The heart is a muscle pump located in the chest, which pumps blood around the body. It keeps pumping from a few weeks after conception until we die. There are a number of different conditions that can affect how the heart works. Below is a brief overview of some of them.
What is the heart?
How does blood travel through the heart?
Blood that has been pumped around the body returns to the heart in the superior and inferior vena cava. It enters the first of the heart's four chambers, the right atrium. From there it is squeezed into the right ventricle which pumps the blood into the lung (pulmonary) circulation. In the lungs, blood picks up oxygen and returns to the left atrium of the heart. It passes through into the left ventricle, the most powerful part of the heart pump, which pumps the blood into the aorta (the main artery) and from there into the rest of the body.
What can go wrong with the heart?
Any part of the heart can have a problem:
- The muscle wall of the heart (myocardium).
- The blood vessels supplying oxygen to the heart muscle (coronary arteries).
- The valves between the heart's four chambers.
- The conducting system that helps the heart to beat regularly and at the right speed.
- The covering of the heart (pericardium).
Heart disease symptoms
Chest pain is the most well-known symptom of heart disease. The typical pain which is caused by angina or a heart attack is described as a central crushing chest pain. It can sometimes cause a heavy aching in the left arm or in the neck or jaw. A heart attack also generally makes people feel sweaty, breathless and extremely unwell.
Other forms of heart disease often cause breathlessness and tiredness as not enough blood is getting pumped around the body to meet all its needs.
If there is a heart rhythm problem or the heart is beating fast then it may cause dizziness or a feeling of palpitations.
How are heart problems investigated?
If your doctor suspects you have a problem with your heart they will arrange some investigations.
The doctor will check your blood pressure and listen to your heart. Looking at other areas of the body as well may give them other clues about what is going on.
Your doctor may arrange for you to have some blood tests. These may:
- check for anaemia which can make you feel breathless (full blood count)
- check your cholesterol level (lipids)
- check for diabetes (blood glucose or HbA1c)
- check for heart failure (B natriuretic peptide or BNP)
Your doctor may arrange for you to have a heart tracing (electrocardiogram, or ECG). This will look at the electrical signals keeping your heart beating. This may be done by the practice nurse at your surgery or you may need to go to the hospital to have it done.
If you have a heart murmur or if your doctor suspects heart failure, they may arrange for you to have an ultrasound scan of your heart (echocardiogram, or 'echo'). This looks at how the blood is flowing through the valves and the different chambers of the heart.
Types of heart disease
The following types of heart disease are included in this leaflet:
- Coronary heart disease
- Valvular heart disease
- Heart failure
- Congenital heart disease
What is coronary heart disease?
This is what most people mean when they talk about heart disease. Coronary heart disease affects the coronary arteries, which are the blood vessels which supply the heart muscle. Sometimes it is called ischaemic heart disease. Ischaemic means blocked blood supply.
The arteries can become furred up with atheroma. Atheroma is made up of fatty deposits that form on the inside of blood vessels, which mean that blood does not flow normally through them.
If the arteries are narrowed then not enough blood will reach the heart muscle. You may have no problems when you are at rest; however, if you are doing some exercise or something that requires the heart to pump harder, it can cause a cramp-like central chest pain which is called angina pectoris, or simply angina. See separate leaflet called Angina for more information.
Coronary artery spasm
Sometimes angina pain may be caused not by atheroma narrowing the artery but by coronary artery spasm. The muscle wall of the blood vessels may go into spasm so that not as much blood is getting through to the heart muscle. This pain may often come on at rest, rather than after exertion. It can be triggered by emotional stress, alcohol or exposure to cold, although there is sometimes no obvious trigger at all.
Acute coronary syndrome
If you develop severe crushing central chest pain, this may be what doctors call acute coronary syndrome . It may be a severe form of angina, called unstable angina, which means the pain comes on even at rest, or it may be a heart attack (myocardial infarction). This happens if one or more of the coronary arteries gets blocked altogether, usually by atheroma, and a part of the heart muscle will have its blood supply cut off and will die.
The severe crushing central chest pain may be associated with feeling sweaty, breathless or nauseous. If you think you may be having a heart attack you must call an ambulance immediately. Getting to a hospital as soon as possible means that you can be given medication to break up the blockage in the artery before too much damage has been done to the heart muscle.
Preventing coronary heart disease
There are a number of factors which make it more likely that you will have angina or a heart attack. These include:
- High blood pressure (hypertension).
- Raised cholesterol.
- Being overweight.
- Family history of heart disease, particularly at a young age.
- Inactivity, or a sedentary lifestyle.
Your doctor may offer you a screening test for some of these risk factors and you may be offered medication to reduce the risk of having a heart attack. See separate leaflet called Cardiovascular Health Risk Assessment.
