Cardiovascular Disease

Cardiovascular disease (CVD) is a general term for a disease (an abnormal condition affecting part of the body) of the heart or blood vessels (tubes which carry blood and oxygen around the body). 

Blood flow to the heart, brain or body is reduced (lowered) because of: 

  • A blood clot (thrombosis)
  • A build-up of fatty deposits (cholesterol) inside an artery (tube which carries oxygen rich blood around the body) leading to hardening and narrowing of the artery (atherosclerosis)

Types of Cardiovascular Disease

 There are three main types of Cardiovascular Disease:

  • Coronary heart disease (CHD)
  • Stroke (also known as a cerebral vascular accident CVA)
  • Peripheral vascular disease (also known as peripheral arterial disease PVD)

Coronary heart disease (CHD)

What is the heart?
The heart is a muscle that is about the size of your fist. It pumps blood and oxygen around your body and beats approximately 60-80 times a minute when resting.

The heart gets its own supply of blood from a group of blood vessels on the surface of your heart, called coronary arteries.

Coronary heart disease occurs when your heart's blood supply is blocked or interrupted by a build-up of fatty substances (known as cholesterol, atheroma or plaque) in the coronary arteries. The coronary arteries are major blood vessels that supply the heart with blood and oxygen.

If your coronary arteries become narrow due to a build-up of fatty substances, the blood supply to your heart will be limited.

This can cause angina (symptoms caused by the lack of oxygen and blood to the heart muscle).

If a coronary artery becomes completely blocked, it will cause a heart attack.

Angina
Angina is a symptom that is caused when the blood and oxygen supply to the heart muscle is restricted. It usually occurs when the arteries that supply the heart become hardened and narrowed.

Symptoms of angina
Symptoms of angina vary from person to person. You may get some of the symptoms listed.

  • Pain or discomfort in the chest
  • A feeling of indigestion
  • Pain or discomfort spreading down the arms (usually the left but can be the right arm too)
  • Pain or discomfort in the neck or jaw
  • Pain in between the shoulder blades
  • Preathlessness
  • Feeling sick and/or vomiting
  • Feeling unusually tired
  • Dizziness
  • Belching (burping)
  • Restlessness

Types of angina
There are two main types of angina: stable angina and unstable angina.

Stable angina
If you have stable angina, your symptoms will usually build up gradually over time and are predictable. For example, you may get symptoms of angina every time you climb stairs or if you are under a lot of stress.

The symptoms of stable angina usually only last for a few minutes following exertion (physical effort) and can be relieved by taking medication called glyceryl trinitrate (GTN).

Stable angina is not dangerous. People who suffer angina can expect to experience symptoms occasionally when -

  • You go out into cold weather
  • When you exercise
  • When feeling very upset, angry or stressed
  • Following large meals

It is important to remember that the items listed above DO NOT CAUSE angina. It is the narrowing of the arteries (CHD) that cause the angina to occur, activities just bring on symptoms. You do not need to avoid activities for fear of causing angina symptoms.

Angina symptoms DO NOT damage the heart in any way, they are just a warning that the heart muscle is not getting enough blood and oxygen.

In fact, regular exercise and activity can actually improve your health and lessen the occurrence of angina symptoms.

What should I do if I get angina symptoms?

  • Stop what you are doing
  • Sit or lie in a comfortable position
  • If you have been prescribed GTN tablets or spray pop one tablet or two sprays under the tongue and wait for 5 minutes. If the pain/symptoms have gone completely you may continue with your activity.
  • If after 5 minutes you still have pain/symptoms take another tablet or two sprays under the tongue and wait a further 5 minutes. If the pain/symptoms have gone completely you may continue your activity. If the pain/symptoms are still there after the second dose (2 doses in 10 minutes) call 999.

If you still have angina symptoms after taking 2 doses of GTN in 10 minutes it is important to dial 999 and get checked out in A&E. GTN widens the arteries to allow blood and oxygen to circulate. If after 2 doses the symptoms are still present it could mean that youhave a blockage in one of the arteries. Seeking help quickly can help stop any damage being done to the heart muscle if there is a blockage in one of the arteries.

Unstable angina
Unstable angina is when angina symptoms start to become more frequent, unpredictable and are occurring with less activity than before, or when resting.

You may be developing unstable angina if the angina symptoms:

  • Start to feel different, are more severe, come on more often, or occur with less activity or while you are at rest
  • Last longer than 10 minutes
  • Occur without cause (for example, while you are asleep)
  • Do not go away even after GTN has been taken

Unstable angina is a warning sign that a heart attack may happen soon. It needs to be treated right away. If you have any worsening symptoms see your doctor as soon as possible.

If you have symptoms which do not go away with 2 doses of GTN medication (one dose every five minutes) dial 999!

People often avoid calling an ambulance if symptoms are not severe for fear of “wasting the ambulance’s time”.  However, it is not the severity of angina symptoms which mean you are having a heart attack, it is the length of time they go on for.

For example, if you have severe symptoms of angina which go away after one dose of GTN and do not come back, that is definitely angina.

However, if you have mild symptoms that continue for a long time despite repeated doses of GTN this is more likely to be a heart attack!

Tests

Electrocardiogram (ECG)
An electrocardiograph (ECG) measures the electrical activity of your heart. Every time your heart beats, it produces tiny electrical signals. An ECG machine records these signals onto paper, allowing your doctor to see how well your heart is functioning.

A number of electrodes (small sticky discs) are placed on your arms, legs and chest. The electrodes are connected to a machine that records the electrical signals of each heartbeat.

An ECG is a snapshot of what is happening to the heart muscle there and then. It can show things that have happened to the heart muscle in the past (e.g. a heart attack), however it cannot show anything that may happen to the heart muscle in the future.

An abnormal ECG reading may indicate that the muscles of your heart are not receiving enough blood and oxygen.

Exercise Tolerance Test (ETT)
An exercise tolerance test (ETT) is similar to an ECG but it is carried out when you are exercising, usually on a treadmill or an exercise bike.

The ETT helps to diagnose (find a cause for) and measure the severity (seriousness) of coronary heart disease.


Many people with coronary heart disease have a normal ECG at rest. During exercise the heart beats faster and needs more oxygen. If one or more of your coronary arteries are narrowed, part or parts of the heart muscle do not get enough oxygen. This can cause the ECG tracing to become abnormal when you exercise. Therefore, if you have a positive ETT (an abnormal reading) you are likely to have coronary heart disease.

If you have already been diagnosed with coronary heart disease, an ETT can ALSO be used to measure how much exercise your heart is able to tolerate (put up with) before the symptoms of angina are caused. The information gained from an ETT is useful for assessing how severe your angina is likely to be and whether you need any further tests or treatment.

Myocardial Perfusion Scan (MPS)
A myocardial perfusion scan (MPS) is an alternative test to an ETT that can be used if a person is unable to exercise or when the results of an ETT are unclear.

MPS involves injecting a small amount of a radioactive substance into your blood. A special camera, known as a gamma camera (medical equipment that detects gamma rays released from a person's body after the administration (giving) of a radioactive drug and so produces pictures of the organ being tested), is used to track (follow) the substance as it moves through your blood vessels and into your heart.

These pictures will show how well your heart muscle is supplied with blood, which it needs to work properly, and it will help your doctor make a diagnosis.

MPS is usually carried out both at rest and when you are exercising. If you are unable to exercise, medication can be used to replicate the effects of exercise on your heart.

Coronary Angiography
A coronary angiography is a test used to take X-ray pictures of the blood vessels (tubes) and chambers (compartments) of the heart. The test can be used to identify whether your coronary arteries are narrowed and determine how severe any blockages are.  This test is also called a coronary arteriography or a coronary angiogram.

A long, flexible, plastic tube called a catheter is inserted into a blood vessel in the groin or arm.  The tip of the catheter is guided to the heart using X-ray pictures.  A special fluid called contrast medium or dye is then injected into the catheter and X-ray pictures of the heart and arteries are taken. The pictures produced are called angiograms.

The fluid that is injected is visible on the X-rays, so the angiograms show up all the blood vessels that the fluid travels through. This reveals if any of the blood vessels are narrowed or blocked, and if the heart is working as it should be.

Coronary angiograms are commonly used to diagnose a number of heart conditions and to decide on treatment. For example, a coronary angiography may be used:

  • After a heart attack (when the heart’s blood supply is blocked)
  • To diagnose angina (when symptoms are caused by restricted blood supply to the heart)
  • To plan surgical procedures, such as a coronary angioplasty (a procedure to widen blocked blood vessels)

Coronary angiographies carry a small risk of serious complications, such as a stroke or a heart attack, which is estimated to be around 1 in 500.  Although this risk is very small, healthcare professionals are usually unwilling to perform an angiogram unless the benefits of the procedure outweigh the potential risks.

