THE NINTH ANNUAL THROB LECTURE

This year's lecture was given by Lesley Richards, the Community Cardiac Liaison Nurse for the Windsor and Maidenhead Primary Care Trust and dealt with the Angina Plan, a home based scheme for treatment of angina sufferers. THROB has a vested interest in this scheme in that it has provided the books and compact discs which are an integral part of the plan. We are also glad to see something being done at last for people with angina since we have been muttering about plugging this gap in cardiac care for the at least the last ten years! Here we have a new initiative - one which has been developed by Professor Bob Lewin of York University, locally road-tested by Slough PCT, found to be very beneficial and which is not vastly expensive. In essence, the Angina Plan provides for a facilitator to visit the patient in their own home and guides them through a programme aided by a manual and CDs. Lesley Richards has now had all the necessary facilitator training and has just begun to see patients referred to her by Wexham Park Hospital's Rapid Access Chest Pain Clinic. Patients may also be referred by local General Practitioners. The Plan extends for a period of 12 weeks starting with a 30 minute initial interview to introduce the manual and CDs to the patient, and three further interviews are conducted during the program to assess progress and deal with any problems arising. The initial interview makes use of a questionnaire to find out the patient's perceptions of angina and its treatment. It also deals with risk factors, introduces the relaxation component (CDs), considers pacing and sets goals. Goal setting and pacing is a fundamental principle of the Angina Plan. One needs to get away from behaviour governed by "good days and bad days", plan activities and stick to the plan.

The Plan adopts a "cognitive-behavioural" approach to managing angina. Lesley explained this baffling term quite simply as "cognative", meaning thinking, will if repeated continually, lead to belief, which in turn guides behaviour. The patient uses the self-help manual to educate themselves which reduces the symptoms and also reduces the dependancy on drugs. While there has never been correlation between the degree of blockage of coronary arteries and angina there does appear to be correlation between beliefs and the management of angina. To control angina one needs to slow down, breathe correctly and control ones thinking. The risk factors are of course the same as for all cardiac conditions - diet, cholesterol level, blood pressure, smoking - all items which need to be controlled.

The Angina Plan answers many questions about the condition and how it affects one's life. Its strength lies in part, to the fact that it is patient led and not health professional led. Learning to alter the thinking processes that may be restricting the patient in their activities, subsequently altering their behaviour, will enable them to better manage their angina thus preventing the progression to a heart attack.

David Read

ANGINA - A DANGER TO WOMEN

Angina is a form of heart disease that affects almost two million people in the UK and according to recent research is more prevalent among women than previously thought. Scientists studying some 100,000 patients aged 45 to 89, said that doctors should pay more attention to investigating and diagnosing patients, especially women who have symptoms of the condition. Work at University College, London, found that each year two women out of every 100 develop angina as the first sign of heart disease - almost as many as men. Many researchers had assumed that many more men than women suffered from the condition mainly because most studies have been carried out on heart attack victims in hospital who are predominantly male. The study found that diagnosing angina in women is more difficult and is not as frequently confirmed with tests, such as angiograms or treadmill exercise cardiograms, as it is in men. It was also concluded that angina in women was linked to higher death rates.

Angina can be brought on by exercise, cold and emotional stress. It is more likely to occur in older people, smokers and those who have high blood pressure, high cholesterol, diabetes, obesity or a family history of heart disease. The British Heart Foundation commented that as women tend to be protected from angina until after the menopause, it has traditionally been thought of as a predominantly male disease. This study confirms that after the age of 45 years, women get as much angina as men, but worryingly, then tend to fare much worse than men when they get it.

NEW HEART DRUG

A new drug in the statin family has been developed which will actually reduce the clogging of arteries - a discovery which could prevent heart attacks and strokes. Results of trials have shown that the drug, rosuvastatin, given in high doses to patients with mild heart disease, reduced the build-up of fatty deposits in the arteries (atheroma), by up to nine per cent. Atherosclerosis is the build-up of fatty plaques in the arteries which reduces blood flow to vital organs. Eventually the plaque can rupture, leading to blockages of arteries which in turn can cause a heart attack or stroke. Atherosclerosis is believed to affect about two million people in the UK producing about a quarter of a million heart attacks, a third of which are immediately fatal.

