A diagnosis is formed by taking a history, carefully discussing your symptoms, examining your heart and interpreting the results of your investigations. In particular your symptoms, past medical history and the results of your investigations will guide discussion about the various treatment options. Even when people have similar symptoms the diagnosis can vary and different treatments may be required.
A coronary angiogram (often referred to as an angiogram) is an invasive test to look for narrowings or blockages to the heart arteries. If the heart arteries are significantly narrowed or blocked then they can be treated by stretching them open with a balloon and inserting a stent to keep the artery open. This is called percutaneous coronary intervention (PCI) or sometimes called angioplasty. An angiogram is first required to assess the heart arteries (or coronary arteries) in detail and in some respects PCI is an extension of this procedure. In some cases PCI will be performed immediately after an angiogram.
This treatment is performed with patients lying flat on a movable table. A small tube called a catheter is inserted under local anaesthetic into the artery in either the wrist or the groin. This tube is then moved using X-Ray guidance up and around the arteries of the body into the heart arteries. There are different types of catheters which are used for each heart artery.
Once an angiogram has identified the narrowed portion of the artery a very fine wire is passed up through the catheter in the wrist or groin into the heart artery. This wire is then carefully passed across the narrowing or stenosis in the artery. A balloon is then guided over this wire and inflated at the location of the narrowing to stretch the heart artery open. This procedure is called an angioplasty and was the original treatment before stents. However, even though this technique was effective in many cases the narrowing of the heart artery would recur within a few months (restenosis). This led to the development of stents which are fine metal scaffolds designed to keep the artery open and prevent the narrowing of the heart artery recurring. To insert a stent after the diseased part of the heart artery has been stretched open with a balloon the stent (which is attached to a balloon) is passed via the fine guidewire to where the narrowed part of the heart artery was located prior to treating with the balloon. The balloon on which the stent sits is inflated to press the stent firmly into the wall of the heart artery and thereby keep the heart artery open.
The stents that are used have also changed. Initially stents were made of metal only (called bare metal stents). However, although the narrowing of the heart arteries recurred less frequently than if the artery had been stretched open with a balloon only this still occurred in some patients (called in-stent restenosis). Some conditions such as diabetes also increased the risk of the narrowing recurring in the stent. More recent stents have special drug coatings on them (drug eluting stents). These coated stents further reduce the risk of the narrowing of the heart artery recurring.
Once the artery or arteries have been treated with PCI an important part of the medication will be Aspirin and other blood thinning agents (eg Clopidogrel, Prasugrel or Ticagrelor). These treatments are given to prevent the stent from forming a clot which could lead to a heart attack. The combination of blood thinning agents used depends on the type of stent that was used to treat the artery. Also the time for which you need to take these blood thinning agents after the artery has been treated with PCI depends on the types of stent used. It is important that you make sure that you take the correct blood thinning agents for the correct period of time after your procedure.
Sometimes an artery can be partially narrowed and it is difficult to work out from just the angiogram pictures whether the narrowing requires treatment with a stent. There are additional tests that can assess part of the heart arteries in more detail. The first is a special ultrasound probe that can be passed over a fine guidewire across the narrowing in the heart arteries to take ultrasound images of the artery to see the amount of narrowing in more detail. This is called IVUS (intravascular ultrasound). This can also give more detail about the wall of the arteries and if their contents (such as if the walls of the artery contain calcium). This can both help with deciding if an artery needs treating but also help to plan the best way to treat a diseased artery with PCI. More recently a new technique called Optical Coherence Tomography (OCT for short) has been developed. This uses a different probe which is passed over a fine guidewire and across narrowings of the heart arteries. Very detailed images of the wall of the heart arteries can be obtained and this technique may be used more often in the future.
Another technique to assess a heart artery in more detail uses a special fine wire to assess the flow across the narrowing and how much the flow is reduced. This special wire is carefully passed across the narrowing in the heart artery. Blood flow in the heart arteries is increased suing a special drug, Adenosine, which is given through a vein in the arm for 1-2 minutes. The obstruction to blood flow across the narrowing can be assessed in more detail enabling a decision to be made whether the narrowing requires treatment. This test is called a pressure wire (also called FFR, fractional flow reserve). There is some evidence that using this technique to determine which heart arteries to treat is better than using other methods (such as just looking at the artery from an angiogram).