Therefore, it is likely that you will only be referred for a coronary angiogram if:

  • The diagnosis of angina remains unclear
  • Your angina symptoms persist despite treatment and/or you are thought to be at significant risk of having a heart attack or stroke and surgery is being considered

Heart attack (myocardial infarction/MI)

A heart attack occurs when blood flow to part of the heart is blocked, most often by a blood clot, causing damage to the affected heart muscle.

The clot is usually caused by a break or tear in the plaque/cholesterol (fatty substance) which lines the coronary artery. As the blood flows through the artery it detects the damage and a clot starts to form over the broken cholesterol in order to “repair” the damaged area. This is also known as coronary thrombosis. Once a clot blocks the artery completely, damage will start to occur to the heart muscle supplied by that artery.

If the blood supply is cut off for a long time and you do not seek medical treatment quickly, the muscle cells are permanently damaged and die, leading to disability or death depending on the amount of damage to the heart muscle.

Heart attacks can also occur when a coronary artery temporarily contracts or goes into spasm, decreasing or cutting the flow of blood to the heart. However this is extremely rare.

Symptoms of a heart attack

  • Chest pain, usually a central crushing pain that may travel into the left arm or up into the neck or jaw, and persists for more than a few minutes. Unlike angina, the pain doesn't go away when you rest. Sometimes it can be mild and be mistaken for indigestion. Some people have a heart attack without experiencing pain
  • Stomach or abdominal pain
  • Shortness of breath or difficulty breathing
  • Nausea or vomiting
  • Excessive sweating
  • Unexplained anxiety and a feeling of “impending doom”
  • Weakness or fatigue
  • Cold sweat or feeling pale and clammy
  • Feeling light-headed or dizzy
  • Palpitations

If you get any of these symptoms it is advisable to seek medical help immediately by dialling 999!

Tests

Electrocardiograph (ECG)
If a heart attack is suspected an electrocardiograph (ECG) is an important test and maybe carried out in the ambulance. If not done in the ambulance it should be carried out within 10 minutes of being admitted to hospital.

An electrocardiograph (ECG) measures the electrical activity of your heart. Every time your heart beats, it produces tiny electrical signals. An ECG machine records these signals onto paper allowing your doctor to see how well your heart is functioning.

A number of electrodes (small sticky discs) are placed on your arms, legs and chest. The electrodes are connected to a machine that records the electrical signals of each heartbeat.

 An ECG is a snapshot of what is happening to the heart muscle there and then. It can show things that are happening to the heart and have happened to the heart muscle in the past (e.g. a heart attack). However it cannot show anything that may happen to the heart muscle in the future.

An abnormal ECG reading may indicate that the muscles of your heart are not receiving enough blood and oxygen.

There are two reasons why an ECG is so important:

  • It helps confirm the diagnosis of a heart attack
  • It helps determine what type of heart attack you have had, which will help determine the most effective treatment for you

Other tests
A number of other tests can be used to assess the state of your heart and check for any complications. However, because heart attacks are medical emergencies, some of these tests are only carried out once your initial treatment has begun and your condition has stabilised.

Blood tests
The damage to your heart that results from a heart attack causes certain enzymes to leak into your blood. Enzymes are special proteins that help regulate the chemical reactions that take place in your body.

If you have had a suspected heart attack, a sample of your blood will be taken so that it can be tested for these heart enzymes. Your enzyme levels will be measured through a blood sample. This will allow the level of damage to your heart to be assessed, and it will also help determine how well you are responding to treatment.

Your blood will also be taken to check your liver and kidney function, glucose (sugar in the blood) levels and cholesterol level.

Chest X-ray
A chest X-ray can be useful if the diagnosis of a heart attack is uncertain and there are other possible causes of your symptoms.

A chest X-ray can also be used to check whether any complications have arisen from the heart attack, such as a build-up of fluid inside your lungs (pulmonary oedema).

Echocardiogram
An echocardiogram is similar to an ultrasound scan (used to see the foetus in a pregnant woman) in that it uses sound waves to build up a picture of the inside of your heart. This can be useful to identify exactly which areas of the heart have been damaged and how this damage has affected your heart’s function and ability to pump blood around the body.

Coronary Angiography
A coronary angiography is a test used to take pictures of the blood vessels (tubes) and chambers (compartments) of the heart using X-rays. The test can be used to identify whether your coronary arteries are narrowed and determine how severe any blockages are. 

This test is also called a coronary arteriography or a coronary angiogram.

A long, flexible, plastic tube called a catheter is inserted into a blood vessel in the groin or arm. Using X-ray pictures, the tip of the catheter is guided to the heart or arteries supplying blood to the heart.  A special fluid called contrast medium or dye is then injected into the catheter and X-ray pictures of the heart and arteries are taken. The pictures produced are called angiograms.

The fluid that is injected is visible on the X-rays, so the angiograms show up all the blood vessels that the fluid travels through. This reveals if any of the blood vessels are narrowed or blocked and if the heart is working as it should be.

Coronary angiograms are commonly used to diagnose a number of heart conditions and to decide on treatment. For example, a coronary angiography may be used:

  • After a heart attack (when the heart’s blood supply is blocked)
  • To diagnose angina (when symptoms are caused by restricted blood supply to the heart)
  • To plan surgical procedures, such as a coronary angioplasty (a procedure to widen blocked blood vessels)

Coronary angiographies carry a small risk of serious complications, such as a stroke or a heart attack, which is estimated to be around 1 in 500. Although this risk is very small, healthcare professionals are usually unwilling to perform an angiogram unless the benefits of the procedure outweigh the potential risks.

Therefore, it is likely that you will only be referred for a coronary angiogram if:

  • The diagnosis of angina remains unclear
  • Your angina symptoms persist despite treatment and/or you are thought to be at significant risk of having a heart attack or stroke and surgery is being considered

What causes Coronary heart disease?

Coronary heart disease is caused by a build up of fatty deposits (cholesterol) in your coronary arteries.

While there is no one specific cause of coronary heart disease, several factors can increase a person's chances of developing CHD.  If a person has risk factors for heart disease, it does not necessarily mean that he or she will get coronary heart disease.  Many people with risk factors never develop heart disease, while people with no risk factors can develop heart disease.

A risk factor for heart disease is something that increases your chance of getting it. You cannot change some risk factors for heart disease, but others you can change.

Non modifiable risk factors:

  • Age. Simply getting older increases your risk of damaged and narrowed arteries.
  • Sex (Gender).  Men are generally at greater risk of coronary heart disease. However, the risk for women increases after the menopause.
  • Family history.  If a close family member has heart disease it puts you at risk. The closer the relative is, the greater the risk. So if your mum, dad, brother or sister has heart disease (rather than aunts, uncles or cousins), it is more likely you will develop the condition too, especially if a close relative developed heart disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before the age of 55 or your mother or a sister developed it before the age of 65.

Modifiable risk factors:

  • Smoking
  • Hypertension (high blood pressure)
  • Hypercholesterolemia (high cholesterol)
  • Obesity (being excessively over weight)
  • Lack of exercise
  • Stress
  • Diabetes
  • Excess alcohol

If you would like help and support making any life style changes see your GP or Practice nurse for more information.

Smoking

Smoking increases your chance of developing cardiovascular disease and heart disease.

Smoking causes cardiovascular and heart disease by:

  • Decreasing (lowering) the oxygen needed to supply the heart
  • Increasing blood pressure and heart rate
  • Increasing the chances of your blood clotting
  • Damaging the cells that line coronary arteries and other blood vessels making them more susceptible to the build up of fatty deposits

Can Quitting Smoking Be Helpful?
If you quit smoking, you will:

  • Prolong your life
  • Reduce your risk of disease (including heart disease, heart attack, high blood pressure, cancer, emphysema, ulcers, gum disease, and many other conditions)
  • Feel healthier. After quitting, you won't cough as much, you'll have fewer sore throats and you will have increased energy levels.
  • Look better. Quitting can help you prevent face wrinkles, get rid of stained teeth, and improve your skin.
  • Improve your sense of taste and smell.
  • Save money; a 10 per day smoker will spend £1277.50 per year on smoking!

Blood pressure

What is blood pressure?
Blood pressure is the pressure (force) of blood in your arteries.  Blood pressure is measured in millimetres of mercury (mm Hg). Your blood pressure is recorded as two figures. For example 120/80 mm Hg.

  • The top (first) number is the systolic pressure. This is the pressure in the arteries when the heart beats.
  • The bottom (second) number is the diastolic pressure. This is the pressure in the arteries when the heart rests between each heartbeat.

What is high blood pressure?
There is no one reading in which high blood pressure is diagnosed. In general, the higher your blood pressure the greater the risk to your health.

Depending on various factors, the level at which blood pressure is said to be high can change from person to person.

