Coronary Heart Disease

Aug 18, 2023

Coronary Heart Disease

Coronary heart disease caused by narrowing and blockage of the heart arteries causes angina, heart attacks and heart failure. It remains one of the commonest causes of mortality in the UK and globally. Public health interventions and improvements in treatment have steadily reduced deaths from coronary heart disease.

This lecture will discuss the causes of coronary heart disease and advances in reducing its effects.

A lecture by Professor Sir Chris Whitty recorded on January 10, 2023 at Barnard’s Inn Hall, London.

The transcript and downloadable versions of the lecture are available from the Gresham College website:
https://www.gresham.ac.uk/whats-on/co…

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Content

0 -> today I'm going to give the first of

2.1 -> three talks about heart disease and this

4.38 -> one is going to be about coronary heart

6.299 -> disease

8.16 -> now the reason for doing this of course

10.139 -> is that the heart is an absolutely

12.54 -> Central and it's extraordinary organ at

15.48 -> one level it's a simple pump but it's a

18.24 -> great deal more than that every day will

21.24 -> pump around a hundred thousand times and

23.46 -> will continue to do so until the day you

26.34 -> die and by doing that it takes oxygen to

30.84 -> your vital organs removes or helps

33.239 -> remove waste and it's very responsive to

36.84 -> increased needs so it'll increase its

39.18 -> rate of pumping the energy well with it

42.66 -> with it it does it if you need it and

45.239 -> then go back to its base rate when you

47.82 -> don't

48.719 -> and it keeps your blood pressure and

51 -> flow optimized for the organs of the

53.28 -> body so it's quite a really remarkable

55.62 -> organ

58.02 -> the function of the heart was actually

59.879 -> not known properly when this college was

63.239 -> founded in 1597 and the first real

66.36 -> Advance after that time was in the 1620s

70.56 -> when William Harvey demonstrated the

72.84 -> circulation of the heart that was a

75.06 -> really extraordinary advance and has led

76.86 -> to a lot subsequently and the heart is

79.68 -> really one of the most studied organs

82.08 -> because of its importance and because

85.1 -> treating heart disease has become a

88.5 -> central part of Medicine

91.68 -> now in very broad terms and of course

93.6 -> I'm I'm giving a broad overview rather

96.54 -> than the multiple uh detailed uh areas

99.36 -> uh in Broad terms there are three sets

102.42 -> of things that can go wrong with the

103.92 -> heart the first of which

106.2 -> um is uh where the heart becomes short

109.02 -> of oxygen uh mainly not exclusively

111.72 -> because the blood vessels that supply

114 -> the heart itself

115.64 -> start to get narrowed or blocked

119.64 -> and that's known as myocardial ischemia

122.34 -> or coronary heart disease that's the

124.439 -> subject of today's talk

126.479 -> now two other things that happen which

128.459 -> would be the subject of two subsequent

129.78 -> ones the hearts Rhythm normally very

132.66 -> reliable can go too fast or too slowly

136.62 -> uh meaning that it works much less

139.44 -> efficiently

140.819 -> and the third thing is that the

142.44 -> structures of the heart might be the

143.819 -> muscles might be the vowels of the heart

146.4 -> are damaged uh for for a variety of

149.28 -> reasons and those broadly are the

152.16 -> majority of the things which cause

153.78 -> problems with heart disease but the one

156.06 -> I'm going to concentrate on really the

157.62 -> most important to those today is

159.66 -> myocardial ischemia or coronary heart

162.06 -> disease

164.819 -> uh its biggest importance is that this

167.519 -> is one of uh the main causes of people

171.3 -> dying in the UK and in every country

174.06 -> around the world

175.62 -> uh it's now the second most common cause

179.4 -> of people dying uh dementia just

182.4 -> slightly ahead of it in the UK but

185.099 -> globally it would be the main cause and

188.519 -> within that heart attacks

191.42 -> myocardial infarctions as they're known

194.58 -> medically are the principal reason

198.3 -> and if you so if you see the slide I put

201.9 -> up here what it shows is that really

204.78 -> quite a significantly greater number of

207.48 -> deaths from this than the next most

209.519 -> common uh cause top one is as I say

212.04 -> dementia and there has been what we got

214.8 -> in the uh the dark colors is the most

217.5 -> up-to-date data from the office of

219 -> national statistics and then in the

221.28 -> light the lighter color bar is the

224.28 -> average over the last five years so

225.599 -> there's been a slight improvement over

226.92 -> that time but

229.08 -> um the uh the fact remains it is a major

232.5 -> cause of mortality

235.4 -> it is however better than it used to be

237.84 -> and if you look at this graph and I've

240.18 -> shown this before in a slightly

241.26 -> different context what you see is that

244.019 -> it back in the 1960s uh heart and

247.44 -> circulatory disease caused around half

250.26 -> the deaths in the country

252.659 -> and it's on that gone down now very

254.939 -> substantially to a still substantial

257.82 -> around quarter of the deaths and what

260.76 -> the graph here shows is the age

262.86 -> standardized mortality rates over the

265.62 -> period 1911 to 2011.

