AF Association Pulse Check Event

Myself and some of my colleagues recently relinquished a Saturday off, and braved the icy cold (read: British) weather to try to meet with the public, and raise awareness of atrial fibrillation through a project spearheaded by the AF Association.

I didn’t organise the event, but was kindly invited along, and jumped at the chance to help some of my amazing Cardiology workmates by checking pulses, and recording rhythm strips using the AliveCor mobile ECG monitor (which I have previously reviewed here).

AF is an atrial arrhythmia, wherein the sinus node does not cause appropriate, rhythmic depolarisation as it normally would. Rather, multiple foci activate, facilitating a motion akin to ‘quivering’, which raises the risk of embolism through the inefficient pushing of the blood into the ventricles. It’s an incredibly dangerous problem if left untreated, so it’s vital that it gets detected, and preferably this would happen early.

NormAF

I go into detail about AF, it’s mechanisms and ECG presentation in this study guide, so have a look at that if you want to understand it further.

As you may or may not be aware, atrial fibrillation is, globally, the most common clinically significant cardiac arrhythmia, and it is thought that whilst 1.2 million people (a conservative estimate) in the UK are known sufferers of the sinus node disorder, a 500,000 have it, and live undiagnosed. The estimated cost of AF to the NHS was somewhere in region of £2.2 billion, in 2008, and given that the prevalence of the arrhythmia has increased year on year, this number may well be higher now.

Obviously, this is far from an exhaustive exploration of AF, but hopefully it gives some insight into why it’s so important to detect and treat, and why initiatives such as this one are a good idea.

We set up shop in Frome’s Westaway shopping centre at around 10am, where members of the public who’d read about the event in the local newspaper were already queueing. We four clinical scientists proceeded to advise and check 85 people throughout the day. We had a surprise visit from Cardiologist’s Kitchen, too!

 

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Mary, of Cardiologist’s Kitchen fame, showed up to say hello!

 

Many people we talked to had little-to-no idea what the condition was, its risks, or how it was treated, so we used literature, ECG examples, and a scale model of a heart, to educate, and taught people how to check their own pulse before performing quick rhythm recordings which we analysed on the spot. More than a few people who attended had known AF, and their questions largely involved their current treatment, and the potential impact AF might have on their life. Most, however, visited so they could get checked over, hopefully putting their mind at rest, and learning something in the process.

We didn’t find any new atrial fibrillation (although we did discover two cases of previously undiscovered AV Block), but of equal importance to arrhythmia discovery, was the community engagement, particularly in a public setting. In clinics it’s easy to fall into a cycle with patients, due to schedules and time pressures, and whilst we all try our hardest to make sure everyone is treated individually, seeing the problem before the person is always possible. Interacting with patients on “their turf” meant the ball was in their court, if you like, and the sheer volume of people who expressed an interest meant it couldn’t have been further from a wasted day.

The feedback we received was overwhelmingly positive, and there was a recurring theme in the gratitude people felt for the healthcare environment coming to them, as oppose to the other way around. Many of those to whom we chatted understand the strain that hospitals and GP surgeries are under, and felt that visiting to be checked for AF, and other such things, would be inappropriate. In many ways, I suppose they’re right, too; regardless of the importance of finding these things, especially as they do not always present with obvious symptoms, healthcare centres, unfortunately, cannot cope with the demand a service such as this would present. To this end, I was glad to have ventured out to participate in this, an outdoor clinic of sorts, and educate the public on what to look for, as well as how they can guage their own heart rhythm and take some more control over their own health. I sincerely hope to do it again soon!

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The AFA is a fantastic charity, so it’d be great if you were to find out a bit more about them by visiting them here.

I’d like to thank my colleagues for asking me to participate, and generally being fantastic people, those who visited us and asked lots of challenging questions, and the kind souls who bought us ginger ale and flapjacks when the temperature reached what *felt* like sub-zero levels.

The statistics used in this post are taken from the BHF. If you want to take a look for yourself, visit the British Heart Foundation, here.

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Cardiologist’s Kitchen Workshop #1

When Cardiologist’s Kitchen put forward its Health Foundation application, it stated that it would run patient workshops at Neston Park Farm & Kitchen to engage patients with professionals and good, healthy food. 