As arteries tend to narrow with age, two years of taking the drug may have the effect of making a narrowed artery three or four years "younger". Ten years of taking the drug could reduce the "age" of the artery by 12 to 15 years. The Royal Infirmary in Edinburgh contributed to the international studies which have been ongoing and while the drug is licensed as a cholesterol lowering drug it is not cleared for the treatment of atherosclerosis. In the latest study 349 patients were given 40mg daily of the drug over a two year period, the maximum licensed amount. The drug was found to significantly reduce bad cholesterol and at the same time increase the good cholesterol.

The British Heart Foundation were cautious in their response to the news, saying that while the results were promising and are likely to translate into a better outcome for heart patients, further studies were required to confirm that fewer heart attacks would occur.

STROKE IDENTIFICATION

During a BBQ a friend stumbled and took a little fall; she assured everyone that she was fine (even after they had offered to call paramedics) and she had just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food; while she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening. Ingrid's husband called later telling everyone that his wife had been taken to the hospital on the next day and at 6:00pm, Ingrid passed away. She had suffered a stroke at the BBQ; had they known how to identify the signs of a stroke perhaps Ingrid would be with us today.

Recognizing a Stroke

A neurologist says that if he can get to a stroke victim within three hours, he can totally reverse the effects of a stroke. He said the trick was getting a stroke recognized, diagnosed and getting to the patient within three hours, which is tough. Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer brain damage when people nearby fail to recognize the symptoms of a stroke.

Now doctors say a bystander can recognize a stroke by asking three simple questions,

1. Ask the individual to SMILE

2. Ask him or her to RAISE BOTH ARMS.

3. Ask the person to SPEAK A SIMPLE SENTENCE coherently (i.e. it is sunny out today).

If he or she has any trouble with any of these tasks, call 999 immediately and describe the symptoms to the dispatcher.

After discovering that a group of non-medical volunteers could identify facial weakness and speech problems, researchers urged the general public to learn the three questions. They presented their conclusion at the American Stroke Association's annual meeting last February. Widespread use of this test could result in prompt diagnosis and treatment of the stroke and prevent brain damage.

( I am indebted to Russell Preston for bringing this important item to our attention. Ed.)

EXERCISE ROUND-UP

Aerobic exercise is physical activity which uses the large muscles of the body (mainly the arms and legs) in continuous exercise of moderate intensity. Walking, jogging, swimming, cycling and supervised exercise sessions, such as aerobic dance classes, step classes or circuit training, all fall into this group. Individuals who undertake regular bouts of aerobic exercise (as opposed to other types of activity such as strength training e.g. weight lifting) are less likely to develop coronary heart disease and for those who have already had a heart attack or undergone surgery, aerobic exercise training has been shown to reduce symptoms and mortality. A recent review of exercise-based cardiac rehabilitation studies looked at 51 separate scientific trials covering a total of 8440 patients and the analysis revealed a reduction in cardiac mortality of 31% for patients who exercised compared with those who did not. (Taylor et al,2004 American Journal of Medicine)

So how much exercise are we talking about for these benefits to be realised? The general consensus of expert opinion is that the chosen aerobic activity needs to 'burn' at least 1000-1500 kilocalories of energy per week and ideally should represent 2000 kilocalories of energy expenditure per week! And what does 'burning' 1500 kilocalories per week involve? The number of kilocalories an activity uses up depends upon several things, firstly the weight of the person performing the activity, secondly, for how long it is done, and finally, how vigorously it is performed. The table shows that for the most popular aerobic activities the approximate number of kilocalories 'burnt' each minute depending on body weight. Of the activities shown, the most accurate predictions of energy expended are those for cycling or walking. This is because they permit an exact speed to be adopted and maintained. In most other activities, especially dancing and circuit training, the vigour of the movements and consequently the amount of energy used, will vary depending on which type of dance or which activity in the circuit is being performed.

So what does all this mean in practice? For instance, how far or for how long do you have to walk to use 1500 kilocalories per week? If you look under the column which is closest to your weight and then come down to where it meets the row for the activity which interests you, it shows the approximate number of kilocalories you would be using per minute. Dividing 1500 by that number tells you for how many minutes you will need to exercise. For example, someone who weighs 62 kilograms and walks at 3 mph, which is a brisk but comfortable pace for most people, will be using 5 kilocalories per minute; 1500 divided by 5 is 300 minutes or 5 hours and at 3 mph is a distance of 15 miles. You will see that someone who walks at the same speed but who weighs 86 kilograms expends not 5 but 7 kilocalories per minute. In the case of the heavier individual 1500 kilocalories will be expended after just 3 hours 34 minutes of walking (a distance of 10.7 miles) because that individual is expending more energy to support his extra body mass.

