Angina

For the past 12 years I have worked exclusively with patients with a condition known as refractory angina. This is when angina stops patients enjoying life to the full and orthodox cardiology has run out of answers.

In my experience fear and confusion dominates the problem. Most patients and their families believe that the heart is progressively damaged with each episode of angina. Nearly all people think that the fatty cholesterol deposit (atheroma) on the inner lining of the arteries that supply the heart (coronary arteries) gradually worsen until they inevitably block the vessel altogether and this causes a heart attack. Most people know that exercise is recommended but worry that they will cause themselves harm if they overdo it. It is hardly surprising that many patients and their families live in constant fear when they have been told by their consultant, "nothing can be done" and "take things easy."

When we set up the UK's first specialist clinic for refractory angina we knew that we had to use a different approach simply because the conventional or orthodox medical model had failed. With no resources and little spare time for this new venture, we had to keep things simple. We realised that patients had a vast experience of the orthodox model and they could help us develop a better approach tailored to their needs. Putting patients at ease and simply listening to refractory angina sufferers taught us that while most were grateful that the system had "kept them alive" they were generally not impressed with the after sales service. Frightening images and ideas are commonly introduced in follow up clinics or by the bedside by professionals who appear unaware of the damaging effects of a careless explanation of a complex issue. Patients commonly recall hearing phrases such as: "there is nothing more that can be done"; "you are a walking time bomb"; " you are living on a knife-edge"; "the next one will be the last."

The aim of this blog is to share my experiences of the sort of things that really make a difference to patients' lives. Knowing that angina does no harm to the heart and that the heart is actually slightly better off after an episode than it was before, is a good place to start.

The question that nearly always follows this relevation is, "why do they do all those heart operations then?" The answer is not simple.

Some, but by no means all operations are "life-saving." By far the commonest heart procedure is angioplasty and stent, where a ballon with an etched metal tube wrapped around it is inflated at the narrowing. The ballon expands the metal tube (stent) which then acts like internal scaffolding. Intuitively this should prevent heart attacks but several trials have looked at whether angioplasty reduces heart attacks or death and it doesn't except when it is performed during a heart attack. Even then it is not clear that stents are any better at reducing the size of the heart attack than simply clearing the blockage with a simple balloon. The majority of angioplasty procedures are not "life-saving" and yet the vast majority of patients I have spoken to had previously agreed to undergo angioplasty and stent precisely because they believed that it would be more risky not to have the procedure. Bypass surgery really does appear to save lives but only in very special circumstances when there are narrowings right at the beginning of the heart's own arteries. If you are offered a cardiac procedure it is worth asking the straight question, "Will this make me live longer and if not what are the alternatives?"

Another good question is, "how long is it likely to last?" It is generally understood that angina returns in about a third of men and abut half of women within three years after a bypass. It is also important to know that the operation itself can leave a painful scar that is sometimes worse than the original angina. Angioplasty (excepting emergency situations) as I have already discussed is not a life-saving treatment and is only partially successful in eradicating symptoms. Obviously some patients experience dramatic improvements but overall the benefits are small and transient.

It is generally accepted that one of the most effective and safest interventions is education as part of a comprehensive rehabilitation process. However, consistent with our experience, the European Society of Cardiology, the American Heart Association and the NHS's Healthcare Commission have acknowledged, this critically important aspect of care is often neglected. Unfortunately, patient and carer education (as opposed to giving information) is time consuming and requires communication skills that are not yet part of the standard training requirement for cardiologists.

I will try to post regular updates on general issues that might be of relevence to you. I will not be answering individual queries.

www.angina.org