Dietary Fats and their effects

The type of fats we consume in our diets and their effects on the health of our cardio-vascular system has become a controversial area in the last five years. Previously the issue seemed to be clear, the concepts easily explicable and easily understood: as much as possible it was considered wise to avoid ingesting saturated fats whilst unsaturated fat was considered to be relatively good for you. This generally understood position has come under considerable pressure in recent years from many interested groups. In the dietary world the pressure has originated from those advocating low-carb diets and such things as paleo diets.

Somewhat unfairly, all fats tend to have a bad name. As far as human health is concerned they are necessary and perform many important functions in the body: they help to maintain warmth, they keep hair and skin healthy and they are used by the body to store energy. Therefore, it is sensible to have some amounts of fats (preferably in the unsaturated form – see below) in your diet. Government guidelines in the West often talk in terms of 33% of diet being made up of fats. Doctor Esselstyn feels that this is far too high and prefers levels of under 10% for optimal heart health.

Fats are a complex and controversial issue, so in order to come to a clear understanding of the issues involved let us examine the facts.

Fats and their effects in the diet is a complex matter than one could spend many years studying and still not fully understand all the ramifications. In many ways the jury is still out on several of the main issues. For clarity's sake, and in order to have a clear if somewhat simplified understanding of dietary fats, we shall break them down into three main groups.

The first group are saturated fats. These are mostly obtained from animal 'products' such as meat, butter, milk and eggs. Not only will they tend to supply the body with excess low density lipids they will also lead over time and in most cases to weight gain and all manner of illnesses that are associated in the ingestion of large amounts these products (heart problems, diabetes, arthritis, etc). Consuming saturated fats will tend to increase the levels of low density lipids in your bloodstream. If you remember from the last post, LDLs are the more problematic form of cholesterol. According to Doctor Esselstyn, it would be wise as far as possible to keep the ratios of LDLs to HDLs as low as possible. This is almost impossible to achieve if one's diet consists of large amounts of saturated fats.

Saturated fats are solid at room temperature. They often look like the classical idea of fat when we picture such things – white, greasy and sticky.

The second group are trans fats or trans fatty acids to give them their full title. These are considered by many doctors to be the worst type of fat you can ingest. In the human body they have the effect of not only raising your bad cholesterol (LDLs) but also lowering your good cholesterol (HDLs). Obviously our desired ratio of 3:1 or better (LDLs to HDLs) will be negatively affected by this process.

Commercially, trans fat is created by adding hydrogen to vegetable oils by hydrogenating them. For commercial companies this has the benefit of making the oil less likely to spoil and hence prolonging shelf-life. The science behind the negative effects of these trans fats on the human body is not completely clear as yet but it is believed that adding hydrogen makes the oils more difficult to digest. They are a relatively new type of fat, hence the human body has had no time to ajust to them and seems to have little or no defence to their negative properties.

For commercial interests though the advantages are clear and hence there is a great reluctance on their part to stop using this process. Some governments around the world have actually made it illegal but most, probably because of pressure form self-interested commercial groups, have failed to legislate despite the very clear evidence of the harm that such fats do. To be fair on this issue, there have also been groups within the industry itself who have led the way and called for a ban on the use of hydrogenated fats. Not all commercial interests are irresponsible in this matter but at the time of writing those resisting change still have the ear of government (at least in the UK and the US).

Trans fats are to be found in many commercial baked goods such as crisps (known as chips in the US), crackers, biscuits (cookies), cakes and many fried foods. Shortenings and many margarines are often high in trans fats. Oddly, these very products often advertise themselves as 'healthy' because the actual amounts of fats involved is less than butter but, let the buyer beware, the type of fat they do not contain is anything but healthy!

The final groups of fats that we shall address today is Unsaturated Fats. These are normally sub-divided into polyunsaturated and monounsaturated fats. They are primarily found in fish, plant oils, nuts and seeds. Many believe that these fats lower your blood cholesterol and, by so doing, reduce your risk of cardiovascular disease. Dr Esselstyn tends to be quite conservative on this issue preferring to reduce the levels of even these less harmful types of fats down to a minimum. These fats maybe better for you than either saturated or trans fats but they are still fats! Intake therefore should be restricted if one wishes to maintain optimum health. I think it can be reasonably stated though that if you are to ingest fats these are the least harmful of the three groups but, even so, intake should be kept to a minimum.

Unsaturated fats, both mono and poly, remain in liquid form at room temperature.

Polyunsaturated fats have the additional benefit of containing Omega-3 fatty acids. This is an essential fatty acid. Such things are called essential because your body cannot create them itself and so must obtain them from dietary sources. Having adequate amounts of Omega-3, especially in relation to the amount of Omega-6 the body has, is considered essential for health, particularly heart health.

The main non plant-based sources of unsaturated fats are oily fish such as herrings, sardines, mackerel and salmon. If you are sticking to a plant-based diet then you need to look to sources such as hazelnuts, pumpkin seeds, sesame seeds, almonds and avocados. There are also many plant-based oils that are high in polyunsaturates such as olive oil, canola oil and sunflower oil. Esselstyn warns however against ingestion of such fats generally, even thought polyunsaturates are a lot better than saturated fat, and recommends against the use of any oils.

Sticking to the Esselstyn diet will involve the avoidance of fats generally. Whilst true that you do need some in your diet it is also the case that it is now thought to be far less than originally envisaged. Certainly recommending that a third of your diet should be fat would generally resist in problems for the body, the likelihood of putting on weight and subsequently vulnerability to such things as diabetes and heart disease.

Esselstyn's diet is not a moderate solution but having heart problems is not a moderate situation! Drastic steps are needed to counteract years of abuse that the body has often had to suffer. The good news is though, if you stick to the diet you will almost invariably quickly lose weight, look and feel healthier and, if all goes well, halt the progress of heart disease and, if adhered to strictly enough, you may even reverse it. This profound and fundamental change is what Esselstyn is offering. There are sacrifices but I think the results are well worth the things that one has to give up. 

