This week I have chosen two questions sent in by readers, both regarding heart related issues. As always, I am delighted to answer any queries in my capacity as a full time NHS GP. However, this must not be a substitute for consulting with your own doctor
QUESTION: My GP noticed a murmur when examining me and sent me for an echocardiogram. I was surprised as I don’t have any symptoms and have always considered myself to be fit and well. I’ve been told that I have aortic stenosis, but that they are just going to follow it up with a yearly scan. Please can you explain – John, 71.
A The aortic valve lies at the exit of the left ventricle (LV), the heart’s main pumping chamber. When the heart contracts and blood is forced out of the LV and into the aorta, the body’s major blood vessel, this valve serves to prevent any backflow of blood into the LV.
The valve normally has three cusps (it may be easy to think of it as like a Mercedes Benz star). With age, the valve cusps become worn and do not open as easily, hence narrowing this outlet.
As the coronary arteries, which supply the heart muscle itself, come off the aorta just above this valve, the amount of blood flowing through these may also be reduced. Typical symptoms are chest pain and/or shortness of breath, more noticeable when you are active, but if the narrowing is severe, they can occur at rest. Some individuals report only a sense of fatigue, which makes sense as neither the body or the heart muscle itself may be getting an adequate blood supply.
If the narrowing is mild you may not have any symptoms. A cardiologist will monitor you with periodic echocardiograms (jelly scan of the heart), as many will progress at such a pace as to not require treatment. However, this is very variable between individuals and if you develop symptoms or a worsening of your symptoms between scans, please alert your GP as you may need your next echo at a shorter interval.
Symptoms of blackout or collapse, especially if precipitated by exercise, must never be ignored as these may be a sign of severe or critical aortic stenosis.
QUESTION I went to my GP because I would really like an angiogram. I get chest pains and I’m worried it’s my heart. He has sent me for a chest x-ray and an ECG. He said that I wasn’t likely to have heart disease at my age, but I’ve read you can get it at any age – Simon, 25.
ANSWER: There are several causes of chest pain, not all of which are heart related thankfully. Cardiac chest pain is less common in younger individuals, as the majority of heart disease is acquired over several decades, unless you have a strong family history of heart disease at an early age.
Symptoms of angina, the main indicator of coronary artery disease, also known as ischaemic heart disease (IHD) are chest pain and/ or shortness of breath, worsened by exercise and relieved by rest. If your doctor suspects you have cardiac sounding chest pain, the first investigations are an ECG to look for any abnormality in your heart rhythm or signs of heart strain. A chest x-ray will look at the size of the heart.
Checking your blood pressure and lipid (fat) levels in the blood will address two of the most modifiable causes of heart disease, these being raised blood pressure and high cholesterol.
The next step is a treadmill test, where you walk on a treadmill while being hooked up to an ECG machine, all in a supervised clinic environment. If your chest pain is due to heart disease, this will be brought on by walking on the treadmill and your ECG will change as a result of the heart muscle struggling due to the increased demands placed on it.
It is at this point that a heart specialist (cardiologist) will consider an angiogram. This is a dye test where a catheter (tube) is fed up through an artery in your groin or wrist. A dye is injected into the coronary arteries, which will then reveal the location and extent of any narrowing or blockages. It is one of the final investigations, usually employed at a point where the specialist is already relatively certain of the diagnosis, and is trying to ascertain whether the disease can be managed with medications, stents or whether it requires surgical treatment, often referred to as bypass surgery.
Angiograms are not without risks, including bruising at the site where the catheter is inserted in your wrist or groin, damage to the coronary arteries themselves, heart attack and even death, albeit in the rarest of cases.
It is for this reason that they are only requested after specialist review, when non-invasive tests, with far less risk attached, have convincingly pointed to a diagnosis of angina.
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