This is the first of two articles Written by Dr Leisa Freeman, Consultant GUCH Cardiologist, and Toni Hardiman, Specialist GUCH Nurse GUCH Clinic Norfolk & Norwich University NHS Hospital. These articles originally appeared in issue 68 (spring 2012) and issue 69 (summer 2012) issues of GUCH News
The remarkable advances of treatments for congenital heart conditions mean that we are now see GUCH patients marching into middle age and beyond. That means that GUCH patients may also acquire other heart-related conditions which affect many older people in the general population. Some acquired conditions are related to lifestyle, such as diet, smoking and exercise, so now may be the time to make some resolutions.
Palpitations or Arrhythmias
GUCH patients have always been more prone to rhythm problems. It is amongst the most common reasons for a GUCH to be admitted to hospital as an emergency. Carrying your GUCH passport and a previous ECG helps the A&E team understand your heart and appreciate the need for prompt treatment and the need for advice from the specialist GUCH team. The rhythm disturbances of GUCH patients may be related to the previous surgical scars or narrowings in the surgical connections.
Getting older also makes certain rhythm disturbances – such as Atrial Fibrillation (an irregular, usually fast, palpitation) – more common. Treatment for rhythm disturbances may include “cardioversion” which is an electrical jolt to return the heart to regular rhythm.
GUCH patients may need this earlier in the treatment regime than other people as their previous surgery makes them more vulnerable to rapid rates. Ablation (usually a key hole treatment to stop an electrical short circuit) or a specialist pacemaker (intra cardiac defibrillator – ICD) may also be required, and this should be carried out at your dedicated GUCH centre. Some rhythm disturbances are more likely to occur if you binge drink or use cannabis or other drugs.
Many people get extra beats or ectopics, which may not be serious and can be checked with a 24 tape.
Ectopics may be more marked before periods or at the menopause in some women.
As you get older your thyroid can become under or overactive. Sometimes thyroid problems run in families. You may be more prone to thyroid problems if you take Amiodarone for rhythm disturbances. Overactive thyroid (hyperthyroidism) may be associated with atrial fibrillation, weight loss and intolerance of heat. Checking the level of thyroid in the blood allows the diagnosis, and treatment can be with tablets or radio iodine to the thyroid gland, or occasionally removal of part of the thyroid gland. Underactive thyroid may
be associated with weight gain, intolerance to cold and generally slowing up, though sadly these features are also normally to be expected as we get older. Both over and under active thyroid can have a profound effect on the heart, irrespective of any underlying condition.
High blood pressure (hypertension)
The pressure generated by the main or systemic pump or ventricle is called the systolic pressure. It creates the surge to send blood with oxygen round the body to the organs. It is like the sea coming up the beach. The diastolic pressure (like when the sea goes back down the beach) is the background level. Ideal systolic pressure is less than 130mmHg and ideal diastolic is less than 80mmHg. This is written as 130/80. As we all get older the aorta and other arteries get stiffer and less compliant and so the systolic pressure in many people rises with age. If left untreated for years, high blood pressure can lead to strokes, heart attacks and heart failure, so treating it early with medication is important. High blood pressure may also stretch the size of the main aorta and people who have a bicuspid valve, Marfan syndrome, Fallot Tetralogy and Pulmonary Atresia with VSD may be prone to dilation of the aorta, so prompt treatment to keep the blood pressure lower is important. Coarctation of the Aorta, even if operated or stented, may make you more prone to hypertension – so checking intermittently with a 24hr blood pressure monitor or assessing the blood pressure with exercise is needed.
There are lifestyle changes you can make to try to decrease your blood pressure. Being overweight increases blood pressure – it is said that for every 1kg (2.2lbs) that you lose, your blood pressure falls by about 4mmHg.
Dietary Approaches to Salt in Hypertension (DASH) suggests that reducing salt intake (and remember many ready meals and take-aways have a high salt content) lowers blood pressure.
Exercise – even walking for 20 minutes 3 times a week – also helps.
So called “hardening” of the arteries is related to the build up of cholesterol fats and calcium in the walls of arteries. In time, especially in small arteries, narrowing can occur, which can lead to “acquired” problems of the heart, brain, kidney and limbs. Maintaining a healthy weight, reducing salt and saturated fats in the diet, not smoking, and exercising regularly all help to reduce your risk of developing atherosclerosis.
Narrowings in the coronary arteries which supply oxygen to the heart muscle may give rise to angina or heart attacks. Angina is an uncomfortable feeling or tightness in your chest, which may spread to the arms neck jaw or back. Some people may feel short of breath at the same time. It mainly occurs with exertion, or sometimes stress, and is relieved by rest. It is quite common affecting about 1in 50 people. The likelihood of developing coronary atheroma is increased by a family history of heart attacks, smoking, high blood pressure, diabetes, high cholesterol and being overweight. Men may develop angina earlier than women as there is some suggestion that the female hormones are “protective”. As a GUCH gets older so the chances of angina developing are increased, and now we are seeing 50 and 60 year olds with Fallot’s Tetralogy, for example, with angina. Coarctation of the Aorta also seems to be associated with angina earlier than other GUCH conditions. Treatment will be a variety of medications. A coronary angiogram may be needed to confirm the diagnosis and if necessary plan treatment with a stent.
Heart Attack or Myocardial Infarction (MI)
If a coronary artery blocks off acutely – with a clot usually on a pre existing narrowing – the resulting pain is quite severe and is associated with sweating and nausea. The ECG (electrical heart tracing) may show typical features of a large blockage (called an ST elevation MI or STEMI). Today this is increasingly treated with stenting or PCI (percutaneous coronary intervention) as the primary immediate treatment. The aim is to open the artery within the shortest time possible from the first episode of chest pain. (Some areas may still have clot busters to open the artery followed by an angiogram within 24 hours). Some heart attacks are associated with less dramatic ECG changes and are called non ST elevation MI or NSTEMI. The key to this diagnosis is the history, the ECG changes, and a blood test for heart muscle damage. Treatment is with blood thinners (aspirin, clopidogrel, heparin) and other tablets and then a coronary angiogram is done to document the narrowed artery and stent it if necessary.
When a GUCH goes to A&E with chest pain, they will get an ECG – so it is really helpful if you take a copy of a previous ECG for the doctors to compare. Even if the result is normal and you are sent home, it is worth letting your GUCH liaison nurse know about the symptoms and the admission as there may be other reasons for your chest pain. The hospital should be providing your GP with an immediate summary of the tests and the admission and it is good to have a copy of that and the admission ECG to show your GUCH team. Remember that taking your GUCH passport – PDF with your diagnosis and previous operations and medications is really important, especially if you can’t remember all the details.