High blood pressure actually means that your blood pressure remains above the recommended guideline each time it is taken. That is, your blood pressure is continually above the guideline level, and is not just a one-off high reading, for example when you are stressed.

High blood pressure can be:

  • Just a high systolic pressure - for example, 170/70 mm Hg.
  • Just a high diastolic pressure - for example, 120/104 mm Hg.
  • Both - for example, 170/110 mm Hg.

How is high blood pressure diagnosed?
A one-off blood pressure reading which is high does not mean that you have high blood pressure (hypertension). Your blood pressure changes throughout the day. It will be lower in the morning when you first wake up and may be high for a short time if you are anxious, stressed or have just been exercising. 

High blood pressure (hypertension) is diagnosed if you have several blood pressure readings which are high, and which are taken on different occasions, and when you are relaxed.

If one reading is found to be high, your doctor or nurse will want to recheck your blood pressure more regularly to build up a picture of what is happening with your blood pressure. This means checking it at different times over a few days/weeks.

It is very important to have your blood pressure checked regularly.

Even mildly raised blood pressure should be monitored. Medication, sometimes with two or even three different medicines may be needed to keep your blood pressure down.

Reducing your daily salt/sodium intake can help keep blood pressure down. Also taking regular exercise can help to keep blood pressure low.

The current guidelines advise that your blood pressure should ideally be 140/85 or less. If you have diabetes your blood pressure ideally should be 130/80 or less.

Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the passage through which blood can flow. It is advisable to get your blood pressure checked regularly with your GP, Practice Nurse or Pharmacist.

Cholesterol

What causes high cholesterol levels?
Cholesterol is a fatty substance found in the body. It is vital for the normal functioning of the body.

  • The liver produces approximately 80 to 90% of our total cholesterol.
  • An unhealthy diet: some foods already contain cholesterol (known as dietary cholesterol) but it is the amount of saturated (animal) fat in your diet which is more important, as this is then converted by the body into cholesterol.
  • Smoking: a chemical found in cigarettes called acrolein stops HDL (“good” cholesterol) from carrying LDL (“bad” cholesterol) to the liver, leading to a build-up of cholesterol and narrowing of the arteries (atherosclerosis).
  • Having diabetes can increase the amount of triglycerides in the blood which can lead to an increased risk of heart disease.
  • High blood pressure (hypertension) as this damages the smooth lining of the arteries and causes cholesterol to attach to the bumpy surface of the arteries.
  • Having a family history of stroke or heart disease as this may mean that your liver over produces cholesterol. This is not the same as familial hypercholesterolemia (FH).
  • There is also an inherited condition known as familial hypercholesterolemia (FH). This can cause high cholesterol even in someone who eats healthily. This is because their liver produces too much cholesterol.

Having a high level of cholesterol in your blood (hypercholesterolemia) can have an effect on your health. Having a high cholesterol level doesn’t cause any symptoms, but it increases your risk of serious health conditions.

Cholesterol levels vary between adults. 

Cholesterol is carried in your blood by proteins, and when the two combine they are called lipoproteins.

There are two main types of lipoproteins:

  • Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells that need it. If there is too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is known as "bad cholesterol". An easy way to remember this is “L” is for “Lousy cholesterol”.  
  • High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and back to the liver, where it is either broken down or passed out of the body as a waste product. For this reason, it is considered "good cholesterol". An easy way to remember this is “H” is for “Helpful” cholesterol.

Another type of lipoprotein is triglycerides.

  • Triglycerides:The body needs triglycerides, as they are extremely important for the overall functioning of the body. They are required for producing energy and they also serve as the building blocks for cells. Triglycerides are the major components of low density lipoproteins and play a key role in the transportation of dietary fat. Too many Triglycerides in the blood are harmful and can increase your risk of coronary heart disease.

The amount of cholesterol in the blood (LDL, HDL and Triglycerides) can be measured with a blood test. Cholesterol levels are measured in mmols per litre.  When a blood test to measure cholesterol is taken it will measure your total cholesterol level and also a breakdown of LDL, HDL and Triglycerides. This is because a total cholesterol level does not identify your risk as accurately.

For Example:                  

             Man A                                                                 Man B

Man A-Bman A-B

Total Cholesterol 6.0mmols                Total Cholesterol 6.0mmols  

          HDL 4.0mmols                                             HDL 2.0mmols
          LDL 2.0mmols                                              LDL 4.0mmols

Even though Man A and Man B BOTH have a  total cholesterol level of 6mmols, Man A is less at risk of coronary heart disease than Man B as he has a higher HDL cholesterol and lower LDL cholesterol.

The average total cholesterol level in the UK is 5.5mmols for men and 5.6mmols for women, which is above a recommended level.

What should my cholesterol level be?
These levels are provided as a guide only! For a personal level see your GP or Practice nurse for a fasting cholesterol blood test and advice.

  • Total cholesterol 5.0mm or less
  • Low-density lipoprotein (LDL) cholesterol 3.0mmol or less
  • High-density lipoprotein (HDL) cholesterol 1.2mmol or more

When should I test my cholesterol levels?
Your GP or practice nurse may recommend that you have your blood cholesterol levels tested if you:

  • Have been diagnosed with coronary heart disease, stroke or mini-stroke (TIA) or peripheral vascular disease (PAD)
  • Are over 40
  • Have a family history of early cardiovascular disease
  • Have a close family member who has a very high cholesterol level
  • Are overweight
  • Have high blood pressure, diabetes or a health condition that can increase cholesterol levels, such as an underactive thyroid

How can I lower my cholesterol levels?

Eat well

Eat three meals a day
Avoid skipping meals and try to space your breakfast, lunch and dinner out over the day. This will help control your appetite (hunger) and will also help control your blood glucose levels.

Include starchy carbohydrate foods at each meal
These include bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. Try to include carbohydrates that are more slowly absorbed (have a lower glycaemic index) as these release energy more slowly keeping you fuller for longer.   Such as pasta, brown rice, grainy breads such as granary, pumpernickel and rye, new potatoes, sweet potato and yam, porridge oats, All-Bran and natural muesli.

Cut down on fats you eat, especially saturated fats
Our bodies need fat in order to absorb vitamins and help the brain and nervous system work properly. However a diet too high in saturated fats is bad for our health. Choose unsaturated fats or oils, (e.g. olive oil and rapeseed oil) as these types of fats are better for your heart. As fat is the greatest source of calories, eating less will help you to lose weight if you need to. To cut down on the fat you eat here are some tips:

  • Reduce saturated fat by having less butter, margarine and cheese or using the low fat options
  • Choose lean meat (meat with no visible fat) and fish as low fat alternatives to fatty meats
  • Choose lower fat dairy foods such as skimmed or semi-skimmed milk, low-fat or diet yogurts, reduced fat cheese and lower fat spreads
  • Grill, steam or oven bake instead of frying or cooking with oil or other fats
  • Watch out for creamy sauces and dressings and swap for tomato-based sauces instead

Eat more fruit and vegetables
Aim to eat five portions of fruit and vegetables a day. This will provide you with vitamins, minerals and fibre to help you to balance your overall diet. One portion is a banana or apple, a handful of grapes, a tablespoon of dried fruit, a small glass of fruit juice or fruit smoothie, three heaped tablespoons of vegetables or a small bowl of salad.

Eat more beans and lentils
These include kidney beans, butter beans, chickpeas or red and green lentils. They have less of an effect on your blood glucose levels and may help to lower your cholesterol level. You could add them to stews, casseroles and soups.

Eat at least two portions of oily fish a week
Oily fish contains a type of polyunsaturated fat called omega 3, which helps protect against heart disease. Types of oily fish include mackerel, sardines, salmon and pilchards.

Keep sugar and sugary foods as occasional treats
Sugar can be used in foods and in baking as part of a healthy diet however using sugar free, no added sugar or diet fizzy drinks/juices instead of sugary versions is a good way to lower the overall amount of sugar in your diet.

Reduce salt in your diet to 6g or less a day
Too much salt in your diet can increase your blood pressure, which can lead to stroke and heart disease. Avoid eating processed foods, as these are usually high in salt. Try adding flavour to foods with herbs and spices instead of salt, for example, pepper.

Limit alcohol intake
The current guidelines suggest drinking a maximum of two units of alcohol per day for a woman and three units per day for a man and having two days a week without alcohol.

One unit is equal to a single pub measure (25ml) of spirit or half pint of standard strength lager, ale, bitter or cider or a small glass of wine (125mls).

Over the years the amount of alcohol in most drinks has gone up, for example wine is often served in glasses that contain more than 125mls. A drink can now contain more units than you think. A glass of wine in a restaurant or pub could contain as much as 3 units.

How to read a food label
Most pre-packed foods have a nutrition label on the back or side of the packaging.

