Heart disease

What is heart disease?

There are many different conditions which can affect the heart, including those which affect the heart valves, the heart wall muscle, the blood supply to the heart, and the electrical currents within the heart.

Heart disease symptoms

These include:

• Chest pain (the most well-known symptom of heart disease).

• Central crushing chest pain (the typical pain which is caused by angina or a heart attack).

• Heavy aching in the left arm or in the neck or jaw.

• Breathlessness and tiredness can occur as not enough blood is getting pumped around the body to meet all its needs.

• Dizziness or a feeling of palpitations (this is common with heart rate or heart rhythm problems).

• Fluid build up, resulting in swelling of the feet/legs and breathlessness due to fluid in the lungs.

A heart attack also generally makes people feel sweaty, breathless and extremely unwell.

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Heart health and blood vessels

Cardiovascular disease

Cardiovascular diseases (CVD) is a general term to describe diseases of the heart or blood vessels. The cause of most cardiovascular disease is a build-up of atheroma - a fatty deposit within the inside lining of arteries. The blood flow to the heart muscle may also be restricted by a blood clot in an artery taking blood to the heart muscle (coronary artery disease). Atheroma or a blood clot may also restrict or prevent blood going to the brain (cerebrovascular disease) or to the legs and feet (peripheral arterial disease). There are lifestyle factors that can be taken to reduce the risk of forming atheroma. These include not smoking; choosing healthy foods; a low salt intake; regular physical activity; keeping your weight and waist size down; drinking alcohol in moderation. Your blood pressure and cholesterol level are also important. All people aged over 40 years should have a cardiovascular health risk assessment - usually available at your GP surgery. If you have a high risk of developing a cardiovascular disease, treatment to reduce high blood pressure (hypertension) and/or cholesterol may be advised.

by Dr Colin Tidy, MRCGP

What causes heart disease?

The causes vary, depending on the type of heart disease. These can include problems with the structure of the heart from birth, faulty genes, and lifestyle factors such as smoking, being overweight, an unhealthy diet, lack of exercise, alcohol and various drugs.

Types of heart disease

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.

In coronary heart disease, 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.

Coronary heart disease includes:

• Angina.

• Coronary artery spasm.

• Acute coronary syndrome, which includes a heart attack (myocardial infarction).

Congenital heart disease

Some babies are born with problems in their hearts. 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) 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:

• A ventricular septal defect; or

• An atrial septal defect.

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.

Tetralogy of Fallot is a condition which is often diagnosed before the baby is born, during an antenatal scan.

Tetralogy means 'four' and there are four heart abnormalities associated with this condition:

• Ventricular septal defect

• Overriding aorta (where the aorta sits over the ventricular septal defect rather than over the ventricle)

• Obstruction to blood flow from the right ventricle

• Swelling of the right ventricle.

Surgical repair is the usual treatment.

Valvular heart disease

See the separate leaflet called Heart Valves and Valve Disease.

Heart rhythm problems

See the separate leaflet called Abnormal Heart Rhythms (Arrhythmias).

Cardiomyopathy

Cardiomyopathies are diseases that affect the heart muscle. There are several types:

• Hypertrophic cardiomyopathy.

• Dilated cardiomyopathy.

• Restrictive cardiomyopathy: 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.

Heart failure

See the separate leaflet called Congestive Heart Failure.

How is heart disease diagnosed?

If your doctor suspects you have a problem with your heart they will arrange some investigations.

Physical examination

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.

Blood tests

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).

Electrocardiogram

A heart tracing (electrocardiogram, or ECG)looks 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 are experiencing the sensation of having a 'thumping' heart (palpitations) and your doctor suspects that your heart rhythm is sometimes irregular, they may want to arrange a 24-hour ECG.

Echocardiogram

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.

Specialist investigations for coronary heart disease

The cardiologist may organise a CT (computed tomography) scan to show whether the coronary arteries are narrowed or blocked by atheroma, after an injection of dye into a vein.

Another type of scan which can be done is a myocardial perfusion scan. A small amount of radioactive substance is used to check blood flow to the heart muscle.

They may also arrange a more invasive test called 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 straight away 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 the treatment for heart disease?

Again, treatments vary depending on the type of heart disease. Treatments include the following:

Medication

Medicines are used to:

• Thin the blood and prevent blood clots forming in the heart and elsewhere in the body (eg, aspirin, clopidogrel, warfarin, apixaban)

• Improve blood flow to the heart (eg, nicorandil, ranolazine, ramipril)

• Slow down the heart rate if it is beating too fast (eg, bisoprolol, verapamil, ivabradine, flecainide)

• Open up the blood vessels in the heart to improve blood flow to the heart muscle (eg, GTN spray, isosorbide mononitrate)

• Reduce fluid build up in heart failure (eg, furosemide, bumetanide)

Surgery

This can range from less invasive procedures such as angioplasty to clear blockages (see above) and pacemaker fitting to control abnormal heart rates and rhythms, to major open surgery such as heart bypass surgeryfor coronary heart disease,heart valve repair or replacementsfor valve disease, and even heart transplants for some conditions.

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.

• Diabetes.

• Smoking.

• Being overweight.

• Family history of heart disease, particularly at a young age.

• Inactivity, or a sedentary lifestyle.

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.

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 the separate leaflet called Cardiovascular Health Risk Assessment.