The length of time required to expend 1500 kilocalories also depends on the intensity of the exercise that can be safely tolerated. The table indicates that, on average, circuit training and swimming expend twice the number of kilocalories per minute as walking at 3 mph – in other words they are more vigorous activities. Someone who attains their target heart rate and rating of perceived exertion of between 3 and 5 on the Rating of Perceived Exertion (see small table) when walking at 3 mph will need to exercise for 5 hours at that intensity to expend 1500 kilocalories. In contrast someone who can perform more vigorous exercise e.g. breast stroke swimming, will need to swim for only 2 hours 46 minutes to achieve a total expenditure of 1500 kilocalories.

Of course, you don't have to do just one type of exercise - you can 'mix and match'. If, for instance, you are coming to one of the THROB classes you will be doing about 25 minutes of circuit training. Someone who weighs 68 kilograms and performs 25 minutes of continuous aerobic activity (rather than interspersing the aerobic work with muscle exercises) will expend about 285 kilocalories (11.4 kilocalories/minute for 25 minutes). In actual fact, when the warm-up time is added to the circuit time the total energy expenditure will be greater, maybe another 75-100 kilocalories. When 285 is deducted from the weekly target of 1500 kilocalories there remains 1200 kilocalories for other activities. Three and a half hours walking at 3 mph would use a further 1155 kilocalories and a spot of ballroom dancing on Saturday night would put you in credit against the following week's 1500 kilocalories!

Although the idea of investing about 5 hours of time and effort each week in one form of activity or another must seem daunting to those who are currently not very active, the return on that investment will be high. People who are active tend to have a more positive outlook on life, have a better self image and find that sleep and relaxation is improved. But for those with heart disease, the biggest motivation is obviously the contribution which exercise makes to a longer and symptom free life. Just remember the following maxims:

Be realistic - Always set yourself an achievable target - if walking is your chosen activity, half a mile to a mile at a steady pace is a good starting point from which you can gradually increase the distance and, therefore, the kilocalories expended.

Be adventurous - Consider trying activities other than walking e.g. cycling or swimming or one of the circuit classes organised by THROB. Variety really does make exercise more enjoyable.

Be prepared - Always warm-up before you exercise. That may simply involve walking slowly to begin with before speeding up or doing the sort of comprehensive warm-up which is done in class. But NEVER go straight into vigorous exercise without doing some gentler movements first.

Be aware - Learn to monitor your response to exercise – all exercisers should be familiar with the rating of perceived exertion scales developed by Borg and widely used in leisure centre and hospital based classes. As your fitness level increases, the activity should start to feel easier and you will be able to increase the duration and/or intensity of what you are doing. However, if you are exercising regularly and find that what you are used to doing is leaving you more breathless than before or if you start to get any chest pain which you did not get previously, seek the advice of your G.P., Phase IV instructor or rehabilitation specialist.

Be convinced - There is a large amount of evidence which demonstrates that increased activity is as crucial to long-term recovery from heart disease as reducing high cholesterol, high blood pressure and quitting smoking. But, unlike high cholesterol, high blood pressure, and smoking, inactivity cannot be even partially solved by tablets or patches. It is very much up to you. THROB and all the instructors who have received specialist Phase IV training to enable them to prescribe effective exercise programmes for cardiac clients are there to offer you the support, advice and encouragement that you may need to get started or for those whose good habits may have lapsed, restarted!!

Kilocalories per minute for various activities and body weights

Activity Weight

56 kilos 62 kilos 68 kilos 74 kilos 80 kilos 86 kilos

8 st 11 9 st 10 10 st 10 11 st 9 12 st 8 13 st 7

Cycling

5.5 rnph 3.6 4.0 4.4 4.8 5.2 5.6

9+ mph 5.6 6.2 6.8 7.4 8.0 8.6

Walking

2 mph 2.5 2.7 3.0 3.3 3.5 3.8

3 mph 4.5 5.0 5.5 6.0 6.5 7.0

Swimming

Breast stroke 9.0 10.0 11.0 12.0 13.0 14.0

Tread water 3.5 3.8 4.2 4.6 5.0 5.4

Dancing

Ballroom 2.9 3,2 3.5 3.8 4.1 4.4

Circuits 9.4 10.4 11.4 12.4 13.4 14.4

Rating of Perceived Exertion

0 Nothing at all

1 Very, very weak

2 Weak

3 Moderate

4 Somewhat strong

5 Strong

6

7 Very strong

8

9

10 Maximum effort

Jenny Bell