The rate at which your heart beats is normally automatically controlled by the heart itself. This can vary quite considerably during a 24 hour period. Our hearts beat more slowly at night and faster when we exercise. Electrical impulses lead to the heart beating. Where there is a disease of the electrical circuits which control the heart then the heart may beat more slowly. This is known as heart block. With some types of heart block a pacemaker is required to speed up the heart beat.
A pacemaker consists of two components; the leads and the generator box. A pacemaker is often inserted with sedation. Patients lie flat on a movable table. Most pacemakers are inserted on the front of the chest just below the collar bone on the left side. This area is numbed first with local anaesthetic. The veins under the collar bone are then identified. Through one of these the leads of the pacemaker are inserted and then passed around to the correct chambers in the heart under x-ray guidance. A small pocket is then made under the skin and a small incision is made. The pacemaker generator is then inserted into this pocket, attached to the leads and then the incision in the chest is the sutured back together. The generator contains both the battery for the pacemaker and also the monitoring equipment to assess the electrical activity of the heart and make sure that the heart is paced (or electrically activated to beat) appropriately.
After the pacemaker has been inserted it needs to be checked to ensure that it works properly and problems with the leads and the generator have not occurred. The remaining battery life also needs to be noted (most modern pacemakers have a battery life of several years). To do this a programmer is placed over the pacemaker whilst lying down and the pacemaker and leads can be assessed. Also if the way in which the pacemaker is working needs to be adjusted this can be done at the same time.
If the pacemaker battery begins to run out then the generator box will need changing. With local anaesthetic and whilst lying down the old generator is removed by making a small cut into the skin and taking it out and a new generator inserted.
There are now special types of pacemakers that can improve the pumping of the heart if it is not pumping properly (heart failure). These pacemakers have more leads but the way in which they are implanted and checked is similar to a normal pacemaker. The main difference is that there is an additional lead. Standard pacemakers contain a lead to pace a heart chamber called the right ventricle (which is responsible for pumping blood around the lungs). They very often also have a second lead which paces the collecting chamber on the right side of the heart, the right atrium. These special pacemakers have a further additional lead which is used to pace the main pumping chamber of the heart, the left ventricle. The lead is passed around a vein on the surface of the left ventricle to aid the contraction and pumping function of the left ventricle. Since both ventricles are paced these types of pacemaker are called biventricular pacemakers.
For some conditions it is now possible to implant a device that will deliver an electric shock to the heart if it is at risk of developing a heart rhythm for which the best treatment is a rapidly delivered shock to the heart to restore a normal heart rhythm. These devices are again inserted in a similar way to a normal pacemaker and they can be checked in a similar way to a pacemaker although sometimes more specialist checking that the device is working correctly is required. These devices are called ICD’s (implantable cardioverter-defibrillators). The various types of pacemakers can be combined so in some patients an biventricular pacemaker is combined with an ICD (a so called Biventricular-ICD).
Whereas an electrophysiology study (called an EP study) provides detailed information about your heart's electrical activity, for some heart rhythm problems an ablation can be performed to treat the abnormal heart rhythm and prevent it recurring. After lying down on a movable table local anaesthetic is inserted into your groin. A flexible tube (called a catheter) is carefully passed through the veins in the leg around and into the chambers of the heart under X-Ray guidance. At the end of this catheter there are small electrodes which are placed carefully on the inside surface of the heart chamber to record the electrical activity of the heart. At the same time an ablation catheter is passed though the vein in the leg into the heart chambers.