Neston head chef Steve Mercer cooked a fabulous 2-course meal for guests, and after a brief interlude by Ali Khavandi and Mary Fifield, there were some indroductions for myself, nurses in Cardiac Rehabilitation and the CardioFITr team (more on these guys in the future), as well as local food producers Fussels, and Fresh Range, whose ingredients made up some of the food.

The workshop wasn’t about us, however; it was a patient-centred event, so the real stars of the evening came in the form of the service users themselves. A select few were gracious enough to share their stories regarding the improvements that Cardiologist’s Kitchen had made to their lives. One had lost a considerable amount of weight and thus, could do normal, everyday things that she had previously found difficult as a result of her (now greatly improved) angina, another was part of the CardioFITr programme, which, run by healthcare professionals and in conjunction with Cardiologist’s Kitchen, uses evidence-based science and medicine to improve physical fitness and promote a continued change in lifestyle. He too, had seen a considerable and positive reduction in weight and blood pressure, and was almost ready to cease his medication for the latter. This is a particularly palpable achievement for the scheme, and proves it actually supports patients to persevere.

A 2010 paper by Curtis Triplitt of The University of Texas titled Improving Treatment Success Rates for Type 2 Diabetes cites clinical inertia as the biggest barrier to treating the condition, so by beginning to see positive results in this manner, initiatives like this really do matter with regards to health and wellbeing. It’s long been known that diet and exercise have a massive impact on health, but anyone who’s struggled with dieting, knows that support is one of the most important factors in sticking to whatever regime one is using to better their health.

As I chatted to patients and heard their stories, I became aware of just how thankful they were for Cardiologist’s Kitchen, and the positive impact it was having on their lives. Many of them had been rushed to the Catheterization Laboratory with a suspected infarct, and regardless of the findings had assumed their lives were irrevocably altered. The advice and specific support given by CardioKit meant they were now turning a corner and seeing measurable changes in their own health. The best part was knowing that they had essentially been encouraged to do it themselves with their own willpower. 

Cardiologist’s Kitchen can be found on TwitterFacebookInstagram and the web.


Review: The Bunch of Grapes

14 Silver Street
BRADFORD ON AVON
BA15 1JY
To book, call 01225 938 088

Price: Lunch £20 (3 courses), Dinner £6.50-£18.50

I (probably) know exactly what you’re thinking; “why is a a cardiology website reviewing a restaurant?”

The reasons are three-fold: firstly, before I began this career, I was a professional chef, and as such, I know my way around food and kitchens. Secondly, The Bunch of Grapes features a menu developed in part by Ali Khavandi, the man behind Cardiologist’s Kitchen, and finally, I was invited to an evening hosted by Ali himself and project manager Mary, and we ate some of the food, so it seemed entirely appropriate.

I’ve always had a lot of love for Bradford on Avon. It looks like the generic description of a town in this country that you’d receive if you were to ask an American to describe “England-but-not-Central-London” – picturesque, quaint, cobbled, Downton Abbey, etcetera. Its subtle gentrification has given rise to a few more shops with the word “craft” in the name, but it isn’t a detriment to the town, and I didn’t see pulled pork on any menu as I wandered around. In fact, this shift has kick-started the local economy, and allowed middle-to-high end gastropubs like The Bunch of Grapes to open.

The eatery sits at the end of a terraced row, and looks rather unassuming from the outside. Once through the doors, however, oak furniture leads you past the deceptively wide casual dining/drinking area, and into the bar.

Now, if you’ve ever been to an establishment that serves both Butcombe Bitter and duck confit (read: gastropub), you’ll know two things are an absolute certainty:

1) Refreshments are the usual fayre, encompassing local ciders, lagers, ales and fancy-looking soft drinks (if you’ve ever tasted an “artisanal” cola, you’ll be well aware that they’re not bad, but they aren’t normally any better than the usual suspects). There isn’t a huge selection of each, but all are reasonably priced and work well with the surroundings and menu.

2) The bar area is found before the more formal dining room, which features smaller, more intimate tables and is far enough away that one can avoid the loud, busy Friday and Saturday evening drinkers.

Both of these things are true here, but The Bunch of Grapes still has a certain individuality to it.

The restaurant offers two main types of menu, one that presents as a kind of upmarket but classic pub food list, and another, more refined selection that seemingly draws more influence from French cuisine. There exists a third nestled in amongst them, however: the CardioKit menu. Consultant Interventional Cardiologist, Ali Khavandi and head chef Steve Carss have joined forces to create a professionally cooked, heart-healthy range of dishes for patrons. Dishes which I was invited to sample.