Sticking with Cholesterol....

The subject of cholesterol and the whole fats question is something of a vexed issue of late. If you were to search online you would find a huge amount of information, much of it completely contradictory. Some will tell you it is wise to keep your cholesterol levels as low as possible whilst others will insist that having a high level of cholesterol in your bloodstream will have no bearing on your future health. To be as honest and straightforward with my readers as possible, I will admit to being a member of the first group and believe firmly, especially if a person has had any heart problems, that they would be well advised to control their cholesterol levels.

Firstly, we need to establish exactly what cholesterol is. If you were to hold some cholesterol in your hand you would find yourself looking at a waxy substance that might remind you of the scrapings from a whitish-yellow candle. Cholesterol is a lipid fat that is made in the cells of your body. There are many different types of cells that create cholesterol but the most productive are those in your liver that make approximately 25% of the total. You do need some cholesterol to keep healthy but your body creates all the cholesterol you need. You do not need to add cholesterol from outside sources (ie your diet!).

Cholesterol itself is performs three main functions in the body: it is used as part of the coating of cells; it makes up the bile acids that help in the digestion process; it allows the body to create Vitamin D and certain key hormones such as testosterone for men and oestrogen for women. Cholesterol is not bad, indeed it is vital to healthy bodily functions, but an excess of the wrong type is.

Cholesterol comes in two main types:

HDL (High Density Lipids) often referred to a good cholesterol.

LDL (Low Density Lipids) sometimes referred to a bad cholesterol but, the really bad ones are VLDL (Very Low Density Lipids) these are the ones that clog up your bloodstream and result in the problem of atheroma and the resulting cardiac issues.

Atheroma is the process of the degeneration of the walls of the arteries. This is generally caused by the build up of fatty deposits and scar tissue. Over time this will result in the restriction of blood flow and lead to cardiac events of all sorts. This formation is what we hope to prevent and reverse using these dietary and lifestyle methods.

A general reduction in cholesterol levels will offer a patient increasing levels of protection from the risk of heart attack but it needs to be stressed that it is not just the levels that are important but the ratio of LDLs to HDLs. Many in the field recommend going for a ration of 3:1 but some go even further and say that ideally one would achieve a ratio of 1:1. Commonly, in countries suffering high levels of heart problems such as the UK or the US, levels of 7:1 or 8:1 are commonly seen although the average is roughly 4.5:1.

Dr. Esselstyn sets a very clear goal in relation to the desired levels and ratios of cholesterol. He aims for a total blood cholesterol figure lower than 150mg/dl (milligrams per decilitre) and levels of LDL lower than 80mg/dl. By following the plant-based diet he recommends (as given in the previous blog) these levels are readily achievable. According to the doctor, at this kind of level you not only protect yourself from the possibility of a future cardiac event but even make possible the reversal of damage to the coronary arteries.

One of the good pieces of news about a plant-based diet is that plants themselves are very, very low in cholesterol. Many websites will tell you there is none at all, but this is not entirely accurate. The levels are so low though that they hardly register. Also, it should be noted, that the sort of cholesterol they do have is of a type that your body can use in a protective manner. To give some idea of the scale, the yoke of an egg (not recommended on the Esselstyn diet!) has 15000 mg/kg of cholesterol; the most concentrated form in the plant world is the European False Flax that contains as much as 200 mg of cholesterol per kg of plant oil. That is a ratio of 75:1. Note that this is in the oil form, again something that Esselstyn warns against, so even these very low levels would be avoided following his diet.

For interest, and to complete the picture, meat contains up to 5000 mg/kg and butter 2500 mg/kg. Without going into the issue of saturated versus unsaturated fats (a subject for a future blog), suffice it to say that the saturated fats are the ones to avoid. Dairy products and meat are high in saturated fats. One can readily see how the avoidance of meat and dairy products logically forms the foundation of Esselstyn's heart-friendly diet.

Finally, after quite enough technical information for one week, a little inspiration. Doctor Ellsworth Wareham was a cardio-thoracic surgeon for most of his long career. A few years ago, at the age of 95, he decided it was time to retire although there was no deterioration in his competence levels and the hospital he worked at tried everything they could to persuade him to continue. He is now 98 years of age and, as you can readily see from the video, remains remarkably healthy physically and sharp mentally. Doctor Ellsworth has been on a plant-based diet since his mid forties...

You are what you eat....

Following the heart attack I spent some time wandering around in the wilderness, feeling a little depressed and dis-empowered. It felt as if I could at best delay the inevitable but no better than that. After seeing various videos featuring ex-president Bill Clinton discussing the changes he had made to his diet under the influence of Doctors Dean Ornish and Caldwell Esselstyn I began to realise that there might be a better way. I did a little research the internet and found several sites relating to these issues, in particular, Esselsytn's own site was most informative and easily understood. He has the happy knack of explaining sometimes quite complex ideas in simple terms.

Having the possibility, through adherence to Esselstyn's dietary and lifestyle suggestions, of not only slowing the progress of the disease but actually reversing its effects felt tremendously encouraging and empowering to me. I could once more be the master of my own destiny.

Esselstyn himself has been a vegan of long standing but often the term 'vegan' is noticeable by its absence in his writings. Perhaps because some people have a very dismissive attitude to vegetarianism and veganism in general Esselstyn tends to adopt the term 'plant-based'. From my personal point of view, I have no problem with whatever they call the diet as long as it is efficacious in relation to the underlying problem. As old Bill Shakespeare once wrote (in Romeo and Juliet): “A rose by any other name smells just as sweet!”

