In the early 1980s, cardiologists were still arguing as to whether bypass surgery to improve the coronary artery flow was worthwhile. There were doubts about its safety and its long-term benefits. In the early days, many bypasses closed off a few months after the operation, leaving the patients no better off.

These doubts are now dispelled. Bypass surgery is now accepted as improving the quality of life of thousands of angina sufferers, and as saving many lives. It has a very high success rate, and the restenosis rate is diminishing year by year.

To bypass surgery has been added balloon angioplasty and, more recently, laser and stent treatment.

Stents and lasers

To balloons and bypasses have now been added stents and lasers. The catheter technology that uses balloons can also put stents in place. Stents are tiny tubes, made up of what looks like wire mesh, that can be placed in the narrowed section of artery to keep it open. The stent is placed there in a folded or collapsed form, and springs open when it is released at the right spot. It can be left there permanently, as the lining of the blood vessel grows around the mesh, holding it in place, and at the same time allowing it to remain wide open.

The catheter technology is also being developed to use lasers to burn away plaques that protrude into the bloodstream, under direct vision enabled by fiber optics. This is still a research procedure, but it cannot be long before it becomes one of the choices for the cardiologist.

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High blood pressure (hypertension), like cholesterol, smoking, and alcohol, deserves a chapter of its own in any book on angina. Hypertension causes complications for the heart in two ways: it directly increases the work done by the heart, so that the demand for oxygen is increased, and it accelerates the process of atherosclerosis, so that the coronary vessels in someone with hypertension are even more affected by atherosclerosis, and therefore narrower, than in someone with normal blood pressure.

Hypertension is linked with higher than normal risks of stroke, heart attack, and kidney disease, and it is vital that it should be controlled in anyone with angina. Professor Giuseppe Mancia of the University of Milan, one of the world’s leading experts in the study of hypertension, recently spelled out to me the risks of the combination of hypertension and angina.

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The “in” word for exercise in the 1990s is aerobics. Aerobic fitness is a measure of how well your heart, lungs, and blood vessels get oxygen to your muscles—in other words, your stamina. You become fitter aerobically by using your larger muscles continuously for a relatively long time. You don’t do so by stopping and starting a lot, as in gardening, golfing, or washing your car. You do become fitter if you continue your exercise until you get slightly out of breath, but can still keep up a conversation.

That is what you should aim at—an exercise lasting around twenty minutes that makes you slightly out of breath, three or four times a week. Don’t be disheartened if you can’t manage it yet, but aim to build up gradually towards that point. Even walking faster than usual for a few minutes is a start towards it, and week by week you will be surprised how much further you can walk before you get to the breathlessness point.

If you are so breathless that you cannot keep up a conversation, or your muscles are getting heavy or sore, then you are working too hard. You will not improve your fitness by exhausting yourself in this way. It is not true that exercise needs to hurt your muscles before it does you good. Muscles that are sore are being starved of oxygen, and that is not the aim!

Obeying this rule means that you should control your own level of exercise, and not be controlled by some outside influence, like the rhythm of music on a tape, or the need to compete with yourself (by, for example, timing your walking speed or distance).

Don’t do too much too quickly. No matter what your exercise, whether it is walking, cycling, running, or swimming, don’t push yourself to go further each time you do it. If your chosen exercise becomes like hard work, you are more likely to give it up, and the more likely you are to be injured. Your aim is to continue for life, and not for just a few weeks.

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Another approach to the cholesterol problem was to target only those with high blood cholesterol levels, and to treat them with drugs. Drugs to lower blood cholesterol levels were studied first in the 1970s, but they have had a troubled history since then.

WHO and Clofibrate.

The first study, the WHO Cooperative Trial of the cholesterol-lowering drug clofibrate, followed 15,745 healthy men in Edinburgh, Budapest, and Prague. Treatment was based on their cholesterol levels. Those in the upper third for blood cholesterol levels were allocated at random either to the clofibrate, or to a placebo. Those in the lower third for cholesterol levels were also given a placebo—they were the baseline control. The study was double blind, so that researchers and patients did not know what they were taking or in what group they were.

The results for heart attacks were mildly encouraging, as the clofibrate group had fewer nonfatal heart attacks than the high cholesterol group given a placebo. However, the clofibrate group had the highest overall number of deaths—a result that stopped the use of the drug in its tracks! This was despite its lowering the cholesterol levels by an average of 9 percent.

The excess of deaths of people taking clofibrate were not due to a single disease or discernible cause. The greatest benefit of cholesterol-lowering was in younger men with moderately raised cholesterol levels, but this was overshadowed by the unexpected extra deaths. The use of cholesterol-lowering drugs in anyone other than people with extremely high cholesterol levels has never fully recovered from that trial result.

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Take glucose in the serum as an example. Every cell in the body needs a continuing supply of glucose to stay alive. The burning of glucose with oxygen is your main supply of energy, so the level of glucose in the blood must remain within very strict limits. If it falls too low, you become faint and weak as your muscles and brain start to fail.

However, if the blood glucose level rises too high, as it does in poorly controlled diabetes, the blood becomes measurably stickier, and thickens. This is a problem for people with diabetes, who are at higher than normal risk of angina if they do not control their glucose levels very closely for this and other reasons.

A raised glucose level, however, is a very minor change compared to a rise in blood fat levels, or if the platelets become “stickier.” Even a small rise in fats—mainly measured as cholesterol—can make the blood much more viscous, and when this is combined with clumps (or aggregates) of platelets floating in the bloodstream in the smallest arteries, it can greatly reduce the smooth and easy flow of blood through them. These are changes that can happen to all of us, not just to diabetics, and that we can do much to reverse. If we let them continue, on the other hand, we are inviting the conditions for angina to develop.

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