by NICHOLAS GALL MSc MD FRCP, consultant cardiologist and cardiac electrophysiologist at King’s College Hospital and honorary senior lecturer at King’s College London. This email address is being protected from spambots. You need JavaScript enabled to view it..
CARDIOLOGY is the medical specialty dealing with heart problems, but also with other related areas such as blackouts of uncertain cause and high blood pressure. In the past cardiology was an extension of general internal medicine, staffed by doctors with an interest in the area.
Over recent years, however, as with many other areas of medicine, physicians have specialised wholly in cardiology.
Technological advances have increased our ability to deal with many heart problems, potentially offering a permanent cure and often offering highlyeffective therapies in a minimally-invasive way, that is without the need for open-heart surgery as might have been required in the past.
Government targets for heart disease because of the significant public health consequences of these conditions have also led to a dramatic expansion in this specialty over the past decade or so.
Heart conditions can present with a number of symptoms, including chest pain, breathlessness, an abnormal sensation of the heart rhythm (palpitations) or dizzy spells/blackouts.
Most cardiologists will see patients with most conditions, at least initially.
However, because of our increasingly complex diagnostic tools and therapies, many cardiologists specialise in particular areas.
Interventional cardiologists deal with heart blood vessel narrowing, which causes chest pain and heart attacks, using balloons and stents (small metal cages) to relieve the problem.
Cardiac electrophysiologists investigate and treat heart rhythm problems, burning away many fast heart rhythm problems leading to a cure (Tony Blair had the treatment some years ago with a modicum of publicity!) and using implantable devices to treat slow heart rhythm problems (pacemakers) and prevent sudden death from fast heart rhythm problems which cannot be ablated (defibrillators).
Other cardiologists specialise in imaging the heart – whether with ultrasound, CT or MRI – the management of heart failure or those with heart problems with which they were born (grown-up congenital heart disease). Heart conditions in children are dealt with by paediatricians, although there is something of a grey area in the teenage years.
Heart surgery, usually involving a bypass, is undertaken by cardiothoracic surgeons; their training is entirely different from that of a cardiologist and they should not be confused.
Cardiologists have a penchant for evidence, perhaps more than many other specialties. We base a large proportion of our management decisions on what studies tell us (so-called evidence-based medicine), although it must always be remembered that not all patients fit the studies. Because of that there are a large number of guidelines produced by various bodies in the UK, Europe and the United States on which we base our management strategies. It can, therefore, be a relatively simple job to define whether ‘the guidelines were followed’.
Our ability to treat heart conditions has dramatically expanded over recent years, with ever more complex procedures being performed in a minimally-invasive manner – often through tubes passed to the heart via tiny holes in the arteries or veins of the leg. Many are performed with local anaesthetic and sedation and usually as day cases.
Every procedure can be associated with a risk of complication and often the apparently minor nature of the procedures may hide the serious problems that can occur. More frequent complications relate to damaging the access blood vessel, which is usually a minor issue. Procedures inside the heart can, however, more rarely lead to serious complications such as heart attacks, strokes, dangerous heart rhythm disorders and the urgent need for open-heart surgery.
Risks are significantly increased in older and sicker patients; those individuals are an increasingly large proportion of our workload and it is now common to consider really quite significant procedures on patients in their 80s.
Furthermore, as research does not tend to focus on that expanding part of our population, decisions about management are often empirical and based on physician judgement.
The complexity of the area – which shows no sign of abating – means that often, in cases of possible mismanagement, it is necessary to consult the correct cardiologist.
Cardiology is now too large a specialty for anyone to be an ‘expert’ in everything, although we will always have an opinion! Personally I work with a number of colleagues on cases so as to provide the best, most up-to-date evidence in each circumstance.