Dr Nicos Spyrou
Practices at: Circle Reading Hospital
He qualified in Medicine at St George's Hospital in London, where he also obtained a BSc in Clinical Pharmacology. He recieved most of this cardiology training at St Mary's and the Hammersmith Hospitals, as well as having worked for Prof Sir Magdi Yacoub at Harefield. Dr Spyrou currently has practises based in Reading and in London.
Dr Spyrou is involved in all aspects of cardiology, including acute coronary syndromes/primary angioplasty, valvular heart disease, arrhythmias, heart failure etc, with particular interests are: interventional cardiology, which includes angioplasty, rotablation and IVUS (intracoronary ultrasound); permanent pacing; and transoesophageal echocardiography.
- Consultant Cardiologist
- Complex Coronary Intervention (angioplasty)
- Rotational atherectomy (rotablation) of coronary arteries
- Bifurcation stenting
- MRI friendly permanent pacing
- Cardiac adaptation/remodelling after myocardial infarction (heart attack)
- Bifurcation stenting of coronary arteries
- Novel stent polymers
- Fellow of the Royal College of Physicians
- Member of the British Cardiac Intervention Society
What is angina?
Angina, by definition, is a chest pain usually related to exertion. It is caused by, in 99% of cases, a narrowing of the coronary arteries – the arteries supplying the heart muscle [with oxygen].
This usually develops either due to smoking, due to high cholesterol, or bad diet or bad genes, as it can be hereditary.
How is angina diagnosed?
People with angina usually present to me with tightness in the chest.
Some people have shortness of breath instead of chest pain. In general, we try to make the diagnosis, either by putting patients on a treadmill to reproduce the symptoms they have when they exercise, or we can do other tests, such as an MRI scan or a stress echo. The latter helps show whether they have a lack of blood supply to the heart or if the heart is not coping well.
The gold standard of discovering if a patient has coronary disease is with an angiogram; this could be invasive or with a CT scan.
How is angina treated?
The next step is to treat the patient with medication. Ideally, we would try to improve the prognosis by giving aspirin and reducing cholesterol. These prevent future heart attacks but do not help the symptoms. We have several medications we give in a stepwise fashion to treat the symptoms.
The medications we give work in various ways, and we use a combination so that we reduce the workload of the heart or open the arteries to improve blood supply.
If we are convinced that the patient has angina, but the medication has cleared the symptoms, we often arrange a CT coronary angiogram to make sure the patient does not have 'prognostic' disease - a narrowing at a place where if it blocked it could cause serious damage, or death.
This scan is a normal CT scan used for brain scans, but now we can look at the heart too. This is a non-invasive test; we inject a dye at the back of the hand, and we can reconstruct the coronary arteries, which gives us a reasonable idea of what is going on. It is not a 100% accurate, so it is not quite as good as doing an invasive angiogram, but this is non-invasive and a 10-minute test.
The gold standard treatment is an invasive angiogram, which is where we can look to inject dye specifically into the coronary arteries, usually from the wrist, using the wrist’s radial artery. We pass a tube up to the heart and inject the dye into the coronary arteries, which allows us to see where there is any narrowing.
We decide to go for an invasive angiogram if the CT was not clear (or if we cannot do a CT scan because the heart rate is too fast), but more importantly if the medication has not cleared the angina and we want to see whether we need to treat the narrowing(s).
During an invasive angiogram, we have several decisions to make. We can measure how important the narrowing is by inserting a pressure wire, which measures the pressure drop across the narrowing. We can undertake an ultrasound of the narrowing, and we can do something called an OCT, optical coherence tomography. The latter is a laser inside the coronary arteries, to help us see the texture of the narrowing and how significant it is, as well as how much calcium, cholesterol deposits, or even different types of clot.
The advantage of this invasive procedure is that we can put a wire through the narrowing and open it up and put a stent in – a wire mesh to open the heart.
If a patient’s narrowing is calcified and is very tough to open, we can break up the calcium and we have two techniques we can use. One is rotablation, which is otherwise termed rotational atherectomy. This is basically a diamond drill, which drills through the calcium to open the arteries.
We can also do an intracoronary lithotripsy, or ICL. This is also called shockwave treatment, which breaks up the calcium and allows us to insert a stent. It is similar to the technique used to break up kidney stones. Sometimes we cannot modify the calcium enough – for example, sometimes a stent will not open enough it is likely to block up.