271.62 -> in the dark uh solid lines what we have

275.04 -> is heart disease peaking in the 60s 50s

278.1 -> and 60s and gradually decreasing Red For

281.16 -> Women uh blue for men in the dashed line

284.34 -> is cancer which is uh

288.259 -> beginning to catch up with an overtake

291.78 -> heart disease and in the dotted line

293.82 -> infectious diseases absolutely dominant

296.46 -> over a century ago and certainly when

298.74 -> this college was founded but much less

301.02 -> important over the last century

304.52 -> coming more up to date over the last few

308.46 -> years this is what has happened to heart

310.919 -> disease in terms of mortality coronary

313.8 -> heart disease per hundred thousand

315.6 -> people sit between 1969

318.44 -> and 2020 which is when these data run

322.919 -> onto and as you can see in the dark bars

326.46 -> at the top

327.74 -> is the male rate the one at the bottom

332.419 -> is the female rate and in the middle is

335.82 -> the average for men and women uh two uh

339.78 -> things ready to follow on from this the

342.24 -> first of which is there has been a

344.58 -> really remarkable reduction uh over that

347.759 -> time in terms of mortality from coronary

351.18 -> heart disease or ischemic heart disease

353.88 -> and the second thing is that this hasn't

355.62 -> happened in a single jump this is not a

358.44 -> single breakthrough this is a whole

360.6 -> series of scientific advances which have

363.96 -> happened incrementally built on top of

366.3 -> one another five percent Improvement

367.74 -> built on another five percent

369.18 -> improvement over time and then steadily

371.639 -> rolled out

373.38 -> the third thing just to note is that the

376.259 -> difference between men and women

377.16 -> although there's still a significantly

379.199 -> greater rate of heart disease deaths in

381.66 -> men has decreased and some of this is

384.479 -> explained by a number of factors in

386.52 -> particular actually changes in smoking

390.539 -> and if you look in people under 75 and

393.539 -> these would be relatively young deaths

395.639 -> in the modern era

397.34 -> you'll see you see a probably even more

401.12 -> dramatic Improvement where the rates of

404.039 -> people dying of heart attacks or

406.319 -> myocardial ischemia are really very low

409.56 -> compared to where they were historically

414.5 -> so what actually causes ischemic heart

417.9 -> disease or coronary heart disease well

419.639 -> the main cause it's not the only one but

421.68 -> by far the main one is atherosclerosis

424.639 -> and this is a buildup of mainly fatty

429.24 -> but also fibrous material in the

432 -> arteries that supply the heart itself

434.22 -> the coronary arteries

437.4 -> and these fatty deposits start actually

440.039 -> very early on in life and then gradually

443.039 -> build up over time and initially it

445.38 -> makes relatively little difference

446.479 -> functionally the heart's got quite a bit

449.58 -> of functional Reserve but you then get

452.88 -> to the point where they built up to a

454.38 -> point there is a critical narrowing and

456.539 -> at that point people can start to get

458.94 -> symptoms they get a bit short of breath

460.38 -> they can start to get pain in the chest

462.18 -> also known as angina come back to angina

466.5 -> and then in some cases the narrowing

470.16 -> actually suddenly gets a lot smaller or

473.58 -> blocks off completely and this is what

476.16 -> tends to cause a heart attack or

478.319 -> myocardial infarction and the usual

480.84 -> mechanism although there are there are

482.699 -> others is you get a inflammation or

486 -> rupture of this fatty material and a

490.199 -> clot forms over the top of that that and

492.9 -> then blocks the remaining artery and

495.84 -> this leads to a heart attack and if an

499.199 -> area of the heart is starved of oxygen

501.96 -> that area of the muscle will be strongly

504.479 -> damaged in the territory of that blood

507.24 -> vessel and it may well die and cease to

510.78 -> be functionally useful so that is what a

513.779 -> heart attack is

515.76 -> fortunately and this underlies a lot of

518.7 -> the improvements we have seen and could

520.8 -> see in the future many of the things

523.32 -> which lead to this happening are

525.48 -> modifiable we can do a lot to change

527.82 -> them

531.66 -> so if you look at that extraordinary

533.82 -> Improvement in heart ischemic heart

535.62 -> disease

536.899 -> three broad sets of things have

540 -> contributed and the first of those is

543.06 -> primary prevention primary prevention is

545.1 -> something which is done Often by the

547.019 -> state but by Society where the state is

551.1 -> simply the mechanism which this happens

553.04 -> to reduce the risk for the whole

555.899 -> population

557.22 -> not asking whether you've individually

559.14 -> got risk just say let's try and reduce

560.76 -> the risk for absolutely everybody and

562.5 -> this of course is a very common disease

566.22 -> then you've got secondary prevention and

567.899 -> that's on top of that is where you say

570 -> this individual person has got a has

573 -> either got early disease or they've got

575.7 -> very specific risk factors or things

578.04 -> that make a disease much more likely and

581.519 -> let's do something specifically for her

584.22 -> or for him to reduce the risk of further

588.839 -> problems in the future and this will be

590.82 -> a discussion between an individual

592.2 -> person a patient and their doctor nurse

595.32 -> or other health care provider generally

596.88 -> to talk about the risks and benefits of

598.86 -> various treatments

601.2 -> that are preventive this is secondary

603.42 -> prevention and the third thing is when

605.339 -> someone has significant disease or has a

608.339 -> heart attack or other major event

609.8 -> treating uh this so that the chances of

613.62 -> dying or having long-term disability as

616.26 -> a result of it is significantly reduced

618.54 -> so you've got primary prevention

619.64 -> secondary prevention which is done for

622.2 -> individuals and treatment after events

625.74 -> or for significant disease

628.2 -> and I'm going to go through each of

629.7 -> those in turn because the Improvement

632.16 -> has to be understood as a combination of

634.2 -> all of these

636.3 -> now for primary prevention of ischemic

638.459 -> heart disease this has several different

641.82 -> components all of which have an

644.16 -> important action if you put all of them

646.44 -> together the impact on heart disease can

648.54 -> be very significant indeed

650.76 -> the first of which is and I'll go

653.22 -> through each of these in turn reducing

654.6 -> smoking and also secondhand smoke

657.5 -> passive smoking where someone else is

659.7 -> smoking and a particular person downwind

662.64 -> of them or near them is exposed to that

665.16 -> smoke because cigarette smoke is

666.66 -> extremely liable to speed up heart

670.56 -> disease very substantially

673.019 -> the second is reductions in air

674.76 -> pollution which have been significantly

676.519 -> underestimated I think in their

678.3 -> importance

679.56 -> then there's doing things which help to

681.54 -> modify the diet in a way which people

684.48 -> are still eating the foods they enjoy

686.16 -> but with less risk and in particular

688.32 -> this involves reducing salt because as

691.019 -> you'll come on to Salt raises blood

692.7 -> pressure and also some of the fats you

695.279 -> can have particular kinds of fats in

696.899 -> foods

698.94 -> very important that we make it easy for

701.399 -> people to exercise at all points along

703.56 -> their life course because exercise is

706.26 -> important and finally reducing the

710.22 -> societal drivers of obesity and I'll go

713.76 -> through each of those in a bit more

714.779 -> detail

716.76 -> starting with smoking

718.62 -> um

719.519 -> smoking leads to premature mortality

722.64 -> often very premature mortality and

725.76 -> symptoms from heart disease it does very

727.68 -> many other things as well as everyone in

729.48 -> the audience will know it causes lung

730.62 -> cancer many other cancers chronic lung

732.72 -> diseases but it also importantly

735.44 -> significantly increases the risk of

738.3 -> heart disease ischemic heart disease

740.64 -> specifically

742.94 -> smokers themselves are very

745.2 -> substantially increased risk to

746.519 -> non-smokers and if you're a passive

748.8 -> smoker or secondhand smoker because

750.66 -> someone else smoking around you that

753.24 -> still has a unappreciable additional

755.459 -> risk

756.72 -> now this is important at an individual

758.519 -> level it's also actually it helps

760.62 -> explain uh some of the significant

763.139 -> difference there is around the UK and

765.54 -> indeed many other countries in terms of

767.459 -> the rates of mortality from heart

769.62 -> disease there is a strong correlation

772.139 -> between the areas of the country which

774.899 -> have high smoking rates and the areas of

777.42 -> the country which have high deaths from

780.779 -> coronary heart disease and you can see

783 -> that in this map on the left darker

