HAPPY CHRISTMAS!

You may think I'm being a bit premature but this is the last issue before the 25th December and anyway, THROB has decided to give all the Ordinary Members a Christmas present this year. As an ordinary sub-paying member you should have found a DVD in your envelope, a DVD which has been purchased at very reasonable cost from the British Heart Foundation by our very astute Treasurer. Personally, I was quite impressed by it. The idea behind it, as far as THROB is concerned, is that it has something in it for heart patients old and new - a reminder for those who suffered many years ago, who might need to polish up their lifestyle and a comfort for those who are still unsettled by recent cardiac events. What we would like you to do is to pass it on to anyone who you think might benefit from it. It will be given to all new members of THROB automatically in future.

The DVD is entitled "Looking Forward - Life after a Heart Attack" and consists of two main parts preceeded by a short Introduction by Professor Bob Lewin who was a pioneer in Cardiac Rehabilitation. The first section of the DVD covers all the main aspects of Cardiac Heart Disease, its treatment and consequences:

- What is a Heart Attack?

- Hospital tests

- Treatment in hospital

- Taking the tablets

- Depression, anxiety and stress

- Leaving hospital and going home

- Joining a rehab group (Phase III)

- Diet and exercise

- Resuming normal life

- Living with diabetes

- Heart support groups

There then follows six case studies provided by heart patients from various walks of life. Although it is largely based on a heart attack it also addresses other aspects of cardiac heart disease such as angina and bypass surgery. There is even a cameo role in this epic production for our President, Dr. Stephen Rex, seen operating on someone in the Wexham Angio suite!

The DVD is user friendly in that it is menu driven so one can click on to any section of it at will. THROB hopes that you will find something in it of benefit and will be able to pass it on to others.

David Read

WHAT THE PAPERS SAY

There seems to be a whole box-full of cuttings to choose from for this quarter - some news good, some not so good and some news bad!

The Government is urging GPs to get more people with coronary heart disease on to statins although the British Heart Foundation says those most at risk could still be missed - ethnic minorities and those socially deprived. This initiative comes just a few months after the Government announced vascular screening for all 40- to 70-year olds. This will entail GPs using computer software which would pick out from patient lists those likely to have high risk of a stroke or heart attack in the next ten years.

One of the bad news stories which caught the eye concerns a chemical called Bisphenol A - or BPA for short. This material is used in plastic bottles and in the lining of tin cans from where it can leach out into the contents. Studies in the United States have shown that taken into the body, BPA more than doubles the risk of a person developing cardiac heart disease (CHD) and diabetes and for this reason scientists have called for measures to limit the exposure to BPA. The European Food Safety Authority has set a limit of 3000 micrograms a day but studies have shown that even 30 micrograms per day can increase CHD. BPA can also get into the human blood stream through contamination of water. Tons of BPA lands up in land-fill sites from where it can be leached out and find its way into drinking water supplies.[It is not beyond the bounds of belief that the increase in CHD worldwide has been caused by something akin to this - a subtle change in lifestyle practice - which has not been recognised by the medical profession. Ed.]

Trials have recently started on a four-in-one heart pill which contains aspirin to thin the blood, a statin to control cholesterol an ACE inhibitor to treat blood pressure and a thiazide to reduce blood pressure. Another snippet among the press cuttings says that taking an Aspirin every day may help prevent osteoporosis - brittle bone disease - which affects three million people in the UK, mainly women. The research work has only been done on mice but there is hope that it will be the same for humans.

More bad news - this time for Warfarin takers. A study suggests that people who take Wafarin regularly are at a higher risk of brain haemorrhage.The Stroke Association have urged patients to continue to take Warfarin but say that it is important to know the correct dosage and to have regular follow-up blood tests. The findings of this study were based on a relatively small sample so the results should be treated with caution.

Now a subject dear to the British heart - tea - but it has to be green tea! This variety is good for getting the blood flowing thanks to the abundance of antioxidant flavonoids it contains. These flavonoids relax the endothalum, a thin layer of cells on the inside of blood vessels which increases the vessel diameter allowing more efficient circulation - but then you probably knew that anyway.....

