New op to unblock dangerously furred-up arteries
MORE than two million Britons have coronary artery disease. Roger Holmes, 69, a retired businessman from Bromley, tells SOPHIE GOODCHILD how he was the first patient in Britain to undergo a new procedure to tackle it.
MY HeART problems began when I was 34, when I had a heart attack while driving home one evening. Thankfully it was mild, but I was kept in hospital for a week. I knew I was young for this but the doctors said it was probably because I smoked (I was on 50 a day). They also mentioned my weight — I’m 16½ st, which is heavy, but not extreme for my height (6 ft 5 in).
I quit smoking immediately and my health was fine for four years.
Then I had a routine check-up under my work medical insurance. It included an angiogram — an X-ray showing the blood flow in your arteries — which showed one artery was slightly furred up.
There wasn’t much that doctors could do back then and I carried on with my life. Then nine years ago, aged 60, I had a cardiac arrest — my heart stopped beating.
I don’t remember it, but my then-wife (we have since divorced) called an ambulance and I was in a coma for two weeks. My organs even began to shut down.
Two weeks after I came round, I was transferred to King’s College Hospital in London, which has a specialist cardiology unit.
They diagnosed atrial fibrillation, an irregular heartbeat. Apparently it can be triggered by high blood pressure and diseased arteries — it was probably why my heart stopped beating.
They fitted me with a cardioverter defibrillator (ICD) — an implant that corrects the rhythm if it goes dangerously wrong by giving your heart an electric shock.
They also gave me aspirin to prevent blood clots and ramipril for high blood pressure.
DespITe my health scares, I’m not someone who acts like life is over after something like that. sailing is my passion, and I carried on doing it.
But by late 2015 I was feeling exhausted. I also began to get breathless walking up the stairs to my new flat. so I went back to King’s, where they found that my heart was still beating too fast.
Then in April of this year, they did another angiogram, which showed one of my arteries was now badly blocked.
They tried to fix it by putting a small mesh tube called a stent in the artery to widen it. They normally expand the stent using a tiny balloon, but my artery was so blocked that the balloon just couldn’t inflate.
They said I had too much calcium in my arteries, which had made them hard and narrow.
A second procedure was booked for the following month. I was told they would try to chip away the calcium with a drill before putting in another stent.
However, when the day arrived, my consultant Jonathan Hill told me they would use sound waves instead of a drill. The idea was that the waves would break up the calcium. I would be the first patient to have it.
First they gave me a local anaesthetic, then inserted a tube and a wire through a blood vessel in my groin. I watched the whole operation, which took two hours, on a screen.
It was surreal: I saw this black wire wriggling around on a fuzzy picture of my heart.
Afterwards I went home straight away, feeling fine, but tired. Now I’m sailing again and my next goal is to run up the stairs to my flat. I’m feeling optimistic about life. THE SPECIALIST Jonathan hill is a consultant interventional cardiologist at King’s College hospital, london. RIsK factors for blocked or narrowed heart arteries — coronary artery disease — include smoking, high cholesterol and obesity.
A soft, fatty, cheese-like material, called plaque, builds up over time in the artery walls. It makes arteries narrow and stiff, restricting flow of blood to the heart and triggering symptoms such as angina (chest pain).
It can cause breathlessness and an abnormally fast heartbeat, as in Roger’s case.
The plaque also contains hard, chalky deposits of calcium.
All of us have calcium circulating around our body in our blood (it’s important for functions such as blood clotting).
But as we get older it’s common for the cells in the artery walls to develop calcium deposits, too. some people get a heavy calcium build-up within the plaque itself in artery tissue.
A common treatment for blocked arteries is to insert a stent to open up the vessel and improve blood supply to the heart.
We use a tiny inflatable balloon to expand the stent, a procedure called angioplasty.
But a heavy build-up of calcium can make the artery so rigid that stent insertion becomes difficult, sometimes impossible. It happens in around ten per cent of the patients I see.
Techniques have been developed to deal with this. They include using a tiny drill to cut through the hard chalky deposits.
But this only treats one part of the artery, and the calcium can run throughout the vessel.
Other approaches involve shaving or sanding away the calcium, but these have similar downsides: they tackle the superficial areas of damaged tissue but not the calcium deeply embedded in the artery.
High-pressure balloons can also be used to insert the stent — these force the arteries open, overcoming resistance and cracking the calcium. But they can also damage the arteries, causing the wall to split.
At King’s we’ve been using a new technique, developed in the U.s., using low-frequency, high-energy sound waves that make the artery flexible again by fracturing the hard calcium into tiny pieces. This method targets the calcium embedded throughout the artery, not just the superficial build-up.
It’s like unblocking a rigid pipe — getting rid of the calcium widens the artery and makes it soft, so it’s easier to insert a stent.
Called coronary lithoplasty, it’s a similar technique to ones used to break up kidney stones, which are then passed out of the body in the urine.
But with this procedure the calcium fragments remain in the artery — there’s no need to remove them.
Another advantage is that the waves only break up rigid diseased tissue — they pass through soft healthy tissue without damaging it.
