THE THROB LECTURE

The eleventh annual THROB lecture was given as a two part presentation by Dr. Jenny Bell and Kevin Johnson. Jenny Bell recounted the origins and early development of the British Association for Cardiac Rehabilitation (BACR) and THROB's involvement in it, while Kevin Johnson dealt with current efforts for improvement in community health, again with assistance from THROB in some areas. Jenny, who was doing research into the use of exercise in cardiac rehabilitation in the early 1990s, joined the Heatherwood cardiac nurse, Lesley Richards, in the weekly exercise sessions for those people then in their Phase IV classes - only it wasn't called Phase IV since the BACR hadn't then been invented! Eventually Jenny took over the running of some classes as new classes were formed by increasing demand.

Jenny started her presentation by pointing out that THROB had been inspiration for getting exercise into the local communities of East Berkshire. Cardiac Rehabilitation was still in its infancy and only offered by a handful of Health Authorities . The principles of general improvement in lifestyle were being taught but the role and extent of exercise was still developing.

The BACR was formed in 1993 and published its Guidelines for Cardiac Rehabilitation in 1995 with the exercise section prepared by Jenny based in part on her work with THROB. The complete guidelines were the result of a meeting of minds, the main ones being the Brompton Hospital, Loughborough Universty,(who specialise in Physical Exercise), Dr. Bethell who started the BACR, and our own Lesley Richards. The latter, together with Pauline Wallace, were already running Phase III and IV classes at Heatherwood and Wexham respectively, and Jenny pulled together the roles of the cardiac clinician and the exercise physiologist in the content of these classes. Jenny said that THROB had acted as a catalyst in this marrying together of the two disciplines. She pointed out that exercise needs a prescription in parallel with a medicinal prescription after a cardiac event, spelling out what exercise, how much, how to administer it safely and pointing out that it is a 'repeat prescription' for the rest of the patient's life . Much of this prescription in the BACR guidelines was based on the THROB classes then running in the Red Cross hut at Heatherwood where principles of warm-up/cooldown and the adaption of exercise to cover varying physical abilities were worked out.

In 1997 Jenny got a grant from the British Heart Foundation to run a pilot training session for Class Instructors which would lead to a certified qualification in cardiac rehabilitation exercise. This pilot was held at the Holiday Inn, Maidenhead with co-operation from the Hotel Manager who just happened to be a THROB member............... In 1999 THROB also assisted the BACR in the production of a video which would accompany future editions of the BACR Training Manual . BACR courses have provided training for over 2000 instructors coming not only from the UK but also Spain, Greece, Portugal and even the Falkland Islands! Comprehensive courses are provided for instructors but there are other courses run for the benefit of health professionals and for Physical Training Instructors.

Jenny concluded her part of the presentation by saying how delighted she was that Cardiac Rehabilitation was flourishing in East Berkshire but ended on a sombre note pointing out that more than 60% of cardiac patients in the UK still do not get offered rehabilitation as we know it.

Kevin then gave a short account of other community health initiatives which have been developed over the last decade responding to the need across the entire age range. 4F - Family, Fun, Food, Fitness is aimed specifically at families with children aged from 5 to 12 years and trying to prevent drop out as the children go through their teens. Then at the other end of the age spectrum there is SMILE - So Much Improvement with a Little Effort. More recently attention has been focussed on pulmonary rehabilitation we are just about to see the start of My Action, a service to angina sufferers.

David Read

HEALTHY EATING

Eating steamed broccoli reduces the risk of a heart attack by boosting the body's ability to fight off cell damage, it has been found. Previous studies showed that people who eat broccoli, especially if raw or lightly cooked, are at lower risk of heart disease and some cancers. Now scientists have found a clear link between high levels of'certain substances found in the vegetable and reduced damage caused by hearts being deprived of oxygen. Normal biological processes associated with eating and breathing lead to the generation of highly reactive chemicals called free radicals. Excessive production of free radicals can harm cells and even trigger cancers. Damage of this type is known to accumulate with age. The brassica family of vegetables including cauliflower, broccoli, cabbage and Brussels sprouts, provide antioxidants that prevent the build-up of free radicals. Broccoli in particular contains sulforaphane, which triggers production of proteins that are part of the body's cardiovascular defence system.