785.519 -> colors are people who are smoking and on

788.579 -> the right darker colors are people with

791.399 -> ischemic heart disease

795 -> now this isn't the only reason for these

796.8 -> differences geographically but it is

798.36 -> probably the easiest to address and were

801.54 -> there to be a massive reduction in

803.94 -> smoking it would significantly reduce

806.04 -> some of the variation we see around the

808.2 -> country

810.839 -> improvements in heart disease can be

812.519 -> very rapid when smoking reduces or stops

815.04 -> and I think we'll just give an example

817.04 -> the last really major bit of primary

821.279 -> prevention against smoking was the ban

825.18 -> on smoking in public places where you

827.82 -> could be affecting everyone around you

831.74 -> and the studies of this showed many

834.72 -> advantages but within the heart area a

837.6 -> significant reduction in heart disease

840.18 -> at a population level occurred and this

842.94 -> was often uh really quite rapid and what

845.22 -> you can see on the right is a study that

847.74 -> looked in this case specifically in

849.48 -> Liverpool but it could have been

850.44 -> anywhere the bar is where the ban on

853.68 -> smoking in public places was and what

855.6 -> you can see is an almost immediate drop

857.48 -> in the number of people who were

859.56 -> admitted with coronary symptoms so

862.56 -> really you can have a very rapid effect

864.72 -> so there's a rapid reduction in Risk

867.06 -> when people stop smoking and then a

868.98 -> longer term reversion back to ordinary

871.92 -> risk over many years

873.66 -> but at any point you stop smoking it

876.18 -> improves the outcome in terms of heart

878.16 -> disease

880.32 -> very important to stress that the model

883.38 -> of the cigarette industry is to take

886.019 -> people at the youngest age they are

887.639 -> allowed by law

889.079 -> and addict them using very very

891.48 -> aggressive marketing

893.279 -> most people who smoke will wish to stop

896.76 -> and therefore the choice has been taken

898.62 -> away from them by being deliberately

900.6 -> Addicted by very powerful very

902.94 -> profitable companies at an early stage

905.579 -> of their lives

909.24 -> fortunately smoking rates are dropping

911.339 -> in the UK for the purposes of Health

914.22 -> painfully slowly but the good news is

916.92 -> that the rates in younger people are

919.019 -> actually probably dropping fastest and

920.94 -> rates of smoking in young people now

923 -> compared to uh when people in my

926.22 -> generation were in their 20s or late

929.16 -> teens are much lower and are still

931.86 -> dropping Uh current generation are

934.32 -> extremely sensible about this

938.72 -> the next big thing that Society can do

941.76 -> to reduce the risk of coronary heart

943.8 -> disease is very common fatal disease is

946.62 -> reductions in air pollution people I

948.72 -> think underestimate quite how important

951.12 -> air pollution certainly was historically

953.399 -> and still is to some extent now outdoor

956.76 -> air pollution

958.04 -> caused by factories by Vehicles indoor

961.68 -> air pollution as well and for those who

963.42 -> are interested in details in this I

964.56 -> wrote a report on this which was

966.24 -> released just a month ago

969.48 -> over the last several decades most forms

972.899 -> of air pollution have dropped very

975.06 -> substantially and I'd like this in in

977.16 -> what we've got is in the dotted black

979.019 -> line on the right is where things were

981.72 -> back in the 1970s and what you can see

984.24 -> is the proportionate reduction in

986.76 -> multiple forms of air pollution for

988.74 -> heart disease coronary heart disease

990.72 -> probably the most important to these is

992.579 -> particulate matter so-called PM 2.5

994.8 -> small particles and these have been uh

997.5 -> dropping for really quite a long period

1000.56 -> of time although this is unfortunately

1002.12 -> flattened out a bit uh more recently

1005.06 -> so this Improvement in air pollution has

1007.639 -> certainly contributed to the very

1009.32 -> significant improvements we've seen and

1011.42 -> there's still some way to go and some of

1013.16 -> the things we're going to see like the

1014.72 -> electrification of vehicles uh some of

1017.18 -> the uh the final reductions uh in many

1019.82 -> of the most polluting forms of Industry

1021.8 -> uh will lead to further reduction in

1024.199 -> Risk

1026.959 -> making exercise easier and fun

1029.72 -> throughout the life course and building

1031.28 -> it into ordinary day or making it

1033.079 -> something which people look forward to

1034.579 -> is also really important to exercise is

1038.12 -> one of the most protective things that

1039.62 -> can be done to reduce the risk of

1042.799 -> coronary artery artery disease

1045.62 -> excuse me heart disease it's also very

1048.199 -> good for many other conditions as well

1050.419 -> but specifically in this situation and

1053.299 -> starting in childhood making exercise

1055.7 -> just the norm things like the daily mile

1058.52 -> is used in very many schools uh walking

1063.08 -> football in older age but also making it

1065.72 -> easy for people to for example have

1067.039 -> active transport we used to have what we

1069.44 -> caught on the right is the distance

1070.94 -> traveled by bike in the UK and if you

1073.4 -> went back to the 1940s and early 50s

1075.32 -> huge numbers of miles or kilometers as

1077.9 -> they now would be were travel by bicycle

1081.28 -> much lower now that is something we

1084.26 -> easily could turn around it would have a

1086.24 -> it would have an immediate and

1087.86 -> significant positive impact on health

1089.539 -> including coronary heart disease

1094.299 -> changes into the diet to the diet where

1097.88 -> they can allow people to eat the things

1099.32 -> they want to eat but reduce the risk can

1102.02 -> have a very major positive impact and

1104.72 -> I'm just going to highlight one in

1105.86 -> particular which is reductions in salt

1109.64 -> salt increases mainly because of the

1112.039 -> sodium in it increases the blood

1114.559 -> pressure for potentially for everybody

1116.84 -> but in reality for the most sensitive to

1120.2 -> Salt are older people

1123.32 -> and in the UK we've had a useful

1127.419 -> reduction of around 15 percent in salt

1130.88 -> over the last decade and most of this

1133.039 -> has been from processed food and I'd

1134.539 -> like to pay tribute to the uh many

1137.6 -> companies which have been involved in

1139.4 -> trying to do this and they usually do it

1140.66 -> incrementally so people don't realize

1142.4 -> that salt is gradually reducing as time

1145.34 -> goes by but we definitely need to go

1147.88 -> significantly further

1149.9 -> some of the products on the market

1151.4 -> thanks to

1153.4 -> far-sighted views by the companies

1155.48 -> involved have gone down by 20 to 40

1157.88 -> percent less salt than 10 years ago but

1160.88 -> certainly there's a lot we could do to

1162.919 -> reduce the saltiness of processed and

1166.1 -> manufactured food I'm going to stress

1167.9 -> that because most of the salt in the UK

1170.84 -> diet is involuntary the people eating it

1173.48 -> have no choice about it they don't know

1175.64 -> it's there they haven't added it into

1177.14 -> their plate it wasn't their choice

1179.179 -> and if you look on the right what we've

1181.28 -> got is salt in processed foods and that

1184.22 -> would include things like breads for

1185.539 -> example and that's up to

1188.96 -> um 60 60 ish percent of the salt in the

1192.2 -> diet Salt that is a natural part of the

1195.74 -> product and then the amount that people

1198.32 -> actually add to themselves so the salt

1200.9 -> that people add themselves in the sense

1203 -> the salt they choose to put in is less

1205.28 -> than 20 percent of the salt they receive

1207.679 -> so it's really the manufactured area

1209.299 -> that we have the biggest opportunity for

1211.34 -> change but of course if people put less

1213.62 -> salt into their food that reduces their

1216.98 -> risks

1219.1 -> and finally in terms of the primary

1221.539 -> prevention things I want to talk about

1222.74 -> this this isn't an exhaustive list is

1225.2 -> obesity

1226.46 -> and in the context of obesity in

1229.94 -> contrast to all the other things I've

1231.38 -> talked about so far smoking uh air

1233.539 -> pollution salt for example where things

1235.4 -> have been improving obesity has

1238.64 -> undoubtedly got worse

1241.96 -> obesity directly leads to cardiovascular

1244.94 -> mortality so even if someone has no

1247.1 -> other issues someone's living with

1249.799 -> obesity the chances of cardiovascular

1252.2 -> disease are much greater that's one of

1253.4 -> the reasons that in medical terms we're

1255.2 -> very keen to reduce obesity does a

1257.299 -> number of other things increases some

1258.679 -> cancers for example

1260.24 -> and it also increases the risk of

1261.919 -> diabetes which itself leads to an

1264.98 -> increased risk of heart disease coronary

1267.2 -> artery disease

1268.64 -> so obesity is a real driver of coronary