First up, the whole roast poussin. It arrived on a heavy, ceramic plate (not a wooden board, thank heavens), and despite having a rather downplayed menu description, was something of a delight! Liberally doused in apple and wholegrain mustard during cooking, and stuffed with whole sprigs of rosemary, the slow roasting process meant that not only was it incredibly tender, but the flavour of both the baste and the rosemary permeated through the wonderfully textured skin and the soft meat. The accompanying mixed leaves and ash roasted leeks were a more underwhelming by comparison, but they weren’t a bad thing by any stretch. Besides which, they were never really going to be the star of the dish. Both elements combined didn’t quite sate my hunger as I wished, and could have done with a starch to accompany them, but it didn’t detract from what was there.

Whole chicken picked clean, dessert was served, and it was another knockout. Indulgence and healthy don’t usually go together when dining out, so it was a refreshing change to be presented with just that. A sweet, roasted half peach served on a just-bitter-enough berry compote. On top of that was a big scoop of vanilla ice cream and a smattering of cress, because healthy eating is boring without something that feels a lot naughtier than it actually is.

In all honesty, it’s just nice to eat a dessert in a gastropub that isn’t cheesecake, or something that’s been baked in the same ceramic bowl that you eat it from. The peach had a lovely crunch to it, and given that the rest of the dish effectively existed as a cold sauce, it summed up both courses; this was an exploration of textures as much as it was of healthy flavours.

I didn’t know what to expect from the CardioKit menu items, to be completely truthful, as I doubted how versatile it was possible to be to justify charging restaurant prices for healthy food, but I was (and still am) happy to be proved misguided. I worked in kitchens that revelled in being an unhealthy treat, but I almost find myself regretting not having brought something like this to customers myself. As a result, I’ll be championing The Bunch of Grapes and Cardiologist’s Kitchen, and I’ll be back to taste the rest of the menu.

Oh, and CardioKit patients get 50% off their food, so there’s no excuse for those in the South West not to visit.

For more information abut both The Bunch of Grapes and Cardiologist’s Kitchen, visit their websites:

cardiologistskitchen.com

thebunchofgrapes.com

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Cardiologist’s Kitchen

Barely a month goes by without a national newspaper displaying words like “science says _________ is bad for your health”.

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Don’t get me started…

I concede that *some* of these headlines might be correct, but it’s worth taking them with a pinch of salt, if you’ll pardon the pun; firstly, “science” isn’t an all-powerful being that performs every possible study single-handedly, so it’s difficult to know exactly who has put forth the particular claim and how many people through whom the information has passed before it gets to the news media, and secondly, “science says…” doesn’t necessarily mean it’s double-blind, peer-reviewed, evidence-based or ethically funded, so between the debunked results of Andrew Wakefield’s infamous autism/ MMR study and big pharmaceutical companies potentially protecting their interests by omitting unfavourable study data, it isn’t a great idea to believe that eating bacon causes your lips to fall off, simply because the junior science editor for The Daily Express tells you it does.

What, then, do you believe? Nobody wants to find themselves being brought into a Cath Lab, and they don’t want the uncertainty that comes with not knowing whether the food that they’re eating is going to help put them in that position. This is where Cardiologist’s Kitchen comes in; Consultant Interventional Cardiologist Ali Khavandi would rather intervene well before you’re being consented for an invasive procedure, and addresses issues with cholesterol, weight, blood pressure and diet by way of a pre-emptive strike using evidence-based dietary and lifestyle changes.

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Cooking Cardiologist, Ali Khavandi

Not unlike this site, the initiative began as a humble health-based blog in 2015, featuring advice and recipes, and was borne through personal, clinical experience. Khavandi’s passion for both cardiology and cooking pushed him to create a resource, and seek a wider market using the same mechanisms employed by the media and the food industry, but using an evidenced basis in cardiovascular wellbeing. The Health Foundation has since granted the Cardiologist’s Kitchen project an award that has allowed the trial of this innovative approach to healthcare to really take off!

Currently, Cardiologist’s Kitchen has partners in GP surgeries, a restaurant and various South West England food suppliers that combine to make conduit for the project’s entire message. Despite still being in relative infancy, Cardiologist’s Kitchen has made headway, and continues to open up avenues via which to get the message out there.

