Heart pain classically comes on with exercise, such as walking uphill or rushing. There are
other typical features such as a constriction or tightness in the chest and that the symptom
can be relieved by rest. Some patients however, don't have the typical symptom and their symptom
may occur in the shoulders or in the arms or in the jaw or the teeth. So diagnosing
angina or heart pain can be difficult. There are some people who feel it like an indigestion.
And that's a really common situation. But when walking, they describe a feeling of indigestion.
And of course, to the patient they don't naturally think immediately of the heart.
Well, the first step in trying to establish whether it's heart related pain is based upon
the history as we've discussed. And classically, the symptom can come on with exercise. If
the symptom is classical, then it's highly likely that the symptom is angina based upon
the history alone, but in most cases, we'll require investigations to truly establish
whether there's underlying coronary artery disease.
These days we have a fantastic set of non-invasive investigations to initiate the diagnosis of
coronary artery disease. The mainstay in my practise is a CT coronary angiogram. This
is a non-invasive test which takes ten minutes to do and involves small x-ray doses and the
use of some contrast. And we can obtain superb images of the coronary arteries in a rapid
non-invasive fashion. This is really helpful. This has developed rapidly over the last few
years with the latest machines being fantastic at diagnosing coronary disease. The second
form of a non-invasive test which I use is a stress MRI scan, which looks to see if there's
any problem with the blood flow in the heart arteries. The next step which is my area of
expertise is with invasive angiography. That's the gold standard really for diagnosing coronary
artery disease. This is a procedure performed under local anaesthetic as a day case. And
in my hands, from the radial artery. And this is the best method to evaluate the true level
of coronary artery disease.
The main risk factors that we know about are
quite well-known publicly. Those are of course smoking but also hypertension, raised blood
pressure, and importantly a high cholesterol. There are others such as diabetes and carrying
extra weight. The main risk factor that is often under looked and which we really do
need to focus on is the family history or the genetics of coronary artery disease. So,
I see many patients either to treat symptoms or for screening who've got a strong family
history of heart attacks or cardiac events under the age of 60. So, the genetics is really,
really important.
Angina is classically a stable condition which
occurs with exercise. So, patients will describe that after walking maybe 400 yards or walking
uphill or briskly, they develop a discomfort and then they have to rest. The important
feature of a stable symptom, angina, is that when they rest, the symptom goes within five
or ten minutes. A heart attack can be quite difficult to diagnose, but typically or classically,
this occurs at rest. Sometimes in the middle of the night but lasts longer than five or
ten minutes and can make the patient feel generally unwell with breathlessness or exhaustion.
The classic symptom is a well-described tight band across the chest; which can be a life-threatening
condition. Sadly, there are some people who have a heart attack which is much more difficult
to diagnose with rather subtle symptoms of mild discomfort at rest. And even more difficult,
there are some people who have a heart attack with no discomfort whatsoever. And that's
quite common in the elderly and in diabetic patients. So those patients who don't have
any discomfort may just feel generally unwell or feel exhausted or have nausea or feel faint.
And in elderly diabetic patients, this is a common picture. And in those circumstances,
heart attacks are frequently missed. A heart attack is sadly still a very, very common
condition. It's one of the commonest causes of death in the United Kingdom at this stage.
There are 200,000 heart attacks each year and about 66,000 patients die from a
heart attack every year, and maybe 22,000 of those are under the age of 75. So, despite
a lot of the progress we've got for the treatment of heart attack which involves opening the
artery very quickly using balloons and metal tubes called stents, despite all of this,
sadly there are still a lot of people who die from heart attacks. And so, detecting
coronary disease and giving the prevention that will help reduce the incidence of heart
attacks is probably one of the most crucial things we do as cardiologists.
There are two main aspect of the treatment of coronary artery disease. The first is the
use of medication to reduce the risk of a heart attack. And that would be aspirin, the
use of a tablet called Astatine which lowers cholesterol, and a Beta Blocker tablet which
protects the heart. The next treatment of coronary artery disease is to open up narrowings
using a balloon and a metal tube called a stent. That's a procedure which I perform
via the radial artery which is the pulse at the wrist. From there, passing a tube up to
the heart to open up the artery and put in this metal scaffold which helps the blood
flow down the heart arteries to relieve all of the symptoms. That's treatment for angina,
but also an emergency treatment for patients who are having a heart attack.