Angioplasty is a day case procedure; it usually takes anything from 15 minutes to four hours; it depends how difficult it is. Usually the patient is awake, but we can give them some sedation if they feel anxious, and they can often listen to music as we do the procedure.
At the end of the procedure, we put a little band on (where we made the 2mm nick in the artery) to prevent bleeding. The patient would generally be allowed to go home around two to four hours after the procedure. If the procedure was through the wrist, the patient can sit up straight after, but if it was done from the grain, they would have to stay flat until we are confident that there is no bleeding.
What about aftercare?
When our patients go home, we’ll tell them we’d like them to stay with someone overnight - just in case they start bleeding. This is rare, as we make sure everything is fine before they leave hospital.
If they only had an angiogram, they may be able to go back to normality the next day; they can drive, too.
If they have had an angioplasty, we will tell them not to drive for a week and that’s what the DVLA advises.
Generally, the patient will gradually start improving. If they were having chest pain symptoms, they may find they benefit straight away, but sometimes the benefit may be in a few days’ time or a few weeks, even.
I will see then them in the clinic around two to four weeks later, depending on how complicated the procedure was. I may do another ECG to see how the heart is coping, and whether there are any changes, and then generally follow up to see if there is any damage to the heart. If everything has settled, depending on how the patient is feeling, we generally discharge them back to their GP.
What are heart palpitations?
Palpitations, by definition, is the sensation of a patient’s heart beating abnormally. In general, it means that the heart is beating a lot faster.
There can be a whole host of diagnoses and the trick is being able to record the heart rhythm when a patient experiences these symptoms.
Some patients have the symptoms all the time and this makes it easier to diagnose. In this instance, they will have an electrocardiogram and we can see what the problem is. Other patients may experience symptoms for a short time, and there are several ways in which we can try and record these instances.
How are heart palpitations diagnosed?
Sometimes, a resting ECG gives us the answer – either if the patient has the arrhythmia at the time (rare), or if we see certain abnormalities that make the patient prone to arrhythmias. We can begin by giving patients a 24 or 48-hour monitor, which records everything. Alternatively, we have some new patches, which the patient wears for two days, or for up to two weeks. The patches record absolutely everything.
We also have monitors patients can carry with them and put them on their chest to record when they have symptoms.
Finally, we can implant a monitor, which stays with the patient for over three years. We do not tend to implant these for those with mild arrythmia; we usually issue this to patients who blackout and therefore cannot take any recordings.
The commonest diagnoses in my older patients is atrial fibrillation. This is an irregularity in the heart rhythm, which some people may not feel at all, while others will experience discomfort. It is a vital diagnosis to make because it can give people a risk of stroke.
We use a special scoring system called CHADS2VASC score - and if the patient reaches a certain point score and has episodes of atrial fibrillation, we have to thin the blood. That is separate to how we treat the arrythmias; if they are high risk, we need thin their blood to prevent them from having a stroke.
After, we try and treat patients with various medication; there is a variety we can use. We’ll try various things but there’s always a possibility of an ablation, where we put wires up to the heart and modify the electrical circuits in the heart.
This is not something I do, but I have a lot of experience as I used to do it as a registrar, and I will refer patients if they need the ablation. The ablation is a last resort option.
Another problem that I see in my patients is supraventricular tachycardia (SVT); this is usually amongst younger patients and is a congenital problem in their heart. It’s a minor problem but the patient will have a fast heart rate. There are many treatment options for this.
Some patients may experience extra beats or ectopic heart beats and may feel like there are butterflies in their heart. Usually, this is not a significant problem, unless it is a sign there is a sign of damage of the heart.
Patients having heart palpitations could have an ultrasound or an MRI scan of the heart, to see whether there is an underlying disease. If not, we try and reassure the patient, and occasionally we give medication, but we try to not give medication for something like ectopic beats.
Another rhythm disturbance of the heart, whereby the patient experiences blackouts, shortness of breath or an inability to exercise, is if the heart is beating too slowly. This is called bradycardia, and in these patients, we will discontinue any medication which may have caused it and consider putting a pacemaker in.
This is an easy procedure and takes anywhere from half an hour to an hour. We use one or two wires, depending on the underlying rhythm of the patient is in.
