09 June 2017
Dr Adam Fitzpatrick discusses heart disease and common complaints, chest pain, palpitations, breathlessness and fatigue.
Chest pain is a strong indicator of damage to the coronary arteries, especially if it comes on under stress, which may be exercise or mental stress. The damage may come on slowly, along with symptoms, or there may be a sudden change, which can lead to a heart attack, correctly known as a myocardial infarction. This usually occurs when the lining of the coronary artery is stripped away and a blood clot forms on the bare area. This happens because the circulating blood treats the bare area as if it were a hole it has to plug. Where the narrowing of a coronary artery builds up over years the symptoms are usually stable, just like the artery wall itself. The first principle of treatment of chest pain is always to identify the exact cause, and there are “stress” tests designed to show up the area of heart tissue that is being supplied with insufficient blood. These may use the electrocardiogram (ECG) or a direct vision of the beating of the heart using an echocardiogram. The tests look at the “uptake” of a marker such as a very low radiation isotope by the heart muscle, and can show that areas with inadequate blood supply do not pump as well as areas with good blood supply. Medicines are good treatments for the lack of blood supply, but there are also many patients offered a bypass operation or a technique to place a stent in the narrowing and squeeze the artery open with a balloon - coronary angioplasty. These are roughly equal in outcome, but are applied according to how extensive the narrowing are.
Patients with palpitations may be suffering from an abnormal heart rhythm. Many patients with palpitations may simply have “ectopic” or “extra” beats. We all have these, and they increase in number if we are under stress, anxiety or have another unrelated illness. For patients, however, they are often very real and troubling. Abnormal heart rhythms can be generated from different parts of the heart and this determines the treatment available. Many issues with heart rhythm do not require any treatment and may often present with no symptoms.
Some types of abnormal heart rhythms have a tendency to get worse over time and can have important long term consequences including an increased risk of stroke, heart failure and dementia. These risks can be reduced by successful treatment. The main aim of which is to control symptoms.
The most important principle of investigation for heart rhythm disorders is to try and record the ECG during the patients symptoms and there are various ways this can be done. Sometimes a patient may be having an ECG when the arrhythmia occurs. In other patients it is necessary to perform an ambulatory ECG monitor, which is worn and carried by the patient for up to seven days. Longer monitoring may be done with an implantable ECG monitor, which may monitor for up to three years. Once the rhythm abnormality is confirmed, treatment can be offered, and this may be with drugs, catheter ablation or pacemakers in selected cases. Catheter ablation requires a specialised cardiac unit with facilities to place a cauterising catheter in the heart when the rhythm has been confirmed, and to cauterise the area of abnormal tissue. It can have very high success rates for patients with certain arrhythmias.
The breathless patient may have abnormal heart function, but heart function can be normal and it is always necessary to consider whether symptoms may be arising from disease of the lungs, or both. The stable investigation for heart function problems, after examination and ECG, is the echocardiogram. This is an ultrasound scan that can profile the heart muscle movements and the condition of the heart valves. Blood tests can be useful for excluding heart failure, and sophisticated scanning techniques have developed for cases where the mechanism of heart dysfunction may be unusual. These are usually available in specialised heart units.
The symptoms that a patient brings to the cardiologist are very important and patients should be sure to bring them all to the consultation with them. A clear description helps to get to the right direction of investigation and lead more quickly to the right treatment.
Find out more about the cardiology service offered at Spire Manchester Hospital.
The content of this article is provided for general information only, and should not be treated as a substitute for the professional medical advice of your doctor or other health care professional.