When your heart goes Boom Diddy Boom Diddy Boom Boom Boom !

The old songs are the best !!

Oh Doctor I'm in trouble ..

Chairing a meeting tomorrow on anticoagulant drugs in Atrial Fibrillation (or AF) - the most common abnormal heart rhythm. 
  
A few facts :

• More than 1 in 200 people over 50 have it - and 1 in 10 over-80's. 
• AF increases your risk of having a stroke 5 fold  
• The reason why people who have AF suffer with strokes is because the top chambers or atria of the heart are beating irregularly and clots form in them, in particular in the left atrial appendage (LAA), a small blind ending pouch off the main left atrial chamber. The clots then break away and travel up through the blood vessels to the brain where they interrupt the blood supply to cause a stroke.  (This ‘appendix’ of the heart is not necessary for normal heart function and is routinely removed during certain types of heart surgery. With the LAA removed the chances of having a stroke are greatly reduced and patients do not need to take warfarin.)
• AF-related strokes are particularly nasty ones, doing more damage or being more likely to prove fatal than strokes not caused by AF. 
• If someone has AF, and another major risk factor for stroke (such as heart failure) they are usually advised to take treatments which thin the blood. 
• This has, until know, meant treatment with warfarin - or rat poison to the man in the street.  
• Warfarin is not easy to control, many other things can interfere with its action, and it involves regular blood tests to monitor - many patients aren't taking enough of the drug  - at least 50% are under treated and so not protected, while over treatment leading to nasty haemorrhages is also fairly common.   
• New drugs have just got their licences - they give  a much more regular control than warfarin - but at about £2.50 a day they work out at twice the cost of warfarin (which is cheap as chips) + the monitoring costs involved with warfarin (total £1.18).  There are hundreds of thousands of people on warfarin, so the NHS will only fund the new drugs for a few. 

On the wards in our hospital (which has a specialised Stroke rehab unit) we help lots of people juggle their warfarin dose. But we will have to wait to hear what our Pharmacy Protocol says before we    prescribe the new drugs (Rivaroxaban or Dabigatran). Given the endless financial strains/overspends/cutbacks, warfarin may remain the only treatment on the menu for now. 


If you don't fancy rat poison, here's a different option - looks like a jellyfish but the Watchman Device is like a tiny fishing net inserted into the major blood to catch clots before they hurtle up to the brain.  

Trials suggest the Watchman device may be as effective as warfarin

Of course, there are many other important aspects of AF that need consideration - 

For more on AF, here's a wonderful poster by the manufacturers of dabigatran. 

or hook in to The Atrial Fibrillation Association  

The only Heavy Metal I need has the atomic number 79..

Especially for those of the Heavy Metal persuasion....

A Swedish report in an journal published by the The Neurological Society of India warns that headbanging can be dangerous..

(is headbanging big in India ?  To the sitar ???)

The risks, it seems, are mostly about damage to the arteries in the brain. The violent movement of the head and neck can shred the delicate blood vessels, causing them to split open or clot up, leading to a potentially fatal stroke

In other words there may be sudden damage to the brain rather than just a gradual loss of brain cells - although we also know that repeated minor trauma to the head such as in boxing, increases the risk of dementia later in life, so when the generation who invented headbanging grow old we may discover a higher rate of dementia among them. 

To quote the article :  

"Head banging is a type of dance which involves violently shaking head in time with music, most commonly heavy metal music. Head banging can be up-down, circular swing, full body, or side-to-side. It is considered that head banging to loud music, while "making you more metal," has associated risks other than acquired hearing loss. Several case reports have indicated the inherent risk in this activity, especially of head and neck injury. We describe a patient with a history of intensive head banging and basilar artery thrombosis (BAT).

A 20-year-old man presented with neck and head pain and vertigo of three weeks duration. His medical history was otherwise normal including drug exposure or abuse. He was a musician and had a history of intensive head banging. He had sought medical help for these symptoms at other facility, but was not worked up to establish the diagnosis. The symptoms progressed in severity and he had intermittent loss of consciousness. On physical examination, vitals were normal and neurological examination revealed left hemiplegia with dysarthria. Computer tomography of brain, electrocardiogram, electroencephalogram, complete blood picture, and blood biochemistry were essentially normal. Magnetic resonance imaging including angiography could not be performed as he was very anxious. Possible diagnosis of basilar artery thrombosis was suspected and he underwent cerebral digital subtraction angiography under general anesthesia, which revealed basilar artery thrombosis. No underlying dissection or vascular malformation could be detected. He was treated with intra-arterial fibrinolytic agents. However, the outcome was complicated by a locked-in state and no obvious improvement has been observed during the follow-up."

Sadly the 20-year old in this case was left  "locked in" - aware but unable to move a muscle, with a very bleak future  ...  

The article explains that there have been reports linking headbanging to all sorts of unpleasant head and neck trauma, with  neurological complications of intensive head banging including subdural hematoma, vertebral artery aneurysm, carotid artery dissection, whiplash injury,  odontoid fracture, and vertebral artery dissection with vertebrobasilar ischemia or infarction.

Terry Balsamo

Terry Balsamo, guitarist from the heavy metal band Evanescence, had a stroke thought to have resulted from head banging.  

The Swedish report warns :

"A high index of suspicion of vascular injury in young persons presenting with persistent unilateral head or neck pain even after a minor trauma should be maintained. This index of suspicion should be even higher in patients with posterior circulation symptoms with antecedent trauma."

The report also lists the following as examples where trivial blunt trauma to the head and neck resulted in vertebral artery dissection (splitting of arteries at the back of the neck which are an important supply to the brain) :

• chiropractic manipulation (beware chiropractic !)
• tennis
• seat belt use
• yoga (gentle, huh ?)
• head banging...

Vertebrobasilar ischemia or infarction (stroke to the part of the brain supplied by the vertebral arteries) as a result of extremes of movement of the cervical spine is probably due to the fact that the vertebral arteries are fixed in the transverse foramina (a hole in the skull where the arteries enter to get to the brain) rendering them susceptible to occlusion or shearing from extremes of neck motion.

Rotation occurs first at the atlantoaxial joint before any rotation occurs in the cervical spine, leading to stretching and compression of the vertebral artery. Occlusion and spasm of the artery has been documented. An tear in the intima (the lining of the artery) can occur with formation of a clot or thromubs blocking the lumen or central space of the artery, which may result in embolization (clotting) in the posterior circulation (the posterior part of the brain's blood supply).

So, if I didn't have enough reasons already, there's another to explain why the only Heavy Metal I need is one that doesn't have headbanging habits..

Now..doesn't a gentle bit of folk music sound nice ?