Eating nuts about twice a week can decrease the risk of developing heart disease by a significant amount. Only two servings a week of eight grams of nuts, enough to cover a small plate can reduce the risk by as much as 11 per cent, according to a study presented to the World Congress of Cardiology. Almonds, walnuts, cashews and brazil nuts were included in the study, as well as peanuts, which are legumes. Surprisingly, eating a small amount of nuts five days a week led to only 'minimal' weight gain, another survey showed. The new nut analysis is part of a huge European study started nearly 10 years ago which is looking into the links between diet and cancer and heart disease. Don't run away with the idea that you can sit in front of the TV swilling gin and eating nuts to protect your heart - all the rest of the lifestyle changes still apply!

New evidence has been published to support the old adage that an apple a day keeps the doctor away. Adults who consume apples, apple juice and apple sauce have a significantly reduced risk of health problems linked to numerous chronic conditions such as diabetes and heart disease. The results were derived from an analysis of adult food consumption data collected In the 1999-2004 National Health and Nutrition Examination Survey, the US government's largest food consumption and health database. They were analysed in a project funded by the US Apple Association. Well they would say that then..................wouldn't they!

David Read

CHOLESTEROL LEVELS, HIGH BLOOD PRESSURE AND VASCULAR MORTALITY

A Patient Oriented Evidence that Matters study otherwise known as POEM (don't you love some of the medical acronyms?) has analysed data on 900,000 patients in 61 different studies to establish whether raised cholesterol levels and high blood pressure are associated with an increase in vascular mortality.

The result of this investigation reinforces what is already known, that higher cho1esterol levels and high blood pressure are associated with an increased risk of vascular mortality. There is a caveat that this study does not actually tell us that lowering cholesterol levels and blood pressure will prevent deaths, but, for THROB members, it would seem prudent to carry on taking whatever medication we have been prescribed to reduce both cholesterol and blood pressure.

Roger Mills

GOOD NEWS

The Department of Health has recently issued a report which shows that the target of reducing deaths from cardiovascular disease for people under 75 by 40 per cent has been reached five years early. They believe that this is primarily due to doubling the number of prescriptions written for statins, though accept that there are other factors involved as well, such as the increase in thrombolysis of heart attack patients and a drastic reduction in waiting times for heart surgery. This probably explains why I am one of the youngest members of my Friday morning class!

Roger Mills

AFFAIRS OF THE HEART - A CASE STUDY

This story all began in August 2003 when my wife and I along with two of our very good friends went to Edinburgh for the weekend to see the Tattoo. Upon our arrival at Waverley I had to pull our suitcase which had a wonky wheel along the platform quite a long way. After that I then had to carry this dodgy case up a flight of stairs to cross the rail tracks.When I got to the top I found myself gasping for breath and apparently I went "ashen". Our friend who was with us is a nurse knew that I was not having a heart attack, however I quickly recovered and we went on our way. A few days later I was in the GPs consulting chambers and then a referral to the Cardiac Clinic at Windsor, I also had to go to Wexham for a scan, the outcome of which was to have an Angiogram at the Brompton. A few weeks later there we were at 0730 hours at the Brompton ready for something to be poked up into my body via the groin area. The feedback I got from the Angiogram was "heart" lifting, I was told they did not think I would require surgery. This proved to be not the case, as when I next went to the Cardiac Clinic at Windsor a different story was told.

It would appear the "governor" a Professor Fox (who I have never met) had looked at the films and concluded that matters were not right and I should be offered surgery. It was explained to me that at my age and condition there was a 96% success rate and at the other end of the scale the risk of heart attack would increase with age. In effect like a window of opportunity which was starting to close. So I agreed, the next step is to be referred to a Surgeon at the Brompton.

