Ischaemic Heart Disease

A lot of times, the pathologist puts ischaemic (same as ‘ishemic’) Heart Disease down as the cause of death. It’s a term that encompasses a whole host of related conditions, all of which are caused by chronic lack of blood to the heart muscle. I’d better explain the medical meaning of ‘chronic’, which is confined to the meaning ‘long term’. ‘Acute’ means ‘short term’. When a doctor uses those words, there is no implication of strength.

So, ischaemic Heart Disease (often shortened to IHD) merely means the heart muscle (‘myocardium’, remember?) has not had enough blood over a long period of time – years, even decades. The cells that make up the myocardium (‘myocytes’) die but, unlike in a myocardial infarction, they don’t die all at once. The body’s response to any long-term shortage of blood is to make fibrous tissue (‘fibrosis’), but the heart still has a job to do.

The problem is, fibrous tissue is useless as a pump, which means that the surviving myocytes have to work harder. To put it simply, it’s a bit like bench-pressing weights day in and day out; the muscle gets bigger. When the patient dies, the pathologist finds a big heart and when the heart muscle is examined, it’s pale because of the high content of fibrous tissue.

The problem is that the fibrous tissue isn’t an efficient electrical conductor. As a result, arrhythmias occur; an ‘arrhythmia’ is a rhythm that is different to the normal regular ‘sinus’ rhythm. Sometimes, the patient can live with an arrhythmia, and therefore the patient may came to the attention of a healthcare professional. If the first arrhythmia is asystole (the heart just stops) or ventricular fibrillation (see before), then the chances are, the patient dies

But why is there not enough blood? Because of coronary atheroma again. When doctors talk of ‘coronary artery disease’ they almost always mean ‘atheroma’.

Heart Attack

What is a ‘heart attack’?  Is it the same as ‘heart failure’? How does a ‘heart attack’ come about? Is a heart attack the same as a ‘coronary’?

To answer the second question first, heart failure and a heart attack are NOT the same; heart failure is when the heart is no longer up to the job of pumping blood around the body (more of which at a later date). A heart attack, known technically as ACUTE MYOCARDIAL INFARCTION, or an MI, is when part of the heart muscle (the ‘myocardium’) dies (an ‘infarction’). Why does it die, though?

The heart needs blood, as does every part of you. It gets it from 3 coronary arteries (the name comes from the same route as ‘coronet’ meaning ‘crown’, because they look (if you squint hard) like a crown around the heart. Unfortunately, they’re prone to ATHEROMA (about which more at a later date) which narrows them by causing plaques to form on the internal surface.

Angina is heart pain caused by a reduction in blood flow to the heart and is often caused by atheroma. Those who get it are lucky, but most people don’t get it. The first sign that they have atheroma affecting the coronary arteries is when a sudden block occurs in one of them, and the blood supply to a part of the heart muscle suddenly stops. The muscle dies and that is a ‘heart attack’.

Why does the blood supply suddenly stop? Usually because the blood clots on an atheromatous plaque, and that blocks the artery completely. So, a ‘heart attack’ is the same as a ‘coronary’, but medics talk of an MI.

Unfortunately, the pathologist won’t see any change in the heart muscle if the patient dies quickly after the MI. She/he won’t see much with the naked eye for quite a few hours, even if it’s examined down the microscope. The clot in the coronary artery is the clue.

But why do people actually die from a heart attack?

Normally, because the heart’s rhythm changes catastrophically due to the shock of the heart muscle death. It may stop beating completely (ASYSTOLE) or it may just twitch uncontrollably (VENTRICULAR FIBRILLATION).

But most people who die of heart disease don’t suffer from a heart attack…

Introduction

Just so that you know that I know what I’m talking about, I’ve been a pathologist for 34 years and I’ve performed over 5,000 post mortem examinations. In the UK, just over 530,000 people died in 2017. You WILL die. I WILL die. It comes to all of us. It affects all of us, because Death will visit our loved ones.

My aim is help you by giving you information, by taking your hand and leading you through the medical jargon and (necessary) procedures that a society has to have when someone dies.

Here are the bald statistics from 2017 in the UK:

150,000 died of cancer

150,000 died of heart or blood vessel disease

73,000 died or respiratory disease

68.000 died of some form of dementia

21,000 died of external causes (including accident, deliberate self-harm and assault of some kind)

But what do those words actually mean? What is ‘cancer’? What does ‘heart or blood vessel disease’ actually involve?

And then there are the procedures. What is an ‘inquest’? When is one required? What is a coroner? Why are suicides different to other forms of death when it comes to the inquest? When does an inquest have to have a jury?

Lots of questions. The answers are fascinating.