London to Glasgow (cardiologists and frailty)

On Wednesday I attended a heart failure study day run by the wonderful cardiac specialist nurse, Sarah Briggs.

As an early student of medicine, I came to understand the ins and outs of how the heart functions – rate and rhythm, stroke volume and cardiac output, Starling’s Law and action potentials.

For the next 15-odd years I had a fair grasp of what was what.

It was only recently with the introduction of a form of measurement called ‘Brain Naturietic Peptide’ (BNP) and a chemical called ‘Neprilysin’ that I lost my way.

You see, the former, the test for a hormone released when the heart is pumping ineffectively was for most of my career restricted to GPs; doctors in hospitals were not allowed to request it for reasons I am not altogether clear – possibly because of expense or the impact of acute illness on the heart and blood results.

We got by OK and mostly, patients in hospital who have a heart problem undergo a detailed assessment called an Echocardiogram; this, a test using ultrasound can take very accurate pictures of the heart muscle, chambers and valves as well as providing information about its effectiveness as a pump.

Where is all this heading?

I will get there in a minute.

First, I wanted to mention Neprilysin (and its inhibitor) as it seems to me to be such a cunning piece of high-tech science it should reach this blog. Then I’ll get to the cardiologists!

Put simply, if the pressure inside the heart increases, because the heart muscle is diseased – perhaps from a heart attack or other influence – alcohol, infection, certain medicines, the hormone BNP is released.

Brain Natriuretic Peptide is a chemical signal that tells the body it has too much fluid and amongst other things, makes the kidneys release water and, we pee more.

This in a way is how water tablets (diuretics) function.

It is this BNP that GPs measure and which if elevated is a sign that the heart (the pump) is not working well (failing).

The pressure that results from a failing heart is what leads to fluid retention in the lungs – breathlessness and potentially in the peripheries, swollen legs for example.

This you might call basic physiology.

The thing that is very clever is the natural response to our internal correction mechanism which is to release a counter-chemical, Neprilysin which breaks-down the BNP, meaning less peeing and more fluid retention.

Some very clever scientists worked this out and subsequently designed a drug that stops Neprilysin from working and, it seems when this is combined with another cardiac drug – Valsartan, the results are great, cardiac function can improve as do symptoms and quality of life for people who might otherwise be quite unwell.

Voila.

I was keen to mention this little bit of science as I worry sometimes that I might come across as a Luddite; against modern medicine, anti-drug. This is wholly not the case and there are some magical medicines (I won’t mention them here, for more details, please see an old blog ‘Medicines, etc’ and another ‘Rod’s Dodgy Drugs’.

Anyway.

Getting back to the title.

What about the Cardiologists?

Well, what struck me, after spending six or so hours in the company of a variety of other healthcare professionals (I don’t think there were any social workers), was that here I was, the guy who likes to listen, to de-prescribe, to determine how best to support people in the last years of their lives as frailty progresses, learning about the very cutting-edge of clinical science and, I wondered, whether the cardiologists, gastroenterologists and whomever, (OK, I will pick on my favourites, orthopaedic surgeons) attend entire study days on older people, frailty, falls and dementia?

Is the relationship reciprocal?

For, just as my older people will have heart failure, significant numbers of patients assessed and treated by specialists will have frailty, dementia, delirium and all the other features of advanced age and psycho-physiological deterioration.

The title Glasgow to London refers to an old blog I wrote about my parent’s complaining, as they travelled to London down the M1 in the 1980’s to see their in-laws that the journey from Glasgow to London was perceived as shorter than the reverse.

We Scots like to travel.

Come on specialists, get registering, come and learn about your old folk!