The diet itself is as much about what it omits as what it includes. In very simple terms, all animal based foods are not allowed. This includes the more direct examples such as meat, fish and poultry but also foods derived from animals such as eggs, butter, cheese and any other dairy products. There are no exceptions. In that way the dietary advice is very clear on this point. An interesting way of thinking about this is why would you want to consume your nutrients second-hand only after they have been consumed by an animal when you can get the nutrients directly? Most of the common animals we eat get their nutrients via eating plants. We then eat them. Surely it is better to cut out the middle man (or middle animal in this case!), and get to the source of the nutrients directly?

Esselstyn is also very strong on the avoidance of all oils, even those that are oft touted as 'good oils'. According to the Doctor, for human beings there are no such things as good oils, in the long run they all damage our arteries. Even those often touted as healthy such as olive oil and canola oil are banned. Doctor Ornish is not quite so binary on this issue but I prefer the simplicity and clarity of Esselstyn's approach.

Refined grains are also to be avoided in favour of whole grains. White bread, white rice, even so-called enriched flour such as that to be found in bagels and most generally available baked goods are deemed to be off the menu. You are allowed grains but only in their whole variety rather than after they have been processed in some way.

Nuts are also banned because of the amounts of fats involved. This may seem drastic but having a heart attack is also pretty drastic in itself. I suppose it depends on how motivated you are to avoiding succumbing to further cardiac events. The one exception he makes is walnuts because of their high omega-3 content. Even this exception is directed at those who are trying to avoid a heart attack rather than those who already have suffered one. In the latter case he suggests that nuts of all sorts are best avoided altogether.

Finally, although these last two are so obvious that they hardly needs stating, avoid sugars and sugar based confections and do not smoke. Concentrated sugars are simply awful for the body but I think by now this is common knowledge. Not smoking goes without saying. If someone still believes that they can improve their health against a background of smoking one would wonder what planet he/she has been of for the last thirty years. To make an unequivocal statement: smoking is terrible for your heart and terrible for your lungs (amongst other unpleasant physiological effects).

After that rather long and wide ranging summation of what you cannot eat you are probably wondering what exactly you are allowed to consume! This is clearly not a diet for those who wish to compromise. The idea is reduce cholesterol down to levels scarcely seen in America and the Western world. This is not simply an attack on cholesterol though as it role in heart disease is far more subtle than was first realised. It is part of an overall and comprehensive strategy that will, if successful, allow your arteries the chance to repair themselves and for normal life to return.

You are allowed to eat just about any type of vegetable and, contrary to our normal idea of a diet, in whatever quantity you desire. You definitely need never go hungry on this diet although there may be a few problems whilst you adjust your mindset away from the unhealthy and disease causing foods towards the more healthy alternatives. After quite a short period it becomes second nature. At this stage the thought of consuming the greasy, fatty, processed fayre that is often served up in the name of food may even begin to become a little unappetising, to say the least. Even the sight of the stuff can become quite off-putting once you have adapted to a healthier, plant-based diet.

Legumes of all sorts are also highly recommended on this diet. Any type of bean or pea and lentils of all kinis are allowed. This gives a huge range of choice. Once you start to look into these things you begin to realise just what a huge variety of healthy food stuffs there are out there for you to choose from. Oddly, once you get into the swing of things, you may even find that your daily diet becomes far richer and more varied than it ever was before.

All whole grain products are allowed. This means that the grain has not been processed in any way (which often reduces it nutritional value). It is not at all uncommon these days for manufacturers even to add oil in the process of producing a loaf of bread. Clearly this is a big no-no on this diet!

Fruits of all sorts are definitely allowed and even encouraged but just be careful not to overdo it. When it is consumed it should be as close to its natural state as possible rather than in any desserts or sweetened forms. There is a type of sugar called fructose in fruits and over consumption of this bears the same dangers as many other forms of sugar consumption. Fruit juices, for this reason, are to be avoided.

You can drink a wide range of beverages such as tea, coffee, water, oat milk and no-fat soy milk. Personally, I can have a few problems with coffee as a strong cup can send the pulse racing so I tend to keep it down to one every now and then. Most of the time when I am in a situation where I previously drank coffee I tend to pick from a pretty comprehensive and wide range of teas that are available in this day and age. In my own case, and particularly when writing, I especially enjoy a pot of fresh green tea.

Even alcohol is allowed on this diet though keep it to sensible levels. Getting drunk on a regular basis is not good on any diet!

To cover for the possibility of any deficiencies, Dr. Esselstyn recommends taking a multivitamin tablet each day, vitamin C and D and a supplement of B12 (1000 mcg daily). People over 50, should look after their levels of vitamin D, therefore Esselstyn advocates supplementing with a tablet each day although getting sufficient exposure to sunshine would also help in its production. Finally, as regards supplements, Esselstyn recommends taking a tablespoon of flaxseed meal every day. This can be taken directly or added to your cereal.

Statins can be a controversial area but the cholesterol lowering effects are clear. Some claim many other benefits and feel that most people would be wise to use them once they approach middle age. Others point out possible negative side effects. If you are able to reduce your cholesterol levels to below 150 milligrams per decilitre then you can probably avoid the need to take statins. If above that, Doctor Esselstyn himself generally comes down on the side of using statins, particularly if you have already had a heart attack.

Ideally, as with many other such interventions, when one goes on this diet one should consult with a doctor before beginning. Have some blood tests done that inform both you and him/her of your cholesterol profile. Then, every three months afterwards have these levels re-checked to ascertain what progress you have made. Medication such as statins may become unnecessary if your levels have reduced below the 150 mg/dl mark.

In next weeks post we will address the problem of cholesterol and its relationship to a healthy heart. There is much misunderstanding in these areas and much controversy too. Again I would urge, in this day of huge amounts of free information (not always accurate though – be careful!) via the internet, to do some of your own research and familiarise yourself with the concepts involved. It is your heart, your health and, to some extent at least, your responsibility!

