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My Cholesterol is too high- which statin do I take? Dr Malik explains…

Cholesterol is a risk factor for heart attack and stroke

Multiple trials show the link between high cholestrol and cardiovascular disease. The great news is that it is modifiable- just like smoking, high blood pressue and even diabetes. The non modifiable ones are your age (you can’t get younger), your gender, your race (south asians are at elevated risk) and your family history (you can’t change who your family are!)

Reducing Cholesterol lowers risk

You can lower choleterol by about 10% with diet and exercise. Statins lower it by about 30%. Different statins have variable effects. And adding Ezetimibe seems to help more than doubling the statin dose, perhaps with fewer side effects.

How low should I go?

In my mind, the lower the better- If you have had a heart attack I would like the LDL <1.4 mmol/l.

We consult at One Welbeck Heart Health- and are proud of it, says Dr Iqbal Malik

Dr Malik, Professor Peters and Professor Mayet now consult at One Welbeck Heart Health, minutes away from Harly Street, and 60 seconds walk from Bond Street Station.

What we do there

Look at this animation of our facilities

We consult there. In additon we can do:

  • ECG
  • Echocardiography
  • ABPM
  • Holter
  • Bloods
  • CTCA
  • MRI

Take a Virtual Tour

This video shows you what the facility looks like

I hope you will agree when you visit that it is a special place to visit. We hope to give you a seamless experience with Consultation, Bloods, and Investigations all under one roof.

Dr Malik explains the anatomy of the heart

Please see the below PDF that was created by Edwards Life Sciences as a free resource. Dr Malik works at Hammersmith Hospital London, and is a senior interventional cardiologist. He also works at OneWelbeck Heart Health, the largest private cardiology practice in London, and is the Medical Director.

Heart Anatomy Guide

Basics of the heart

The heart is a pump. Imagine a washing machine- It needs electricity- so does the heart (it has a built in electrical system). It needs a water supply –so does the heart (blood in this base). It needs the drum working –so does the heart (those are the heart chambers). To work properly, and beat 70-80 times per minute, al needs to be order- the heart lasts longer than any washing machine!

 

The chambers of the heart

The heart has 4 chambers.

The ones on the right side collect blood from the body and brain (the right atrium) and the  push it to the lungs (the right ventricle). This is a low pressure system. It only need to get to the lungs- they are close by. The pressure needed is about 30mmHg. The right ventricle 9s crescent shaped and wraps around the left ventricle.

The ones on the left collect blood from the lungs (the left atrium) and push it all over the body and brain (the left ventricle). The left ventricle is thus the most important chamber. It is bigger and stronger than the right ventricle and needs to generate 100-120 mmHg pressure to allow blood to pump to your brain when you are standing up. The left ventricle is like an ice-cream cone, with the right ventricle like your hand wrapped around it.

 

The electricity and pacing system in the heart

The heart has a built in pacemaker- it lives in the top of the right atrium. It is called the sino-atrial node (SA node).  It fires of at about 70 beats a minute until it needs to beat faster- when it can accelerate to over 180 if needed. It sends electricity around the atria making them contract.

It also fires off the secondary pacemaker – The atrio-ventricular node (AV node). It sits in the model of the heart. That is clever in that there is a built in delay- so that the atria have time to empty into the ventricles before they contract.

The AV node has “bundles” of cables that go to the left and right ventricles, again clever as then that means that the contraction of the ventricles occurs from the  apex of the “ice-cream cone”, so that efficiency is maximised.

 

The valves

Blood should only flow one way, just as water in the washing machine should only flow one way. The heart has 4 valves to help the 2 ventricles pump.

Right side- Inflow: tricuspid valve, outflow: pulmonary valve

Left side- Inflow: mitral valve, outflow : aortic valve

Problems with the right sided valves are tolerated better than left sided as the right is a low pressure system.

Valves can leak or narrow- just as in your washing machine.

 

Disease of the heart

Electrical

  1. Too slow (bradycardia)- the pacemaker is failing and a new pacemaker may be needed
  2. Too fast (tachycardia)- there are other parts of the heart that accelerate the heart way above normal- this could be ventricular tachycardia (from the ventricle) or supra-ventricular tachycardia (above the ventricle). Treatment may be medication or cutting the short –circuit (ablation)
  3. Atrial fibrillation (AF)- that is usually tool fast a beat, but can also go too slow. Treatment is with medication or ablation.

Muscle disease (cardiomyopathy)

There are many types of these- affecting the ventricles- some with weakened and stretched (Dilated cardiomyopathy), some too chunky and thus not working well (hypertrophic cardiomyopathy). These will need specialist diagnosis and treatment.