1273.26 -> artery disease and the problem we have

1277.1 -> here is people living with over being

1279.5 -> over having being overweight and people

1282.26 -> living with obesity the proportion of

1284.48 -> people in the population has steadily

1286.52 -> increased and if you could look on the

1288.02 -> graph there what you can see is just the

1289.82 -> average weight has steadily shifted to

1292.46 -> the right to where right is heavier

1294.38 -> towards people living with obesity

1297.86 -> this is particularly depressing as what

1299.72 -> we're seeing is uh areas of significant

1302.9 -> Rising obesity and these are much more

1305.36 -> common in areas of deprivation and

1307.34 -> that's actually got worse over the last

1309.44 -> few years

1310.82 -> so this is something we really do need

1312.14 -> for a tackle uh fairly forcefully

1316.039 -> so those are primary prevention things

1318.02 -> we can do to all of society to reduce

1319.7 -> the risk of heart disease Now we move on

1321.74 -> to secondary prevention and this is

1323.44 -> where people will have treatment for

1326.059 -> particular conditions or risk factors or

1328.46 -> very early disease

1329.98 -> and there are I'm call back four but I'm

1333.679 -> going to talk about uh two in uh detail

1336.32 -> the first

1337.88 -> um is to help at an individual level

1340.58 -> someone who's smoking to quit someone

1344 -> who's living with obesity to help them

1346.46 -> reduce weight uh someone who's not doing

1349.82 -> exercise to increase exercise so this is

1352.34 -> kind of targeted uh things but things

1355.4 -> I've talked about already as risk

1356.78 -> factors

1358.4 -> the second thing is to identify people

1361.22 -> who've got high blood pressure

1362.179 -> hypertension and treat those

1365.659 -> the third is treating high cholesterol

1368.74 -> in people who've got that and finally

1372.08 -> which I'm not going to talk about I've

1373.28 -> done a full aggression lecture on that

1374.72 -> two people who are interested in it is

1376.64 -> diagnosing and treating diabetes as

1380.059 -> early as possible

1384.44 -> so let's start off with high blood

1385.94 -> pressure hypertension this is a major

1389.6 -> common and treatable risk factor for

1393.38 -> ischemic heart disease now just to

1395.24 -> understand a bit about the numbers when

1398.24 -> your heart is

1399.7 -> Contracting the force in the blood is

1402.2 -> going up it's part of the way it pumps

1403.82 -> it and you get a high blood pressure

1405.679 -> reading caused a systolic blood pressure

1408.74 -> and then when it relaxes you get a lower

1412.28 -> blood pressure and that's what's called

1413.78 -> the diastolic blood pressure and all of

1416.48 -> us have got those two readings systolic

1418.1 -> and diastolic

1420.44 -> high blood pressure hypertension

1422.32 -> contributes to doesn't cause all of but

1425.059 -> contributes to about half of heart and

1428.419 -> circulation disease so it's a really

1429.919 -> substantial risk factor

1431.84 -> and it's common around 28 of the UK

1435.32 -> population

1437 -> now two things to say which are I think

1439.94 -> critical on this the first of which is

1441.559 -> there are multiple possible ways in

1444.44 -> which blood pressure can be reduced so

1446.6 -> if something doesn't suit someone we can

1449.24 -> move from one uh thing uh to another

1452.72 -> and secondly there are a lot of people

1454.64 -> who are living and this is what these

1456.08 -> data on the right show uh there are a

1458.48 -> lot of people in the UK living with

1461.059 -> obese sorry living with uh hypertension

1463.82 -> who are not aware they have it and

1466.64 -> therefore are not on treatment so it's

1469.28 -> not a matter of their choice they're not

1470.48 -> even aware that this is a risk which

1473.36 -> could be managed down significantly

1477.2 -> and this is a shame because blood

1479.059 -> pressure is actually very easy to not to

1480.799 -> measure now we have automated machines

1484.159 -> are widely available and it is I think

1487.28 -> important for everybody but particularly

1488.78 -> people once they reach uh sort of 40s

1491.299 -> and above to know their numbers

1493.7 -> because we can measure blood pressure

1494.84 -> anywhere one of these machines cheap and

1497.36 -> robust very really pretty accurate you

1500.179 -> can measure them at the doctor or with a

1502.82 -> nurse but you can also measure them at

1504.26 -> home buy them from local chemists at

1507.559 -> work shops measuring blood pressure

1509.72 -> there are many many places it's possible

1511.7 -> to do that and then you'll know whether

1513.44 -> you've got a high systolic or diastolic

1516.2 -> blood pressure and the readings that

1518.24 -> generally speaking tend to trigger

1520.28 -> treatment are either a high systolic

1525.26 -> blood pressure above 140 or a diastolic

1529.52 -> blood pressure of above 90. usually with

1532.82 -> repeated meeting readings

1535.82 -> now there are certain things you can do

1537.2 -> to reduce blood pressure which don't

1539.059 -> require drugs at all they include

1542.08 -> reducing your salt intake talked about

1544.4 -> before reducing alcohol because alcohol

1546.919 -> pushes blood pressure up exercise the

1550.4 -> more you exercise within in in general

1553.1 -> the lower your blood pressure

1555.22 -> and losing weight even a little will

1558.679 -> help so it's not there are lifestyle

1562.22 -> things we can do to improve our blood

1564.44 -> pressures

1566.6 -> but there are also uh very many drugs

1569.24 -> which can reduce blood pressure

1571.52 -> and they work by different mechanisms so

1573.32 -> I'm going to go through several of them

1574.34 -> because they're very important drugs and

1575.779 -> several of the people in the audience

1577.039 -> will be on them many of the people in

1578.6 -> the audience will be on them at some

1580.1 -> point uh in their lives so it's worth

1581.96 -> understanding a bit about them

1584.179 -> the point to make about this though is

1585.919 -> that whichever mechanism they use by

1588.62 -> reducing the blood pressure they reduce

1591.32 -> the risk of ischemic heart disease

1595.1 -> now which is the best drug for you for

1597.74 -> me if we have hypertension uh depends on

1600.86 -> many factors as it depends on age

1602.6 -> depends on existing heart disease some

1604.7 -> drugs many drugs have particular

1606.559 -> additional benefits it depends on

1609.08 -> ethnicity to some extent it depends on

1611.779 -> side effects some people some drugs suit

1613.76 -> some people better than others so if

1616.279 -> people go in there treated in the side

1618.98 -> effects are problematic another drug can

1621.799 -> be used

1623.24 -> common ones these aren't exclusive

1624.98 -> exclusively all of them common ones

1626.659 -> which I'm going to talk about in a bit

1628.58 -> more detail are ACE inhibitors

1632.38 -> think or things called Angiotensin II

1635.24 -> receptor blockers they have a lot of

1636.559 -> similarities I've come on to that

1638.36 -> calcium channel blockers

1641.02 -> thiazide diuretic drugs and beta

1645.26 -> blockers there are others but those are

1647.24 -> really the main groups of drugs you'll

1650 -> get in the UK

1652.22 -> and these may be used in different

1654.38 -> combinations most people we treated on

1656.179 -> one drug but some people are treated on

1658.64 -> two or more

1661.46 -> now I think it's worth going through the

1663.2 -> mechanisms of these so for the next five

1664.7 -> slides I'm going to go through the

1665.84 -> mechanisms of these individual drugs

1667.159 -> just to get a feel for uh where they

1669.26 -> came from and how differently they act

1671.72 -> but the final uh thing they do is reduce

1674.36 -> the blood pressure

1675.679 -> the first are the ACE inhibitors and for

1678.44 -> many people now these will be the first

1680.659 -> line drugs to be used

1683.6 -> these work on something called the renin

1685.659 -> Angiotensin system and this is the

1688.76 -> kidney

1690.159 -> notices when blood pressure drops

1693.08 -> and it then activates a system the

1696.74 -> Iranian antitencing system which

1698.96 -> actually leads to the blood pressure

1701.059 -> being pushed up

1703.159 -> so that's the kind of the underlying

1705.2 -> mechanism that it works on it's a kind

1706.76 -> of it's a way it's it's a way in which

1708.799 -> uh the body controls blood pressure but

1712.159 -> sometimes the set point is too high

1714.86 -> and the first drugs that were found to

1718.1 -> work on the system to reduce blood

1720.559 -> pressure uh were shown to block this and

1723.62 -> they in fact originally came from the

1725.779 -> Brazilian pit viper this Photograph on

1729.2 -> the right

1730.34 -> Now by multiple uh and and the way the

1733.279 -> reason this is important for the pit

1734.84 -> viper was by dropping the blood pressure

1736.52 -> in eggs catastrophically which the drugs

1739.58 -> do not uh it could lead to

1742.46 -> um uh disabling its prey

1746.24 -> this led by many steps uh to the draw

1750.02 -> the first of the most of the widely

1751.64 -> available ACE inhibitors a drug called

