Angiography at Wexham Park

At long last we have a local capability for carrying out angiograms. The Cardiology Department at Wexham has just commissioned its new facility although the official opening will not be until some time in the near future. Already over 100 patients have benefitted from the new service. Slough, unfortunately, provides a rich source of patients as it has the highest incidence of Coronary Heart Disease (CHD) in the south-east. This is due largely to the fact that ethic minority groups are four to five times more likely to develop CHD and it occurs at a younger age. There are also a fair number of Eastern Europeans in the area and they are all generally avid smokers, and therefore have a higher risk of developing CHD.

The new facility at Wexham is of course only for angiography; the angiograms produced are only a diagnostic tool. The equipment will show exactly the state of the heart and the coronary arteries and will guide staff to the best corrective treatment which will be carried out elsewhere - usually at the Brompton Hospital. In the fullness of time it is envisaged that the facility will be expanded so that further procedures will be possible. These might include angioplasty, the ballooning out of blocked arteries, the insertion of stents, small perforated tubes inserted into sites of blockage in coronary arteries, and insertion of pacemakers and defibrillators.

The angiography facility is integrated into the Coronary Care Unit at Wexham but has its own access. The Angiography Suite consists of the catheterisation room where the angiograms are done, a seven-bed ward for patients, since having an angiogram is a day procedure and the usual administration areas. The whole project cost £2.8 million with the cost of the imaging equipment coming from the National Lottery New Opportunities Fund. The equipment is state-of-the-art and is one of the first of its type worldwide. It will be used as a Reference Unit for training and technological development.

The Angiography Suite is expected to carry out up to about 750 coronary angiograms each year and it is clear that the addition of this facilty will significantly reduce the waiting time for getting proper diagnoses. As many of will no doubt remember, it is the waiting and the "not knowing" which can be the worst part!

By-pass surgery through the keyhole!

"Having successfully completed Phase III of my cardiac rehabilitation course at the Windsor Leisure Centre, I have now joined THROB for the next phase at the Carnation Hall in Winkfield.

I gather from your Magazine Editor, that I am possibly the first recruit who underwent an 'endoscopic coronary artery by-pass'at the end of April this year and it is for this reason he has asked me to write this article. Whilst on holiday in 2003 with my family, walking the coastal footpaths, I became short of breath and was subsequently diagnosed by the Brompton Hospital to have blocked arteries. Initially I thought the problem might have been connected to angina, but how wrong can you be. My surgeon explained, whilst conducting his angiogram examination, what the problem was and what he proposed to do about it. He explained that because I was reasonably fit, not over-weight; not a smoker and that I had not had a heart attack that it would be six months before he could undertake the operation. True to his word I was called in and within six days released. From the first time I met my surgeon, Mr. De Souza, I knew I was in excellent hands. His confidence was passed onto me and the whole episode was, so far as I was concerned, plain sailing.

The endoscopic coronary artery by-pass is carried out by making an incision of about 100mm just below the left nipple and two small holes on the left hand side, just below the ribcage. Using minute equipment the surgeon clears the blockages, and in my case attached an overworked artery to one of the other arteries which he had cleared. My breathing difficulties have now completely disappeared and all I have to show for it is one small scar and evidence of two puncture incisions. I must say what a wonderful hospital The Brompton is and how very professional all the doctors and nursing staff were.

Since undertaking the Phase III course at Windsor, I realise how lucky I was to have this new state of the art key-hole surgery operation and not what many of you have had - the conventional 'zip fastener and vein operation'. I am now back at work, albeit on restricted hours, and thanks to the circuit training programme very fit and healthy. I look forward to continuing in this way for a long time to come.

Anthony Stevens.

Miracle drug on the way?

According to an article in a recent issue of The British Journal of Cardiology, a new drug is currently being trialled that could cause a revolution in cardiac care and could truly be called a miracle drug. Claims are made that the pill will reduce weight, assist with smoking cessation, improve cholesterol profiles and reduce insulin sensitivity (a known precursor to diabetes). The drug, called Rimonabant has been trialled in two centres- one concentrating on weight loss the other on smoking cessation.

In the weight-loss trial in Canada 1,036 overweight or obese patients , all following a calorie controlled diet, were randomly given either rimonabant 5mg or rimonabant 20mg or a placebo tablet for one year. Patients in the 20mg group lost significantly more weight than those on placebo and experienced significant positive changes in weight measurement reduction, increased high density lipoprotein ( the good stuff) reduced low density lipoprotein ( the bad stuff) and reduced insulin sensitivity. Those patient diagnosed as having Metabolic Syndrome (a cluster of risks associated with the onset of Coronary Heart Disease) at the start of the trial was 52.9% and this reduced to 25.8% with Rimonabant. The drug was said to be well tolerated with the most frequent side effect reported as nausea (12.7%) and dizziness (10.4%) in the 20mg group. Interestingly drop-out rates due to ""side effects" were 7% for placebo and 8.4% for Rimonabant.

In the Smoking Cessation Trial in Cincinnati US there were 787 smokers who were motivated to quit but had failed on average on 4 previous occasions. The smoked on average 23 cigarettes a day and were randomly allocated to 20mg or 5mg of Rimonabant or placebo tablet. Results showed that those in the 20mg group had nearly double the success rate with 36.2% quitting compared to 20% treated with placebo. On average patients also loss weight on the drug while those on placebo gained weight.

