Heart disease
(including angina and high blood pressure)

Advice on lowering blood pressure

Q . I have high blood pressure 200/120. I am on medication and have been for 6 years. But nothing seems to lower it. I have been investigated and all the consultants say is live with it. But I am due to have a couple of operations soon and I think these will be cancelled due to the bp.I am taking tablets terazosin hydrochloride 5mg, co-tenidone 100/25mg, amlodipine besylate 10mg. Can you give me some advice? I did go through spinal surgery 7 years ago.

A. Some people can have hypertension which is difficult to treat. It can often be hereditary although many people don't realise as their relatives never had their BP checked to find out in the first place. It is impossible for me to give you advice over your medication without seeing your notes and previous medical history. It is worth asking your anaesthetist and surgeon whether it might be possible to perform the operation with a nerve block rather than general anaesthesia. This can be useful for some people. It may be that your hypertension is related in some way to the operation you are seeking on your spine, ask about it.

Sorry I cannot be of any greater help.

Advice on aorta operation

Q . My father, who is 83 (today) has an aneurism of the aorta. It is 6cm in size. His consultant has asked him to consult his three sons before making a decision about a possible operation. He has been told that because of his age and history of heart desease (minor) that it is a serious operation. He had also been told he could live for between six months and sixars without an operation.

Could you please give me some general advice for me to pass on to him on this matter.

A. My Dad is 81 and lost his leg to survive 2 years ago so I will be the first to say that the 'well he has had a good innings' mentality doesn't really make it any easier, especially if you happen to be on the wrong end of the scalpel. In truth this is a serious operation for any prson but age is against him. As most of these operations occur in older men most will be 'serious operations' anyway. I will not try to kid you, his chances are limited and your surgeon is being honest. At his age his life expectancy is not great to start off with. The 'blow out' in his artery will almost definitely rupture at some point but just exactly when is a guess at best.

He needs to make his own decision. The surgery will lay him low for weeks and can never be guaranteed. At the same time doing the operation 'cold' while things are under control is a great deal safer than when it actually bursts. WE all must die at some time, the how is often more important tha the when. If it ruptures,it will be painful and,if not treated immediately, fatal. The operation is also painful afterwards. He obviously has caring, loving sons about him. Not every man has this and they die lonely people. Talk to him, present the facts, support him. Let him decide, not the surgeon.

Why is my blood pressure so high in the mornings?

Q . I am a hypertensive patient. My blood pressure goes very high in the mornings. On the average 160/102. I am on medication which brings my pressure to relatively normal during the day and sometimes till 10:00pm at night but as soon as I wake up around 7:00am, my pressure is high. No doctor has been able to tell me why? Can you please?

A. Blood pressure has a circadian rhythm. In other words it changes according to the body clock just like many hormones. During the night it falls to a low level and hormones such as adrenaline, which influences heart rate and output, also fall. After about 4am there is a steady rise until at around 5am it is back to daytime levels. Adrenaline is also produced which speeds up the heart. This is important because you will soon be vertical after being horizontal for a long time. The heart must compensate by increasing the pressure so blood will reach the brain.

Jumping straight out of bed and standing upright can often cause a faint for exactly this reason. Meanwhile the medication you took the day before has more or less worn off and your heart is maintaining a higher pressure. Once you take your medicine, which is probably a mixture of drugs, the blood pressure falls. Taking your medicine at night may be the answer but it carries the risk of a faint in the morning. It is also least effective during the time when you need it most - during the day. Do not change the way you take your medicines without first asking your doctor. Under no circumstances stop them suddenly.

Is resting heart rate of 55 OK?

Q . I'm a 52-year old male, overweight, not fit. I drink one glass of wine a day and I've never smoked. My resting heart rate is about 55. Is this normal? If not, what does it mean?

A. Heart rates are the cause of much unnecessary consternation. Heart patterns are often much more important. In your case simply giving your heart rate provides very little to work on. Generally speaking a low heart rate, especially if it is one returning to baseline after exercise, is a sign of a healthy body. If your heart rate fails to rise sufficiently with exercise or on getting up from lying down, it can cause light headedness and weakness. This can be a sign of low thyroid activity (the gland in your neck which determines basic body metabolism) but may also reflect a problem with the heart itself.

Generally speaking if you feel well and do not suffer from any dizziness or light headiness it is probably normal although it would be wise to have your heart and thyroid checked by your GP.