These labels usually have information on energy (calories), protein, carbohydrate and fat. They may also give extra information on saturated (animal) fat, sugars, sodium, salt and fibre. Nutrition information is provided per 100 grams and sometimes per portion of the food, for example per half pack.

Nutrition labels are often shown as a panel or grid on the back or side of packaging. For example the image below shows the nutrition label on a ready meal.

Nutrition

Typical values (as consumed)
Energy

per 100g
 541kJ/128kCal

per pack
2011kJ/476kCal

%GDA
24%

your GDA*
 2000kCal

Protein

4.9g

18.2g

Carbohydrates

20.8g

77.4g

of which sugars

1.5g

5.6g

6.2%

90g

Fat

2.8g

10.4g

15%

70g

Of which saturates

2.3g

8.6g

43%

20g

Fibre

2.1g

7.8g

Sodium

0.1g

0.5g

g

Salt equivalent

0.3g

1.3g

22%

6g

*Recommended guideline daily amounts for adults (GDA)

How do I know if a food is high in fat, saturated fat, sugar or salt?
These guidelines help you work out if a food is high in fat, saturated fat, salt or sugar.

Total fat
High: more than 20g of fat per 100g
Low: 5g of fat or less per 100g

Saturated fat
High: more than 5g of saturated fat per 100g
Low: 1.5g of saturated fat or less per 100g

Sugars
High: more than 15g of total sugars per 100g
Low: 5g of total sugars or less per 100g

Salt
High: more than 1.5g of salt per 100g (or 0.6g sodium)
Low: 0.3g of salt or less per 100g (or 0.1g sodium)
 

Other lifestyle changes can also make a big difference. It will help to lower your cholesterol if you do regular exercise and quit smoking.

If these measures are not helping to reduce your cholesterol and you continue to be at a high risk of heart disease, your GP may prescribe a cholesterol-lowering medication such as statins. Your GP will take into account the risk of any side effects from statins and the benefit of lowering your cholesterol.

Obesity
Obesity is defined as a body that has an excess of fat. Excess fat, especially around the waist, can cause health problems, including heart disease, high blood pressure and diabetes. The reasons behind the health risks are not completely understood. Side effects of obesity include increased blood cholesterol and triglyceride levels and lower levels of HDL cholesterol, which is considered the healthy cholesterol. Blood pressure rises in obese people who are then at greater risk of developing diabetes and stroke. Diabetes can add to the risks of heart problems.

Obesity occurs when more calories are taken in than are expended (used up). Eating excess amounts of food containing fats leads to weight gain and obesity. Fat and obesity are measured through a body mass index (BMI) formula and waist circumference.

Waist Circumference
Waist circumference in women that is greater than 35 inches is considered high risk for obesity and heart disease. Waist circumference in men should measure 40 inches or less to remain healthy.

To measure your waist, the measurement needs to be taken between the top of the hip bone and the lowest rib (usually around your tummy button). Ensure the tape is snug, but does not squash the skin. The measurement should be taken when the person being measured has breathed out.

Body Mass Index (BMI)
BMI compares height to weight to conclude the amount of body fat. To check your BMI use an online BMI calculator or see your GP or Practice nurse who can give you this reading.

  • A BMI of 18.5 or less is considered underweight
  • A BMI of 18.6 to 25 is considered normal
  • A BMI of 25 to 30 is considered overweight
  • A BMI of 30 and over is considered obese
  • A BMI of 40 or above is considered morbidly obese

Physical inactivity
Does exercise help prevent heart disease?  Being physically active halves your risk of heart disease. This is because exercise:

  • Lowers blood pressure, which is a major risk factor for heart disease
  • Increases HDL cholesterol that transports fat away from the arteries and back to the liver for processing
  • May reduce levels of LDL cholesterol that can form fatty deposits in the arteries and contribute to heart disease
  • Improves circulation by preventing blood clots that can lead to heart attack and stroke
  • Increases fat loss
  • Helps weight-loss
  • Can help build up muscle mass

Exercise also reduces stress by releasing feel-good hormones called endorphins

How can I increase activity levels?
Some simple ways to increase activity levels are:

  • Take the stairs instead of the lift to tone your legs and buttocks
  • Walk to the shops instead of driving, and carry the shopping bags home to give your arms a good workout
  • Cycle or walk short journeys rather than using the car
  • Get off the bus or train a stop early
  • Use your lunch break to go for a walk

Make exercise enjoyable
The more enjoyable exercise is, the more likely you will do it on a regular basis.  One of the main barriers to exercise is time and money.  People often think they haven’t got the time or the money to exercise. However, exercise doesn’t have to be done in a formal setting like a gym and it doesn’t have to cost money. 

Any activities that increase your heart rate and make you feel slightly short of breath whilst doing it counts as exercise.

For example:

  • Energetic household chores like vacuuming, washing the windows and gardening
  • Putting on some music and having a dance
  • Playing with the kids in the garden
  • Taking the dog for a walk

You may want to invest in a pedometer, an electronic device that clips on your waistband and records how many steps are taken. These can now be purchased for as little as £2. This will give you a base level from which to increase. Experts recommend 10,000 steps a day. However that can seem like an impossible target. Wear your pedometer for a few days to work out your average daily steps, and then aim to increase your steps by 50-100 steps per day. It doesn’t matter how many steps you are currently doing, the aim is to increase them.

Beginning an exercise plan can be difficult if you have been out of the habit for a while.  Talk to your doctor about whether it's safe to start.

People with high blood pressure, angina or who already have a heart problem should always consult a doctor before starting any exercise programme.

Most people can take regular exercise at a level that benefits them. It doesn’t matter what level you are starting from. The aim is to build up gradually each week.

Diabetes
Diabetes is associated with an increased risk of coronary artery disease. Both conditions share similar risk factors, such as obesity and high blood pressure. Click on the link for more information about diabetes.

Stress

How Does Stress Increase the Risk for Heart Disease?
Medical professionals aren't sure exactly how stress increases the risk of heart disease. Stress itself might be a risk factor or it could be that high levels of stress make other risk factors (such as high cholesterol or high blood pressure) worse. For example, if you are under stress, your blood pressure goes up, you may eat too much, you may do less exercise, you may drink too much alcohol and you may be more likely to smoke.

Research also suggests that it could be because chronic stress exposes your body to continually elevated levels of stress hormones like adrenaline and cortisol. Cortisol is an important hormone in the body produced by the adrenal glands and involved in various bodily functions. However, if cortisol levels remain high, studies have shown it can have a negative impact on health, for example, by putting you at risk of increased blood pressure.

Studies also link stress to changes in the way blood clots, which increases the risk of heart disease, a heart attack and stroke.

What Causes Stress?
Stress can be caused by a physical or emotional change or a change in your environment that requires you to adjust or respond. Things that make you feel stressed are called "stressors."

Stressors can be minor hassles, major lifestyle changes, or a combination of both. Being able to identify stressors in your life and releasing the tension they cause are the keys to managing stress.

Below are a few common stressors that can affect people at all stages of life.

  • Illness, either personal or of a family member or friend
  • Death of a friend or loved one
  • Problems in a personal relationship
  • Work overload
  • Starting a new job
  • Unemployment
  • Retirement
  • Daily hassles
  • Legal problems
  • Financial concerns

Does stress affect everyone in the same way?
People respond in different ways to events and situations in life. One person may find an event joyful, but another person may find the same event miserable and frustrating. Sometimes, people may handle stress in ways that make bad situations worse by reacting with feelings of anger, guilt, fear, hostility, anxiety, and moodiness. Others may face life's challenges with ease.

How can I tell if I am under too much stress?
As stress begins to take its toll physically, emotionally and on your behaviour, a variety of symptoms can result. Check off the symptoms you recognise in the following lists. If you identify a large number of signs in yourself, don't panic. There are many simple ways to alleviate stress.

How your body may react

  • Breathlessness
  • Headaches
  • Aches and pains
  • Tendency to sweat
  • Nervous twitches
  • Cramps or muscle spasms
  • Pins and needles
  • High blood pressure
  • Feeling sick or dizzy
  • Constant tiredness
  • Restlessness
  • Sleeping problems
  • Constipation or diarrhoea
  • Craving for food
  • Indigestion or heartburn
  • Lack of appetite
  • Sexual difficulties

How you may feel

  • Aggressive
  • Irritable
  • Depressed
  • Fearing for your health
  • Fearing failure
  • Dreading the future
  • A loss of interest in others
  • Taking no interest in life
  • Neglected
  • That there's no-one to confide in
  • A loss of sense of humour

How you may behave

  • Have difficulty making decisions
  • Avoiding difficult situations
  • Frequently crying
  • Have difficulty concentrating
  • Biting your nails
  • Denying there's a problem
  • Unable to show true feelings

In ticking off your own reactions, you can get an idea of the way you respond to stress.