For Roger’s treatment, we inserted a catheter (a small tube) into his heart via the groin — it can also be inserted via the wrist or arm.
ONCe the tube is positioned in the affected artery, we feed a thin wire down the tube with a tiny balloon at the end and a stent over the top of the balloon.
The external end of the tube is connected to a battery-powered generator the size of a radio.
We press a button, which prompts the generator to activate tiny transmitters under the balloon’s surface.
These send out the sound waves into the artery walls, fracturing the calcified plaque into tiny pieces.
It takes one microsecond to deliver one wave — patients need 20 to 80 waves to fracture the calcium. Afterwards, we inflate the balloon so the stent expands. The balloon is then deflated and removed.
King’s and the Royal Brompton Hospital in West London are among seven centres in europe taking part in a global trial, evaluating the safety of this new device.
The next step is to treat more patients, and then do a bigger trial in more centres.
My prediction is that the technique will become routine in hospitals in the next few years.
It’s a simple procedure, and another tool in our box in treating heart disease.
BOTH patients and young doctors like diagnostic tests — blood tests, of course, but also tests that let you see inside the body, such as scans. If you have persistent bladder problems or acid reflux (heartburn), for instance, then the chances are that at some point a relevant specialist will have put an endoscope — a flexible tube with a camera on the end, of which there are many types — inside you to have a good look around.
An overreliance on such technology, however, means that if a test comes back clear, some doctors, particularly younger ones, will say there is no illness and then be at a loss as to how to manage the symptoms. The result is an undiagnosed and potentially more distressed patient.
We should not forget the old-fashioned approach to medicine, where you spend time listening to the patient’s problems and working out how best to help them.
As a gastroenterologist, I understand why patients want tests. Take irritable bowel syndrome (IBS); there are a million people whose symptoms are extreme and debilitating. By the time they come to me, they will have already had a couple of colonoscopies (an examination of the intestine), but want further tests, such as an MRI scan, because they are convinced that something has been missed.
Modern gastroenterologists, wanting both to keep patients happy and fearing they will be for the high jump if they miss something as sinister as cancer, are very inclined to ‘scope’ and scan.
It was very different in pre-war days. Physicians did not have all these gadgets and technologies. Instead, the emphasis was on talking to patients, honing the bedside manner and communicating with them effectively.
They would run through the symptoms and come up with a diagnosis based on the patient’s story and treat them on that basis.
Younger doctors don’t feel so comfortable doing that. And the problem with all these modern diagnostic technologies — scopes, X-rays, CT scans, MRIs and so forth — is that there are conditions that they simply cannot detect.
Put simply, tests are not the be all and end all. And it is inadvisable to rely on them at the expense of good old-fashioned doctoring skills and diagnosis.
This is particularly true with ‘functional conditions’, where there are very real symptoms but no structural abnormalities that will show up on a scan — such as irritable bowel syndrome.
We don’t entirely know what is going on with IBS, but it is thought to be related to an oversensitivity in the gut. We also know that IBS patients’ bowel muscles contract more strongly, causing a spasm-type pain, but there are no abnormalities that can be detected by any test.
Consequently, patients can be caught up in a cycle of fruitless testing. And, ultimately, the doctor tells the patient: ‘I can’t find anything wrong with you. Everything normal, or it might just be IBS.’
But that word ‘normal’ is a problem. I learned very early on in my career that if you bounce up and tell an IBS patient: ‘Good news! Your colonoscopy is normal!’ you will quickly see their face drop.
They do not want to know what is not wrong with them. They want a proper diagnosis, to have their symptoms legitimised and taken seriously.
I don’t have an issue with these investigations per se — it is practising safe medicine after all. But once you have ruled something out, it is pointless to keep doing tests.
I don’t do very many because, often, they don’t provide the answers. If I do feel that one is is required, the conversation I have with the patient beforehand is crucial. I will explain that, if I am right, it will be negative, and that means the problem is IBS, a legitimate and often horrible condition.
Then we will do our best to help them manage it. I’ll be upfront, explaining that I’m not going to be able to cure them, but that if we can give them a 50 per cent improvement, it means we are doing well. Usually, they are happy with that.
Sometimes just listening to patients talk uninterrupted for ten minutes can make them feel a bit better. My field is not the only one where the enthusiasm for tests can be problematic either — every branch of medicine has its ‘functional conditions’.
RHEUMATOlOGISTS have fibromyalgia, where the joints are very painful, but when you do scans they look perfectly normal. Cardiologists have something called non-cardiac chest pain. It is thought to be down to an oversensitive gullet going into spasm, but the symptoms are identical to angina and patients often repeatedly go to A&E, panicking that they are having a heart attack, but each time a scan shows nothing wrong.
Of course, you would be mad not to investigate someone with chest pain. The problem is that a third of people with this symptom will have nothing structurally wrong, so they will simply be told not to worry.
Similarly, you would be foolhardy not to fully investigate a patient you fear has breast cancer, say.
So I’m not knocking these modern technologies; it is just vital that we retain our old skills as we learn the new ones.