There is still much work to be done on the drug and it is predicted that it would not be available until 2006 at the earliest but it points the way to a future when many drugs will have "combination effects" reducing the need to take handfuls of tablets. Nevertheless it is helpful to remind ourselves that lifestyle measures of diet and exercise to reduce obesity remain the most sensible way of tackling this increasingly worrying risk factor.

Lesley Richards

Changing World ?

How old are we really? It's no good taking into account peoples looks today. On the television the actors and actresses look for the most part a lot younger than they are. With all sorts of body skin and parts being changed by private clinics this encourages people to look better. This would according to many experts to be anti-ageing effect through feeling and looking young, but is this true? Apparently not, because I have been told that the ageing process comes in two parts. They are your chronological age and biological age they are not always the same. The amount of oxidative damage to your cells can be measured by what's called a "biological terrain test" giving a redox value of your blood. This in effect measures those free radicals, the rogue molecules that do so much damage. Genetically you are made in a certain way but your body is a machine and how you look after it can to some extent determine how well you age. We are a bit like an old car or bike that over a period of use has developed various faults. You can repaint the body work and perhaps make it look good but we all know that what's under the body work will determine how well it will run. which In the end we all get sent to the scrap heap, the damage being sadly irreversible at that point in time. New research will in time enable homo sapiens to live longer. This could bring new problems. Imagine, instead of having only a couple of grand children having perhaps two hundred in all grand-, great-grand, great-great-grand, great-great-great grand children. Just how would you remember all the birthday dates and what you gave each one last year so you don't send the same present twice!

Brian Barrett

Annual THROB Lecture (Draft)

The Seventh Annual THROB Lecture was given by Lesley Richards and was entitled "The National Service Framework - so what's in it for me?" It soon became apparent to us older persons that it had nothing to do with the military or conscription but was in fact a framework for giving an acceptable health service across the nation. Lesley started by reminding her audience what it was like to go to their General Practitioner in the days of their youth. GPs were very autonomous, each had his own way of dealing with a particular ailment and often took time to seek further help on your behalf. Over the past 30 years or so more flexibility was introduced by the formation of Group Practices but it has only been since the Information Technology explosion of the 1990s that there have been significant changes to GP services. The government suggested that a new system be introduced which would be research based and offer the best possible treatment for each disease based on that research. This has become Known as ôevidence-based medicineö and to this end the National Institute for Clinical Excellence (NICE) was set up - to kitemark treatments as it were. This resulted in GPs being given guidelines and protocols for treatments. The government were also looking hard at disease prevention and produced the inevitable White Papers, the 1997 one "Our Healthier Nation", leading eventually to the publication of the National Service Frameworks - one for each of many key areas such as coronary heart disease (CHD) cancer and diabetes. In the case of CHD there is already evidence of improvement of service in that the target for giving a heart attack patient a clot-busting drug is set as within 30 minutes of arrival at hospital and whereas only 40% of patients were within this target prior to the NSF, the figure has now improved to 80%. This is but one example but the NSF deals with every aspect in the patient pathway, ambulance, reception, assessment, diagnosis etc., right through to rehabilitation.

The implementation of the new frameworks has been assisted by the introduction of new GP contracts which came into effect in April 2004. Each surgery can earn "points" for the treatments they provide which will eventually be turned into money by the local Primary Care Trust to supplement the basic payment given to GP Practices. Quite literally points mean prizes. As an example, the new contract states that a patient should be offered an appointment to see a doctor within two days. Of particular interest to members of THROB is the fact that all cardiac patients should be put on to a register, seen on an annual basis and given a blood test, a blood pressure (BP) check and their smoking status reviewed. These checks may be done at times of surgery visits for other problems or one will be invited to a clinic run by the Practice Nurse. In the latter case the examination and the advice given may be more than is required by the new contract but the Practice does not earn points for health promotion advice of any sort under the terms of the GP contract. The NSF however does stipulate health promotion advice so it can be seen that there are still ôgapsö between what GPs offer and the NSF idealö. Surprisingly, this also extends to the giving of an ECG. If as a result of your monitoring, you fail to meet the targets set for parameters such as BP and Cholesterol you may be offered drug treatment although the individual has the choice of accepting this treatment or not. The current CHD recommended drugs are Aspirin, Beta-blockers, ACE Inhibitors and Statins although not all patients will require all drugs.

The object of this new Framework and the new GP contract is to provide equality of healthcare across the Nation - it doesn't matter where you live or which surgery you choose. There are dangers and drawbacks as in many things today. Lesley pointed out that the new system can be more stressful for surgery staff, that doctors have lost some of their autonomy which may upset some GPs, that it could lead to a culture of "box ticking" which would lead to a loss of quality of care and that the system is open to small bits of cheating if "points" are to be maximised. There is also a problem with what is known as inappropriate intervention but this is meant to be covered by exception reporting which will still earn the practice its points. A good example was quoted - the decision not to give the 101-year old patient a full cardiac review and lots of new drugs.

In summary, Lesley said that CHD care is now structured, organised and evidence-based and GPs are rewarded for good care. The experience and opinion of the patient will be taken into account and prevention of any further deterioration in the health of the individual will be given the highest priority.