A Danish study has examined the records of almost 700,000 women between the ages of 51 and 59 who were on Hormone Replacement Therapy (HRT), from1995 to 2001. They found that for the 51-54 age group there was a 24% increase in the risk of heart attack. More than four more years of HRT increased the risk still further but no significant risk increase was seen in the older age groups suggesting that the increase in risk arises in the earliest years and then dies away. [One can but think that there are several factors influencing these results which were not addressed. Ed.]

Finally there are a couple of items in the paper which relate to other articles in this issue of THROBNews. Tim Grove's piece about the Mediterranean diet brings succour to those of the damaged heart, but also, according to my paper, halves the risk of skin cancer. Although exposure to the sun is clearly the biggest cause of the problem, a recent study shows that diet could also be a factor. Cancer UK pooh-poohed the results of the study - but as we all know, the Mediterranean Diet is very satisfying!

The second item relates to Lesley Richard's article on statins and in particular on the use of "Ezetimebe" which is combined with Simvastatin in a drug called "Inegy". This drug is suspected of increasing the risk of cancer. Almost 200,000 prescriptions for Inegy were dispensed in the UK last year. The study, carried out on 1873 people over a five year period, found that there were 105 cases of cancer for those taking the drug compared to 70 on a placebo. Some leading cardiologists say that it could be statistical chance, Oxford University said two other studies found no cancer link, and the British Heart Foundation said if patients are worried they should talk to their GP.

David Read

AN ASSORTMENT OF WAYS TO REDUCE CHOLESTEROL

Once again we see statins are in the news - and it's mostly good news that is reported about statins - we now hear that GPs are being encouraged to identify those patients who are at significant risk of developing heart disease or strokes over the next ten years with a view to prescribing a statin to lower cholesterol and hence lower risk. The evidence is pretty clear now that statins are the most useful tool in the box for achieving this aim, and the pros and cons have been debated before in these pages so I won't stray into that area on this occasion. However, what do we advise for those people who either cannot tolerate statin drugs or choose not go down that particular route to lower cholesterol - what are the alternatives?

Well first things first. If you found that statin drugs, (common doses 20-40mg of simvastatin) cause significant side effects then it's worth considering a very low dose of simvastatin (10mg) combined with another non-statin cholesterol drug called Ezetemibe. Ezetemibe ( brand name Ezetrol) works on the digestive system and not via the liver and so is not subject to the same side effects as statins. Even if 10mg of simvastatin cause a problem then Ezetemibe can be used alone to help lower cholesterol. Make no mistake it will not be as effective as a statin but it will make some difference. You can discuss this option with your GP.

There are also non-drug alternatives - the results may be less spectacular but there are significant improvements that can be achieved. Science is discovering more all the time about the mechanism that lies behind the cholesterol story. We have known for some time that LDL cholesterol is "bad" and HDL cholesterol is "good" (i.e. protective) and recent discovery that damage to LDL cholesterol can increase its negative effect is yet another part of the picture. As was reported in the last issue of THROB News that eating our veggies, particularly green ones like broccoli, can help reduce this kind of damage by protecting against 'free radicals' which are the chemicals in our bodies that tend to increase cell damage and speed up the ageing process. So get those 5-a day fruits and veggies inside you for a long and healthy life!! And encourage the kids and grandkids too as they are the ones who need to be protected for the future.

I'm often asked about the use of Plant Sterol products such as Benecol or Flora Pro-Active and whether they do "what it says on the tin". The short answer is yes they do. Fortunately advertising standards means these companies would not be able to make the claims that they do if there were no proven effects. In the past the problem was around the quantities needed when using a margarine spread but the problem is now easier to solve with the use of the little yoghurt drinks as one drink comprises one dose.. so taking one per day is all that is required to achieve an effect. This is not a cheap option as the drinks are quite pricey but it is an alternative to consider.