If they have atrial fibrillation – where the heart is beating irregularly – and we decide we’re going to keep them in atrial fibrillation, we only need one lead to make sure the heart doesn’t go too slow, and that gets put into the right ventricle. If they have normal rhythm or intermittent normal rhythm, we put in two leads – one in the right ventricle and one in the right atrium.
To do this, we make a slit in the skin, under the collarbone on one side. If they are right-handed, this will be on the left, and if they are left-handed, this is on the right. From there, we dissect to find the vein and pass the wires and place them in the right places.
We test that they are stable, and we connect the pacemaker battery under the skin. This will last for 10 years and we can monitor the pacemaker.
What about aftercare?
After a pacemaker procedure, the patient will go home on the same day. We will monitor them regularly with pacing checks; this involves putting a gadget on their skin to see how much they pace, how much they are using it, how much battery they’re using, and when it needs replacing. The pacing check can be done at Circle Health
This is a successful treatment and we even use it on 100-year-old patients, as there is no age limit.
What is valvular heart disease?
We all have four valves in our heart. The left-sided valves are the most important – the mitral and aortic valves. If they start to deteriorate, you may have several symptoms, including shortness of breath, due to the valves not working properly.
The valves might not work properly, either because they have become narrow, or they have become leaky – or both. This can be a congenital problem, or it can develop as the patient grows older, or as the valves become calcified from wear and tear.
In general, patients see me because they have either shortness of breath, or because someone has listened to their heart and could hear a murmur.
A murmur is usually turbulent fluid around the valves – either because the valve is leaky or because there is fast flow through a narrowed valve. Imagine if you are holding a hose and you’re watering; if you press the hose and you make the exit narrower, the water will go further. That is what you can hear: the fast flow when the valve is narrowed.
How is valvular heart disease diagnosed?
We start by examining the patient and measuring their blood pressure. Listening with the stethoscope can often tell us exactly which valve is malfunctioning. We can then take a picture and video of the valves by ultrasound or echocardiography.
Sometimes it is difficult to be sure, so we might arrange an MRI scan of the heart to look at the valves. We often follow up patients regularly, if they have this problem, depending how bad the valves are.
We have certain criteria to guide us when we need to intervene – either to replace or repair the valves. For example, if the aortic valve has narrowed; we wait until it reaches a certain level and we use several measures, such as the gradient across the valve or the area of the valve.
What treatment options are available?
Only when aortic valve narrowing reaches the right level – and only if the patient has symptoms – do we consider aortic valve replacement. The valve replacement for the aortic valve, could be an open operation or a percutaneous. We generally reserve the percutaneous option (TAVI or TAVR) for older people and it is a new technique. If the valve is leaky, we cannot really do it percutaneously; it must be an open operation to replace a valve – either with a tissue or a metallic valve.
Now, the mitral valve is slightly different. Though rare, a narrowing can be caused by rheumatic fever, which is scarcely seen in this country. The patient then may be short of breath.
The most common problem with the mitral valve is the valve leaking, or mitral regurgitation. This can be congenital, or it could be that the valve was slightly abnormal from birth and it gradually gets worse. It may also be due to the patient having a heart attack, which in turn damages the valve, or it could be that the heart is dilating, or stretching the valve.
Either way, patients can become short of breath, but the trick with the mitral valve is to operate on patients before they become symptomatic. We used to wait for people to have symptoms, but then we found that after we performed the operation, only 50% of them improved and 50% deteriorated badly.
So, what do we do with patients who have mitral regurgitation? We follow up regularly, with ultrasounds, to measure the size of the heart.
We must move quickly if we think the valve is leaking significantly – and we may repeat the scan once a year, following up with the patient to ensure everything is alright.
A mitral valve problem quite often predisposes to arrhythmias as well, a lot of patients develop AF (atrial fibrillation) and have a slight risk of stroke as a result.
What about aftercare?
I would look after the patient. For example, should they have more new symptoms, I would see them at short notice, and if they do not have any new symptoms, I would see them once a year.
At the point where I decide that something needs to be done, I usually arrange for an angiogram, to make sure that their coronary arteries are okay, and we will then refer them for the operation.
We usually refer them to London as this cannot be done in our Reading practice; we have several options of surgeons.
After the procedure, the patient visits me for a follow up. If it is a metallic valve, I tend to see them once or twice, as in general, the valve will not deteriorate. If they have a tissue valve, they will have a regular follow up with a scan every year.
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