Certain heart rhythm problems are due to abnormal electrical impulses developing at certain sites within the heart. These areas where the abnormal electrical impulses develop are then treated with the ablation catheter by applying radiofrequency impulses to a small area of the heart and thereby destroying or ablating the source of the abnormal heart rhythm. The commonest heart rhythm problem that can be treated is atrial fibrillation (AF). In AF the origin of the abnormal electrical impulses is often from the veins that drain from the lungs into the left atrium, the pulmonary veins. To treat the AF the electrical activity in these veins needs to be isolated from the rest of the left atrium, called pulmonary vein isolation. Different types of heart rhythm problem require different treatments. The exact procedure and the amount of ablation required is discussed before the procedure. Some of these procedures can also take much longer to perform than others depending on the amount of ablation that needs to be performed to treat the heart rhythm problem. With some rhythm problems the rhythm disturbance may recur and this may require a further ablation. Once successful, however, and ablation will prevent the heart rhythm problem from occurring in the future.
If you have been diagnosed with angina or have recently had a heart attack it is likely that at some point you will have a coronary angiogram. This assesses if there are narrowings in the heart arteries (the coronary arteries). It shows where in the arteries they are located and how many narrowings or blockages there are. Although it is often possible to treat the narrowings with angioplasty and stents sometimes there are too many narrowings to treat in this way. In this case you may be recommended to have a bypass operation to treat your coronary artery narrowings or disease.
Traditionally coronary artery bypass surgery (often referred to as a CABG, coronary artery bypass grafting) is open heart surgery. The surgeon will open the front of the chest by cutting the breastbone in half along its length. This then allows access to the heart to position the grafts onto the heart arteries after the part that is narrowed or blocked. A graft is either an artery from another part of the body or a vein that is used to bypass the narrowings of the heart arteries. Before the grafts are attached the heart is placed on a bypass machine. This machine is connected to the main arteries of the body and pumps blood around the body to maintain the supply of oxygen and nutrients to the organs of the body whilst the bypass grafts are attached to the heart.
There are commonly 3 types of grafts that are used. The first are the veins in the leg. These are removed at the same time as the heart surgery is performed. One end is attached (or grafted) to the heart artery as described above. The other end is attached to the aorta, the main artery which sits just above the heart and supplies blood to the entire body (with the exception of the lungs). The other types of grafts are both arteries. One is the long artery that travels just on the underside of the chest wall (called the left internal mammary artery or LIMA for short). This starts by branching off from the main artery under the collar bone (called the subclavian artery). This part of the artery is left connected to the artery under the collar bone. The other end of the artery is freed from the chest wall and placed beyond the narrowings in one of the heart arteries. This type of graft is usually placed on an artery call the left anterior descending artery. This is an important heart artery that supplies a large part of the main pumping chamber of the heart (the left ventricle). This artery is commonly used because it is known that patients that are treated with bypass surgery using this artery as one of the grafts tend to do better overall. The second artery that can be used is one of the arteries from the wrist and forearm (the radial artery). As with the vein grafts one end is placed after the narrowings in the diseased heart artery and the other end in placed in the aorta.
Although there are often cases where both angioplasty and stenting or heart surgery can be used to treat diseased heart arteries the more diseased arteries that you have the more likely that surgery will be considered a preferred treatment option and advised. In particular if there is disease in each of the 3 main arteries that supply the heart (sometimes called 3 vessel disease) then it is more likely that surgery will be advised as the best treatment option. A large artery called the left main stem gives rise to 2 of the other main coronary arteries. If you have significant narrowing or disease of this left main stem artery then again it is more likely that surgery will be recommended. However, each case is different and specific and the options available in each case are always discussed in detail.
More recently it has become possible to do either part or all of a heart bypass operation without using a bypass machine (this is sometimes called ‘off pump’ surgery). There is also sometimes the option to avoid cutting the breastbone to get to the heart to attach the bypass grafts. These types of operation are becoming more common.
Heart valves can become either narrowed (stenosed) or leaky (regurgitant). When the disease of a heart valve becomes severe it may need to be replaced or repaired.
As with coronary artery bypass surgery this is open heart surgery. The surgeon will open the front of the chest by cutting the breastbone in half along its length. This then allows access to the heart to remove the old valve and replace it or to repair the valve. Before the heart valve can be repaired or replaced the heart is placed on a bypass machine.This machine is connected to the main arteries of the body and pumps blood around the body to maintain blood flow and the supply of oxygen to the organs of the body whilst the operation on the heart valves occurs.