Managing Stress

Some causes of stress are unavoidable. You cannot prevent or change stress such as the death of a loved one or a serious illness. However, you can find healthier ways to cope with the stress in your life.

Healthy ways to cope with stress

  • Go for a walk.
  • Call a good friend
  • Take some exercise
  • Write in your journal
  • Take a long bath
  • Light scented candles
  • Take regular breaks
  • Play with a pet
  • Work in your garden
  • Get a massage
  • Curl up with a good book
  • Listen to music
  • Watch a comedy

If you feel things are getting on top of you and you are not coping well with stress, speak to your GP or Practice nurse who will be able to help.

Treatments for coronary heart disease (CHD)

Medicines
Many different medicines are used to treat CHD. However, treatment can differ between individuals. An assessment will be carried out by your GP or consultant and the medications prescribed will have been chosen carefully.

Your GP or specialist will be able to discuss the various options with you.

Common medicines used to treat people with CHD include:

  • Anti-platelets; medicines that make your blood less likely to form clots, reducing your risk of having a heart attack. For example, Aspirin and Clopidogrel.
  • Statins; medicines which slow down the production of cholesterol and help to prevent atherosclerosis (narrowing of the arteries). For example, Atorvastatin and Simvastatin.
  • Beta-blockers; medicines that reduce your blood pressure and the amount of work your heart has to do. For example, Bisoprolol and Atenolol.
  • Calcium channel blockers; medicines that relax and widen your arteries. For example, Verapamil and Diltiazem.
  • Anticoagulants; medicines that help to stop blood clots forming. For example, Warfarin.
  • Angiotensin-converting-enzyme (ACE) inhibitors; medicines that lower your blood pressure and are often used in people with or to prevent heart failure and after a heart attack. For example; Ramipril and Lisinopril.
  • Nitrates; medicines that relax your coronary arteries, allowing more blood to reach your heart. For example, Glycerine Trinitrate (tablets or spray) and Isosorbide mononitrate.
  • Anti-arrhythmic; medicines which help to control your heart rhythm. For example, Amioderone and Flecanide.

Coronary angioplasty
Coronary angioplasty is also known as percutaneous transluminal coronary angioplasty (or PTCA for short), balloon angioplasty, balloon dilation or percutaneous coronary intervention (PCI for short).

Angioplasty may be a planned procedure for some people with angina or as an urgent treatment if the symptoms have become unstable, for example when having a heart attack. Having a coronary angiogram will help doctors find out if you need angioplasty. Coronary angioplasty is also performed as an emergency treatment during a heart attack.

A catheter (fine, flexible, hollow tube) with a small inflatable balloon at the end is passed into an artery in either the groin or arm. The doctor then uses X-ray screening to direct the catheter into a coronary artery (artery on the heart) until its tip reaches a narrow or blocked section.

At the narrowed part of the artery the balloon will then be inflated so that it squashes the plaque (fatty substance) in the narrowed artery. This allows the blood to flow more easily.

The catheter contains a stent (a small stainless steel wire mesh tube). As the balloon is inflated (blown up), the stent expands so that it holds the narrowed artery open. The balloon is then deflated (let down) and removed leaving the stent in place.

Coronary artery bypass grafts
Coronary artery bypass grafts are also known as bypass surgery, heart bypass, coronary artery bypass surgery (or CABG for short).

Bypass grafts are performed in patients where the arteries become narrowed or blocked and are unsuitable for stents.  A coronary angiogram will help doctors to decide if you are suitable for treatment.   

A blood vessel (either an artery or vein) is taken from another part of the body (often the leg or chest) and inserted (grafted) between the aorta (the main artery leaving the heart) and a part of the coronary artery beyond the narrowed or blocked area. This allows the blood to bypass (get around) the narrowed sections of coronary arteries.

Heart transplant
In a small number of cases, when the heart is severely damaged and medicine is not effective, or when the heart becomes less efficient at pumping blood around the body (heart failure), a heart transplant may be needed.

A heart transplant involves replacing a heart that is damaged or is not working properly with a healthy donor heart.

Resuming sexual activity following a heart problem

Following angina, a heart attack or heart surgery it is normal to be worried about resuming your sex life.

However, for the majority of people it is perfectly safe to do so.  Many people think sex will be too strenuous and may bring on or worsen their heart problems.  This is not true!  Having sex will increase your heart rate (pulse) and your blood pressure but no more than if you were to walk up two flights of stairs.

There is no evidence to show that having sex will increase your risk of a further heart problem.

There is no set time you should wait before resuming sexual activity following a heart attack.  However, following heart surgery such as a coronary artery bypass it is advisable to wait 4-8 weeks to ensure everything has healed well.

There are lots of things that you can do to reduce your anxiety about sex, such as:

  • Choosing a relaxing atmosphere
  • Caressing and touching may be a helpful start to increase your confidence
  • Keep the room and bed at a comfortable temperature

When you are ready to resume intercourse think about the following:

  • Avoid having sex after a heavy meal
  • Avoid too much alcohol before sex
  • Find a comfortable position
  • Ask your partner to take a more active role
  • If you have a GTN spray or tablets, keep them where you can reach them just in case you need them

What should I do if I get chest pain/angina symptoms?
Following heart surgery (coronary artery bypass grafts) it is extremely unlikely that you will get chest pain caused by angina (lack of oxygen to the heart muscle), as the bypass grafts will now supply the heart muscle with plenty of oxygen.  It is more likely that you will have muscular pain from the surgery itself and the remaining bruising.  So it is important that you wait until everything has healed before resuming sexual activity.  However, most couples find that kissing, cuddling and other sexual contact during the healing period is satisfactory.  Continuing to take the prescribed pain relief tablets should help.  However, if you have unexplained or ongoing pain it is advisable to speak to your cardiac specialist nurse or doctor.

If you have been diagnosed with angina or have had a heart attack (myocardial infarction) it is normal to have occasional angina pains following exertion (physical effort).

Any activity or exercise that increases the heart rate and blood pressure may cause angina.  Your cardiac nurse or doctor should advise you regarding physical activity and exercise.

If you develop chest pain/angina symptoms during sex (or any other physical activity):

  • Stop what you are doing.
  • Sit or lie in a comfortable position.
  • If you have been prescribed GTN spray or tablets pop one tablet or two sprays under the tongue and wait for 5 minutes.  If the pain has gone completely you may continue with your activity.
  • If after 5 minutes you still have chest pain/angina symptoms take another tablet or two sprays under the tongue and wait a further 5 minutes.  If the pain has gone completely you may continue with your activity.  However, if you still have pain after 10 minutes (you will have had 2 doses and waited 10 minutes, 5 minutes between doses), dial 999.

Erectile dysfunction following a heart problem
Erectile Dysfunction (ED)is the inability to get and maintain an erection that is good enough for satisfactory sexual intercourse.  ED is also known as impotence.

ED can have a range of causes that can be both physical and psychological (mental).

Causes include:

  • Narrowing of the blood vessels going to the penis - commonly associated with high blood pressure (hypertension), high cholesterol (hypercholesterolemia) and coronary heart disease (narrowing of the blood vessels in the heart).
  • Medicine – some medicines that you will have been given following a heart problem, such as beta-blockers and diuretics, can cause ED.  Do not stop taking these medicines as they are extremely important.  If you think that one of the medicines you are taking is affecting your ability to get an erection speak to your cardiac nurse or doctor who will be able to help.
  • Psychological causes – such as stress, anxiety, bereavement and relationship problems
  • Drinking too much alcohol
  • Smoking
  • Obesity – being excessively overweight
  • Taking recreational drugs – for example cocaine
  • Neurogenic – a stroke, Alzheimer’s disease, spinal cord injury, pelvic surgery (such as prostatectomy) or pelvic injury
  • Hormonal problems – for example an overactive thyroid

How common is erectile dysfunction?
ED is a very common condition, particularly in older men.  It is estimated that half of all men between the ages of 40 to 70 will have some degree of ED.

ED can have a significant impact on both your quality of life and your partner’s.  However, in most cases, ED can be treated.  Although you may be embarrassed, it is important that you talk to a healthcare professional who can diagnose ED so that the cause can be identified.

For more information about treatment and recovery from ED see our ED webpage.

Stroke

What is the Brain?

The brain is the control centre for your body and it sits in your skull at the top of your spinal cord.

The brain has three main parts.

  1. The cerebellum.
  2. The cerebrum, which has two parts, the left and right cerebral hemispheres.
  3. The brain stem, that controls a lot of the 'automatic' actions of your body such as breathing and heart beat, and links the brain to the spinal cord and the rest of the body.

Your brain is wrapped in 3 layers of tissue and floats in a special shock-proof fluid to stop it from getting bumped on the inside of your skull as your body moves around.