Various problems but fearing a heart attack

Q . Since 12/24/00 I have broken out in some sort of a rash on my chest - a lot of red bumps all over but I think it is a new fragrance they have purchased for me for Christmas. The bumps are red and itchy and dry like. But my big concern is that over the last couple of nights I have been feeling a lot of cold sweats and a very sharp pain on my left side by my armpit and my heart has been kind of racing while I'm sitting down and have sharp chest pains every once in a while.

Not too long ago I was in the ER for a cyst and when I was laying down on the bed my heart would race and when I would stand up my heart would slow down. Doctors were concerned but let me go. I think I'm on the verge of a heart attack but am not sure. Please let me know something a.s.a.p I'm 25, male hispanic in Chicago about 5 11" 290lbs.

A. What you describe may be a number of unconnected problems. Yes, the dry itchy red bumps could well be an allergic reaction from chemicals. Generally you will find it where you splashed the stuff.

The cold sweats with a sharp pain in your armpit may be a chest infection especially if your heart is racing. You would normally feel short of breath as well, with pain when you breathe in. It is less likely to be a heart attack although it would be useful to know your lifestyle as well as any previous medical history for you and your immediate family. What kind of cyst was it? Any lumps under the armpits need to be investigated. Having said all this it could just as easily be a panic attack but I suggest you see you own doctor to check.

Hole in heart

Q . Please could you advise. I am a healthy 40 year old, and 4/5 years ago had an echocardiograph which detected I have a small hole in my heart. At the time I was advised not to do anything about it and carry on exercising which I do 4/5 times a week. Is there any benefit in having the hole repaired and what is the long term effect on my heart if any? Thank you.

A. You mention that you are a healthy 40 year old but that some years ago an echocardiogram showed a small hole in your heart. You do not say, however, why the echocardiogram was done in the first place, although I suspect it was due to the fact that your doctor had heard a small heart murmur. The latter is caused by turbulent blood flow surging through a hole in the heart.

You have already been advised not to do anything about it and to carry on exercising. I doubt, therefore, whether there would be any benefit at all in having the hole repaired and it would appear that the hole is so insignificant that it has not caused any problems at all. On this basis, it is unlikely to cause any problems in the future. 

Having said this, I clearly do not know the details of your problem and I would strongly advise that you go and discuss these issues with your doctor.

Headache and seeing spots caused by high blood pressure?

Q . My boyfriend recently found out that has high blood pressure. But lately he's been experiencing headaches and sees spots. Sometime is he's out in the sun for a long period of time - he gets that. He rests for a couple of days, take his medication and feel all right. He's trying to stay on his diet and trying to relax more. But this weekend his head ached again and he had a. He's still in bed sleeping and resting for a couple of days. This headache and seeing spots is it caused by high blood pressure?

A. I understand that your boyfriend has recently found out that he has high blood pressure and that he has been getting headaches and seeing spots in front of his eyes. In the great majority of cases high blood pressure is not associated with any symptoms. The concerns about raised blood pressure are more the fact that it increases risks of problems such as heart attack and stroke. For this reason, raised blood pressure needs to be adequately treated and will need careful follow-up. As stated, it is rarely associated with symptoms, although if it is very severe/poorly controlled some people do notice headaches. In most cases, however, headaches are due to something other than raised blood pressure.

I suspect from what you tell me that his headaches are likely to be stress related, particularly since you say that they are benefited by rest. You also mention a fever but do not state whether in fact the temperature is actually raised.

In view of the symptoms I would strongly advise that your boyfriend goes immediately to see his own doctor and discusses these symptoms with him/her to ensure that both his blood pressure is adequately controlled and that there is no other reason for the other symptoms you mention.

What is left ventricle failure?

Q . Could you please explain what "left ventricle failure" is and what are the symptoms?

A. I am slightly concerned at your question as it sounds as though you have picked up this term from health professionals who were discussing either your own or a relative's condition. It is worth remembering that these types of discussions are often 'thinking out loud' and may not have any relevance to your problem.

The heart is made up of four chambers two of which - the ventricles - do all the real work pumping blood either to the lungs (right ventricle) or to the rest of the body (left ventricle). If the left ventricle is incapable of pumping efficiently (LVF) as a result of muscular damage following a heart attack for instance, a number of symptoms can occur. Breathlessness is one of the commonest and is caused by fluid building up in the lungs. Ankle swelling, or fluid at the base of the spine if lying down, can also occur. Reducing the amount of water in the body though diuretics is one way of reducing the effects of LVF.

