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June 2011

Heart disease & high blood pressure

Heart disease and high blood pressure are invisible, insidious medical problems. There are often no outward signs, at least in the earlier stages. Often, the first thing people know is when they become seriously unwell as a result of increased blood pressure or heart disease.

BLOOD PRESSURE

Blood pressure is the force exerted by the blood on the walls of the arteries when the heart beats. It is expressed as two different numbers: the systolic (the higher number) and the diastolic (the lower number) which simply relate to the pressure being exerted at different points in the heart beat cycle.

What is high blood pressure?

High blood pressure, or hypertension, causes the heart to work harder than normal. It can increase the risk of heart attacks, stroke, congestive heart failure and atherosclerosis as well as damage to other organs such as the kidney and the eyes.

It is widely accepted that consistently high blood pressure is harmful. It can be an indicator of other, underlying problems and it causes problems itself. Blocked or thinning arteries can lead to higher blood pressure as the heart has to work harder to push the blood through, leading to higher pressure around the whole system.

Forcing the heart to work harder puts a greater strain on that muscle which can lead to it being damaged in the longer term. Consistently high blood pressure which goes untreated can cause the heart to enlarge and become less efficient. This can lead to heart failure and an increased risk of heart attack.

Symptoms

Some people do have symptoms such as headaches or dizziness which are due to raised blood pressure. However, many people are completely unaware of any symptoms until things have reached a critical point. When there are no symptoms, people will not usually go to the GP because they have no reason to think there is a problem. However, even when there are no symptoms damage can still be done internally and the risks set out above are still increasing. This is why it is important to have periodical health checks with a GP or Practice Nurse. Regular monitoring of blood pressure levels can identify a potential problem before it arises.

Causes

The vast majority of cases of high blood pressure have no identifiable cause. Sometimes it can be caused by kidney problems, adrenal gland problems or congenital heart problems but far more often, the cause cannot be pinned down. However, there are clear indicators for those who are more at risk. Diet, exercise and family history all play a large part in the risk of an individual developing high blood pressure. Those who eat well and exercise regularly and effectively have much reduced risks of high blood pressure whilst those with a family history of high blood pressure are far more likely to experience the same thing themselves, although the effects can be lessened by having a good diet and exercise regime.

If high blood pressure goes untreated, especially if someone is also obese, or a smoker, or has high cholesterol or diabetes then the risk of a heart attack is several times greater than for someone without high blood pressure.

High blood pressure also speeds up the process by which the arteries harden. This does happen naturally as we age but consistently high blood pressure accelerates this change. When the arteries are hardened or narrowed they cannot supply the blood needed by all of the organs in the body and those organs begin to work less effectively.

Diagnosis

This is very simple. Most of us have had our blood pressure checked at some time or another. One high reading in itself is nothing to worry about. However, if there is a series of three or more raised readings further tests and investigations should be carried out to determine the cause.

Treatment

High blood pressure cannot be ‘cured’. However, the blood pressure can be managed so that it is reduced to a safer level. Adopting a healthy lifestyle may be all that is needed to bring an individual’s blood pressure down to an acceptable level. For those who have a more significant problem there are drugs available which can assist with the process. Your GP will be able to advise you whether a healthy lifestyle alone should be sufficient to reduce your blood pressure or whether drug treatment will also be needed.

HEART DISEASE

Whilst people usually refer to ‘heart disease’, doctors often refer to ‘cardiovascular disease’. This covers the heart (‘cardio’) and the blood vessels which surround and work with the heart (‘vascular’). However, cardiovascular disease is a term which usually means a disease caused by atheroma. This is a fatty deposit in the lining of the arteries. These deposits make the artery thinner and so the blood flow through the artery is reduced.

Risk factors for developing atheroma

There are a number of different sets of factors: lifestyle, treatable and fixed factors.

The lifestyle factors are those which we can most easily influence: smoking, poor diet, lack of exercise, excess salt in the diet are all things which increase our chances of developing atheroma. These are things that we can all take action to reduce and thereby keep our hearts as healthy as possible.

The treatable or partly treatable factors are things such as high blood pressure, high blood cholesterol levels, diabetes, kidney disease and high triglyceride (fat) blood levels. These things can be controlled by medication but the lifestyle factors above are also important in managing many of them.

The fixed factors are things that individuals cannot influence in terms of reducing that factor but all of the factors outlined above can still be tackled to give any individual the best possible chance. The fixed factors include a strong family history of heart disease, being male, severe baldness in men, early menopause in women, age and ethnicity.

