and were followed for 6 months afterward. These patients showed, on average, a significant improvement in their functional capacity and quality of life. The authors point out, as well, that the EECP was well-tolerated in these patients.
Since there were no control subjects in this small study, no firm conclusions can be drawn about how useful EECP might be in treating heart failure. But the study was impressive enough to launch a larger, randomized clinical trial that should provide more definitive data on how well EECP might benefit patients with heart failure. The PEECH trial has already begun.
Despite the fact that the potential benefits of EECP in heart failure are still being evaluated, the FDA was sufficiently convinced of these benefits that it cleared the makers of the EECP system (Vasomedical) to begin promoting EECP for heart failure.
Most cardiologists have not embraced the use of EECP for heart disease, quite justifiably citing the need for larger clinical trials. However, since cardiologists don't like EECP even when it is of proven benefit, patients with heart failure who are interested in this treatment option should watch for results of the PEECH trial, and if they prove positive, should take the initiative in bringing up the option of EECP to their doctors.

From Richard N. Fogoros, M.D.,
A useful treatment for angina your cardiologist doesn't want to hear about.
Recent data documenting the effectiveness of Enhanced External Counterpulsation (EECP) for the treatment of angina has failed to bring this apparently effective procedure into the mainstream of cardiology practice. In this article, DrRich discusses what EECP is, how it works, and why cardiologists are avoiding this safe, noninvasive treatment like the plague.

What is EECP?
EECP is a mechanical procedure in which long inflatable cuffs are wrapped around both of the patient’s legs. While the patient lies on a bed, the leg cuffs are inflated and deflated with each heartbeat. This is accomplished by means of a computer, which triggers off the patient’s ECG so that the cuffs deflate just as each heartbeat begins, and inflate just as each heartbeat ends. When the cuffs inflate they do so in a sequential fashion, so that the blood in the legs is “milked” upwards, toward the heart.
EECP has two potentially beneficial actions on the heart. First, the milking action of the leg cuffs increases the blood flow to the coronary arteries. Second, by its deflating action just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries, which reduces the work of the heart muscle in pumping blood into the arteries. Both of these actions have long been known to reduce cardiac ischemia (the lack of oxygen to the heart muscle) in patients with coronary artery disease. Indeed, an invasive procedure that does the same thing, intra-aortic counterpulsation (IACP, in which a balloon-tipped catheter is positioned in the aorta, which then inflates and deflates in time with the heartbeat), has been in widespread use in intensive care units for decades, and its effectiveness in stabilizing extremely unstable patients is well known.
While a primitive form of external counterpulsation has also been around for a long time, it has not been very effective until recently. Thanks to new computer technology that allows the perfect timing of the inflation and deflation of the cuffs, and produces the milking action, modern EECP has been greatly enhanced.
EECP is administered as a series of outpatient treatments. Patients receive 5 one-hour sessions per week, for 7 weeks (for a total of 35 sessions). The 35 one-hour sessions are aimed at provoking long lasting beneficial changes in the circulatory system.

How effective is it?
EECP now appears to be quite effective in treating chronic stable angina. A randomized trial with EECP, showed that EECP significantly improved both the symptoms of angina (a subjective measurement) and exercise tolerance (a more objective measurement) in patients with coronary artery disease. EECP also significantly improved “quality of life” measures, as compared to placebo therapy.
More recent data show that this improvement in symptoms following a course of EECP seems to persist for up to five years.
Furthermore, there is also preliminary data suggesting that EECP may be useful for treating unstable angina, as adjunctive therapy after revascularization (i.e., with angioplasty, stent, and/or bypass surgery), and even as first-line (instead of last resort) therapy for more routine forms of angina.
Finally, clinical trials have suggested that EECP may be useful in improving symptoms in patients with heart failure.