When will I be normal?

Q . I am 73 5'4" and weigh 7st.11lbs and in April this year experienced breathlessness. I have been treated for 5 years with HBP and when visiting my GP this April the reading was 210/50. The trouble has always been the systolic pressure. I was changed to Ramipril tabs 2.5.mg but my GP immediately doubled this to 5mg. I also take a 40mg water tablet Frusemide and 100mcg of Thyroxine daily. The effects are still being felt. When will I be normal?

A. I note that you have been treated for the last 5 years for high blood pressure and when visiting your GP recently the upper (systolic) reading was raised at 210 mmHg but with a normal lower pressure (diastolic) of 50 mmHg. Isolated raised systolic blood pressure (hypertension) is very common in older people, although in your case the difference between the systolic and diastolic is very high, and I would be inclined to ask your GP to do a full cardiovascular assessment, including both a clinical examination and an ECG if this has not been done recently, just to make sure that all is otherwise well.

Isolated systolic hypertension can be quite difficult to treat but it is important that it is treated as your risks of cardiovascular disease such as a heart attack or a stroke are increased if the pressure is raised. I note that you have recently been changed to a drug called Ramipril which is normally a very effective blood pressure lowering agent. It is one of a class of drugs called ACE inhibitors which acts on what appears to be a fundamental pathway in the body which may be associated with raised blood pressure and so it is a very appropriate treatment. There is also evidence that these drugs have some cardiovascular and kidney protective properties over and above their blood pressure lowering effects. The dose that you were started on, 2.5 mg, is the normal starting dose and it is given at this dose initially for safety reasons.

It is normal practice, however, to increase the dose further fairly rapidly as your GP has done. In fact, I would advise a further doubling of the dose to the maximum recommended dose of 10 mg in consultation with your GP over the next few weeks both to try and get your blood pressure down and also to produce the best form of heart and kidney protection.

Water tablets such as Frusemide are also useful in lowering blood pressure and the combination of an ACE inhibitor with a water tablet is usually quite effective in lowering blood pressure. If this combination is insufficient, however, to bring your systolic reading down to ideally <140 but certainly less than 160 mmHg then you may need an additional blood pressure drug. There are a range of such treatments, all of which combine very well with the combination that you are already on. You will need to discuss this further with your GP.

You also mention that you have been experiencing breathlessness. You do not indicate whether this is only on exertion or whether you also notice it at rest and whether it wakes you up at night. You should go to see your GP and discuss this further. It is possible that the breathlessness is related to an element of heart failure and again the combination of Ramipril and Frusemide is a good treatment as this will not only lower your blood pressure but also is an effective treatment for heart failure.

As I mentioned above it is worth getting a full physical assessment, together with an ECG. I think it likely that your GP will also advise you to be sent to a specialist cardiac centre to have an echocardiogram. This is a very simple test but will give a very good indication of heart function - it is totally painless! This will certainly tell the heart specialist and your GP whether you do have an element of heart failure and help with further management.

Finally, I note that you are on 100 mg daily of Thyroxine. I assume that you are on this because you have an underactive thyroid gland. It is important that your GP does a blood test every so often to check that you are on the right dose of Thyroxine and I assume that he/she does do this and that you are on the correct dose. It is, however, worth asking about this.

What is low blood pressure?

 Q . I am writing on behalf of male friend (50) who has recently collapsed from low blood pressure although he has been taking tablets for high blood pressure for the last 4 months and exercising regularly. He has no history of medical problems.

Firstly could you explain what causes low blood pressure and perhaps why this would cause someone to collapse and also (if possible) give any reason as to why this would happen given his circumstances.

Apart from exercise and healthy diet is there anything else he could be doing to curb the blood pressure problems?

A. While it is marvellous to have a concerned friend or relative to bring problems to the attention of a health professional it always lacks the essential detail of talking to the person themselves, so there is no way I can give you a definitive diagnosis without more information and examination of your friend. Even so, let's look at some of the things you quite rightly raise.