Your brain is a powerful, complex organ. It is constantly dealing with hundreds of messages from the world around you and from your body, and telling your body what to do.

It gets the messages from your senses - seeing, hearing, tasting, smelling, touching and moving.The messages travel from nerve cells all over the body. They travel along nerve fibres to nerve cells in the brain.

Cerebral Vascular accident (CVA) or Stroke
A stroke is a serious medical condition that occurs when the blood supply to the brain is disturbed.

Like all organs, your brain needs oxygen and nutrients provided by the blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain damage and possibly death.

A stroke is a medical emergency. Quick treatment is vital because the sooner a person receives treatment for a stroke, the less damage is likely to happen.

There are two main types of stroke:

  • Ischemic: This is the most common type of stroke caused by cardiovascular disease. The blood supply is stopped due to a blood clot. This can cause temporary problems (transient ischemic attack or TIA for short) or more permanent damage.
  • Haemorrhagic: This type of stroke is caused by a weakened blood vessel supplying the brain which bursts and causes damage to the brain.

Ischemic stroke
Ischemic stroke accounts for about 87 percent of all cases.  Ischemic strokes occur as a result of an obstruction (blockage) within a blood vessel (tube which carries blood) to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis. These fatty deposits can cause two types of obstruction:

Cerebral Thrombosis
Cerebral (brain) thrombosis (clot) refers to a thrombus (blood clot) that develops at the clogged part of the vessel leading to the brain. The clot is usually caused by a break or tear in the plaque/cholesterol (fatty substance) which lines the carotid artery. As the blood flows through the artery it detects the damage and a clot starts to form over the broken cholesterol in order to “repair” the damaged area. Once a clot blocks the artery completely, damage to the brain will start to occur.

If the blood supply is cut off for a long time and you do not seek medical treatment quickly, the brain cells are permanently damaged and die, leading to disability or death depending on the amount of damage to the brain.

Cerebral Embolism
Cerebral embolism refers generally to a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck. A piece of the blood clot breaks loose, enters the bloodstream and travels through the brain's blood vessels until it reaches vessels too small to let it pass, therefore causing a blockage.

A second important cause of embolism is an irregular heartbeat, known as atrial fibrillation. It creates conditions where clots can form in the heart, dislodge and travel to the brain.

Transient Ischemic attack (TIA)
A transient ischemic attach (TIA) is similar o a full stroke but the symptoms are temporary; lasting between a few minutes and 24 hours. A TIA is awarningsign that there may be a risk of a more major stroke in the near future. It shouldneverbeignored. If you have any symptoms of a TIA you should dial 999 immediately.

What causes an Ischemic Stroke?
The causes of ischemic stroke are the same as the causes of cardiovascular disease.

Modifiable risk factors:

  • Smoking
  • Hypertension (high blood pressure)
  • Hypercholesterolemia (high cholesterol)
  • Obesity (being excessively over weight)
  • Lack of exercise
  • Stress
  • Diabetes
  • Excess alcohol

Haemorrhagic Stroke

Haemorrhagic stroke accounts for about 13 percent of stroke cases.  It results from a weakened blood vessel that ruptures (bursts) and bleeds into the surrounding brain. The blood collects and compresses (squashes) the surrounding brain tissue. This causes brain cells to become damaged and die.

The two types of haemorrhagic strokes are intra-cerebral haemorrhage or subarachnoid haemorrhage.

  • Intra-cerebral haemorrhage. This means your stroke has been caused by bleeding inside your brain.
  • Subarachnoid haemorrhage. This means your stroke has been caused by bleeding on the surface of your brain in the subarachnoid space (formed by two membranes that cover the brain).

Causes of a haemorrhagic stroke
The greatest risk factor for haemorrhagic stroke is having high blood pressure. About two in three haemorrhagic strokes are caused by this factor.

Other factors that may increase your risk of haemorrhagic stroke include the following.

  • Swelling of a blood vessel in your brain (intracranial aneurysm). This may be caused by high blood pressure, or may just be something you are born with.
  • Weakening of the blood vessels in your brain. This can happen because of uncontrolled blood pressure or sometimes because of a build-up of a protein called amyloid in the blood vessel walls (cerebral amyloidosis).
  • Abnormalities in the way in which blood vessels have formed in your brain (arterio-venous malformation).
  • Anything that increases your tendency to bleed. This can include having treatment with an anticoagulant medicine (e.g. Warfarin) or having a condition such as leukaemia or haemophilia.
  • Use of some illegal drugs, such as cocaine.
  • Having a head injury. This may cause blood vessels to burst and bleed into or around your brain.

Symptoms of a stroke

If you suspect that you or someone else is having a stroke, phone 999 immediately and ask for an ambulance.

FAST


FAST helps you to assess the three specific symptoms of stroke.

Facial weakness - can the person smile? Has their mouth or eye drooped?

Arm weakness - can the person raise both arms?

Speech problems - can the person speak clearly and understand what you say?

Time to call 999

Symptoms in the FAST test identify about nine out of 10 strokes.

Other signs and symptoms may include:

  • Numbness or weakness resulting in complete paralysis of one side of the body
  • Sudden loss of vision
  • Dizziness
  • Communication problems, difficulty talking and understanding what others are saying
  • Problems with balance and coordination
  • Difficulty swallowing
  • Sudden and severe headache, unlike any the person has had before, especially if associated with neck stiffness
  • Blacking out (in severe cases)

Tests

When someone has shown symptoms of a stroke or a TIA (transient ischemic attack), a doctor will gather information and make a diagnosis. He or she will review the events that have occurred and will:

  • Get a medical history
  • Do a physical and neurological examination
  • Have certain blood tests done
  • Get a CT or MRI scan of the patient
  • Study the results of other diagnostic tests that might be needed

Diagnostic tests examine how the brain looks, works and gets its blood supply. They can show the injured brain area.

Diagnostic tests fall into three categories.

  • Imaging tests give a picture of the brain similar to X-rays.
  • Electrical tests record the electrical impulses of the brain.
  • Blood flow tests show any problem that may cause changes in blood flow to the brain.

Magnetic resonance imaging (MRI)
MRI (magnetic resonance imaging) uses a large magnetic field to produce an image of the brain. Like the CT scan, it shows the location and extent of brain injury. The image produced by MRI is sharper and more detailed than a CT scan so it's often used to diagnose small, deep injuries.

Electroencephalogram (EEG) & Evoked Response
Two basic tests, EEG and Evoked Response, show the brain's electrical activity.

In an EEG (electroencephalogram), small metal discs (electrodes) are placed on a person's scalp to pick up electrical impulses. These electrical signals are printed out as brain waves.

An Evoked Response test measures how the brain handles different sensory information. Electrodes record electrical impulses related to hearing, body sensation or vision.

B-mode imaging, Doppler testing and duplex scanning
Several blood flow tests exist; most use ultrasound technology. A probe is placed over the suspect artery — especially arteries in the neck (carotid) or at the base of the skull vertebral) — and the amount of blood flow is determined.

Examples of blood flow tests are B-mode imaging, Doppler testing and duplex scanning. These tests give detailed information about the condition of arteries.


Angiography, arteriography or arteriogram
Another blood flow test is a medical procedure called angiography (arteriography or arteriogram). This test is like a cardiac catheterisation, only the catheter is placed in the arteries of the brain rather than in the arteries of the heart. In this test, a special dye is injected into the blood vessels and an X-ray is taken.

Angiography gives a picture of the blood flow through the vessels. This allows the size and location of blockages to be evaluated. This test can be especially valuable in diagnosing aneurysms and malformed blood vessels and providing information before surgery.

Treatments for Ischemic stroke

Clot Busting Drugs
Ischemic strokes can be treated using a 'clot-busting' medicine called alteplase, which dissolves blood clots. This is known as thrombolysis. However, alteplase is only effective if started during the first four and a half hours after the onset of the stroke. After that time, the medicine has not been shown to have beneficial effects. Even within this narrow time frame, the quicker alteplase can be started the better the chance of recovery. However, not all patients are suitable for thrombolysis treatment.

You will also be given a regular dose of aspirin (an anti-platelet medication), as this makes the cells in your blood, known as platelets, less sticky, reducing the chances of further blood clots occurring. If you are allergic to aspirin, other anti-platelet medicines are available.

Anticoagulants
You may also be given an additional medication called an anticoagulant. Like aspirin, anticoagulants prevent blood clots by changing the chemicals of the blood in a way that prevents clots from occurring. Heparin and Warfarin are two anticoagulants that are commonly used.

Anticoagulants are often prescribed for people who have an irregular heartbeat (atrial fibrillation) that can cause blood clots.