 For many years there was an attitude afoot wherein the person suffering health problems went to their doctor and hoped to get some kind of medication to make the problem go away. Essentially, the role of the patient was almost entirely passive whilst the doctor and the medical profession were cast in an almost omnipotent role. Increasingly in recent years, this is no longer the case. Your health is your own responsibility. So many of the ailments we suffer in these times are as the result of unhealthy lifestyles and attitudes, and poor diets. Merely allowing doctors to intervene when you suffer the effects is not good enough! It is your life, your health and your choice.  

The Aftermath. What to do?

The events referred to in my previous blogs transpired some two and a half years ago now. Happily, for me at least, I have survived this initial stage and even find myself in reasonably good health at the time of writing. Unfortunately, a fair percentage of heart attack victims never make it this far, particularly those who choose to continue the lifestyle that was, to a certain extent at least, responsible for them suffering a heart attack in the first place. Factors such as smoking, drinking to excess, lack of exercise and stressful lifestyles are obvious enough but perhaps the biggest single change that people such as I need to consider is their diet.

My own personal history in this matter seemed, at the surface level at least, to be relatively good. I had been a vegetarian for 27 years, had only smoked during my distant youth and I barely drank alcohol, only indulging in the odd glass of wine or beer once or twice a month. Unfortunately, all was not as it seemed though. My diet, although lacking meat and many of the problems related to the ingestion of it, was still not good. I had an ongoing weakness for cakes, biscuits and many other mass-produced, high in sugar, confections. Added to this, I had also spent many years in a high stress occupation that necessitated working long hours on shifts, often having to work with some degree of intensity late at night. During that period of my life I faced several health challenges and although that was long in my past now the ongoing effects were not so easily eradicated.

So it was that I found myself in middle age having to deal with the reality of suffering a heart attack and the somewhat disconcerting feeling that it could all so easily happen again. I had thought that the current, relatively low stress lifestyle that I adopted at the time would protect me. My exercise options were somewhat more limited than most due to the impact of a long-term back injury but I still managed to swim three times a week. The heart attack had proved me wrong though. Whatever it was that I was doing it was clearly not working. At this stage I have to admit to a certain feeling of helplessness, of being a passive victim of circumstances. This was not a good feeling...

The after-care advice that I received from my health provider basically told me to do all the things I had previously been doing anyway: exercise, avoid fast food, de-stress, don't smoke. There seemed also to be an unwritten and unspoken assumption in all this too, a sense that all a patient could do was forestall the inevitable, to put the dreaded event back in time but not to heal, not to actually get permanently better.

So it was that I found myself feeling like a ship without a rudder, sailing to who knows where but with the certainty that eventually it would not be a good place. I recalled from my earlier studies in psychology a group of experiments conducted by Martin Seligman into learned helplessness. Basically the results of these were that when you put an animal into a no-win situation it acquired a habit of not looking for other options even when these were in fact open to it. The animal 'learned' to be helpless. This now felt much like the situation I found myself in.

This continued for some months after the initial heart attack. There was a certain wariness to everything I was doing, as if I was at some level expecting another 'event' at some stage. When and how it would happen I had no idea, but there was a persistent feeling of inevitability that tended to take much of the fun out of life. The feeling of no longer being in control, of no longer having choice, is not a good one in this situation.

During this time of drift, through sheer serendipity, and through a mutual interest in psyhology, I had met a certain Russell Monsurate on Facebook. His posts interested me and he seemed to have a very positive attitude to life in general, which I greatly appreciated at this stage. In particular, he often seemed to post articles relating to cardiac health. It was one of these that was to change both my psychological and, if my current well-being is anything to go by, my physiological state. 

The article itself referred to the changes in former president of the US Bill Clinton. This piece originally caught my attention as I had long been an admirer, although not an entirely uncritical one. Despite his shortcomings, one always had a feeling that his heart was in the right place, even when that heart appeared to be ailing as he reached his fifties.

At the age of fifty eight Bill Clinton had undergone a bypass procedure. Such drastic occurrences in one's life do tend to focus one's attention. In Bill Clinton's case, despite making some changes, he did not fundamentally address the problem of his famously indulgent diet. The former president had always been known for his appetite and, despite the warning, his excesses in this area still remained relatively uncurbed. Three years later he suffered another 'event', this time calling for the insertion of a couple of stents.

At this stage his former medical adviser, Dean Ornish, wrote a letter to Clinton pointing out the inevitable result of continuing down the path he was taking and a way that he could, with patience and persistence, avoid this apparent inevitability. What Ornish suggested was a drastic change of diet. He advised the avoidance of meat, fish, dairy products and any processed so-called 'fast foods'. He also advised a minimal reliance on oils.

Ornish's view was further supported by Dr. Caldwell Esselstyn. Clinton reviewed the evidence and his own parlous state of being and decided that he needed to take the plunge. What followed was an immediate improvement in the state of his health. He began to lose weight, going down some 20 lbs in the first year alone. Blood tests started to show, and continued to show, a great improvement in all the classic markers related to coronary health. The former president, on seeing the obvious success of the diet in his own case, became not only a follower but a keen advocate of this vegan, plant-based diet.

From my personal point of view, if Dr. Esselstyn's book was to be believed, the really good news in all this was that cardiac problems of this sort could not only be slowed down but the process can actually be reversed. It seems that the body's remarkable ability to heal itself applies to this area too. Not that surprising really, but having subconsciously assimilated the assumptions of many in this area, I had believed that all that was left to me was delaying the inevitable. Now, for the first time, I realised that one has a lot more choice, a lot more control than that. One can not only slow down the progress of heart disease but, if one remains disciplined, one can actually reverse the process.

 This was good news indeed.

It's Deju Vu All Over Again...

I have to admit now, looking back from a distance of a couple of years, that part of me was tempted not to have the second procedure. By this time I had read about and was well aware of the relatively slight dangers of an angiogram and the much greater risk of having another angioplasty. I wanted to find some good, or even not so good, reason to say that a second operation was unnecessary, thus avoiding the seeming inevitability of having to go through the same thing all over again.