Although all valves can be replaced not all valves are commonly repaired. The mitral valve (this is the valve that sits between the left atrium and the left ventricle which is the main pumping chamber of the heart) can often be repaired and long term results with mitral valve repair are excellent.
If the valve needs to be replaced there are two types of valve in common use. The first is made out of biological material. These are called tissue or bioprosthetic valves. The second is a mechanical (metal) valve. The main difference is that with a mechanical valve the blood will need permanently thinning afterwards with an anticoagulant to prevent clots forming on the valve. Tissue valves do not require this. On the other hand tissue valves do not last as long as mechanical valves and a further operation may be required. The advantages and disadvantages of each option will be fully discussed before the operation so that an informed choice can be made.
More recently other techniques to treat heart valve disease have been developed. These include TAVI (trans catheter aortic valve implantation) and the Mitraclip. These are discussed elsewhere.
TAVI (transcutaneous aortic valve insertion) is a new procedure for replacing the aortic valve avoiding the need for open surgery. This treatment is performed with patients lying flat on a movable table with general anaesthesia. A small tube called a catheter is inserted into the artery in the groin or in a small area to the left of the chest (called a transapical approach). Through this a wire is then moved using x-ray guidance up to the heart and carefully passed across the narrowed aortic valve. A balloon is then guided over this wire and inflated at the location of the narrowed valve to stretch the heart valve open. After the aortic valve has been stretched open with a balloon a new valve which has been compressed onto another balloon is passed over the wire and positioned across the old valve under x-ray guidance. The balloon on which the valve sits is then inflated to push the new valve into the wall of the aorta which is the main artery that supplies nearly all the organs in the body. This is a new and complex procedure and involves a large team of people. It also carries risks similar to having an aortic valve replacement. At present this form of treatment is usually only offered to patients where the risk of open heart surgery to replace the aortic valve is too high. As in any case, the procedure and any associated risks are discussed fully beforehand.
Balloon mitral valvuloplasty can be used for treating narrowing of the mitral valve (mitral stenosis). The mitral valve sits between one of the collecting chambers of the heart (the left atrium) and the main pumping chamber of the heart (the left ventricle). By far the commonest cause of mitral stenosis is rheumatic heart valve disease. As rheumatic heart valve disease is rare in the Western world with the use of antibiotics this procedure is now rarely performed. The mitral valve is opened by stretching it with a balloon placed across it (mitral valvuloplasty).
High blood pressure (hypertension) is one of the commonest conditions in the Western world. It is a risk factor for heart disease and increases the risk of both heart attacks and strokes. There are many medications that can treat hypertension. In most patients a combination of several medications are needed to bring the high blood pressure under control. Some people continue to have high blood pressure despite being on several medications for blood pressure.
There are many systems in the body that contribute to and control our blood pressure. One such system within the nervous system is the sympathetic nervous system. This sympathetic nervous system has many functions. In high blood pressure it is more active than normal particularly in the arteries that supply the kidneys. This leads to the kidneys secreting substances into the blood stream that further increase the blood pressure.
Renal artery denervation is a procedure that blocks this response. This procedure is performed with patients lying flat on a movable table. A small tube called a catheter is inserted under local anaesthetic into the artery in the groin. This tube is then moved using X-Ray guidance up to the kidney arteries (renal arteries). Images of the renal arteries are then taken using X-Rays and the injection of a dye (also called contrast) through the catheter into the renal arteries. A special device is then passed carefully through this catheter into the renal artery. This device contains an electrode which then delivers radiofrequency energy to the wall of the renal artery. This destroys the sympathetic nerve fibres in this artery and this blocks the response of the sympathetic nervous system to the high blood pressure. This should then lead to a reduction in blood pressure.
This technique is relatively new. Initial results were promising especially for those patients who had hypertension which was difficult to treat. More recent results have been mixed and it remains to be seen exactly how effective this treatment will be in the future for controlling high blood pressure.
Traditionally the only option to treat leaky (or regurgitant) heart valves has been surgery with replacing the valve or repairing it. A more recent method has been developed to treat leaky heart valves. The leaky valve is partially clipped together which reduces the leakiness. In particular this type of treatment has been developed for the mitral valve. This is a large valve that sits between one of the collecting chambers of the heart (the left atrium) and the main pumping chamber of heart (left ventricle).