1753.38 -> captopril but this was the first of many

1756.919 -> others that people may well have come

1759.14 -> across in the UK a narrow apparel

1761.14 -> lisinopril there are several others just

1763.94 -> a comment on drug naming instantly

1765.679 -> rather like all of us drugs have a

1768.44 -> surname which actually tells you the

1770.72 -> family they come from and a kind of

1772.82 -> first name that tells you it's them so

1774.62 -> the prills are all generally speaking

1777.32 -> ACE inhibitors

1780.38 -> so the asymmeters work by preventing an

1782.779 -> enzyme

1784.419 -> producing Angiotensin II which is a

1787.46 -> signal drug and this leads to narrowing

1790.7 -> anti-tensity at least narrowing of the

1792.5 -> blood vessels and therefore forces the

1795.5 -> heart to work harder and the blood

1797.779 -> pressure to go up that's the way it

1799.279 -> normally acts so by blocking that you

1802.22 -> get the reverse you get

1803.74 -> relaxation of the arteries and veins and

1807.32 -> therefore the blood pressure drops and

1809.96 -> the heart has less strain on it

1813.44 -> as with all drugs and there's no drug

1815.12 -> without side effects there are side

1817.82 -> effects to this drug probably the most

1819.919 -> common one that's the reason for people

1821.24 -> to stopping it and it sounds trivial

1822.98 -> until you've got it but it's a very

1824.419 -> important one is cough and people can

1827.96 -> get a very annoying cough which means it

1831.26 -> needs to be stopped and another drug is

1832.94 -> used it reverses when people stop the

1834.98 -> drug

1836.179 -> because this is a both a very effective

1838.76 -> mechanism to address the Angiotensin

1842.02 -> receptors but also the side effects from

1845.72 -> the ACE inhibitors I've just talked

1847.22 -> about another class of drugs working on

1849.26 -> exactly the same system has been has

1853.52 -> been produced and these are the

1855.559 -> Angiotensin receptor blockers

1857.98 -> also known as Angiotensin II receptor

1860.539 -> antagonists

1862.7 -> so they work very much like the ACE

1865.399 -> inhibitors in Practical terms they can

1867.2 -> be almost used interchangeably but

1869.059 -> instead of the mechanism acting on the

1871.46 -> enzyme what they do is they actually

1873.2 -> block The receptors and there are a

1875.72 -> variety of drugs again which you can

1877.1 -> have uh losartan for example is one of

1880.58 -> the ones that may be widely used they're

1882.74 -> all they all tend to be have this uh tan

1885.559 -> at the end and

1888.52 -> this class of drugs has very different

1892.76 -> side effects and doesn't in particular

1894.919 -> have the cough problem that can be uh a

1898.34 -> reason people want to stop taking ACE

1900.32 -> inhibitors

1905.539 -> working by a completely different

1907.159 -> mechanism are calcium channel blockers

1911 -> the body uses calcium to signal to large

1914 -> numbers of cells in large numbers of

1915.559 -> environments including muscle cells

1918.74 -> and some of the calcium channels when

1921.74 -> they over when they open are going to

1924.38 -> signal to blood vessels that they should

1927.08 -> constrict and initiate that construction

1932.12 -> so the drugs that work as calcium

1935.659 -> channel blockers aim specifically to

1937.34 -> block these particular calcium channels

1940.419 -> there are many tour types in the body

1943.159 -> but these particular ones and examples

1945.559 -> of drugs that do this are things like

1947.12 -> nifedipine

1948.5 -> uh and the principal action therefore is

1952.279 -> to stop the constriction and therefore

1953.96 -> lead to a relaxation of blood vessels

1956.059 -> and so reduce blood pressure

1958.82 -> they also can reduce spasm of coronary

1962.179 -> arteries so this can be useful for

1964.159 -> symptoms in some people

1966.08 -> and they do have side effects including

1968.36 -> for example fluid retention

1973.46 -> a completely different mechanism again

1975.159 -> are the thiazide diuretics and these

1979.039 -> work in the kidney and they mainly work

1982.039 -> by reducing reabsorption of sodium which

1986.059 -> is being reabsorbed by the kidney the

1987.919 -> whole time to hang on to it and this

1990.679 -> reduces the sodium and the total water

1994.299 -> and this is the principal mechanism it's

1997.76 -> thought by which these reduce blood

1999.98 -> pressure but they also May dilute blood

2002.5 -> blood vessels to some extent so these

2005.26 -> are diuretics

2008.62 -> and the final um uh anti-hypertensive I

2011.919 -> want to talk about and all of these

2013.419 -> drugs are important in for other uses as

2015.58 -> well are beta blockers

2018.059 -> these were um

2020.88 -> discovered and developed back in the

2024.159 -> 1960s

2025.36 -> um uh so James Black photographed here

2027.7 -> was one of the leading Pioneers in this

2030.279 -> area and this started from the

2032.799 -> understanding that adrenaline is used by

2035.019 -> the body as part of the flight and fight

2038.039 -> mechanism and it leads to the heart

2040.299 -> going faster and blood vessels

2043.24 -> constricting it's basically getting the

2044.5 -> the body ready for for action

2049.06 -> so adrenaline stimulates and these are

2052.179 -> the important bits for this particular

2053.859 -> drug it has other actions as well it

2055.96 -> stimulates beta receptors and on several

2059.32 -> organelles and the beta blockers block

2062.919 -> this and stop the adrenaline having the

2066.099 -> actions of making uh the blood pressure

2069.399 -> go up and the heart pump more rapidly

2072.879 -> and again many of these drugs have wide

2075.879 -> uses in medicine including for reducing

2078.04 -> blood pressure examples include Atenolol

2080.379 -> or brisoprolol so LOL ending for most of

2084.7 -> these drugs

2088.419 -> so those are examples of multiple types

2091.96 -> of antihypertensive and which one is

2094.179 -> best for someone as I said at the

2095.679 -> beginning varies

2097.72 -> the next big risk which can be dealt

2099.88 -> with by drugs is reducing cholesterol

2102.52 -> high cholesterol specifically high LDL

2105.82 -> cholesterol is associated with coronary

2108.58 -> heart disease and is part of that

2110.32 -> buildup plaque in the uh in the blood

2114.04 -> vessels which causes coronary heart

2115.66 -> disease

2117.16 -> LDL tends to rise with age and of course

2119.56 -> the risk of coronary heart disease also

2123.04 -> Rises with age

2126.099 -> the drug statins have really given us

2129.52 -> extremely powerful tool to reduce

2132.28 -> cholesterol and there is clear evidence

2134.619 -> of benefit particularly for people

2136.78 -> who've previously had a heart ischemic

2139.9 -> heart disease problem

2142.32 -> but also for people who haven't but have

2145.48 -> got raised cholesterol it might be a

2147.579 -> family genetic reason

2149.64 -> but I've got raised cholesterol and what

2152.92 -> I've shown you won't see the details of

2154.3 -> this the point I'm making on the right

2155.44 -> is multiple different subgroups have

2157.599 -> been looked at in big studies in this

2160.96 -> case a mass analysis of 186 over 186 000

2166.06 -> patients

2167.7 -> randomized to statins or not and they

2170.98 -> demonstrated all ages and with multiple

2173.98 -> outcomes including coronary heart

2176.079 -> disease there are improvements so

2178.66 -> reducing cholesterol and those who've

2180.579 -> got raised cholesterol can be highly

2183.22 -> effective

2185.5 -> various drugs can reduce LDL cholesterol

2188.74 -> the most important group are the statins

2191.38 -> and they are currently first line

2193.18 -> treatment and drugs such as a

2196.26 -> torvastatin inhibit an enzyme and this

2201.099 -> plays a central role in producing

2203.859 -> cholesterol in the liver

2207.4 -> but there are other drugs that are

2209.44 -> coming along and are now in deployment

2212.04 -> and they work by completely different

2214.42 -> mechanism and there are several drugs

2217.3 -> which inhibit by a variety of different

2219.099 -> mechanisms something called

2223.079 -> pcsk-9 and an example of this is the

2227.079 -> drug in glycerin and these increase the

2231.76 -> liver's ability to reduce cholesterol

2235.06 -> essentially

2238.119 -> um currently these drugs are used only

2240.579 -> uh where statins either can't be

2242.5 -> tolerated and statins are usually very

2244.06 -> well tolerated by the great majority

2245.56 -> people uh or where there are other

2248.079 -> reasons uh that they maybe needed as

2251.5 -> additional

2252.76 -> um treatment

2257.56 -> so you've got primary prevention the

2259.66 -> secondary prevention particularly

2260.8 -> anti-hypertensives reducing uh

2262.72 -> cholesterol and targeted action to help

2265.24 -> with things like smoking and losing

2268.06 -> weight

2269.14 -> but even with optimal prevention many

2272.2 -> people will go on to have cardiac events

2273.94 -> although significantly fewer than

2276.04 -> without and I think as probably most

2278.32 -> people know but it's worth remembering a

2280.839 -> very severe pain in the chest uh is one

2283.359 -> of the things that should make people

2284.68 -> think about uh have they got a coronary