Blood pressure: If your blood pressure is too high, you may be given medicines to lower it. Two medicines that are commonly used are:

Thiazide diuretic: this reduces the amount of water in your body and widens the blood vessels, which decreases blood pressure. For example, Bendroflumethiazideand Chlortalidone.

Angiotensin converting enzyme (ACE) inhibitors: these widen the blood vessels and reduce blood pressure. For example, Lisinopril and Ramipril.

  • Statins: Medicines which slow down the production of cholesterol and help to prevent atherosclerosis (narrowing of the arteries). For example, Atorvastatin and Simvastatin.
  • Carotid endarterectomy:  Some ischemic strokes are caused by a narrowing in the carotid artery, which is an artery in the neck, which takes blood to the brain. The narrowing, known as carotid stenosis, is caused by a build-up of fatty plaques.  If the carotid stenosis is particularly bad, surgery may be used to unblock the artery. This is done using a surgical technique called a carotid endarterectomy. It involves the surgeon making an incision (cut) in your neck in order to open up the carotid artery and remove the fatty deposits.

Treatment for Haemorrhagic stroke

Medications

  • Anti-hypertensive medications. These are typically one of the first medications to be administered. Since haemorrhagic strokes are often caused or worsened by high blood pressure, one of the primary goals of haemorrhagic stroke treatment is to reduce blood pressure safely.
  • Anti-anxiety medications. Stress can raise blood pressure, so anti-anxiety medications may also be given to help patients remain calm during a haemorrhagic stroke.
  • Hyper-osmotic medications. These are special medications that may be given to help relieve pressure in the brain in the event that the brain begins to swell due to extra fluid.
  • Anti-seizure medications. Because of scar tissue in the brain following a stroke, seizures frequently occur. To prevent this from happening, anti-seizure medications are often prescribed.

Surgery
Sometimes, surgery is needed to save the patient's life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. For example, a haemorrhage due to an aneurysm or AVM (brain arterio-venous malformation) requires special treatment.

For other types of bleeding, removal of the haematoma (blood clot) may occasionally be needed, especially when bleeding occurs in the back of the brain.

Surgical clipping
Surgical clipping may be used when the stroke is caused by a ruptured aneurysm (bulge in the wall in the blood vessel) in the subarachnoid space. It is also used to prevent aneurysms from rupturing. The procedure is always performed by a neurosurgeon (doctor who specialises in brains), preferably one with expertise in cerebro-vascular disease.

In order to clip an aneurysm, the neurosurgeon first must perform a craniotomy — a surgical procedure in which the brain and the blood vessels are accessed through an opening in the skull. The surgeon blocks the blood flow into the aneurysm by applying a metal clip to its base (neck) where it connects to the blood vessel. This stops the haemorrhaging into the subarachnoid space and redirects the blood flow along its proper route.

Aneurysm clips are made of titanium and come in all different shapes and sizes. The choice of a particular clip is based on the size and location of an aneurysm. The clip has a spring mechanism which allows the two "jaws" of the clip to close around either side of the aneurysm, separating the aneurysm from the blood vessel. These clips are designed to be left in place permanently.

Endovascular Coiling
This is a newer, much less invasive technique for treating certain types of ruptured and un-ruptured aneurysms. The procedure can be performed under general anaesthetic or light sedation by a neurosurgeon, an interventional neuroradiologist, or a specially trained neurologist using real-time X-ray technology, called fluoroscopic imaging, to look at the patient's vascular system and treat the disease from inside the blood vessel.

Endovascular treatment of brain aneurysms involves inserting a thin plastic catheter into the femoral artery in the groin and passing it through the vascular system into the head and into the aneurysm. A tiny platinum coil is threaded through the catheter and positioned in the aneurysm, blocking blood flow into the aneurysm and preventing rupture (bursting) (or re-rupture).

Hypothermia
Hypothermia is currently being investigated as a treatment following severe stroke and brain haemorrhage to prevent permanent brain damage. It involves lowering the temperature of the brain to protect brain cells from death due to trauma or lack of blood flow and oxygen.

Ventriculostomy
This treatment is used to prevent the formation of blood clots (intra-cerebral haematomas) following or as a result of haemorrhagic stroke and reduce pressure in the cranium (part of the brain). Cerebrospinal fluid (CSF) is constantly being made and drained from the brain. A leak of blood from a haemorrhage can interfere with the normal drainage of CSF, causing a fluid build-up. In ventriculostomy, a drain is inserted into the fluid spaces in the brain. The drainage reduces pressure in the veins and reduces the risk of second stroke or other damage.

Sexual activity following a stroke
Your recovery from a stroke will have taken you through a mixture of stages. Coming to terms with what has happened to you takes time and at first you will have been concentrating on the more practical aspects of your stroke such as learning to walk, talk and care for yourself.

Further down the line your mind may turn to more personal matters such as starting or renewing a sexual relationship. If being sexually active was important to you before your stroke it is likely that you will feel that way again. However there may be some physical and emotional issues that now have to be considered.

Stroke affects everyone differently and to different degrees so it is very unlikely for two people to have exactly the same experience.

Fear
A common fear following a stroke is that having sex will bring on another stroke. There is no reason why after a couple of weeks you cannot begin to have sex if you feel ready to do so. Medical evidence supports this. If you still feel unsure about having sex then arrange to speak to your doctor or stroke specialist nurse.

Physical changes
Having a stroke does not have to mean the end of being sexually active, although some changes may be needed. Physically a stroke can affect men and women in different ways.

  • Decrease in libido: Both men and women may find that libido (sex drive) is lessened due to tiredness, anxiety, depression, low self-image and concerns for the future. A woman may find that sexual arousal takes longer after her stroke. There may be a loss of sensation or a degree of vaginal dryness, which may hinder sexual activity.

    A man is more likely to be concerned if he finds he is unable to achieve or sustain an erection (erectile dysfunction). This can happen after a stroke for many reasons but it is also common after any serious illness. After a stroke, even if one side of the body has been affected, the nerve processes involved on the unaffected side are usually enough to sustain an erection.

    There are many causes of erectile dysfunction (ED); side effect of some medications, conditions such as diabetes and prostate problems may also cause erection problems in men.

    Unfortunately, some blood pressure lowering drugs can cause erectile dysfunction in men. This is completely reversible by changing to a different group of drugs.

    Therefore, it is vital that you discuss this with your doctor so that something can be done about it.

    Your GP may review your medications and if needed refer you to a specialist.
  • Increase in libido: A minority (small number) of people experience an increased libido (sex drive) and sexual activity after a stroke.

    Very rarely a stroke can cause a disorder called hypersexuality, which can be related to the area of brain damaged by the stroke. This is described as an abnormal, increased sexual desire.
  • Blood Pressure: Many people worry that having sex will raise their blood pressure too high. Sex only affects your blood pressure in the same way as exercise does. It is very rare for strokes to happen during sexual activity but if this is worrying you, you should speak to your doctor or stroke specialist nurse for reassurance.

Emotional changes
Both men and women experience similar emotional problems after a stroke. How you feel about yourself can lead to you losing confidence in yourself. Adjusting to the changes in your life after a stroke can take time to come to terms with and many people experience anxiety and depression as a result. This can have a knock on affect on your desire for sex.

There can be a subtle change within a relationship when a partner becomes a carer, especially when assistance is needed with personal care. This can sometimes cause embarrassment or affect the way you feel about each other.

Communication is important: keeping closeness and intimacy within your relationship will help to overcome difficulties.  It is important to keep talking to each other. You can express your feelings in many different ways, through talking but also with physical contact such as kissing and cuddling. Getting the better of anxiety and shyness in taking the first step may be the biggest hurdle to overcome.

Potential Difficulties
It is very important to remember that there are physical, emotional and social reasons for a decline in sexual function and satisfaction after a stroke.

Physical difficulties

  • Tiredness
  • Delayed arousal
  • Vaginal dryness
  • Erectile Dysfunction
  • Loss of movement
  • Loss of sensation
  • Having a urinary catheter

Emotional difficulties

  • Fear of erectile dysfunction or loss of sex drive
  • Actual loss of sexual desire
  • Changes in self image
  • Decreased confidence
  • Low self esteem
  • Change in social role - in family and community
  • Embarrassment
  • Anxiety
  • Depression

Other difficulties

  • Unwillingness to participate in sexual activity
  • Degree of physical disability involved
  • Inability to discuss sex
  • Plan for sexual activity in advance, just as you would plan for any other activity.

Practical steps to improve things 

  • Pay attention to personal hygiene as this makes most of us feel more attractive and better about ourselves.
  • Choose a time when both of you are feeling rested, relaxed and when privacy is guaranteed.
  • Avoid a heavy meal or wait a couple of hours after eating.
  • Avoid excessive alcohol as this can have an effect on the ability to achieve or maintain an erection.
  • Alcohol can also increase tiredness and drowsiness.
  • If your stroke restricts your movement and /or sensation, explore different positions, which might suit you both better.
  • Try talking with your partner, and identify any problems you are experiencing. Ways around any difficulties can be found.
  • Having a urinary catheter need not prevent you from having penetrative sex. Females can tape the tube out of the way; males can wear a condom with the tube folded back over the penis.
  • Try using lubrication jelly.