Collapsing from low blood pressure is rare unless the person is taking anti-hypertensive medication or has some sort of heart dysfunction/disease. It may well be that the medication itself is causing the problems if it is lowering his blood pressure to far. Some of the treatments prevent the heart from lifting the pressure sufficiently when the person, for instance, stands up or gets out of bed for the lying position. The brain is very sensitive to the tiniest drop in blood flow and will withdraw labour before you can say 'everybody out'. Your friend should take care when standing and/or have his medication checked. Keeping blood pressure down is usually a greater problem than the reverse and hypertension can wreck perfectly good kidneys, livers and hearts - not to mention brains - before it is diagnosed and treated. Your friend should not stop taking his medication but keep up with the exercise. He is lucky to have someone who cares, many don't.

High cholesterol but doesn't want to take medication

Q . I had a blood test regarding possible trouble with my prostate. When I went to my doctor regarding the result of the blood test, the doctor told me that my prostate was fine but I had high cholesterol of 7.2. I was very surprised and worried. I have been given atorvastatin to take which I have been taking since September, but am not keen on taking tablets as I would prefer to take natural remedies.

My wife's friend is a nurse and was told that I shouldn't have had anything to eat as that might effect the cholesterol reading. I had breakfast the morning of my blood test so therefore I don't know what to do. I wonder if you could kindly advise as also I am not overweight and do plenty of brisk walking.

A. You give me two areas of potential concern, yet they may be of no consequence which is the doubled edged sword of any test. Let's look at the prostate test first.

The PSA (prostate specific antigen) test is a good indication of prostate enlargement but the results must be considered carefully with respect to age and the possibility of prostate cancer. As you get older, the levels of PSA do rise so it can be difficult to be sure that this represents anything very nasty going on. Even so, a rise in PSA over a short period of say a year must be taken seriously especially if you have any symptoms of prostate disorder such as problems with passing water, blood in the urine or pain in the groin/back. It would be worth having the test repeated in six months.

The high cholesterol can be equally misleading as a single test. It is a bit like taking a photo of someone and they blink - obviously they don't walk around with their eyes shut all day. You need an average over a few months. The most accurate test is taken in the morning before you eat otherwise there is a natural rise in some of the fat components of the test. On top of that, the 'total cholesterol' is virtually useless as the ratio between high density cholesterol and low density cholesterol is more important. Keep the highs high and the lows low is the name of the game.

It may be possible to keep your levels correct with diet and exercise alone. It's worth talking to your GP, but remember that factors such as family history, diet, smoking and previous medical history are vital.

Lipitor and beer

Q . I am taking Lipitor for cholesterol control. I have had elevated enzyme levels for the last 5 blood tests. My doctor tells me to stop beer drinking completely. I did for 3 months but the levels stayed high. This last period I resumed drinking 5/6 or so beers a day and the enzyme levels actually decreased. Now I know that drinking 6 beers a day is not good but couldn' t Lipitor be the problem? I took Zocor for 3 years with no elevated enzyme levels.

A. Both Lipitor (atorvastatin) and Zocor (simvastatin) are very widely used drugs for the treatment of raised cholesterol. There is now an overwhelming weight of evidence which demonstrates that raised cholesterol (and, in particular, a fraction of cholesterol called low density lipoprotein i.e. LDL-cholesterol) is associated with significantly increased risk of cardiovascular disease particularly heart attack.

There is also now extremely good evidence that lowering cholesterol by using these statin agents is associated with significant reduction in risk of cardiovascular events such as heart attack. This is true for people who have previously had a heart attack and for high risk groups who have not yet had a cardiovascular event e.g. those who not only have raised cholesterol but have other risk factors such as cigarette smoking, diabetes and high blood pressure.

Although statin agents are normally extremely well tolerated, and are indeed amongst the most commonly prescribed drugs, occasional people taking these will notice muscle pain with an elevation of a muscle enzyme called creatine phosphokinase (CPK). I doubt, however, whether this is the enzyme to which your doctor is referring as I would expect a similar enzyme rise with Zocor which you took for three years with no elevated enzymes. 

I suspect that your GP is referring to your alcohol consumption which is associated with a rise in liver enzymes and nothing to do with statin treatment. Stopping alcohol intake for three months may not be sufficient to return these enzymes levels to normal. You mention resuming drinking five to six beers per day and having a decrease in enzyme levels. This is interesting but I think that you may be kidding yourself into assuming that this level of alcohol intake will cause you no problems. You do not mention whether your five to six beers per day is pints or half pints, but even if it is half pints it is still above the recommended levels for healthy drinking. If it is pints of beer per day then you really are asking for trouble.