2287.44 -> event which could include a heart attack

2289.839 -> many other possible causes and heart

2293.14 -> attacks in particular or myocardial

2294.88 -> infarction is where as I said at the

2297.579 -> beginning the coronary artery gets

2300.16 -> blocked and therefore there is

2302.44 -> insufficient oxygen to the um the muscle

2305.92 -> that that artery supplies and you get

2309.94 -> pain and damage and eventually death of

2313.3 -> these cells which that artery supplies

2321.46 -> now in terms of the symptoms people get

2323.079 -> from heart disease there are several and

2327.04 -> there are three broad conditions I think

2329.079 -> it's worth talking about the first is

2331.119 -> angina then unstable angina and then the

2334.96 -> most serious of these myocardial

2337.54 -> infarction or heart attack

2340.119 -> so angina which is the narrowing of the

2342.22 -> blood vessel but it is stable occurs

2345.7 -> generally on exercise or other things

2347.98 -> that stress the heart

2349.72 -> it's typically chest pain but they may

2352.18 -> have jaw pain they may have arm pain and

2355 -> they may have shortness of breath or

2356.8 -> other things can happen with it but the

2359.859 -> thing about stable angina is that it is

2362.44 -> predictable so someone will find that

2364.66 -> they get angina for example they get

2366.94 -> their chest pain if they walk up two

2368.74 -> flights of stairs and if they rest then

2371.68 -> the angina goes away and if they walk up

2373.66 -> another two flights of stairs back it

2375.82 -> comes

2378.16 -> unstable angina and myocardial

2381.94 -> infarction

2383.94 -> heart attack

2386.52 -> are a similar type of pain other

2389.26 -> symptoms I'll come on to but these occur

2392.619 -> or continue at rest so maybe someone

2394.9 -> started with a typical angina as they

2398.2 -> walked up the stairs but then just the

2399.52 -> pain doesn't go away this is a medical

2402.94 -> emergency

2404.68 -> and a sudden shortness of breath

2407.079 -> cleanliness dizziness or nausea

2410.339 -> even in the absence of chest pain can be

2414.22 -> possible symptoms not everybody who has

2416.98 -> a heart attack has pain although the

2419.44 -> great majority do

2424.599 -> now there are many possible causes of a

2428.02 -> market of chest pain and myocardon

2430.72 -> function hashtag is only one of them

2434.38 -> but the things which would people would

2436.9 -> be thinking about when assessing with a

2439.78 -> paramedic if a nurse if a doctor is

2441.88 -> assessing first thing are the symptoms

2444.339 -> and the history had what brought it on

2446.44 -> including age so the same kind of chest

2449.079 -> pain in someone who's 30 has a very

2451.18 -> different probability in much lower

2452.8 -> probability of being out attack for

2454.24 -> example than someone who's in their 70s

2459.28 -> so the symptoms in history the next

2461.32 -> thing is the heart tracing

2464.38 -> and there are certain changes on the

2466.599 -> heart particularly what's called St

2468.88 -> elevation whether where after the little

2471.82 -> beat the QRS complex uh the uh the

2476.26 -> Baseline goes up above where it normally

2478.9 -> should be which signify a significant

2482.98 -> heart attack

2484.359 -> and finally and importantly blood tests

2487.119 -> these have changed over time but now in

2490.18 -> the UK and most places globally the key

2493 -> blood test is something called troponin

2496.06 -> and if those are raised they demonstrate

2498.579 -> uh usually damage to the heart

2503.079 -> so if someone comes in with possible

2504.64 -> heart attack symptoms there are broadly

2506.92 -> three possibilities

2508.48 -> the first one is that this isn't from

2510.82 -> the heart

2512.56 -> now some of the things which feel really

2515.14 -> bad in terms of pains in the chest are

2517.3 -> not dangerous at all very unpleasant but

2520.119 -> not dangerous they're not from the heart

2521.38 -> and they don't have any uh particular

2523.619 -> long-term implications for example

2525.52 -> spasming of chest or muscles some things

2529.06 -> may be dangerous but are not heart

2530.32 -> attack something like a clot in the lung

2532.3 -> can cause pain in the chest so there are

2535.839 -> serious things that aren't art attacks

2537.52 -> which are also need treatment

2540.4 -> uh but in any case these are not

2543.4 -> myocardial infarction

2545.44 -> the second possibility which is the

2547.24 -> Other Extreme in a sense is when the

2549.76 -> paramedic the nurse the doctor does an

2551.74 -> ECG and what they see is this St

2554.68 -> elevation and what you can see in the

2557.079 -> right is the normal little bump P wave

2561.16 -> the QRS and then there's a flat area and

2563.859 -> then the T wave which follows that

2566.099 -> follows that in a St elevation that area

2570.28 -> is raised and this indicates that

2573.7 -> someone has had a significant heart

2575.5 -> attack called an st elevation myocardial

2579.16 -> infarction shortened to stemi

2582.52 -> and these are likely to need urgent eye

2585.46 -> emergency

2586.859 -> interventions including

2589.38 -> physical ones like catheterization

2593.74 -> third possibility is you may get the

2595.48 -> typical symptoms and there may be some

2597.7 -> changes in the ECG or there may not be

2600.72 -> but what you don't have is the St

2603.76 -> elevation and in general if there's a

2607.119 -> significant change to the troponin blood

2608.8 -> test

2609.599 -> this is thought to be a and what's

2612.099 -> called an end stemi a non-st elevation

2614.52 -> myocardial infarction it's a heart

2616.359 -> attack but a smaller one in general and

2619.359 -> if it's not it is very typical but they

2623.02 -> don't have the the blood changes it

2625.599 -> tends to be called unstable angina so

2628.54 -> the heart muscle hasn't died or been

2630.819 -> seriously damaged but there's no doubt

2633.76 -> that there's a very very near Miss

2636.099 -> I'm putting those together because

2637.599 -> although they are different they are

2639.4 -> treated broadly the same so those are

2641.74 -> the three uh broad outcomes uh not hot

2645.28 -> from the heart stemi

2647.14 -> SD elevation Mark hard infarction or

2649.839 -> nstemi or unstable angina

2654.339 -> fortunately the treatment of heart

2656.68 -> attack has substantially improved

2660.54 -> over the last few decades

2664 -> in the 1960s this thought it's estimated

2667.18 -> that around seven in ten people died of

2669.819 -> myocardial infarction uh now uh seven in

2673.06 -> ten people survive and if people get to

2675.4 -> hospital uh the outlook for most people

2677.38 -> the myocardial infarction is actually

2678.76 -> now very good

2680.74 -> and this has been achieved by a series

2683.14 -> of scientific advances each one of which

2686.319 -> has lowered the chance that someone who

2688.48 -> has a myocardial infarction will go on

2691.18 -> to die from it and I'm just going to

2693.28 -> highlight one because it's a

2694.72 -> particularly

2696.119 -> spectacular example of a very important

2699.22 -> trial that has changed practice in this

2701.079 -> area this is a trial from 1988 so first

2704.14 -> a while ago and it was done about 17 000

2707.26 -> patients this is a big trial done in

2709.96 -> people with heart attack which uh with

2712.66 -> uh with st elevation mi in the main not

2715.78 -> absolutely exclusively

2717.76 -> and the first thing they found was at

2720.22 -> that stage routine care

2722.8 -> was associated with 13 mortality so 13

2726.88 -> of people would die

2729.22 -> who had a heart attack

2731.14 -> and by this stage several things have

2732.819 -> already been done blood thinners uh beta

2735.16 -> blockers variety of other things were

2736.48 -> already being used so things had

2738.339 -> improved already

2740.74 -> if people were randomized to aspirin

2743.26 -> just one aspirin tablet and then aspirin

2746.5 -> to follow up mortality dropped by 20

2749.74 -> percent

2751.9 -> and then if they were given a clot

2753.94 -> busting drug and the one that was then

2755.619 -> used at that stage of something called

2756.819 -> strepto kinase which broke up clots uh

2760.54 -> mortality was also reduced by 20 percent

2764.68 -> and if you put those two drugs together

2766.54 -> the mortality rate from a heart attack

2768.579 -> dropped by 40 so there's one trial

2771.76 -> demonstrated that two drugs could lead

2773.92 -> to a reduction of 40 percent mortality

2776.8 -> and improvements of kidney continues

2778.54 -> since then but this was a particularly

2780.579 -> important Milestone and uh 30-day

2783.88 -> mortality is now less than five percent

2787 -> and can be down to two percent so this

2789.339 -> is a really major change because some

2791.38 -> people sadly die at home before or on

2793.839 -> the way to hospital and don't get as far

2796.18 -> as the hospital

2799.72 -> now worth pausing on the two drugs that

2802.18 -> I've just talked about because they are

2803.5 -> are important the first is one that that

2807.099 -> almost everybody will have in their

2809.26 -> medicine cabinet uh aspirin

2811.72 -> and this was really the first drug that