It has now got round to March 2004 and it was decided I would have a triple by-pass and a replacement Aortic Valve which would be a "Pigs Valve". I have to admit I left the Brompton a little shaken at the thought of being opened up to quite a considerable extent. I was also told the job would be done in approximately 6 months time. The next thing to happen was a home visit from a Cardiac Nurse who went through the whole process in detail, giving advice on self preparation etc. We also attended a Seminar at Wexham where human heart valves were available for inspection , also a model heart with a demonstration of it being opened up and valves being replaced. No punches were pulled just facts of what was going to happen to me and others. I also agreed to take part in a research programme sponsored by the British Heart Foundation, this took the form of two groups, one to have regular visits by a Cardiac Nurse, where you could ask for advice about ones impending surgery and of course one was checked over. I found myself in the other group which was where the visit consisted of being weighed, blood samples being taken, but no advice could be sought. The purpose of the research was to determine if it was best to leave people to their own devices prior to surgery, or to have regular advisory visits. Both groups had to fill in quite lengthy questionnaires following each visit. I have no idea of the conclusion of this research as it is still ongoing.

Sunday October 10th was the day for being admitted to the Brompton where I was given a bed and forms to fill in. I was then given an electric shaver and two disposable heads and told to shave the chest and both legs and arms, this is to enable a choice where the veins would be taken from. I was also amazed as to how much hair I got from these regions During the course of the evening I had a visit from the Surgeon who was going to do the business. He also wanted to make sure I understood the risks and benefits and emphasised the risk of the 4% which had more than a sobering effect on me.

I am now starting to get very frightened. I donned the "Gown" and was told to get into bed. I am taken, still in the bed, to the operating theatre, where somebody confirmed that the tags on my wrists referred to me, I then disappeared into total oblivion and beyond.

The next thing I knew was coming round in the Intensive Care Unit, Lord above knows how many hours later or what day it was, I had a mask on and was given a sip of water with a straw via a hole in the side of this mask. My first thoughts were "you have cracked this Bousher" and I then realised the 4% no longer applied and I felt the emotion of elation.

I now start to come to my senses and I realised I had a cluster of tubes coming out of my neck, wires coming out of chest and of course a catheter. The tubes were for putting stuff in and taking stuff out and were colour coded, presumably these tubes went to different locations. Now the day after surgery is known as "day one" and the "home plan" is put in place and day six (Sunday) was my target "home day", this meant that certain tasks like removing things from my body and self sufficiency for oxygen intake and so on had to be achieved. Days two and three were for resting up, and the start of the removal of some tubes - the first item to be removed from my body was the catheter. I was however amazed how much tubing came out of me during the removal process which was not unpleasant. The next thing to be removed was the automatic dosing equipment for Morphine. Having been given a manual button to push for Morphine, I had to push it once just to try it!! On day three I had to have a "supervised" shower after which I was moved back to the ward where I started.

Round about this time the Physiotherapists appear on the scene, these ladies are very forceful and determined and having seen some of the antics of some patients I can see why. They are part of the "home" process and they have to get one mobile. As oxygen intake is but one reason, they show you a route to walk around the wards and by the time day four has ended one has to have gone up and down two flights of stairs unaided and without getting out of breath, of course one can only do this under supervision.

Day 4 sees the removal of the cluster of tubes, I think there were eight in number, any pain killers were now given orally along with other tablets. The wires in my chest were the last items to be removed, fortunately they never had a need to use them.

Day 5 is the day before home day and one is starting to get a little excited and you are still being constantly checked that oxygen intake levels are up to snuff., as one is now, to a very large extent, on one's own.

Day 6 (Sunday) is the only day of the week a cooked breakfast is served - which went down very well. The morning soon went and after the lunch rest period my family had turned out in force to collect me. I was given pills and potions to start me off and we all departed from the Brompton Hospital, with me being a very happy man.

I cannot praise the Surgical and Nursing Staff of the Brompton enough, they were brilliant, very professional and caring, what I was told would happen did happen. You often hear many complaints about the NHS but all I can say is I had top class service and the Brompton is to be commended. The follow up treatment I have received and continue to receive is also top class.

Alan Bousher