Lesley Richards

MEDITERRANEAN DIET

I have been writing for the THROB newsletter for the past six years and most of what I have written has been on exercise. So in discussion with the editor of the newsletter David Read, I thought we would write about the Mediterranean diet. The Mediterranean diet is recommended to all people with coronary artery disease. The origin of this diet spreads across 16 different countries and is usually defined as the diet that was consumed in many regions of Greece and in southern Italy in the early 1960's. This style of diet is characterised by large amounts of olive oil, nuts, seeds, whole grains, fruits, vegetables, and oily fish with a reduction in saturated fats and processed foods. Over the next few editions of the newsletter I will cover in depth each aspect of the Mediterranean diet starting with oily fish. At the end of each article David will add a lipsmacking recipe!

The benefits of oily fish

Oily fish contains large amounts of Omega-3 fatty acids, which has beneficial effects in reducing blood pressure, the tendency for blood to clot, regulating heart rhythm and reducing the bad part of cholesterol. Furthermore, research has also shown that an increase in the consumption of oily fish will reduce the risk of coronary and total mortality in individuals who have suffered a heart attack.

What are the best sources of Omega-3 fatty acids?

All fish contains Omega-3 fatty acids, although larger amounts are found in oily fish. Oily fish should be included in your diet and you should try to eat between two to three large portions each week. However, if you are a spouse or partner who does not have coronary artery disease the recommended amount of fish consumption is one large portion of oily fish and one large portion of non-oily fish per week. Listed below

are some examples of oily fish.

- Salmon (fresh or tinned)

- Mackerel

- Herring

- Fresh tuna (not tinned)

- Trout

- Sardines

- Kipper

- Pilchards

- Anchovies

If you are a vegetarian or cannot tolerate the taste of fish, fish supplements may be used as an alternative. Fish oils supplements are a better source of Omega-3 fatty acids than fish 'liver' oils supplements. Your local pharmacist may be able to offer you advice on the best type of Omega-3 fatty acid supplements to take.

Tim Grove

WEBWATCH

Being THROB webmaster, from time to time I "surf the web" to look at other cardiac rehabilitation websites. Earlier this year I decided to put two of these to the test. Firstly www.cardiac-rehabilitation.net - supported by the British Heart Foundation (BHF) Cardiac Care and Education Research Group - and secondly www.bhf.org.uk - the BHF website itself. The first website declared "Cardiac Rehabilitation in your area - Find your nearest cardiac rehabilitation programme - enter your postcode" . Imagine my dismay after entering my Maidenhead postcode that I was given the addresses and telephone numbers of the NHS Hospitals in Amersham, High Wycombe, Hillingdon and Wexham Park !! But worse was to follow as I found when I rang the BHF "contact us" telephone number (0845 70 80 70) only to be told that THROB did not exist in Maidenhead, Ascot or Slough - despite the fact that THROB was now affiliated to the BHF !! It was obviously time for "Disgruntled of Maidenhead" to go into battle !!

My first e-mails to the BHF on the subject yielded very little other than one priceless statement - from somebody who will remain nameless - that "Cardiac Rehabilitation is an NHS responsibility". That just made matters worse ! So the next step was to write letters (twice !) to four of the Directors or Trustees listed on the BHF website which elicited a speedy response and eventually led to the locations of THROB exercise classes being given to the ladies on the 0845 70 80 70 help desk and available to any likely caller. With regard to the www.cardiac-rehabilitation.net website I was politely told to contact the University of York who administer it !

York proved to be a little easier eventually eliciting a ten minute phone call from "Professor Bob". We eventually agreed that his website didn't do "what it said on the tin" and that it might be a good idea to come clean and perhaps direct people to the BHF website to get a fuller picture of the wider cardiac rehabilitation scene. I was assured that something would be done and the latest e-mail says:- "Dear Sid . Just to keep you updated. The amendments have not been made to the database as yet but they are in hand and will be completed shortly". Time will tell.

However everything does not always have a happy ending. Today I managed to bypass the ladies on the telephone help desk and looked at the "In your area" section on the BHF website www.bhf.org.uk which states "If you are looking for your nearest Heartstart UK emergency life support training scheme, Cardiac Support Group, BHF Professor or BHF Shop please enter address details and select a search option below - Please enter the postcode, town or street name". Oh dear - THROB did not feature at all.