Sexual fulfilment 

There are other ways of expressing your feelings for someone and achieving sexual fulfilment even if you cannot manage penetrative sex. Most people feel the need for and benefit from physical contact and you can give and receive a lot of pleasure through kissing, cuddling and massage.

Remember if sex was important to you before your stroke there is no reason why you cannot have a sex life after your stroke, whether this is starting a new relationship or resuming an old one. However, keeping an open mind and giving yourself time to adjust is often the solution to getting your sex life back on track.

Peripheral Vascular disease (PVD)

What are the arteries?

Oxygen from the air is absorbed (soaked up) into your bloodstream through your lungs. Your heart then pumps oxygen rich ('oxygenated') blood through a group of blood vessels, the arteries, to tissues including your organs, muscles and nerves, all around your body.

Arteries are elastic (stretchy) blood vessels (tubes) that carry blood away from the heart.

There are two main types of arteries: pulmonary arteries and systemic arteries.

The pulmonary artery transports blood from the heart to the lungs.

Systemic arteries deliver blood to the rest of the body.

What is Peripheral vascular disease?
Peripheral vascular disease (PVD) also known as peripheral arterial disease (PAD) is most common in the arteries that supply blood to your legs.

Peripheral vascular disease usually develops when fatty deposits (plaque) builds up on the walls of your arteries. This is called atherosclerosis. The fatty deposits cause your arteries to narrow. This means that the supply of blood to your muscles and tissues is reduced.

Peripheral vascular disease can also affect other arteries including those in your neck or near your pelvis. If you have peripheral vascular disease, it can increase your risk of heart attack or stroke.

What causes Peripheral vascular disease?
Over time, as you get older, your arteries naturally begin to harden and get narrower, which can lead to atherosclerosis and then PVD.

However, there are many factors that can speed up this process. These are known as ‘risk factors’.  A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease.

Non Modifiable risk factors

  • Age. Simply getting older increases your risk of damaged and narrowed arteries.
  • Sex (Gender). Men are generally at greater risk of cardiovascular disease. However, the risk for women increases after menopause.
  • Family history. If a close family member has cardiovascular disease it puts you at risk. The closer the relative is, the greater the risk. So if your mum, dad, brother or sister has cardiovascular disease (rather than aunts, uncles or cousins), it is more likely you will develop the condition too. Especially if a close relative developed this at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before the age of 55, or your mother or a sister developed it before the age of 65.

Modifiable risk factors:

  • Smoking
  • Hypertension (high blood pressure)
  • Hypercholesterolemia (high cholesterol)
  • Obesity (being excessively over weight)
  • Lack of exercise
  • Stress
  • Diabetes
  • Excess alcohol

If you would like help and support making any life style changes see your GP or Practice nurse for more information.

Symptoms of Peripheral vascular disease
The most common symptom of peripheral vascular disease is painful cramping in your leg muscles triggered by physical activity such as walking or climbing the stairs. The pain usually develops in your calves, but sometimes your hips or thigh muscles can be affected. It can feel mild to severe.

The pain will usually go away after 5 to 10 minutes when you rest your legs. This pattern of symptoms is known as "intermittent claudication" (claudication is a Latin term that means "limping").

Other symptoms of PVD may include:

  • Hair loss on your legs and feet
  • Numbness or weakness in the legs
  • Brittle, slow-growing toenails
  • Ulcers (open sores) on your feet and legs, which do not heal
  • Changing skin colour on your legs, turning pale or bluish
  • Shiny skin
  • The muscles in your legs may shrink
  • You are unable to feel a pulse in your leg or the pulse feels much weaker than normal
  • Men may develop erectile dysfunction (impotence)

Tests

The ankle brachial pressure index
The ankle brachial pressure index (ABPI) is a widely used test in the diagnosis of PVD, as well as a useful way of assessing how well you are responding to treatment.

First, your GP measures the systolic blood pressure in your upper arm (the blood pressure when your heart beats and forces blood around your body). Then they will take a similar measurement in your ankle.

They then divide the second result (from your ankle) by the first result (from your arm).

If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same and the result of your ABPI would be 1.

But if you have PVD, the blood pressure in your ankle will be lower due to a decrease in blood supply, so the results of the ABPI would be less than 1.

In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way of seeing the effect of physical activity on your circulation (blood flow).

Ultrasound Scan
An ultrasound scan is a scan similar to the one used to see the foetus in a pregnant woman where sound waves are used to build up a picture of the arteries in your leg. This can identify exactly where in your arteries blockage or narrowing occurs.

Angiogram
An angiogram is a test used to take pictures of the blood vessels (tubes) of the legs using X-rays. The test can be used to identify whether your arteries are narrowed and determine how severe any blockages are.

A long, flexible, plastic tube called a catheter is inserted into a blood vessel in the groin. The tip of the catheter is guided, using X-ray pictures, to the arteries (blood vessels) supplying blood to the legs.

A special fluid called contrast medium or dye is then injected into the catheter and X-ray pictures of the arteries are taken. The pictures produced are called angiograms.  The fluid that is injected is visible on the X-rays, so the angiograms show up all the blood vessels that the fluid travels through. This reveals if any of the blood vessels are narrowed or blocked and whether any further treatment is required.

CT Scan
A CT scan uses X-rays and a computer to create detailed images of the inside of your body.

MRI Scan
An MRI scan uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body.

Treatments for PVD

Lifestyle changes
Making lifestyle changes to improve symptoms and reduce your risk of developing a more serious cardiovascular disease (CVD), such as coronary heart disease. See Modifiable risk factors.

Medications
Taking medication to address the underlying cause of PVD and reduce your risk of developing another CVD.

Statins
If blood tests show that your levels of cholesterol are high, you may be prescribed a type of medication called a statin. Statins are medicines which slow down the production of cholesterol and help to prevent atherosclerosis (narrowing of the arteries). For example, Atorvastatin and Simvastatin.

Anti-hypertensives
Antihypertensives are a group of medications used to treat high blood pressure.  It is likely you will be prescribed an antihypertensive drug if your blood pressure is higher than doctors would like it to be.

A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor.

ACE inhibitors block the actions of some of the hormones that help to regulate blood pressure. They help to reduce the amount of water in your blood and widen your arteries, which will both decrease your blood pressure.

Antiplatelets
Anti-platelets are medicines that make your blood less likely to form clots, reducing your risk of having a heart attack. For example, Aspirin and Clopidogrel.

Cilostazol
Cilostazol is  a medication used to treat intermittent claudication. This is a cramping pain that develops in the legs when you walk and is due to peripheral vascular disease.

It is a vasodilator (medication which widens the blood vessles) and increases the distance you can walk before pain develops.

It relieves the symptoms of intermittent claudication in two ways. It increases blood flow by widening the blood vessels of the affected areas and therefore increases the distance you can walk before pain develops. It also reduces the clotting activity of blood cells called platelets.

Surgery
There are two main types of surgical treatment for PVD:

Surgery is not always successful in treating PVD and is usually only recommended under the following circumstances:

  • Your leg pain is so severe that you are essentially disabled as you are no longer able to walk any significant distance.
  • Your symptoms have failed to respond to medications.
  • The results of tests, such as ultrasound scans, show that surgery is likely to improve symptoms.

Angioplasty
An angioplasty is usually carried out under a local anaesthetic, which means you will be awake during the operation but your legs will be numbed by the anaesthetic, so you will not feel any pain.

The surgeon will insert a tiny hollow tube known as a catheter into one of the arteries in your groin. The catheter is then guided to the site of the blockage.

On the tip of the catheter is a balloon. Once the catheter is in place, the balloon is inflated, which helps widen the vessel. Sometimes a hollow metal tube known as a stent may be left in place to help keep the artery open.

Bypass Graft
A bypass graft is performed under a general anaesthetic, which means you will be asleep during surgery and you will not experience any pain.

During surgery the surgeon will remove a small section of a healthy vein in your leg. The vein is then grafted (joined) onto the blocked vein so the blood supply can be bypassed and go around the blockage and into the healthy vein. Sometimes a section of artificial tubing can be used as an alternative to a grafted vein. 

Disclaimer
All content within Mediplus Patient Info pages is provided for general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional.  Mediplus is not responsible or liable for any diagnosis made by a user based on the content of the Mediplus website.  Mediplus is not liable for the contents of any external internet sites listed, nor does it endorse any commercial product or service mentioned or advised on any of the sites.  Always consult your own GP if you're in any way concerned about your health.

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