I would strongly advise that you go and discuss these issues with your doctor and find out which enzyme levels he/she is referring to. If it is an elevation in your liver enzymes then you really should drastically reduce your alcohol intake or, even better, stop altogether. Even if the liver enzyme levels are not raised, drinking five or six beers per day is certainly not advisable and will do you damage long term. If it is the level of CPK which is raised then this might indicate a need to stop the statin treatment and take an alternative cholesterol lowering tablet although, as stated, it does not sound to me that this is the problem.

Blood pressure

Q . During the last 2-4 times I have had my blood pressure taken it has been a little high, 120/80. I'm not sure why it is. I have been exercising regularly for the past 2 years. Before I started exercising my pressure was 120/60. I drink about 4-8 cups of coffee about 3 days a week.

Also, my grandfather on my mother's side died from cancer. My grandmother on my father's side had borderline diabetes and died of congested heart failure. Are my chances of getting cancer high/diabetes high?

A. I would need to know your age, but 120/80 is not very high and would, for instance, be acceptable in a 50 year old man. You have, correctly, had your BP checked more than once. This is important as an average of around three readings are needed over a month or so. A single high reading is as meaningless as taking a photo of someone who happens to blink and then you conclude they walk around with their eyes shut all day. Similarly, the actual operation of taking a blood pressure tends to put it up, especially if you are waiting for a long time before being seen. It's called the 'white coat effect' although there can't be many GPs wearing white coats these days.

The fact you exercise regularly is singularly important and will pay great dividends later in life. Obesity is a big factor and you increase your risk by being significantly overweight. Smoking is a negative risk factor and will increase your risk from cancer, your other concern. A great deal depends on the age of your relatives when they suffered from heart failure or cancer. If it happened over the age of say 70 years then the risk factor from genetic inheritance is very small. If it occurred at around 45 years then it is much higher. Diabetes does run in families but if she was only borderline, weight reduction and exercise was probably all that was required. Generally I would say you are doing most things right to avoid heart disease if you are exercising, do not smoke, keep your weight in check and drink moderately. 

Tightening of heart

Q . I am experiencing a tightening of the heart; little 'jabs' of pain (not strong pain, but an 'awareness' that my hear is there!). My lungs also tighten. This occurs periodically, even when I am just sitting down, and dissappears after a few seconds.

I recently had a heart and blood pressure test, and I seem to be okay there. These symptoms have occured in previous years, usually with the coming of the cold weather. I also do drink rather too much (binges of a bottle or more of wine in an evening),although I don't know if there is a connection?

A. Us men should take any chest pain seriously. The heart usually gives us some warning that it is a tad fed up with the pay and conditions before withdrawing labour. At the same time this is it, so far as life is concerned, not a dress rehearsal, so we should enjoy it and not worry constantly about clogs for the popping of.

You describe short periods of pain with a 'tightening'. Generally the heart will complain most during exercise when oxygen demand is highest but thickened blood vessels limit it most. The pain is described as a crushing tightness, not the short episodes you comment on. You also describe 'lung tightness' but don't say if you are breathless. Serious heart disease will cause breathlessness especially when lying down. Not quite what you are experiencing. It sounds as though you have a heightened awareness of your heart when there are no distractions. Any serious heart problem will not be so considerate. On the other hand if you smoke, have a family history of heart disease or lead a very sedentary life it would be wise to change your lifestyle.

A bottle of wine per evening is on the high side but wine in moderation - a couple of glasses per day - is protective against heart disease. If this doesn't settle, you should see your GP.

Pain above sternum and heart burn

Q . I'm 44, and recently I have been suffering from bad heart burn, and pain above my sternum. Also continual awareness of heart beating and occasional sensation in my left arm. Would you be able to give me some advise on what the problem could be and what I should do about it. I have been suffering from alot of stress at work and wondered if this had anything to do with this.

A. Yes, heartburn is common with stress, especially if you are drinking too much alcohol and eating badly. Yes, it can produce all the symptoms you describe, even the pain in your arm and yes, it can sit just above your sternum.

Unfortunately, it can very easily be confused with heart pain. Thankfully the heart does tend to give us some warning when it is getting fed up with the pay and conditions before withdrawing labour. This can be in the form of breathlessness on exercise, swelling ankles or chest pain. It is usually, but not always, made worse on exercise. Stress is a big factor as is smoking. A family history of heart disease is also a big factor.