Assessing the cardiovascular risk

This is something that can be done by the GP or Practice Nurse. A score is calculated which takes account of all relevant risk factors and gives an indication of the individual’s risk of developing a cardiovascular disease over the following 10 years.

Current UK guidelines suggest that anyone over 40 should have their cardiovascular risk calculated as well as any adults who have a strong family history of early cardiovascular disease (i.e. a father or brother who developed heart disease or a stroke before the age of 55 or in a mother or sister before the age of 65) or a first degree relative (i.e. parent, sibling or child) with a serious hereditary lipid disorder.

The score provides a percentage risk of developing cardiovascular disease within the next 10 years. Anyone with a score of 20% or more is considered to be at high risk, a score of 10-20% is moderate risk and a score of under 10% is low risk.

Treatment

Treatment is usually only offered to those at high risk. That might be high risk from the assessment described above or because of other known factors such as an existing cardiovascular condition, diabetics or people with certain kidney disorders.

The treatments which are available are quite varied but will always incorporate lifestyle changes to give individuals the greatest possible chance of benefitting from the medication or other medical treatments advised. Drug treatment, usually with a statin, will usually be advised and if there is high blood pressure that might be treated with medication also.

If someone has been assessed as at low or moderate risk they will not usually be given drug treatment but will be encouraged to tackle the lifestyle factors set out above.

WHAT CAN GO WRONG?

In this context, the most usual complaint is that someone was not monitored and problems were not identified when they could have been, sometimes with devastating consequences.

Thompsons are acting for the widow of a man who went to see his GP regularly with high cholesterol and complaining regularly of chest pain. He also had a significant family history of cardiovascular disease. He was not referred for any investigations and even basic blood pressure monitoring and cardiovascular screening was not done. He was aged 45 when he suffered a fatal heart attack in May 2010. We are advising his widow on the advice he was given and whether or not this was sufficient, given the strong indicators of risk in his personal and family history. He has left behind a wife and a young son.

Thompsons are also acting for the widow of a man who began to feel very tired and developed an ache on the left side of his body. He was concerned that it might be heart related and went to see his GP the following day as the symptoms had not subsided. His GP dismissed his concerns and diagnosed a viral infection. The day after seeing the GP, having continued to feel unwell but trusting in the GP’s assessment of his condition, he did not seek another opinion and later that day he had a fatal heart attack. Court proceedings have recently been issued in this matter on behalf of the deceased’s widow with supportive expert evidence both on the actions of the GP at that initial consultation and on the deceased’s chances of surviving had the appropriate action been taken when he first saw his GP.

In another case, Thompsons have obtained an admission of liability from an NHS Trust for the failure of their A&E clinicians to investigate the possibility of a problem with the heart. Again, this case had a tragic outcome and the man concerned died as a result of his heart condition. He had begun to develop intermittent chest pains. He had a strong family history of heart disease and had a number of personal risk factors from his own medical history and lifestyle, which were all known to those treating him. He went to his local A&E department reporting severe chest pain which he described as feeling as if “he had someone sat on his chest” but he was diagnosed with probable musculo-skeletal chest pain and sent home. He went to see his GP a few days later and was referred to a chest clinic but before that appointment could be made he had suffered a fatal heart attack. The NHS Trust have accepted that he should have been admitted into hospital for investigation of his chest pain and that, if he had been admitted, he could have been treated so that his death would have been avoided.

In another example, Thompsons are representing a man who thankfully survived but suffered a series of seven heart attacks which led to him suffering a brain injury as a result of his brain being starved of oxygen. He was at work when he began to suffer from central chest pain, dizziness and feeling faint. He went to see his Occupational Health nurse who noted a family history of heart disease but stable blood pressure. After approximately one hour in Occupational Health he was told to return to work but to come back if he felt unwell again. He returned approximately half an hour later still complaining of central chest pain but no dizziness. He was advised to see his GP if he didn’t improve and the Occupational Health Nurse apparently called the GP surgery to tell them of the issue. The GP notes, when examined, contained no mention of such a call having been received. Thompsons’ client went home and did make a GP appointment but before he could attend he collapsed with a cardiac arrest. Before his arrival at hospital he suffered a further six cardiac arrests and he sustained brain damage as a result of lack of oxygen. Thompsons’ client was only 36 years old at the time and was a known smoker. Thompsons have obtained an admission of breach of duty from the employers in relation to the treatment received in Occupational Health and have also obtained some concessions over the damage done by that breach of duty. The case is not yet concluded but at least our client is now certain to recover compensation for his injuries.

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Further information on these issues can be found as follows:

British Heart Foundation: www.bhf.org.uk
Heart UK: www.heartuk.org.uk
British Nutrition Foundation: www.nutrition.org.uk