Specialist investigations for coronary heart disease
An exercise tolerance test can help to show if chest pain is caused by angina. You will walk on a treadmill while attached to an ECG machine. If angina pain happens, or your heart is under strain, it will show up as a change on the ECG tracing.
The cardiologist may also arrange a coronary angiogram. A small tube called a cardiac catheter is inserted through the skin and passed through the blood vessels until it comes to the heart. Then dye which can be seen on X-rays can be put into the blood vessels supplying the heart muscle. The cardiologist will then be able to see if any of the arteries are narrowed or blocked by atheroma.
If narrowing or blockage is found then they may be able to proceed straightaway to a procedure to open up the artery. Angioplasty is a procedure in which a small balloon is passed through the cardiac catheter to the place where the artery is narrowed. Then it is inflated in the blood vessel to open it up. A wire mesh tube called a stent may be left in the artery to keep it open.
What is valvular heart disease?
The four valves in the heart stop the blood flowing backwards once it has entered one of the chambers of the heart.
- The tricuspid valve stops blood flowing back into the right atrium.
- The pulmonary valve stops blood flowing back into the right ventricle.
- The mitral valve stops blood flowing back into the left atrium.
- The aortic valve stops blood flowing back into the left ventricle.
A healthy valve is made of tissue which is flexible and strong. Valve disease can be caused by the valve becoming too stiff so that it doesn't open properly (stenosis) or by the valve becoming too floppy and not closing properly (regurgitation or incompetence).
One way that a doctor can tell that you have a problem with a heart valve is that they may hear a heart murmur. Normally blood flows smoothly through the heart. However, if there is any turbulence which may be caused by a faulty valve then that creates an extra sound that can be heard when your doctor listens with a stethoscope. By listening in different places and by paying attention to which part of the heart sounds are affected, they may be able to tell which valve is affected and whether it is incompetent or stenosed. They will confirm the diagnosis with an echocardiogram which will show just where the turbulent flow is happening.
What causes valve problems?
The most common cause of heart valve problems is degeneration. As we get older the valves get weaker and the tissues forming them may get stiffer. Sometimes the valve may develop calcium deposits (calcify) which make it stiff.
Heart valve problems can be caused by rheumatic fever. This is quite rare in the UK in the age of antibiotics but is quite common in some parts of the world.
Valve problems can be caused by infective endocarditis. See below for more information.
Some valve problems can exist from birth. These would generally be picked up when the baby is checked after birth or at a few weeks of age.
What are the symptoms of valve disease?
A small amount of narrowing or leakiness in a valve may cause no problems at all. However, if it gets more severe, the heart will have to work harder to keep the blood pumping as normal. This may lead to:
- Chest pains.
- A feeling of the heart pounding in the chest (palpitations).
- Fluid retention - for example, around the ankles.
What is the treatment for valve problems?
While the symptoms of valve disease can be managed with medication, the best way to sort out valve problems is with surgery. Sometimes valves are replaced, sometimes repaired, sometimes stretched.
What are the heart rhythm problems that may occur?
The heart's regular rhythm is maintained by a conducting system that carries electrical signals to different parts of the heart muscle to make them squeeze (contract) at the right time. Various things can disrupt this electrical conduction. The effects will depend upon which part of the heart muscle is affected. Heart rhythm problems are called arrhythmias.
Many people have the experience that their heart is missing a beat. In fact, it is more often an extra beat with a slightly longer pause after it, and it is almost always completely normal. Sometimes people become more aware of extra beats when they are feeling anxious or stressed, and then the worry about the extra heartbeats can make them feel worse. However, it is quite normal and does not indicate a problem with the heart.
This is a normal variation in heart rate which occurs mostly in young people. The heart rate speeds up as you breathe in and slows again as you breathe out.
The most common arrhythmia which causes problems is atrial fibrillation. The atria quiver, rather than beating regularly, and the ventricles still pump normally, although not in a regular rhythm. Sometimes the ventricles beat too fast, and medication such as beta-blockers helps to slow it down. Atrial fibrillation can be intermittent (paroxysmal) or permanent.
Sometimes it can be reversed using an electric shock (cardioversion).
If it is permanent, the quivering atrial muscle can lead to the formation of small blood clots. If these leave the heart they can cause a stroke, so it is recommended that people who have atrial fibrillation take an anticoagulant, such as warfarin, or one of the newer anticoagulants, to stop these small clots forming.
If the heart muscle is damaged, most commonly by a heart attack (myocardial infarction), then the electrical signals will not get through normally:
- Ventricular tachycardia occurs when the heart is beating very fast and not very efficiently.
- It can often lead to ventricular fibrillation, which means that the muscle quivers rather than beating. It can sometimes be reversed with a defibrillator.
What is cardiomyopathy?