There were some signs that part of my problems may have been down to the medication, I had been prescribed beta blockers which had the effect of making my already slow heart rate even slower. Indeed, on the first night in hospital, it had regularly been recorded at around 42 beats per minute. Such a rate is fine for a high level marathon runner or someone intending to take part in the Tour de France, it is not so good however for a middle aged gent leading a somewhat more easy-going lifestyle.

Dr. Amersey, on seeing the charts, immediately changed my now long list of medications to exclude the beta blockers and also reduce the statins intake. My cholestrol reading had come back as 3.6; relatively low and not really in need of being controlled by medication. In view of these changes, I was tempted to ask for a reprieve, say two or three weeks, to see if the new regime changed the way I felt, and thus avoiding the need to undergo another procedure. Feeling I had dodged a bullet the first time, I felt no particular enthusiasm to put myself in the firing line once more.

The doctor, calm and logical as ever, explained the advisability of taking things a step further. Given the nature of my condition the risk of not undergoing the procedure was far greater than then risk involved if it was avoided. There was still some reluctance on my part but I understood that, in real terms, it was the most sensible course of action.

So it was that I found myself signing the consent form once more. There was a sense of surrender, a sense of ‘que sera sera,’ whatever will be will be. For me, oddly, there was also a sense of peace in that inner surrender and I found myself surprisingly calm as I settled down to await the procedure. I had been told I was second in line so to just make myself comfortable for a while until it was my turn.

I had just opened a copy of ‘Alex’s Adventures in Numberland’ when the doctor suddenly reappeared.

“Sorry George, the previous operation has been cancelled, you’re next!”

And so it was that within a bare few minutes I found myself once more being wheeled into theatre. A lot of the nurses were, by now, familiar from a fortnight before.

“Back so soon?” one of them asked, smiling.

“Yes, I enjoyed it so much the first time that I just couldn’t wait to come back for more… ” I explained.

Once more the nurses busied themselves with the usual attachments, once more I was positioned on the long, narrow bed, my hand tucked beneath my body, once more the brief explanation as to what was going to happen next.

Having punctured my oh so sensitive right groin the first time, it was now decided that they would go in through the left side. A young doctor, trying hard to affect a level of nonchalance, injected the lignocaine into the top of my thigh and proceeded to attempt to feed the needle into the femoral artery. The process did not go well however and, several times, I was told to ‘relax.’ Not the easiest or most natural thing to do when someone is trying to puncture a vital artery in a very sensitive part of your anatomy, followed by pushing a rather large needle into the hole thus created...

Dr. Amersey took over at this point. I felt it as something of a relief to be back in his capable hands. Within just a couple of minutes the dye was dispersed once more into the arteries of my heart and then… silence. For a minute or two all I heard were a few faint mumbles as the team went into something of a huddle.

Eventually, Dr. Amersey appeared from behind the perspex screen, a look of some concern on his face. I had seen this expression before. In fact this was the third time. Deja vu all over again…

“We have had a look and although the first two stents look fine there does seem to be something of a blockage in a branching artery.”

He waited for a response but what could one say?

“Go on.”

“Well, from the previous images we looked at, the blockage would appear to have developed in the last couple of weeks.”

He let the implications of this sink in for a second or two. The obvious question was why would it have developed now when the flow of blood around the heart should have been improved by the previous stenting?

“I think the best course of action would be to insert a further stent into the branch artery… with your permission?”

Again, what can one say in such a situation? As the patient you are caught between a rock and a very hard place. Potentially damned if you do, almost certainly damned if you don’t. Not a real choice, you have to go for it. I nodded my assent.

“OK, thank you. By now, you know what to expect,” he said, with a certain underplayed irony in his voice, “It’s possible you may feel some build up of pressure in your chest. Let me know if it becomes too uncomfortable.”

With this he disappeared once more behind the perspex screen and made his preparations. Lengths of catheter tubing were requested along with a smaller size drug eluting stent than the previous two. In but a few short minutes all was ready.

I listened to the soft voices of the doctor and the team, calm yet focussed, reassuringly concentrated on the task in hand: rescuing my ailing heart. Within a minute or two the catheter was being inserted. The next stage involves guiding the stent itself up through the arterial system. In theory, one cannot feel any of this directly but you do notice small changes in pressure in your chest. After all, the flow of blood in the arteries is outward, away from the heart. The sheath, catheter and stent are all opposing that flow to various degrees.

Somehow, this time, although more aware of the dangers than previously, it felt easier. I was well aware that there are risks involved but I felt a high degree of confidence in the team of people performing the task. There was something very reassuring in the professional manner in which they worked. Requests would be made, curtly yet politely, responses would be made, quickly and accurately. If there was a problem it was quickly and efficiently dealt with. The thought crossed my mind, this procedure may not end well but it would not be for lack of effort on the part of these people.

Soon I heard the now familiar count once more: “Going up, 2,4,6,8, 10 and 12…stopped at 12.” The count was spoken once and then echoed in confirmation. I felt the pressure climb in my chest. For a brief moment it was actually quite uncomfortable. I waited for a few seconds, still felt the pressure, and so pointed it out to the doctor.

My comment was acknowledged but, fortunately, almost immediately the feeling of pressure subsided. For a few more minutes there was the sound of muffled conversation from behind the screen, as hard as I strained to hear I could only pick out the odd word here and there.

The doctor pushed back the screen. He smiled briefly, reassuringly, before telling me that he considered that it had gone well. The only downside was that a blood blister had appeared beneath the site of the opening in the femoral artery and they would therefore not be able to plug the wound in the normal way. Pressure would need to be applied to the site for some time in order to get the wound to set.

I was relieved to have made it through once more and the prospect of some pain as the left groin area was pressed firmly immediately over the wound seemed, relatively speaking, of little consequence. I have to admit though… it really did hurt!

The nurse apologised a couple of times for causing me such pain but there was no need. Pain inflicted when one is aware that the intention behind the process is your well-being is much easier to bear.