Valve disease

The main ones in adults are:

  1. Aortic stenosis- the aortic valve is severely narrowed (stenosis) and you have chest pain, breathlessness or dizzy spells, seek urgent attention. Severe symptomatic aortic stenosis (SSAS) has a 4% per month death rate.
    1. Treatment can be with surgery or transcatheter aortic valve intervention  (TAVI or TAVR). Dr Malik is an expert in TAVI and run the Imperial College Healthcare NHS Trust program.
  2. Aortic regurgitation-the aortic valve is leaking, and this puts a strain on the left ventricle.
    1. Treatment can be with medication, with open heart surgery or with TAVI
  3. Mitral stenosis- the mitral valve is thickened and narrowed. this is mainly due to rheumatic heart disease, and thus is less common in western countries.
    1. Treatment is with medication, surgery, or balloon stretching- which in younger patient may avoid open heart surgery
  4. Mitral regurgitation- leaking mitral valve. This can be due to problems with the leaflets or problems with the ring the leaflets are on- if the ring stretches, then the leaflets don’t meet and the valve leaks.

Coronary disease:

Blood gets to the heart via coronary arteries. If these get narrowed, then the heart muscle is starved of oxygen and glucose. It cant work. This can happen slowly or suddenly

  1. Sudden blockage- a heart attack, or myocardial infarction (MI). Treatment is urgently needed. Muscle is dying every minute there is a delay. You should get to hospital and the cardiologist will try to open the blood vessel with an angioplasty and stent (known as PTCA or PCI). Dr Malik has treated 1000’s of heart attacks in the last 20 years.
  2. Slow progression- angina is caused by progressive narrowing. The heart can cope better with this, but it can lead to chest pain on exertion, breathlessness, or tiredness. Treatment may me medication, a PCI or Coronary artery bypass surgery (CABG). You will need tests and probably a coronary angiogram to decide the best treatment for you.

In this brief overview of the heart and its functions, Dr Malik has tried to cover some of the more common problems. What is clear is that the heart is an amazing organ. Look after it and it will keep going for nearly 100 years. As proven by Prince Phillip in March 2021.

Complex PFO closure with Dr Iqbal Malik

Dr Malik does a live PFO closure. A PFO or patent Foramen Ovale, is a flap in the heart that is needed in the womb, but serves no purpose in the adult. It can in rare cases be associated with stroke. Closing the PFO with an umbrella device leads to a much reduced chance of recurrent stroke. Dr Malik is a leading expert in the procedure, and as in this video, often demonstrates his techniques to other physicians. He works in London at Hammersmith Hospital, and OneWelbeck Heart Health.

Paravalvar Leak closure by Dr Malik

Dr Malik does a live Paravalvar leak (PVL)  closure- see the video of this highly complex case. The patient was very symptomatic with a huge hole in the centre of his heart, as a result of some sutures giving way a few months after lifesaving open heart surgery. He was now classed as inoperable by the surgeons who saved him the 1st time he was sick, Dr Malik put some “plugs” in and our patient has gone back to work!  This type of operation is done by a handful of operators in the UK- Dr Malik demonstrated this at a recent International meeting- the EST 2021 session on 13th February 2021. He works in London at Hammersmith Hospital, and OneWelbeck Heart Health.

Why we aim for tight blood pressure control in patients with hypertension

Blood pressure tends to increase as we get older and by the age of 60 about half of the population in the UK will have high blood pressure. For many this will start at a much earlier age.

This is really important because for every 12mmHg increase in systolic blood pressure (the top value) or every 5mmHg increase in the diastolic blood pressure (the lower value), the chance of having a stroke is increased by 40% and the chance of having a heart attack is increased by 25%. High blood pressure is often silent, causing no symptoms, so patients don’t know that they have it. That’s why we should regularly check our blood pressure so we can detect if it starts to go up early.

The picture shows that the higher the blood pressure, diastolic or systolic, the higher the risk of stroke. There is a similar relationship with blood pressure and the risk of heart attacks.

The risk of getting high blood pressure or diabetes is very high in our White European (Caucasian) patients. However, it is more than twice as common in our South Asian, and four times as common in our African-Caribbean, patients. For diabetes, the risk in South Asians is four fold and in African-Caribbean patients, three fold.

A huge amount of research has been done on the treatment of hypertension and several studies have shown that for every 5mmHg reduction in diastolic blood pressure, the stroke risk is reduced by about 40% and the heart attack risk by about 15%. For systolic blood pressure every 12mmHg reduction in systolic blood pressure leads to the similar reductions in risk.

It’s because there is such a big benefit from treatment that we are so keen to measure blood pressure and if raised, to treat it very well.

There is some controversy about how low we go when we treat high blood pressure and there are differences between the UK, European and USA guidelines. There is recent evidence that getting the blood pressure to lower levels than we previously aimed for gives even greater protection from heart attacks and strokes. For many patients with hypertension a target blood pressure of 130/80mmHg or lower will be their optimal target blood pressure.

Good blood pressure control can be achieved with exercise, weight loss, reducing alcohol intake and dietary changes in some patients, though others may need medication. It’s important to assess patients individually and advise what the best blood pressure target is for them; one size doesn’t fit all.

LINK TO THE UK GUIDELINES:  https://www.nice.org.uk/guidance/ng136