I strongly suggest you nip down to your GP straightaway and get checked over. If it is simply heartburn, then there is no harm done and you can write back in and call me a dolt. But if it is your heart complaining, early diagnosis makes all the difference. Meanwhile take one aspirin a day, unless you are taking any blood thinners such as Warfarin, but do not delay seeing your doctor. A happy heart is a happy worker. Please let me know how you get on.

Could this be angina?

Q . I sometimes get chest pains or dull feelings in the left side,arm & leg, usually as sharpe twinges, sometimes longer periods. noticable more when at rest. Is this likely to be angina.

A. Take chest pain seriously. We men are very bad at getting these things checked out. Having said that, the pains you describe do not sound like angina. The blood vessels which supply the heart with oxygen and nutrients can become gradually thickened with arteriosclerosis. This decreases the rate at which oxygen can be delivered to the heart muscle. You generally don't notice this until you need to do some vigorous exercise then the heart very quickly tells you to slow down. The pain is a central, often crushing kind of pain which can move up into your jaw, across to your left arm or even down into your abdomen. It generally disappears after a few minutes of rest. As the thickening gets worse so your tolerance to exercise decreases with more pain for less activity. Nitrates help keep the blood vessels open.

You describe something which is far more likely to be the chest wall muscles and is a form of cramp. Being inactive is a common link. Paradoxically being very active and lifting heavy weights all day can also cause these pains. If you find they disappear with a bit of stretching and motion then there is little cause for alarm. Even so, if you smoke, have any heart disease in the family, are often short of breath or get these pains when walking or climbing stairs, you should check it out with your GP.

Beta blockers causing depression

Q . Question for my dad (age 64) who has just had pace maker fitted and is also on beta blockers (sotalol). He is very depressed and, as I know beta blockers can cause depression, wondered whether there were any beta blockers on the market that don't have this side effect?

A. While mood changes may be a feature of beta blockers they are not always the cause of depression. It would be worth looking at your father's other drugs and his general lifestyle first before changing his medication. Simply going through the surgery involved in implanting the pacemaker can leave a temporary depression as the person feels much more vulnerable and dependent on the machine. All sorts of fears - often illogical, but nonetheless disturbing - can rise to the surface: Can they walk through a metal detector? (people often do without realising it as they can be hidden, but caution is the name of the game) What happens if the battery runs out suddenly? (it can't). Will using a microwave oven cause it to malfunction? (not unless they are sitting inside it). Reassurance and support are vital. If your father continues to be depressed you should discuss this with his GP.

Chances of heart problems?

Q . My father died of a heart attack aged 61. Didn't smoke or drink. I take a drink but don't smoke. What are my chances of having heart problems, and is it in the family. What preventative measures should I take?

A. There is certainly an inherited tendency to heart disease particularly if it occurs in one or both parents at a relatively young age. This is particularly the case with heart disease occurring in a father under the age of 50 years and a mother under the age of 60 years. I also note that your father did not smoke - smoking is a major risk factor for heart disease although alcohol in moderation is not.

Given that your father was relatively young when he died of a heart attack, it is advisable to discuss your concerns with your doctor and he/she may perform a "well man" assessment. This should include measurement of your blood pressure, cholesterol and a check to make sure you do not have diabetes. If you have any of these risk factors for heart disease then they should be treated.

Beyond this, it is important to lead an active and healthy lifestyle. This should include regular exercise which may be as simple as a brisk walk for 30 minutes every day, losing weight if you are overweight and avoidance of weight gain. It is vitally important not to smoke. Alcohol in moderation is not a risk factor for heart disease and provided you limit yourself to a maximum of 21 units of alcohol per week (1 unit equivalent to a small glass of wine, half a pint of beer or a single short) then this really should not be an issue. In addition, there is some evidence that alcohol in moderation (a unit per day) can actually help prevent heart attacks. This is one explanation for the "French paradox" i.e. why is it that the French who consume a high fat diet (but also a lot of red wine) have much reduced risk of heart problems compared with the UK population? This is an issue which remains controversial!

A healthy diet should contain a high proportion of calories as complex/unrefined carbohydrates (e.g. wholemeal bread, vegetables, fruit and high fibre cereal), avoiding as far as possible refined carbohydrate (i.e.cakes, sugar, sweets, biscuits, sugary cereals, sugary drinks etc.) and being careful with your intake of fat.