In no time at all I was back in the familiar environs of Elizabeth Ward. It felt like I had hardly left the place. Many of the same staff I had met the first time around were on duty once more and it actually felt good to be reacquainted with them. For the first few hours I was confined to the bed, most of the time spent completely horizontal to give the wound a chance to heal properly. After about three hours I was allowed to gradually increase the angle of my body until, finally, I could sit up in bed.

My younger brother, David, appeared at this point. It was good to see him once more. We chatted away for some time. David tends to be in one of two modes, the first is rather self contained and one struggles to eke even a few words out of him, the second is much more open, voluble and effusive. Fortunately, on this occasion, he was very much in the second mode and the conversation flowed easily and interestingly. The only downside for me was the ongoing effects of the diamorphine I had been given which rendered me a tad sleepy at times.

A couple of hours later it was time to knit the wound together. This involves more pressing on the groin. The pressure needs to be very firm for it to work so there is an amount of pain involved for the patient but it also tends to be hard work for the nurse. The sister who was to carry out the procedure was in charge of the ward that evening. She was of a somewhat slight build and the sheer physicality of having to try to hold the pressure on the groin for that length of time was clearly quite a strain. She stuck to the task however and, after the fifteen minutes and numerous apologies for causing me discomfort, the wound was sealed. I think we were both quite grateful!

The week following the second angioplasty was both better and worse than previously. Better in the sense that, although I was not exactly glowing with health, the improvement was clear. I no longer experienced the breathlessness I had before and the light sensitivity seemed less intense. The downside was the injury to the groin, collateral damage from the procedure, as our transatlantic cousins might term it. The bruising was a sight to behold as it came out over the first few days. Gorgeous long lines of purple, separated by about six inches, in between which the skin was a strangely exotic shade of muddy yellow.

Walking, even very short distances, was more than a tad difficult for a few days. My cat, Cooking Fat, often seems to display a certain empathy at one level, oft times sleeping beside me when I have been low. On another level she displayed an almost criminal disregard for the sensitivities of my much bruised groin by leaping unexpectedly onto my lap from all angles and at any time. Not so good…

There was a feeling of gratitude that persists to this day. I feel grateful to the people who have helped me on this occasion, grateful to those who helped me on previous occasions, grateful simply to have come through at all. Several times in my life it could have turned out very differently. In particular, I am grateful to the NHS and the staff therein. They come in for a lot of criticism at times but I for one have good reason to be thankful to both the institution itself and the staff within.

I had gotten through the worst of it, now it was time to figure out how I could avoid going through the same thing again, if at all possible...

The Phoney War

Back on the ward, there was a feeling of relief, a feeling of simply not wanting to be in this same situation again in this lifetime if I could help it. The wound was uncomfortable but I knew this was just a temporary setback. It seemed that, for now at least, I had come through relatively unscathed. A few words from Churchill came to mind; “There is nothing quite so exhilarating as being shot at without result!”. Exhilaration may have been too strong a word in this case but there was a definite sense of having ‘dodged a bullet.’

After an angiogram/angioplasty procedure one is confined to bed for several hours in order to allow the wound in the groin time to heal. In this particular case, they had inserted a plug into the hole in the femoral artery, a relatively modern technique which avoids the need for a lengthier and more painful procedure whereby the site of the wound is pressed upon very firmly for some 15 minutes or so. For those of us who are a tad sensitive in the groin area, the very thought of it brings tears to the eyes!

For the next day or so, until the moment I escaped the confines of Whipps Cross Hospital, I was feeling strangely elated, almost slightly euphoric. Whilst in the limited spaces of Elizabeth Ward my increasing mobility and sense of general well-being were very reassuring. On the Tuesday morning I found myself busily engaged on the phone arranging all manner of things that needed to be done for those around me and myself. It felt good to be in charge of one’s life again, instead of just a passive victim of circumstance. As much as I appreciated the care and attention of the staff in the hospital, there was still a strong desire to be released from their ministrations and, once more, to feel oneself a free and independent person.

Before leaving I was treated to a visit from Caroline of rehab who offered enlistment into a program of exercise for those who had suffered a heart attack. I let her know of my limitations (the back injury) in such areas but gladly accepted her offer. Next came the rather exotically dressed lass from the pharmacy, a sight for slightly sore eyes resplendent in figure hugging dress and knee high boots, dispensing drugs and advice on how to take them. The list of medicaments was long, seven in all if one doesn’t count the ‘emergencies only’ GNT spray. There were statins, ACE inhibitors, anti-platelets and even beta blockers. I was a tad concerned at the last as my heart rate is pretty slow at the best of times but I was assured that in this situation it would take a load off of the embattled organ.

Phil Johnson, a good and trusted friend of many years standing. picked me up at around half three in the afternoon. He carried my bag along a section of the seemingly endless corridors of Whipps Cross. He was not walking particularly fast but even so I had to ask him to slow down. The light outside seemed somehow brighter than usual even though the day was overcast. I waited near the outpatients  department and enjoyed the sights and sounds of life going on around me once more.

Phil drove at a reasonable pace back to his maisonette just off Hermon Hill. Although his driving was by no means unreasonable, I still seemed to feel every bump along the way. On arrival, I got slowly and tentatively out of the car, feeling surprisingly vulnerable and frail. This was not at all what I had expected. I was well aware that I had had a heart attack but, at the same time, had felt like I was getting stronger and stronger, particularly during the previous 24 hours. That was in the hospital though. Now, exposed to the outside world, it was becoming obvious that all was not yet well.

I stayed with Phil and his wife, Simone,for several hours, most of which was spent strewn across their huge red sofa, being supplied with all I needed for the evening. They both seemed somewhat concerned, I think I may have looked even frailer than I felt. Eventually, around ten or so, Phil drove me home.