CardioKit

Patients with new or existing high blood pressure can get a CardioKit pack at affiliated GPs. I got one to sample, which contained some money off vouchers, health advice and information about the project. In addition, The Bunch of Grapes gastropub, found in Bradford on Avon, just outside Bath, offers some menu heart-healthy menu items devised by both Ali Khavandi and head chef Steve Carss (I’ve sampled some of these too; they’re delicious).

Chinese Chicken
The recipe for this Chinese chicken and more, is available on the Cardiologist’s Kitchen website 

The website is the real central feature of the initiative, with healthy recipes, incentives for transforming your attitude to heart health, and evidence-based discussion on food fact, cutting through scaremongering in the bad science which can sometimes surround food.

CardioKitTeam

Rather marvellously, it encourages the use of local suppliers by offering deals and home delivery on their seasonal produce. They’re also in the process of developing ready  meals specifically designed to improve cardiovascular health.

By using CardioKit, the aim is to lessen the need for medication, and support local business as well as your own heart. If you’re reading this, and it applies to you as a patient, then I urge you to have a look. If you’re a practitioner, definitely do the same, and get in contact with the CardioKit team to see how you can get involved.

For more on Cardiologist’s Kitchen, visit their website at: cardiologistskitchen.com

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Inspired by the advice presented on Cardiologist’s Kitchen, I made a rather lovely Jamaican beef curry, the (really easy) recipe for which I will share here:

250g lean diced beef

4 banana shallots, thinly sliced

1 x jalapeno chili, diced. (Leave the seeds in if you’re a daredevil)

1 x carrot, peeled and chopped

1 x small sweet potato, peeled and diced

1/2 mango, diced

2 garlic cloves, sliced

1 box passata

1 tbsp. jerk paste (jerk seasoning will do fine, but add 2 tbsp.)

1tbsp garlic granules 

1 tsp. tomato puree

100ml chicken stock

Greek yoghurt

Flat leaf parsley, roughly chopped

Salt and Pepper, to taste

Rice, any kind, and enough to feed 2 people

With a little oil, brown the beef until sealed sufficiently. Add the shallots, sweet potato, and sliced garlic, and cook for another few minutes. Throw in all of the other ingredients and reduce heat. Simmer for 60 mins, or until the beef is tender, and use this time to cook your rice. Serve with some chopped parsley and a dollop of yoghurt.

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Is Screening all Young People for Cardiac Disease Cost Effective?

In Western medicine, especially the U.K. and U.S.A., mandatory screening for cardiac disease in young people doesn’t exist.

The NHS currently offers screening for the following:

  • Newborns (blood, cardiac, hearing tests, and physical examination)
  • Pregnancy (foetal abnormalities, blood tests, and infectious disease)
  • Diabetic eye testing (annual follow-ups for cases confirmed in >12 year olds)
  • Cervical (every 3 years for 26-49 year olds, and every 5 years for 50-64 year olds)
  • Breast cancer (50-70 year olds, 70+ individuals can self-refer)
  • Bowel cancer (55-74 year olds)
  • Abdominal Aortic Aneurism (65 year old men. Over 65s can self-refer)

These tests are designed to aid in patient healthcare and to alleviate the long-term financial burden on the heath service, but as you can see, they’re fairly narrow in their scope. Aside from newborns, the vast majority of the screening programmes cater to individuals in later life, or after index presentation/diagnosis. If one suspects an abnormality, then of course, there are many private options available, and in fact, cardiac screening for precursors to sudden cardiac death (such as hypertrophic cardiomyopathy) is in place for young athletes. Given that the estimated number of young people with the abnormality currently stands at 1 in 500, it has been theorised with this and other cardiac diseases in mind, that mandatory screening for young people could ease the cost on the NHS, enhance patient treatment/safety and the emotional fallout that comes as a result of the morbidity associated with serious cardiac conditions.

The results of a nationwide U.K. screening programme known as Cardiac Risk in the Young imply that mass-screening that also encompasses ECG in addition to the standard physical exam and history increases the likelihood of early diagnosis and actually saves money.

The results are the endpoint of a 4-year process, involving roughly 30,000 young persons who were screened using the above methods, all of which were performed and interpreted using the relevant professionals and governing body guidelines.

