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An electrocardiogram
(ECG)

meeT THe experT

Matters of the heart are not to be treated lightly.
Luckily, Dr Narbeh Melikian is on hand to help

Stable angina

patients with suspected angina should undergo
a comprehensive cardiac work-up (medical
evaluation). prompting investigation is important
to prevent progression to a heart attack.
Initial tests aim to confirm that symptoms
originate in the heart and include an
electrocardiogram (eCG, a heart trace),
echocardiogram (an ultrasound scan of the
heart) and a stress test (which can be done
using medication such as adenosine or with
exercise on a treadmill or bicycle). Some
patients may also require a computerised
tomography (CT) or magnetic resonance
imaging (mrI) scan of the heart. If preliminary
tests are positive, most patients will need to
undergo a coronary angiogram to obtain
accurate information about the diseased
coronary artery. The results of the angiogram
will determine whether the patient requires an
angioplasty or a bypass operation to restore
normal blood flow to the heart. While undergoing
tests, patients are often started on a course of
medication such as aspirin, beta-blockers and
statins in order to stabilise the heart.

Unstable angina and
heart attack

Both unstable angina and heart attack are
medical emergencies and therefore require
immediate admission to hospital. In most cases,
an eCG, an echocardiogram and a blood test

reducing your risk
Treatments are available for
a variety of heart conditions

* Chest discomfort (stable angina and
heart attack)
* CHD risk factors, especially high
blood pressure
* Angiography using the femoral and
radial (wrist) arteries
* Angioplasty with drug-eluting and
bio-absorbable stents
* Closure of 'holes in the heart' (PFO
and ASD)
* Renal denervation for high blood
pressure
* Palpitations and atrial fibrillation (AF)
* Heart failure
* Fractional flow reserve (FFR)
* Intra-vascular ultrasound (IVUS)

Dr Narbeh Melikian (pictured, left) is a leading consultant
cardiologist and senior lecturer in cardiology, based at King's
College Hospital, London. He has a large practice encompassing
all aspects of interventional and non-interventional cardiology, including: management
of chest discomfort (angina and heart attacks), cardiovascular risk factors in particular
high blood pressure, valvular heart disease, palpitations such as atrial fibrillation
and heart failure. His particular expertise lies in interventional cardiology in which
he has an international reputation. He performs over 250 angioplasties every year
(including procedures from the radial/ wrist route) placing him among one of the
highest volume operators in the country including primary angioplasty for heart
attacks as part of the King's Heart Attack Centre (HAC). Dr Melikian also closes
patent foramen ovale (PFO) and ASDs (atrial septal defect - 'holes in the heart')
and performs renal denervation for high blood pressure.
Dr Melikian qualified from the University of London in 1996 and trained at
Hammersmith Hospital and King's College Hospital in London, before undertaking a
two-year Interventional Cardiology Fellowship at the Aalst Cardiovascular Centre in
Belgium. He has received multiple academic distinctions throughout his career, including
the Golding Bird and treasures Medals and the Foord Caiger Prize in Cardiology. In
2007, he was awarded the prestigious British Cardiac Society John Parker Fellowship.
In addition to his clinical practice, he has an active research programme based at King's
College London and is a faculty member of euro-PCR. In 2012, he was invited to join
a panel of cardiologists providing cardiac care at the London Olympic Games.

'every episode of chest discomfort
should be taken seriously'
(to measure a chemical called troponin) may be
adequate to reach a diagnosis. A high troponin
level is diagnostic of a heart attack. patients
with unstable angina are initially treated with
blood thinning medication to improve
circulation to the heart. This is often followed
by angioplasty to treat the culprit narrowing.
However, if a heart attack is suspected,
patients will need immediate medical attention.
The cutting-edge treatment for a heart attack
is emergency angioplasty (alternatively known
as primary angioplasty) which unblocks the
diseased artery and conclusively restores blood
flow to the heart. In the UK, primary angioplasty
is performed in Heart Attack Centres (HACs),
which provide a round-the-clock clinical service
to patients across a wide geographical area.
The emergency services often take suspected
heart attack cases directly to the regional HAC
in order to prevent any delay in treatment. If
a patient cannot be taken to HAC in a timely
fashion, 'clot-busting' drugs can also be used
to treat a heart attack (this is a process known
as thrombolysis). However, this is far less
effective than primary angioplasty.

Coronary angiography,
angioplasty and stents

Angiography is the gold standard test to
investigate a narrowing in a coronary artery. A
thin, flexible tube called a catheter is inserted
into a blood vessel from either the groin or wrist
and the tip is passed to the heart under x-ray
guidance. A special dye is then injected into
the arteries, and x-ray images (called

angiogram) are taken to identify narrowed
or blocked vessels.
In diseased arteries, a thin wire is passed
through the catheter along the length of the
artery, over which a miniature balloon is
delivered to the narrowed section. The balloon
is inflated to squash the fatty deposits into the
artery wall. A microscopic wire mesh (a stent) is
often wrapped around modern balloons, which
remains in place when the balloon is deflated
and removed. modern stents are coated with
medication (drug-eluting stents) or have the
ability to dissolve inside the body over a period
of 18 months (bio-absorbable scaffolds). Both
these features reduce the recurrence of disease.
This procedure is known as angioplasty,
and is now the treatment of choice for CHD as
the blood flow through the coronary arteries
usually improves afterwards. Angiography and
angioplasty are minimally invasive procedures
which are done under local anaesthesia.

FOR MORE INFORMATION
Practice details
PRIVAte
London Bridge Hospital 020 7407 3100.
Bupa Cromwell Hospital 020 7460 5700.
Harley Street Clinic 020 7935 7700.
The Guthrie Clinic at King's College Hospital
020 3299 3192.
NHS
King's College Hospital NHS Foundation
Trust 020 3299 9000.
At Home Christian Jessen 2014

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