Cardiomyopathies are diseases that affect the heart muscle. There are several types:
In hypertrophic cardiomyopathy the heart muscle becomes thickened. It is most commonly an inherited condition but can be due to high blood pressure (hypertension). It may cause breathlessness, chest pain, a feeling of the heart pounding in the chest (palpitations) or dizziness, or there may be no symptoms at all.
In dilated cardiomyopathy the heart muscle becomes stretched and weak. This is sometimes inherited and can also be caused by viral infections, alcohol, poor diet, drugs or other poisons.
This is a rare form of cardiomyopathy in which the heart muscle is not able to relax completely between heartbeats.
Arrhythmogenic right ventricular cardiomyopathy
This is rare and only affects the right side of the heart.
What is heart failure?
Heart failure is a condition in which the heart is no longer pumping efficiently. Anything which affects how well the heart is working can lead to heart failure. The heart often becomes enlarged, which your doctor may notice on physical examination. You may be aware of a feeling of the heart pounding in the chest (palpitations). Heart failure symptoms may come and go.
Right heart failure
If the right side of the heart is not pumping normally then fluid will build up in your ankles and legs.
Left heart failure
If the left side of the heart is not pumping normally then fluid will build up in the lungs, causing breathlessness.
Often both sides of the heart are failing to some extent so you may have both sets of symptoms. In addition, you may feel tired, dizzy, sick or generally unwell.
What is the treatment for heart failure ?
There are a number of tablets that doctors use to reduce the symptoms of heart failure:
- ACE inhibitors help to protect your heart and help your body deal with fluid better.
- Beta-blockers help to put less strain on the heart.
- Diuretics (sometimes called 'water' tablets) will help your body to get rid of some of the excess fluid.
There are also implantable devices which will help to control the symptoms if heart failure is being triggered by a heart rhythm problem.
What is congenital heart disease?
Some babies are born with problems in their hearts and this is one of the things that the doctor will check your baby for in the baby checks shortly after birth and again when the baby is about 8 weeks of age. Many heart problems are picked up on ultrasound scans done before birth .
Heart murmurs are quite common in babies and young children and do not always indicate that there is a problem with the heart. Because a murmur is caused by turbulence in flow through the heart valves, if the heart is beating fast (perhaps because the baby is unwell with a high temperature (fever) then that can cause a flow murmur, which disappears once the child is well and the heart is beating at a normal speed again.
However, murmurs can be caused by the heart not developing properly before birth. Sometimes a hole remains in the wall (septum) between the left and right side of the heart. This can be either:
Coarctation of the aorta is a condition in which the main artery that leaves the heart, the aorta, is narrowed so that blood does not flow properly around the body.
Sometimes other blood vessels around the heart have not developed properly and the problems this causes will vary depending on which vessels are affected.
Sometimes the heart muscle itself has not fully developed. This is likely to be picked up before birth so that a plan to look after the baby can be in place as soon as the baby is born.
Some forms of congenital heart disease (for example, some valve problems) may be mild and may need nothing more than monitoring from time to time. Others may require urgent resuscitation and complex surgery or even heart transplantation.
Which infections may affect the heart?
As well as dilated cardiomyopathy, mentioned above, there are several infections which can affect the heart.
The endocardium is the layer of tissue lining the inside of the heart. Infective endocarditis generally affects the valves of the heart.
You are more likely to get it if you already have a valve problem, if you have a problem with your immune system or if you inject drugs.
People who are at high risk of developing endocarditis should be aware of the symptoms of infective endocarditis and report any concerns to their doctor. Some surgical procedures increase your risk of developing endocarditis, and your doctor will advise you if you need antibiotics to reduce the risk of infection.
Myocarditis is inflammation of the muscle wall of the heart. It is most commonly caused by a viral infection. There are a number of viruses which are common, such as influenza or chickenpox, but which cause myocarditis rarely. If you develop chest pain, breathlessness or a rapid or irregular heartbeat following an infection, see your doctor who will examine you and may arrange an ECG to check for the changes seen in myocarditis.
Rheumatic fever is caused by a germ (bacterium) that commonly causes sore throats. It is very rare in the developed world. It can cause inflammation in any part of the heart: muscle, endocardium, valves, or the covering of the heart (the pericardium) and it can cause chest pains, breathlessness and a fast or irregular heart rate.
It is treated with antibiotics but when the inflammation has settled it may leave some residual damage, particularly if it has affected the valves, which increases the likelihood of developing infective endocarditis later.
How can you look after your heart?
As well as the things listed above under 'Preventing coronary heart disease', you can help to look after your heart by taking regular exercise that gets your heart beating faster. It is recommended that you do about 30 minutes of exercise that gets your heart pumping faster (aerobic exercise) each week. However, even increasing your activity level a little bit will have health benefits.
Following a Mediterranean diet based on eating lots of fruit, vegetables and grains, and lower amounts of red meat and processed foods, has been shown to reduce the risk of heart disease.
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