Today I want to update you about something incredibly common, and will likely have touched many of our lives one way or other: coronary artery disease. There’s so much to say it’s hard to know where to start, as there were so many related sessions presented at the European Society of Cardiology meeting.
Let’s start with diagnosis. The latest guidelines are keen to point out that not all patients will present with the same symptoms, that doctors should be aware of this, and not necessarily discount the diagnosis if a person does not have what might be considered ‘typical’ symptoms. Women, and diabetics, for example, often may have other symptoms such as breathlessness, indigestion, nausea, vomiting and even sleep disturbance!
There were a number of sessions on CT coronary angiography. As you may know I am a huge fan of this test, and if you haven’t seen it please do check out the content specifically on this in the members area.
(A quick digression please – you may have heart of a calcium score. This is in my view a very poor relative of a CT coronary angiogram, missing a large amount of potentially serious disease. In fact, only this week I saw a lady in her 50s who had what we call ‘soft plaque’ on her CT scan, yet her calcium score would have been 0. My view was shared by many experts at the conference. I simply do not use calcium scoring as a reliable test)
We are lucky in my hospital to have such good access to CT coronary angiography. However, not uncommonly, patients have only minor furring up of their arteries on a CT scan, yet significant symptoms. Traditionally (and I will humbly include myself in this) cardiologists may have dismissed patients as not having heart symptoms if the CT has reported only a small amount of disease. The new guidelines encourage Cardiologists to consider what is called invasive functional testing if non-invasive tests are negative but they still suspect the heart to be the cause.
It’s actually quite difficult to put this in easy to understand language, but I’ll do my best! Essentially there can be dysfunction of the blood vessels’ ability to deliver blood to the heart even in the absence of a narrowing. If found to be the case, there are medications that can help (which would normally not be tried if the CT was reassuring). I am certainly not advocating invasive testing for a large number of patients, but in those with persistent symptoms despite medication I will certainly be thinking of this now.
Whilst I’m on medication, there’s another change in the guidelines for people with chronic coronary disease (which really includes anyone with a prior heart attack, angina, or stable furring-up on a scan – chronic in a medical sense means long-term, and does not relate to severity). This recommendation has come about because of a trial showing benefit of a drug called colchicine, which should be considered in such patients to reduce heart attacks, strokes, and the need for stents or CABG surgery. Colchicine is an anti-inflammatory medication, and we know that inflammation is hugely important in many diseases. It’s one reason why we see more heart attacks at the time of other ‘inflammatory episodes’ for example a flare of colitis or arthritis. It will be interesting to see how this space evolves. Most patients with chronic disease aren’t even under the care of a cardiologist but are in primary care, and GPs through no fault of their own simply won’t know the latest evidence.
All the new guidelines focus on shared decision making between patient and cardiologist. This as a principal is absolutely right, but there are some important practical considerations. Firstly a lot of this is complex stuff, and patients need to get the information to make a decision on their treatment in a way they can understand. Secondly, that takes time to do properly, time to weigh it up, and time to make a decision. In the average short consultation, that is a tough ask. There are also a proportion of patients who will simply say ‘I’ll do whatever you think is best’, so knowing your patient, and having a sense of what is best for them as an individual is critical.
As a regular reader you will know I am always droning on about the importance of a healthy lifestyle, and I was pleased to see the great and the good of the guideline writing committees of Europe agree with me. It’s hard to overstate the benefits of getting the basics right – avoiding smoking, maintaining a healthy weight, nutrition, exercise. Today isn’t the day to go into that in detail, but I’ll leave you with the thought what can you do better this week? Can you sneak in a bit more exercise? Can you have the willpower to say no to something you suspect you might feel guilty about 5 minutes after eating it? These things aren’t easy, but they do work.