2813.88 -> was also found to have activity against

2815.44 -> platelets

2817.359 -> platelets are uh bits of the blood which

2820.78 -> are involved in clotting and so by using

2823.48 -> a drug which reduced platelet activity

2825.46 -> the risk of clotting was significantly

2827.74 -> reduced now this is a very old drug uh

2831.46 -> willow bark which is where this

2832.839 -> originally came from was used for fever

2835.24 -> and aspirin does work against fever from

2838.42 -> at least the time of Hippocrates so

2840.7 -> that's about 400 BC so this is a very

2842.8 -> old drug

2844.5 -> it was promoted for fevers in the UK in

2848.38 -> the 1760s

2849.96 -> and

2851.94 -> by stages got to the point where it was

2855.04 -> commercialized and the Bayer company

2857.04 -> took it on initially from about 1897 and

2860.56 -> called it aspirin

2863.02 -> used a lot against pain and also against

2868.42 -> fever

2870.16 -> the first trial to start for heart

2872.92 -> disease started in 1971 and

2876.94 -> um I think people were really astonished

2878.619 -> by the fact that a drug that was so

2880.48 -> widely used and had been in everyone's

2882.24 -> grandparents medicine cabinets just that

2884.38 -> not their own had was turned out to have

2886.72 -> such uh remarkable improvements in heart

2890.079 -> disease mortality

2894.94 -> um so several other drugs have

2896.44 -> subsequently come along which are also

2899.099 -> helped to reduce platelet activity and

2903.64 -> now if someone has a heart attack they

2907 -> will generally be given two antiplatelet

2909.28 -> drugs aspirin and one of these ones so

2912.52 -> drug for example like called

2915.24 -> Clopidogrel is quite usually quite often

2918.88 -> used

2920.46 -> in people who've had a heart attack or

2922.78 -> about to have cardiac procedures of

2925.24 -> various sorts

2927.099 -> and they're usually given with aspirin

2928.599 -> in the long run people will often

2930.22 -> continue on aspirin indefinitely

2933.04 -> but they're mainly working against these

2935.14 -> tiny dots you see on the blood film on

2936.94 -> the right which are platelets

2939.94 -> so thrombolytic clot busting drugs

2943.3 -> are the next drug I just want to talk

2945.46 -> about was the other one in that Isis

2947.98 -> trial I talked about the first was

2950.02 -> streptocinase

2951.96 -> this uh is was is actually produced

2954.94 -> Naturally by bacteria particularly beta

2957.88 -> hemolytics streptococcus it was isolated

2960.579 -> in the 1930s and the bacteria probably

2963.28 -> does it to break down clots so that it

2964.96 -> can move around the body can not be

2966.7 -> trapped by clots

2968.8 -> who's isolated used for breaking down

2971.02 -> clots medically and then subsequently

2973.18 -> some new drug classes the TPA drugs

2978.22 -> usually abbreviated as

2980.22 -> have been used but what all of them do

2983.079 -> is they break down recently formed clots

2986.319 -> and I've Illustrated this on the right

2988.48 -> just because I think it just shows the

2990.28 -> point on the left what you've got is at

2993.88 -> the hand of someone where one of their

2995.319 -> arteries has clotted off and then

2997.96 -> they're given one of these drugs and

2999.88 -> then you can see on the right the same

3002.64 -> x-ray of the blood flow through the

3004.92 -> through the hand has completely gone

3007.14 -> back to normal so they can break down

3008.64 -> these clots and lead to the blood flow

3011.579 -> going back to what happened before the

3013.14 -> clot was formed

3016.56 -> but what has been the next stage of

3019.74 -> development is that for most people who

3022.56 -> have an st

3024.079 -> raise a severe myocardial infarctional

3027.599 -> heart attack as stemi uh will now be if

3031.079 -> they're within a relatively short period

3032.94 -> of the symptoms starting move straight

3035.099 -> on to have an angiogram which is where

3039.54 -> uh the the uh they put some down and

3042.24 -> look at the blood vessels of the heart

3045.06 -> and then if there's a narrowing that

3046.92 -> they can

3048.26 -> increase or if there's a blood clot they

3052.319 -> can remove there will be direct action

3054.9 -> to widen the arteries immediately and

3058.8 -> therefore relieve the oxygenation of the

3061.8 -> heart and what happens is people put in

3064.26 -> a a sort of small probe that's got a

3067.44 -> balloon in it and around it a mesh and

3070.26 -> then when it's gone through the

3072.119 -> narrowing that is expanded and the mesh

3076.02 -> increases is and then the balloon is

3078.42 -> collapsed again removed and the mesh is

3081.24 -> left holding the blood vessel open

3084.48 -> and this is used both in emergencies and

3086.76 -> as I come on to in people treating

3090 -> symptoms of angina

3092.46 -> but in terms of improvement in heart

3095.52 -> outcomes this has been another very

3098.4 -> major step forward in terms of our

3100.559 -> management of heart attacks

3104.64 -> now this procedure has been around for a

3108 -> while but it's been steadily improving

3109.44 -> in its quality over time a whole series

3111.78 -> of different improvements have occurred

3114.38 -> two I'd particularly like to identify

3117.319 -> drug eluting stents ones that actually

3119.94 -> produce drugs and make it less likely

3121.92 -> they'll be clotting around that Network

3125.04 -> and biodegradable stents where some of

3127.44 -> them may actually just disappear over

3129.839 -> time

3130.859 -> but the improvements are occurring as I

3133.14 -> say the whole time

3138.059 -> now how rapidly uh you want someone we

3142.14 -> or we would want to go to stenting

3145.619 -> depends on the situation

3147.839 -> if a patient has an st elevation

3150.559 -> myocardial infarction a stemi they will

3153.3 -> usually if it's recent onset go directly

3155.64 -> to having angiogram to see if something

3159.119 -> can be done directly and if that can't

3162.359 -> be done rapidly they will probably have

3164.7 -> a clot busting drug

3166.7 -> as I've previously described

3170.52 -> if they have an end stemi or an unstable

3172.74 -> angina they'll often quite rapidly over

3175.92 -> days two weeks go for angiogram and if

3179.579 -> necessary

3180.8 -> procedures

3182.72 -> but that may not be immediate in fact it

3185.099 -> usually is not immediate at least in the

3187.38 -> UK

3188.22 -> and then if someone's just got stable

3189.9 -> angina where as I say if they walk a

3192.66 -> particular distance or go up a certain

3194.099 -> number of stairs they get the symptoms

3195.559 -> they'll often be investigated with an

3198.72 -> angiogram and may have stents but these

3202.319 -> are done as more of an elective

3203.579 -> procedure so not at an emergency

3209.099 -> there has been an increasing move to

3211.559 -> make sure that people who don't need to

3213.839 -> have

3214.76 -> a coronary artery procedure don't have

3218.88 -> one and most widely thing that's used at

3222.18 -> the moment is coronary or cardiac CT

3226.859 -> and this is a much this is a essentially

3229.619 -> almost entirely not completely Untitled

3231.66 -> uh non-invasive approach to looking at

3235.26 -> narrowing of the coronary artery and if

3237.3 -> it's normal people then don't need to go

3239.339 -> on to have a puncture in either their

3241.26 -> wrist or groin and a um a procedure

3246.119 -> where something dies squirted into their

3248.46 -> heart so it's a way of screening people

3250.68 -> out essentially who have typical

3253.38 -> symptoms but if they have significant

3255.9 -> problems seen on that or if that's not

3259.38 -> available or not appropriate then

3261.3 -> they'll go directly to PCI to the Angie

3266.72 -> angiography and angioplasty where we put

3270.3 -> in a balloon

3271.7 -> if they have appropriate blood vessels

3275.4 -> not it very much depends on the

3277.079 -> individual and their own set of problems

3282.059 -> the other thing which can be done to

3284.46 -> um uh so angioplasty is a way of going

3288 -> through the narrowing and then putting a

3292.02 -> stent in so that the blood vessel

3294.3 -> continues an alternative way of doing

3296.94 -> this is coronary artery bypass grafting

3300.54 -> and this can be taking one of the

3303.24 -> arteries

3304.52 -> for example the internal mammary artery

3307.46 -> that from another bit of the system

3309.54 -> plugging it into the heart or it may in

3312.359 -> some cases involve taking veins and

3314.579 -> providing a bridge around a particular

3317.46 -> narrowing of the blood vessels

3321.359 -> um camaraderie bycast grafting remains

3323.339 -> an extremely effective and important

3326 -> operation but it's a major operation

3329.52 -> um usually people will spend several

3331.26 -> it's involves splitting the chest open

3333.24 -> in most cases although there are newer

3335.94 -> techniques certainly may mean time and

3338.22 -> intensive care and quite a period of

3340.079 -> time to recover

3341.28 -> so it's highly effective but not without

3343.859 -> risk and therefore the choice between

3348.02 -> angioplasty doing things within the

3350.7 -> arteries and the surgery is has to be

3356.28 -> done on a case-by-case basis and if