A Multimap press release for 18 April 2005 (!!) states:

Multimap, Europe's leading online mapping provider, and the British Heart Foundation have joined forces to help in the nation's fight against heart disease. Multimap's "Storefinder" service is now live at www.bhf.org.uk, enabling people to find their nearest BHF shops, Heartstart UK emergency life support training schemes, Cardiac Support Groups and BHF professors, in a matter of seconds. ( www.multimap.com/press/press_releases/pr106_bhf)

Here we go again !

Disgruntled of Maidenhead (a.k.a. Sid Barker)

NEW TECHNIQUES IN CARDIAC SURGERY

A small percentage of patients have neurological complications following surgery that may include mental confusion, memory loss and stroke. Elderly patients, in particular, are at higher risk for these complications. One of the most exciting innovations in coronary artery bypass grafting (CABG) over the past five years has been the introduction of "beating heart" or "off-pump" coronary artery bypass surgery (OPCAB). This surgical technique entails immobilising certain areas of the heart with cardiac stabilisers, allowing the heart to continue beating during surgery instead of stopping the heart and placing the patient on a heart-lung machine.

It should be remembered that the heart-lung machine revolutionised cardiac surgery and made it possible for surgeons to stop the heart and repair diseased coronary arteries. This machine temporarily serves as the patient's heart and lungs during the operation so that the heart can be stopped, giving the surgeon a motionless area in which to work and do the repairs.

Neurological effects may be associated with heart-lung machines and although the reason for these neurological effects is not yet definitely known, many physicians believe the changes are related to the fact that emboli (tiny blood clots) are dislodged into the bloodstream when the heart-lung bypass machine is used.

The desire to avoid or minimise these complications led to off-pump coronary artery bypass (OPCAB) grafting There are some known benefits to OPCAB: less chance of wound infection, less bleeding postoperatively, lower incidence of kidney complications, quicker recovery from anaesthesia and quicker recuperation.

In comparing off- and on-pump cardiac surgery it is important to keep in mind that the overall outcomes of cardiac surgery, whether they are done using the heart-lung machine or not, are excellent. The incidence of strokes is very small, even in elderly patients, who would be more likely to have compromised circulation than younger patients. Patients who are at high risk for complications from cardiopulmonary bypass are particularly good candidates for OPCAB. These include individuals with chronic lung disease vascular disease, previous strokes or mini-strokes and those in their 70s or older.

OPCAB is not for everyone, however. Those who have valve disease, enlarged ventricles or large amounts of fat and muscle around their coronary arteries are not good candidates for this surgery. If you are contemplating cardiac surgery, talk with your cardiologist or surgeon about whether you are a candidate for off-pump surgery. As with any surgical technique, experience is important, so if you are considering off-pump surgery, you will need to be referred to a surgeon who has performed a high volume of OPCABs.

Remember!! The overall outcomes of cardiac surgery, whether done using the heart-lung machine or not, are excellent.

Lesley Richards

HEART VALVE REPLACEMENT TRIALS

I am constantly being amazed at the feats of surgeons carrying out the most difficult of procedures using keyhole surgery. The latest is the replacement of heart valves, particularly in hearts which are elderly and therefore of potential interest to many THROB members.

Thousands of elderly patients who are too frail for open heart surgery have been given new hope by surgeons conducting trials on two procedures for replacing heart valves without the need for invasive surgery. In total, four patients have received new valves as part of the trials at King's College Hospital, London. The patients all suffer from aortic valve stenosis, which is caused by narrowing of the aortic valve. The traditional way of treating the problem is to replace heart valves through open heart surgery, but most patients with aortic valve stenosis are elderly and often suffer other illnesses, which makes the operation extremely risky.

Recently two patients underwent transapical aortic heart valve replacement - a procedure never carried out in the UK before. The operation involves cardiac surgeons implanting a heart valve using keyhole surgery through the apex (bottom) of the heart. The second procedure, which has already been tested at some UK hospitals, was given to two patients at King's. It involves a heart valve being implanted through a leg artery. One of the team which carried out the trial procedures, said; "Thanks to these techniques, none of the four needed to be admitted to an intensive care unit after surgery. They all recovered without complications and were ready to be discharged home only a week after surgery."

How the dickens do you get a valve up a leg artery? Is someone pulling my leg artery? Answers on a postcard please!

David Read