Often in my weekly blogs I discuss a certain topic, research trial or medical news item, but having spent the whole of this past week on-call, I thought it might be interesting to simply give you an insight into what it looks like ‘on the front-line’ of acute heart care in my hospital.
On-call weeks are never quiet. Sometimes they’re busy, sometimes they’re very busy — but this one felt different. The turnover of patients has been extraordinary. In terms of the sheer number of people coming in with acute heart attacks, I genuinely can’t remember a busier week in the last ten years of being a consultant.
The reassuring part is that, by and large, people have presented and been treated very quickly and have had good outcomes. Modern cardiology is incredibly effective when it comes to heart attacks. But sadly — and perhaps inevitably — there have also been a few deaths. And those cases always give pause for thought. Heart attacks are highly treatable, but they can still be sudden and catastrophic. That contrast is something that never really leaves you, no matter how long you’ve been doing this job.
Weeks like this make me reflect, more than ever, on the importance of primary prevention, or in other words, taking steps to prevent a health outcome before it happens. I can’t help but think that many of the heart attacks I see today could, at least in part, have been prevented if we had managed risk factors better ten, twenty, or even more years ago — particularly cholesterol and blood pressure. Far fewer people smoke now than they once did, which is a real public-health success. But other factors — especially excess weight, obesity, cholesterol, and blood pressure — remain hugely problematic.
One patient in particular has stayed with me. He was only a few years older than I am, in his early fifties, and on the face of it had no conventional risk factors. His cholesterol wasn’t especially high. He had no obvious family history of heart disease. His blood pressure was normal — if anything, on the low side. He exercised regularly. Yet, he had a heart attack from which he was lucky to survive as his heart actually stopped. In cases like that, I inevitably start thinking much more about genetic predisposition, even in the absence of a classical family history. This is where our understanding has moved on enormously in recent years. We now know that inherited risk doesn’t always declare itself through obvious markers, and that it can be assessed using modern tools such as genetic analysis and more comprehensive blood testing.
There have been other patients this week who’ve prompted a very different kind of reflection.
One man I’ve looked after for several years now has been living with very advanced heart failure — to the point that he has previously been assessed for heart transplantation. Unfortunately there are far more people who need a transplant than there are donor hearts available. In the UK, only a couple of hundred heart transplants are performed each year. Because of that, it’s absolutely vital that donated organs — which are an extraordinarily precious gift — are used in a way that honours the donor, their family, and loved ones, and gives the recipient the very best possible chance of a good outcome. Patients on transplant waiting lists are therefore prioritised very carefully, based on a number of clinical factors.
This week, that has meant having some very nuanced — and understandably emotional — discussions with this patient’s family. Everyone, of course, wants the very best for their loved one. But for heart transplantation to be successful, the rest of the body has to be in very good condition too.
One of the commonest barriers to transplantation is high pressure in the lungs. This can occur as a consequence of long-standing heart failure itself, but it can also arise from intrinsic lung disease. Over time, a failing heart may gradually adapt to pumping against higher lung pressures. However a newly transplanted heart has not had that time to adapt. The concern is that if a new heart is transplanted into an environment with very high lung pressures, it may fail — and if that happens, a donor heart has effectively been lost. That would be a tragedy for everyone involved.
So these are difficult, but vitally important conversations to have. There is still hope for this patient, and ongoing assessment continues, but these realities need to be understood clearly and honestly.
At the other end of the spectrum, this week has also reminded me that age, in itself, is not always the deciding factor. Just yesterday, I saw a 95-year-old lady whose heart rate was dangerously slow and who clearly needs a pacemaker. In her case, age alone is not a barrier. She was in amazing shape, and looked not a day over 80!
By contrast, earlier in the week I reviewed a man who, in relative terms, was not that old — around 80 — but who has dementia. Although, on paper, he met guideline criteria for a pacemaker, decisions like this are never just about guidelines. His dementia made the consent process far more complex. I feel very strongly about decisions to treat or not to treat in such patients, probably in part because my own mum has dementia. When I spoke to the patient’s wife, I shared that with her. She told me that her husband had always been very clear that if he were ever to develop dementia, he would not want medical interventions. In that context, although the theoretical answer might have been to proceed with a pacemaker, the right answer for that individual was not to. Sometimes, choosing not to intervene is actually far harder than proceeding with a procedure — but it can be the most compassionate and appropriate decision. The patient was discharged back to his nursing home without a pacemaker, and I believe that was the right outcome for him and his family.
Finally, this week has also been difficult in another way. Walking around the wider hospital seeing cardiology referrals, it’s been striking just how full everywhere is. Earlier in the week, a major incident was declared because of the sheer number of patients in hospital and lack of empty bed spaces. Despite working in a large, modern hospital — built at enormous expense — I was still seeing patients with heart attacks being cared for in corridors, simply because there were no ward beds available at that point in time. I don’t want to over-dramatise this, but I do think it’s important for people to understand that these pressures are very real, particularly through the winter months. Much of the reason for this is acute pressures due to viral respiratory illnesses, and in fact you will see in this week’s video I have succumbed myself! I can’t recall the last cold I had and am lucky to enjoy very good health, so it’s rather irritating to be so snotty.
We’ve been talking about winter pressures for as long as I’ve been a doctor — over 25 years now — but it remains upsetting to see heart attack patients in corridors. That, however, is the reality of our work. What I would add is how well the staff manage, and how understanding the patients are under these circumstances.
Weeks like this remind me why prevention, thoughtful decision-making, and honest conversations matter so much — not just for individual patients, but for the system as a whole.