3359.04 -> someone's got relevant things the

3362.76 -> cardiologists and the surgeons will come

3364.8 -> and talk to them about which they think

3366.18 -> is most appropriate

3368.7 -> but over time uh and this is just UK

3372 -> data on the top line what we've got is

3374.94 -> the number of people who are having the

3378.02 -> angioplasty PCI and on the bottom uh

3381.72 -> what we've got is a number of people

3383.339 -> having a coronary artery bypass

3385.28 -> operation and as you can see they're

3388.079 -> still used but many more people will

3391.02 -> have this relatively straightforward and

3392.76 -> quick procedure often people can go go

3395.22 -> home if they I mean it electively the

3398.16 -> same day or the next day

3399.74 -> compared to this major operation

3407.04 -> and then in those who've had any kind of

3408.9 -> cardiovascular event whether it's angina

3410.52 -> or a heart attack they'll generally be

3412.5 -> put on several drugs they'll be put on

3415.619 -> antihypertensives if they're not already

3417.72 -> on them and we've talked about those

3419.4 -> already they'll be given drugs to reduce

3422.099 -> their cholesterol particularly statins

3425.16 -> they'll be given one of the drugs or two

3426.96 -> of the drugs acting uh or more acting on

3430.319 -> the

3431.119 -> hormonal system and things like beta

3435 -> blockers and ACE inhibitors which I've

3436.5 -> again talked about already and they'll

3439.98 -> usually be given an antiplatelet drug

3441.48 -> aspirin or others

3443.94 -> and they'll have this group of drugs and

3445.619 -> it seems a lot of drugs but all of them

3448.02 -> have really clear evidence of benefit

3450.359 -> and additive benefit so the combination

3453.119 -> is better than any one of the drugs

3455.04 -> alone and that significantly reduces the

3457.74 -> risk of them having another major event

3459.859 -> uh subsequently

3463.98 -> I'm just going to talk about one more

3465.9 -> drug class and that's because quite a

3468.24 -> lot of people again will be on them now

3470.88 -> or will know people on them and that's

3472.74 -> things a drug class called nitrates this

3475.319 -> is an old drug it was originally noticed

3477.839 -> the people who are handling

3479.359 -> nitroglycerin explosives had symptoms

3482.88 -> and this has been known since the uh in

3486 -> the mid-1800s and it was recognized as a

3490.5 -> treatment for angina from the 1870s at

3495.359 -> the end of the 1870s

3497.88 -> what they do the nitrates do is they can

3500.7 -> be given by a variety of mechanisms the

3504.24 -> most common ones are either a spray or a

3506.099 -> tiny tablet under the tongue for very

3508.68 -> rapid relief so if someone's got angina

3510.8 -> they can give them a prevention by a

3513.839 -> drug by Mouse which is gradually

3515.96 -> released over a period of time or

3518.16 -> they've been given us a patch those are

3520.319 -> the most common ones there are there are

3522.599 -> other ways of giving them those are the

3523.799 -> most common and what they do is they

3527.339 -> relax the coronary arteries and indeed

3529.98 -> other arteries now they don't unlike the

3533.22 -> other drugs I've talked about they don't

3534.839 -> change the long-term Outlook but what

3538.14 -> they do do is reduce symptoms so they're

3540.66 -> very important drugs as part of symptom

3542.94 -> relief

3546.059 -> two other points before I summarize what

3550.5 -> we've talked about

3552.48 -> the first is most people with angina or

3556.619 -> very high proportion of people with

3557.76 -> angina have it due to narrowing of the

3560.4 -> blood vessels of the heart

3562.799 -> and those will be seen on angiography or

3565.38 -> on CT or on MRI

3568.98 -> however it is possible for people to

3571.079 -> have angina which is still ischemic

3572.76 -> heart disease but with normal coronary

3575.22 -> arteries

3576.319 -> and there are a variety of reasons for

3579.299 -> this but two in particular just worth

3581.339 -> highlighting are people who have

3583.26 -> coronary artery spasm so the artery is

3586.619 -> normal but it's spasms and this causes

3588.599 -> ischemia and the second is microvascular

3592.44 -> angina where it's not in the big vessels

3595.5 -> the big coronary arteries but in the

3597.54 -> much smaller vessels and the treatment

3599.04 -> for those is different than you if you

3601.68 -> had a particular narrowing in one of the

3604.02 -> coronary arteries

3606.359 -> so I'm making that point just because

3608.22 -> some people like angina have to have

3610.26 -> slightly different treatments than some

3612.24 -> of the ones I've just been talking about

3613.44 -> all for slightly different reasons

3615.54 -> the second thing I thought it was worth

3617.119 -> highlighting it was inflammatory

3619.92 -> conditions

3621.9 -> we've known for a long time that

3624.299 -> increasing inflammation increases the

3626.94 -> risk of cardiovascular disease it does

3629.88 -> it does this at least two broad ways

3633.079 -> people who have inflammation it probably

3636.24 -> accelerates the buildup of

3638.96 -> atherosclerosis and the development of

3642.38 -> cardiovascular disease and for example

3645.66 -> air pollution this is one of the ways in

3647.339 -> which it is thought in fact to have its

3649.619 -> activity

3650.7 -> and secondly if people have an acute

3652.799 -> inflammatory event which should include

3655.559 -> several different medical conditions but

3657.72 -> probably most commonly infections this

3660.54 -> increases the risk that people will have

3663.299 -> an ischemic heart acute event such as

3667.26 -> unstable angina or myocardial infarction

3669.599 -> we've known this for many years many

3671.7 -> infections can cause this the more

3674.16 -> severe the infection

3675.859 -> the bigger the chance that someone will

3678.48 -> have a subsequent heart attack and the

3680.339 -> longer the period of time which may go

3681.72 -> out for weeks or months that they are at

3684.299 -> increased risk so a very severe

3685.92 -> pneumonia for example in intensive care

3688.38 -> has a much higher risk than someone

3690.54 -> who's just has mild pneumonia and that

3693.9 -> has higher risk than someone has uh

3696.48 -> relatively minor symptoms and the most

3698.52 -> reason to those of course is covid where

3701.04 -> after severe covid we know that there is

3704.76 -> a significantly increased risk of

3706.859 -> myocardial infarction and for slightly

3710.28 -> less severe yeah but still significant

3712.26 -> covered a lower risk but still a risk

3714.839 -> nonetheless

3715.92 -> so inflammation and heart disease go

3719.4 -> quite strongly together

3721.74 -> and then finally

3723.799 -> the I like to just conclude by tying

3727.92 -> together the various points I've made

3731.04 -> we've really seen remarkable

3732.54 -> improvements over the last many decades

3735.839 -> in ischemic heart disease coronary heart

3739.319 -> disease

3740.819 -> and these have been a whole series of

3743.94 -> incremental improvements in primary

3746.22 -> prevention in secondary prevention and

3749.16 -> in treatment in primary prevention these

3751.079 -> are included reductions in smoking

3753.68 -> reductions in air pollution in some

3756.9 -> cases systematic improvements in

3759.359 -> exercise

3761.839 -> improvements in terms of diet

3763.559 -> particularly reductions in salt

3766.2 -> in second intervention we've now got a

3768.18 -> very wide range of things we can do to

3770.28 -> reduce people's blood pressure if they

3771.96 -> have hypertension the key thing is to

3773.339 -> identify it and to reduce cholesterol

3776.22 -> for example statins

3778.619 -> and then treatment of acute events

3781.26 -> particularly heart attacks myocardial

3783.059 -> infarction have really substantially

3785.099 -> improved where the chance that someone

3787.14 -> if they call 999 and get a healthcare

3792.119 -> rapidly can reduce their risk of dying

3795.9 -> or having long-term problems as a result

3798.24 -> have really

3800.4 -> substantially improved through

3802.5 -> combinations of drugs and emergency

3805.68 -> stenting and for the right people

3808.28 -> surgery when that is needed

3811.68 -> so many things have come together to

3814.2 -> improve this many of those improvements

3816.78 -> will continue for example the reduce the

3818.78 -> continuing reduction in smoking is a

3823.079 -> major positive thing but there are some

3825.9 -> headwinds and that's probably the most

3827.22 -> important of those is the steadily

3829.079 -> Rising obesity where people are living

3831.359 -> with obesity and living with overweight

3833.94 -> because of the environments that they

3835.98 -> live in

3837.119 -> so there's a lot in the future to look

3840.42 -> forward to drugs will improve procedures

3842.579 -> that improve but I think we should

3844.079 -> acknowledge there are also some things

3845.52 -> that we need to do to tackle uh these

3848.579 -> other risk factors which are are going

3851.52 -> to lead to significant numbers of people

3853.2 -> having preventable heart disease thank

3855.96 -> you very much

Source: https://www.youtube.com/watch?v=TGK5ryAuKhg