The next week was spent very gently reading, writing a little, waiting for the expected recovery. Indeed, for a time, I did seem to get a little better but would still find myself breathless climbing stairs and would still experience moments of faintness. The bruising in my groin and upper thigh was impressive, gorgeous shades of purple, blue and yellow. As ever, I rationalised my lack of a faster recovery, if my groin and thigh were like that then it would seem only natural that something similar had occurred internally. Recovery would be a matter of patiently waiting for the bruising internal and external, to subside.

I had been encouraged to take some exercise when I could so I went for a short stroll beside a lake in Wanstead Park. It was a sunny day and pretty soon I found that I was reacting badly to the light. After just a few minutes I had to sit down just  to allow myself the chance to recover. This wasn’t the recuperation that I had hoped for.

Over the next few days I struggled on and, after a couple of weeks or so, I was actually feeling a tad more comfortable, although the photo phobia seemed to grow more and more bothersome with every sunny day. Two friends, John and Erica, had invited me to share a trip to the British Museum to see an exhibition on early European Christianity’s addiction to the notion of relics. It sounded interesting so I decided to take a chance and embark on my first trip to London for a month.

I had only just started driving again which felt like something of a liberation.  I left the car in a side street close to Woodford Station and tried to walk the short distance to the ticket office. It was a sunny day and immediately the photophobic effect was obvious once more. Every white, or even light, coloured wall  or surface seemed to glare unbearably. It felt a little like the snow blindness I had experienced in Austria many years previously, this time though it was accompanied by feelings of light-headedness and even nausea. When I reached the barriers I was feeling quite ill and had to make a decision whether to go or stay; once through, I was more or less committed to the journey.

With some reluctance I decided to go. Taking the seat on the train I immediately felt better and was relatively fine until reaching my destination, Holborn. Once there though, I had to walk a short distance to a coffee shop where we had decided to rendezvous. Reaching the meeting point, even though it was but a short distance, became a struggle, so much so that I could feel the sweat running down my back at the effort involved. Every light coloured surface seemed to be breaking up into darker blotches. Finally, and much to my relief, I reached the basement of the coffee shop. John and Erica were already there and looked concerned at my discomfort. After taking a seat in a deep and cosy chair  and chatting with some expectation about the exhibition I soon became much more comfortable.

The exhibition itself turned out to be a beautiful presentation of a variety of relics from the early Christian era. Across Europe in the middle ages, all manner of relics recovered from the crusades were revered for having been involved in the story of Christ. There were splinters from the cross, a piece of bread from the last supper, even a towel said to have been wrapped around the head of Christ as he took the cross upon his back. All incredibly implausible of course, but bread (literally in the case of the relic!) and butter to the early Christian church. People would make pilgrimages in order to have a chance to even simply be in the proximity of such relics. Added to those connected to the Bible story there was also many artefacts connected with various saints. Many of these were body parts taken from the corpses (allegedly!) of martyred saints immediately following there martyrdom. Quite gruesome and, in many cases, equally implausible.

Coming out of the exhibition I still found myself weak and a little breathless but I did seem to be managing the demands of the situation quite well. Strange, looking back at it now, that same process of  rationalisation that I mentioned in a previous blog, that same willingness to believe the more mundane explanations for one’s symptoms, served to prevent me from the realisation that I will still in trouble. This process seems to be a defence mechanism that many of us share, a way of shielding us from the harsh realities that confront us at times in life.

All this was to change just two days later. I had been invited to undergo an exercise test at Whipps Cross to see if I was ready for the rehab program. It consisted of walking on a running machine whilst the operator, a sympathetic Irish fellow by the name of Brian in this case, gradually increased the inclination of the apparatus.

For the first half a minute or so I was OK. My body was festooned with connections so my heart could be monitored during the process and, at first, nothing unusual was apparent. Then the slope was increased. Within seconds the chest pain returned. I soldiered on. The inclination was increased and, almost immediately, so was the discomfort in my chest. I started to feel quite faint. Brian, monitoring the ECG and enquiring as to how I felt, decided quite suddenly to stop the test. He looked somewhat perturbed.

“George, I think you should come back into hospital” he said.

“Hmm, bit inconvenient right now Brian” I responded, “When do you think it could be arranged?”

“I think now would be the right moment!”

I had made all manner of arrangements for the coming days but I could see from the look on his face that he was quite concerned. I enquired if it was at least OK to return my car home and get a friend to bring me back but even this was, according to Brian, inadvisable.  When he said now he really had meant it and so it was that within a few minutes I found myself sitting in a wheelchair being wheeled along the interminable corridors of Whipps Cross back to Accident and Emergency to undergo further tests with a view to readmitting me.

Back to square one it seemed. There was some concern amongst the staff in A&E that I was having a second heart attack there and then. More electrodes were attached to my chest, ECGs were taken and samples of my blood were extracted from my much punctured arm.

My basic nature is, fortunately, inclined towards the optimistic, but, sitting there in A&E with little idea as to how serious this latest event might be, I have to admit to getting just a tad fed up with the vagaries of my heart.

Don't Stint On The Stents...

At the centre of the theatre was a long, narrow bench above which were an array of screens. At the head end of the bench was a heavy scanner on a semi-circular tracker. I was laid upon the bench which, for a change, was actually comfortably long enough to support my elongated frame. Four or five nurses buzzed around me, fixing a drip to the cannula in my left arm, attaching numerous electrodes for an ongoing ECG, placing my right hand beneath my buttock and then, all needed preparations completed, sliding a long, lime green, paper sheet over me.

I looked up at the ceiling where someone had thoughtfully provided an impressionistic scene of Epping Forest, canada geese wondering around a muddy pond. The nurses chatted reassuringly as they busied themselves with a multitude of tasks. Finally, Dr. Amersey came in and briefly went over once more the likely sequence of events. Normally, he explained, they would consider using an artery in my arm to gain access to the arteries around the heart but, in my case, the tubing that was normally utilized may prove too short for the task so they were proposing going in through the femoral artery in the groin.

