Imagine having a pain in your chest that cannot be cured.
Imagine that you have been to hospital but the tight sensations persist. And imagine this has gone on for years, despite many attempts at treatment.
This type of difficult-to-cure heart pain may well be ‘refractory angina’. ‘Angina’ is where the blood supplying the heart muscle itself, as opposed to the blood flowing through it, becomes restricted. ‘Refractory’ in this case means resistant to treatment. The condition is suffered by an estimated 50,000 people in the UK – although because it is difficult to diagnose, exact numbers are not known.
Whether refractory or not, angina itself – suffered by nearly two million people, or nearly 4% of the entire UK adult population – is deeply unpleasant. There is an increased risk of heart attack or stroke, and it feels like pressure, tightness, squeezing, or burning. The pain can start behind the breastbone and spread to the shoulders, arms, neck, jaw, back, or stomach.
So...imagine that going on for years. Even after interventions like having a stent fitted, or having heart surgery like a bypass operation. Solving such difficult, or refractory, cases is where the interventional cardiologist at the Royal Brompton comes in. Essentially a kind of heart detective.
Today he is seeing a lady with heart pain in her early sixties who has come from over 100 miles away. She is lying in the cath lab in front of us, while the cardiologist and his team prepare to investigate. As usual in this specialist hospital, the patient is not only surrounded by a bustling team of people in masks and scrubs, but by a formidable array of equipment.
The scanner itself is an oblong-shaped box mounted on a large, semi-circular arm which cradles the patient, and transmits x-rays that are received by another box sitting underneath. These produce ‘live’ moving images so that both in the lab, on a huge plasma-like screen, and in the control room on multiple smaller screens, you can see an intricate mass of grey shadows and root-like tentacles, all pulsing with the same slow, steady beat.
This is the patient’s heart and, surrounding it, the blood vessels that are the focus of today’s work. On other screens, there are moving graphs of red and green zigzags, charts, numbers. Wires and pipes hang everywhere. Beeps and clicks and hums are the only noise, punctuated by the occasional calm conversation by the medical team.
“With this kind of angina, we need to look at the really small vessels that supply the heart muscle – the vessels so small you cannot see them conventionally,” the cardiologist explains.
He has fed a wire-like catheter tube through a hole in the patient’s wrist and on the TV screens, we can now see it approaching the heart. Little puffs of liquid dye that can be seen by the x-rays appear at the end of the wire.
It is a tough case to crack. The patient has been to several hospitals already. Propositions have been made, treatments implemented, investigations continued. Still nothing. The cardiologist enjoys this challenge. Not for him the satisfaction of obvious cases, familiar solutions, and quick fixes.
This is a clinician who enjoys a really intractable problem, one that others have failed to solve. A curiosity focused more on what we don’t know, than what we know. “We are often unpicking something other doctors have said,” he says. “We think we have a complete understanding of what is going on in our patients, but you have to be humbler than that. The more you look, the greater the complexity.”
He works with a colleague to study the results of today’s scan, analysing charts, going over previous drug regimes, looking at previous notes. At one stage, he posits a theory, but today’s tests prove him wrong.
I am struck by the lifetime of training and research that has gone into his expertise. The clinical pathway he presides over today – the path today’s female patient is now on – has taken literally decades of work to develop. He refers to potential retirement “in a few years” and I realise it his decades of exploring the heart that make him such an astute sleuth.
He talks about the tools of his trade, the giant leaps made by technology over the decades that modern cardiology has evolved. “I remember during my training visiting a hospital in the States where they had more MRI scanners on one floor than we had in the whole of the UK at the time.” But, in the end, it is not about the scanners, the MRIs, the PETs, the CTs, but about the people using them, that gets the results. “Even the tools we have now have their weaknesses. No tool is perfect. You have to look at the whole patient, holistically, and think, what is the wider context?”
It is in fact just like one of those crime dramas where there is one overwhelmingly obvious clue but it is how that clue fits together with the whole scene, the wider story, with more than one character, that provides the actual solution.
There is something else too. “We are going to get an answer, one way or another. Even if this initial strategy doesn’t work we will find other options to support them. There are the pain services at Guy’s and St Thomas’, and the rehab services at Harefield.” This is not just about a lifetime of medical research and expertise, of understanding that technology can get you a long way, but not all the way. It is also about determination. A determination to help patients, to solve their disease, to get to the truth. As the cardiologist says: “The impact we can have on these patients is profound.”