One other issue is that people of Asian extraction living in the UK do appear to have an increased risk of heart disease (as well as diabetes). In this population it is particularly important to follow the above advice about healthy lifestyle and getting a "well man" assessment to exclude the possibility of raised blood pressure and cholesterol and to screen for diabetes.

If you have no other risk factors or, if present, they are aggressively treated and you lead a healthy lifestyle this will significantly reduce your risks of a heart attack. Note that if you do have any of these risk factors clinical trials have shown conclusively that effective treatment will significantly reduce risk of cardiovascular disease.

What is an angiogram?

Q . I have been told by my doctor that I need to have a coronary angiogram to investigate the pain I get in my chest when I exert myself. What is this and is it dangerous?

A. People who suffer from angina experience chest pain on exertion and sometimes at rest and this is usually due to narrowing of the coronary arteries. In many cases the best form of treatment for this can only be determined by an investigation called a coronary angiogram. This is now very much a routine test done in hospital where a catheter is introduced in a groin or arm blood vessel and then through into the coronary arteries. Dye is then injected though the catheter, down the coronary arteries and x-ray pictures taken. This allows a good picture of all the coronary vessels and areas of narrowing/blockage can be detected. In this way a decision can be made as to whether an angioplasty or a coronary artery bypass graft could be helpful.

Sometimes coronary angiograms are also done if a person with known coronary disease is being considered for surgery, where angina is difficult to treat or worsening or if angina occurs after a heart attack.

In experienced hands, complication rates for this procedure are extremely low.

Drugs for angina

Q . I have angina and my doctor's prescribed beta-blockers, aspirin and a nitrate. What are these and what do they do?

A. There are now many drugs which are used to relieve the symptoms of angina (chest pain either at rest or on exertion, usually due to narrowing of the coronary arteries causing reduction of blood supply to the heart). These agents may not only relieve symptoms but may also reduce your risk of going on to develop a full blown heart attack. This is particularly true for low dose aspirin which prevents your blood platelets (vital for clotting) from clumping together. In addition, long acting nitrates widen coronary arteries and decrease the pressure inside the heart lessening the angina pain. You can also take a short acting nitrate in the form of a spray or tablet under the tongue which can be used at the onset of an angina attack. Beta-blockers reduce heart rate and force of contraction thereby reducing the amount of oxygen the heart needs when exercising so that angina pain is less likely to occur. 

Other agents which may be used include a calcium antagonist which reduces oxygen consumption of the heart and improves angina symptoms and a drug called an ACE inhibitor which can help protect the heart from further events such as heart attack and is also used in other situations such as to treat heart failure and high blood pressure.

There are several examples of each of the above agents so discuss these with your doctor and find out which drugs you are on and why.

Chest pain when climbing stairs

Q . I have been getting some discomfort in my chest on climbing hills. What should I do?

A. These symptoms should never be ignored. There are a number of reasons why people can get discomfort in the chest, but in all cases you need to see your doctor to get a full assessment, including heart trace (ECG). This may be normal at rest and frequently an exercise ECG may be required. By putting extra stress on the heart by an exercise test any abnormalities can commonly be picked up. An exercise ECG is normally done in a specialist cardiology centre in the local hospital. If it turns out that these symptoms are caused by angina, this is usually due to narrowing of the coronary blood vessels to the heart and needs attention. It usually involves further investigation together with drug treatment to relieve symptoms and sometimes the requirement for an angioplasty or even coronary artery bypass grafting.

Coronary artery bypass graft

Q . My doctor says I need a coronary artery bypass graft as my coronary arteries are very narrowed. What is involved?

A. This has now become very much a routine operation in major centres in the UK although it still involves major surgery. The operation is done under general anaesthetic where a blood vessel is removed from the leg or chest and then used to bypass the blockage. During the operation the heart is stopped and blood diverted using a special machine which continues pumping blood to all the vital organs. At the end of the procedure the heart is restarted. The death rate for the surgery is now extremely low and the operation provides relief from symptoms of angina in the great majority of cases and may also increase life expectancy. A proportion of the grafts are not as successful as one would hope and there may be a return of symptoms of angina. The operation is generally, however, very successful.

Angina and angioplasty

Q . I've been getting some chest pain on exertion (angina) and my specialist says that I may be helped by an angioplasty. What is this and how is it done?