All I could remember of the femoral artery was what I knew from reading Hemingway’s ‘Death in the Afternoon’ as a teenager. The femoral artery was the one place that the bullfighters in the book feared being gored as, once severed, the flow of blood tends to be both immediate and copious.

I was injected with a couple of shots of lignocaine to numb the site. To some extent it was successful but, even so, as the needle was slipped beneath the skin in the proximity of the inguinal lymph nodes, I began to experience some degree of discomfort. I tried to grin and bear it, focussing my attention on the meandering geese on the ceiling, but my efforts were doomed to failure as I winced from the pain.

“Would you like some sedative?” asked the concerned Dr. Amersey. An emphatic “Yes” was my reply. As a guy, the general expectation seems to be that one should put up with a degree of discomfort without moaning and, in general, I am pretty OK with that but... one also needs to know one’s limitations! A nurse was instructed to feed some anti-emetic into the cannula, mercifully followed by a dose of diamorphine. The familiar, slightly woozy, feeling flooded through my body quickly followed by the relaxing effect of the drug.

Every now and then I would receive the instruction to ‘relax.’ As you can readily imagine this was, in practice, much easier said than done! The procedure is not the most relaxing process in the first place but having someone slide a needle up through your groin and into your femoral artery would not be the first choice on my list as a way to relax. Still, I did as much as I could and tried to focus my mind on the pastoral scene above my head.

In time, and with a degree of difficulty, the needle was in place and a wire was passed up through the arterial system destined for the vicinity of my heart. I could scarcely make out anything that the doctor was doing as he worked behind a thick perspex screen designed to give him some level of protection from the radiation emitted by the fluoroscope. The surgeon also wears a leaded jacket designed to offer a further level of protection. As a patient you have no such defences but, hopefully at least, one is only exposed to the x-rays for the relatively short amount of time involved in the procedure.

The time came to inject the dye; I was warned that I might feel a little pressure at this point. I looked across to the screens above and to my left. Strange to see the motion of the blood and dye around one’s own arterial system. The images were very clear though, as was the problem that Dr. Amersey pointed out. One artery barely seemed able to allow blood to flow through it at all. He explained that now we were in this position, probably the best thing to do would be to immediately go ahead with an angioplasty. This involves place a stent, a small metal tube, inside the affected artery in order to hold back the atheroma (area where the artery has narrowed) and allow blood to pass through freely once more. He explained that although the procedure had a certain level of risk he believed that in this case it was the only sensible alternative.

I nodded my assent. I will admit I was not overly keen to undergo such a procedure but the alternative seemed even worse. It was explained to me that I would feel some pressure as the stent was put in place. The doctor asked for a length of what appeared to be plastic tubing and a stent of a certain size. Within a couple of minutes the process had started and he delicately, and very skilfully, pushed the stent into the affected artery.

Once again, I was told I may feel some pressure in the chest and, sure enough, within a few seconds, I did. It felt somewhat like having the heart attack all over again, maybe not quite so intense but really quite similar. The doctor and one of the nurses began to count in unison: “Going up, 2,4,6,8,10,” each confirming the other. This count is performed as air is pushed into the balloon that is inside the stent. Inflating the balloon causes the cage-like structure of the stent to expand. Whilst this is occurring though, there is a considerable build up of pressure in the chest. I could feel my temperature going up and was aware of a certain faintness. I was given the chance to rest for a second and then the count started once more: “Going up, 2,4,6,8,10,12…hold at 12.” The pressure was quite high at this point but, finally, it was done. The stent was in place.

There was some discussion taking place between the doctor and a couple of nurses but I could not quite make out what was troubling them. A minute or two later, Dr. Amersey appeared from behind the perspex screen, his expression an odd mixture of satisfaction at a job well done and yet clearly a little concerned at one and the same time. It was one of those “Do you want the good news or the bad news?” moments.

“Well” he announced, “that went very well. The stent is in place and it looks to have settled in well but, unfortunately… ”

I had some idea what was coming but let him continue.

“…as we carried out the procedure, one of the nurses noted a second arterial blockage. With your permission, I would like to go ahead and attempt to put a second stent in place.”

It was an odd moment for me. On the one hand I had thought that the procedure had finished and I had survived relatively intact, there was some sense of relief in this thought and to be told that this was not yet the case was not exactly what I wanted to hear. On the other hand, if there was a second blockage, I should be grateful to the nurse for being so attentive. There was no other sensible choice really, I gave my permission and even thanked the nurse who had noticed the problem.

The second one seemed more intricate than the first. Once more I was warned of the change of pressure, once more I felt this in my chest. The balloon holds back the arterial flow so it is scarcely surprising that pressure would result. For my part, I was just about exhausted at this point. The heart attack had generally left me somewhat weakened and this kind of continuous stress is quite difficult to bear uin that state.

As the pressure built up in my chest I found that I could not bare to look at the screens any more and instead focussed my attention on the red headed nurse standing at the back of the theatre, looking on attentively. In a normal sense, staring in such a way may have been perceived as quite rude but from my point of view consciously and quite deliberately distracting my own attention in those moments really helped.

I heard the now familiar counting in the background, felt the pressure building, was aware that my head was swimming a little and aware of the desire that this should all be over soon. For now, I had had enough.

A few brief minutes later, Dr. Amersey once more appeared from behind the perspex screen. He looked hot, a little flustered even, but elated. He confirmed that the stent was in place and, as far as he could tell, it had all gone as well as could be hoped. I looked across to the clock, nearly two hours had passed, and back to Dr. Amersey. He appeared tired and a little drawn now.

“Are you OK?” I asked.

“Back is aching a little,” he explained, ” these leather jackets weigh you down over time.”

I felt and expressed my gratitude to him. A wave of emotion, relief for the most part, rose up within me. I could scarcely speak. A nurse had to hold a plug in place in the femoral artery for some minutes. This was painful but the pain was of a type that was easier to bear.

I knew the worst was over, for now...