This treatment is performed with patients lying flat on a movable table. A small tube called a catheter is inserted under local anaesthetic into the vein in the groin. Through this a wire is then moved using X-Ray guidance up and around the arteries of the body and then carefully passed across the leaky mitral valve. A device with the clip attached is then carefully passed over this wire to the mitral valve under x-ray guidance. The clip is then positioned on the mitral valve. An assessment of how well the clip is reducing the leakiness of the mitral valve is made using an echocardiogram and if the result appears to be satisfactory then the clip is then attached permanently to the mitral valve (deployed). Sometimes more than one clip is needed. This is a new technique and the long term results are not yet clear.
There are many problems of the heart that are present at birth, congenital heart defects. Some of the commonest congenital heart defects are often called ‘holes in the heart’, this is where there is an abnormal connection between two chambers of the heart. This commonly occurs between the two collecting chambers of the heart, the left and right atria. These share a common part of their wall which is called the interatrial septum. If there is a connection between these two chambers then depending on the location and the exact nature of the problem it can either be called a PFO (patent foramen ovale) or an ASD (atrial septal defect). The size and other features of an ASD or PFO are always assessed using a transthoracic echocardiogram and a transoesophageal echocardiogram.
In many cases, but not all, it is necessary to close these holes. This can be done by open heart surgery and an operation to close off the hole. However, this is large procedure and requires heart bypass. For many cases, depending on the exact size, nature and location of the hole, this can be closed with a closure device.
This treatment is performed with patients lying flat on a movable table. A small tube called a catheter is inserted under local anaesthetic into the vein in the groin. Through this a wire is then moved using x-ray guidance up and around the arteries of the body and then carefully passed across the ASD or PFO. A closure device is then carefully passed over this wire to the mitral valve under x-ray guidance. The device is then positioned across the ASD or PFO. An assessment of how well the device is preventing blood flow across the ASD or PFO is made using an echocardiogram and if the result appears to be satisfactory then the device is then attached permanently across the hole (deployed).
Even if there is a slight amount of leak across the ASD or PFO after the device has been inserted this often disappears over time as a thin layer of tissue will slowly grow over the device covering it. This can be assessed with an echocardiogram.
Atrial fibrillation (AF) is one of the commonest conditions in cardiology and over 1% of the population suffer from AF. For the treatment of the AF there are two approaches called rhythm and rate control. For rhythm control (which means to try to keep the heart in a normal rhythm) drugs are sometimes used which include medication such as a beta blocker (eg Atenolol or Sotalol). If it is not possible to use these to change the heart rhythm back into a normal heart rhythm then a cardioversion can be attempted.
A cardioversion is a short procedure which takes only a few minutes to perform. It is performed under a general anaesthetic so you will be put to sleep for a short period of time. Often a transoesophageal echocardiogram is performed at this point to check that there are no blood clots in the heart (if there is any suggestion that there might be blood clots in the heart then the cardioversion is not performed). After this two paddles are placed in specific positions across the chest (occasionally on the front and back of the chest) and an electrical shock is applied to the heart to change the rhythm from AF back to a normal rhythm, sinus rhythm. After this the anaesthetic is allowed to wear off and most patients wake up a few minutes later. After a cardioversion the chest where the paddles were applied can be a bit sore but this usually wears off after a couple of days.
Before a cardioversion in most cases the blood will have been thinned for a period of time beforehand (usually at least six weeks) with medication called an anticoagulant, for example Warfarin. This is to prevent the formation of blood clots which could dislodge and might lead to a stroke. Blood tests to ensure that the blood is thin enough (or appropriately anticoagulated) are performed before a cardioversion.
Following cardioversion even though your heart may return to a normal rhythm, we would in general wish to recommend continuation of anticoagulation as you would be at risk of recurrent atrial fibrillation.
Sometimes other heart rhythms are treated with a cardioversion. If someone has a heart rhythm problem that is making them very unwell with a low blood pressure then there is not time to wait to thin the blood down and an emergency cardioversion will be performed with anticoagulation commenced afterwards.