From Richard N. Fogoros, M.D.
How EECP works, and who it may help
Who is likely to benefit from EECP?
Based on what is already known, EECP should be considered in anybody who still has angina despite maximal medical therapy and prior revascularization. No cardiologist could argue logically against this. And, frankly, if a patient insisted on trying EECP prior to agreeing to purely elective revascularization for chronic stable angina, the cardiologist might not like it, but would be hard pressed to give anything beyond a purely emotional reason as to why this should not be tried.

Why does EECP work?
The mechanism for the sustained benefits seen with EECP still amount to speculation. Everyone can agree that there are good reasons for EECP (just as for IACP) to benefit the heart while the therapy is actually taking place. But as to why the benefit of EECP persists even after the therapy is finished, no one can say for sure.
There are preliminary data suggesting that EECP can help induce the formation of collateral vessels in the coronary artery tree, by stimulating the release of nitric oxide and other growth factors in within the coronary arteries.
There is also evidence that EECP may act as a form of “passive” exercise, leading to the same sorts of persistent beneficial changes in the autonomic nervous system that are seen with real exercise.

Can EECP be harmful?
EECP can be somewhat uncomfortable, but is not painful. In fact, it is apparently very well tolerated by the large majority of patients.
But not everyone can have it. People probably should not have EECP if they have certain types of valvular heart disease (especially aortic insufficiency), or if they have had a recent cardiac catheterization, an irregular heart rhythm, severe hypertension, significant blockages in the leg arteries, or a history of deep venous thrombosis (blood clots in the legs). For anyone else, however, the procedure appears to be quite safe.

From Richard N. Fogoros, M.D.
Why cardiologists don't like it - and what you should do about it
Despite its increasingly apparent potential usefulness, EECP is hardly taking the cardiology world by storm. In fact, it seems that for most cardiologists EECP is not even on the list of potential treatments for coronary artery disease. Why is that?
There are several possible reasons. Let us dispense with the most obvious first, namely, that EECP doesn’t pay well. A series of 35 treatments costs $5000 to $6000 dollars. That’s not chicken feed, but keep in mind that we’re talking about 35 hours of therapy over 7 weeks, which involves not only the doctor’s time but also the time of office staff, nursing personnel, etc., etc. Still not a terrible return, but when you consider that a cardiologist can often bill that much by spending a morning in the lab.
Then there’s the fact that EECP remains somewhat intellectually unsatisfying. To your average cardiologist, there’s no reason at all that anyone should have thought it would work in the first place – that temporarily providing counterpulsation would have lasting effects. And the fact that it apparently does work is merely blind luck, and leaves investigators scrambling ridiculously to explain why it does. This is a less than satisfying way to advance science.
In addition, to most cardiologists, EECP is logistically difficult. To accommodate patients for EECP, they would not only have to purchase expensive equipment, but also would have to radically change the organization of their offices, their office staff, and their space.
Finally, and most importantly, EECP has nothing in common with what cardiologists do. Cardiologists study and treat the heart, for goodness sake. They stress it, image it, measure it, pace it, shock it, stent it, ablate it, revascularize it, and bathe it in drugs. What they do takes years of specialized training and expertise, millions of dollars of high-tech equipment, and tremendous manual dexterity, and it brings them significant prestige, even within the medical community.
This is the real reason the average cardiologist is completely ignoring EECP, as if it doesn’t even exist. They simply can’t believe anyone really expects them to do this.
In any case, you may need to raise your cardiologist’s consciousness. If you have coronary artery disease that has proved difficult to treat, then you need to bring EECP up yourself.
Once enough patients show themselves to be aware of this new therapy and to be expecting it, suddenly EECP will no longer be beneath cardiologists, and they’ll eagerly find a way to incorporate it into their practices.

How can you receive EECP?
If you are a candidate for EECP and wish to pursue it, start with your doctor. If your doctor discourages you from pursuing EECP, make sure he/she gives you a good reason for discouraging it. Good reasons would include: you don’t have the sort of coronary artery disease or angina that would benefit from EECP; your coronary artery disease is of the type that requires revascularization; or you have one of the contraindications for having EECP.