8.1% of the 30,000 were deemed to produce an abnormal 12-lead ECG, 3.5% had an abnormal physical exam and/or history, and 0.5% showed abnormality in all three areas. 11.7% underwent echocardiography to confirm or deny the presence of dysfunction, 0.9% were referred for cardiac MRI, 1.7% were moved on to longer-term ECG monitoring, and 1.7% had exercise stress testing.

87 abnormalities associated with SCD syndrome were positively diagnosed at the 2-year follow up mark, accounting to 0.3% of the cohort, and 83% of this number was done so using the ECG alone. Interestingly this 83% was found in individuals who presented as asymptomatic, and would likely go undiagnosed otherwise.

The cost of this screening and subsequent treatment of a positive identification is estimated to be 20% lower than the cost of treatment and screening using current requirements, due to its lowering of false positives from 21.8% to 4.3%. This, in turn, lowers the amount of unnecessary follow ups, so this study may have great implications for young athletes, and non-athletes alike in helping to spot these potentially fatal conditions, many of which can be managed.

More on this story and more at: Cardiac Risk in the Young

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PPG Change Complications; What Textbooks Don’t Tell You

I recently spent the day inside the catheterisation laboratory, specifically in the pacing lab. After a few relatively straightforward implants, we reached the final case of the day; a pacemaker change. The patient in question had 4 months of reported battery life left on his pulse generator, so on paper, it was merely a case of opening the pocket in which his old device was housed, and switching it out for a new one that would stimulate his heart for the years to come.
Textbooks are great, in that they detail a procedure from start to finish, usually from everyone’s perspective, covering all bases regarding technique, equipment, potential emergencies, and possible troubleshooting options should the need arise.

These emergencies range from device malfunction to cardiac complications, and cover most things in between. I haven’t read a textbook that outlines what should be done if the patient suffers from dementia, however…

The procedure began late due to the difficulty in cannulating the individual, given they didn’t really understand where they were, and began thrashing around wildly in confusion as soon as the needle was introduced, but eventually they were brought into the lab and set up on the table. Local anaesthetic was administered whilst myself and other members of staff present tried to ensure that the patient was as calm as possible.

This proved rather difficult, as the patient was understandably scared; bright lights and masked strangers staring down at you aren’t a pleasant experience for anyone, so add a severe perception deficiency into the mix, and it’s only going to be worse.

Once the procedure proper had begun, it got so much worse.

If you’ve ever been in a lab or theatre when an electrocautery is being used, you’ll know how loud it is. Trying to keep a confused patient calm, and focussed on your voice alone, is incredibly difficult when you’re being drowned out by a deafening beeping noise. The consultant performing the change was having to work 3 times harder than normal whilst completing his task, because of the patient’s inability to understand what was happening, and more importantly, why it was happening. 

There were 6 staff in the operating lab, and of those six, the only one able to fully focus on their job was the consultant. The rest of us tried to hold a limb each, to stop them from flailing and causing potential injury. 

The chief priority was the patient’s overall well being, so when the radiographer received a rather nasty set of deep scratches, she endured the pain and tried to reassure the patient.

When the registrar’s fingers were being held so tightly together that they almost broke, she quietly asked if I could free them using one of my available hands, and continued talking to the patient.

When I was struck in the face as a result of removing a hand from the patient’s leg in order to do the above, I didn’t make a sound, as I didn’t want to frighten the patient anymore.

In this patient’s mind, we were causing discomfort for no reason, and as a result, this patient was fighting as though his life depended on it, but nobody said anything that might give cause to further agitate him no matter how much was thrown at them in that situation, because the fact is, we were there to help the patient and their safety came before our own.

No amount of reading could have prepared me for that situation, but even a small amount of warning, or advice, would have been a boon. To that end, I’ll say this; 

Scenarios such as the above WILL happen. It’s inevitable. Just stay calm, communicate with everyone around you and never forget why you’re there. Of course it’s not right that you sustain an injury on the job, but the bigger picture comes first and then you can set about producing system changes.

Detecting CAD with Vocal Biomarkers

Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).

CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk  and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.

Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.

The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.

150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.

The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.

BV hope that future development of this technology can be used to screen patients telephonically.

 

The poster outlining the study can be found here

Beyond Verbal on the web.

The TSP resources relating to CAD can be found here and here.Heart