A. This is a technique to widen a narrowed coronary artery (or arteries) using a tiny balloon on a catheter. This is introduced into the body though puncturing a blood vessel in the groin under local anaesthetic and then feeding the catheter though the heart into the narrowed coronary artery. When in the correct position, the balloon is inflated to widen the coronary artery. Several obstructions can often be dealt with at the same time. About a third of vessels dealt with in this way narrow again within the first six months after the procedure so that sometimes a tiny metal stent is inserted to stop the vessel from narrowing/closing. Angioplasty can be a very successful procedure reducing anginal symptoms significantly.

Angioplasty and panic attacks

Q . I HAVE JUST HAD AN ANGEOPLAST TWO WEEKS AGO AND AM EXPERIENCING SOME PANIC ATTACKS IS THIS USUAL

A. Angioplasty is a way of widening narrowed coronary arteries using a tiny balloon and a catheter. This is introduced into the body through puncturing a blood vessel in the groin under local anaesthetic and the passing the catheter through the heart into the narrowed artery. When in the correct position, the balloon inflated to widen the coronary artery. Since about the third of vessels dealt with in this way will narrow again in the first 6 months, sometimes a tiny metal stent is inserted to stop this happening. Angioplasty can be very successful by reducing symptoms of angina (chest pain due to poor blood supply to the heart) significantly.

It is not unusual to experience panic attacks after any medical/surgical procedure particularly those involving major organs such as the heart. I am afraid this is the kind of thing that reminds us of our own mortality and although this procedure is carried out in most cardiology centres on a routine daily basis and with a very low frequency of problems, for most people it is clearly a "nerve racking" experience. This is usually a great healer and I expect your symptoms will settle down. It would be worth, however, going to discuss these problems with your General Practitioner who hopefully will be able to reassure you but may in addition think it necessary to prescribe a mild tranquiliser short term. Angioplasty is a very safe procedure and commonly associated with excellent results.

Controlling blood pressure

Q . My GP tells me that it is very important to control my blood pressure. Why is this and how is it done?

A. Most people with raised blood pressure do not feel ill and often wonder why their GP wants to prescribe blood pressure lowering tablets. Unfortunately, high blood pressure (hypertension) is associated with a significantly increased risk of heart attack and, in particular, stroke. There is now very good evidence that lowering raised blood pressure will significantly protect against these problems.

There are a whole range of blood pressure treatments which can be used and sometimes several different types of blood pressure tablets may be required to get down to a suitable blood pressure level. It is important that everyone over the age of 35 has at least an annual check of their blood pressure. If it is borderline raised then more regular checks will need to be done. If significant hypertension is confirmed then treatment is necessary.

High lipids

Q . The practice nurse says that I have high lipids. What does this mean and do I need any treatment?

A. Lipids refer to fat levels in the blood, most importantly cholesterol. Everyone has fat in the blood but if these levels are raised then this significantly increases your risk of blood vessel disease (silting up of the arteries — arteriosclerosis) which may lead to heart attacks or stroke. It is now possible to do an overall cardiovascular assessment which takes into account your level of cholesterol, age sex and whether or not you have high blood pressure, smoke or have diabetes — this gives an overall risk of heart attack or stroke over the next 10 years and helps your doctor decide whether or not you should be on lipid lowering tablets.

The tablets normally fall into a class of agents which we call statins. Statins are extremely good at lowering blood cholesterol levels and have a protective effect against cardiovascular problems. It is sensible if you are a man over the age of 35, and particularly if you have a family history of heart disease, that you have your cholesterol checked. Indeed if one or both parents had heart trouble say below the age of 60 years then it is never too early to get your cholesterol checked.

Preventing heart attacks

Q . My father had a heart attack in his 40's. What can I do to prevent me having one?

A. There is certainly an inherited tendency to heart disease particularly if it occurs in one or both parents at a relatively young age. It is important that you go and discuss your concerns with your doctor and he/she may perform a “well man” assessment. This should include measurement of your blood pressure, cholesterol and a check to make sure that you do not have diabetes. If you have any of these risk factors for heart disease then they should be treated.

Beyond this, it is important to lead an active and healthy lifestyle. This should include regular exercise - which may be as simple as a brisk walk for 30 minutes every day - losing weight if you are overweight and avoidance of weight gain. It is vitally important not to smoke. Possession of one or more these risk factors together with your strong family history significantly increases your risk of heart disease. Your doctor can do an overall assessment of your likely risk of heart disease and advise you further on the appropriate actions to take.