When blood vessels go wrong, why are we better at treating the heart than the head?

The strange discrepancies between how we treat strokes and heart attacks.

When I started practice in the early 1990s, medical attitudes to strokes and heart attacks couldn’t have contrasted more starkly.

Heart attacks were often dramatic and challenging; there were plenty of treatments to deploy, and much high-tech gadgetry to play with. Good outcomes were immensely satisfying, a confirmation that medicine made a difference. A stroke, on the other hand, felt like a depressing fait accompli. There was little to be done by way of treatment, survival was a matter of chance, and many patients were left with profound disabilities from which any recovery was painstaking and marginal.

The pathology underlying the two conditions is broadly similar. Every organ relies on uninterrupted perfusion of blood for its oxygen and nutrition. Clearly blood has to be liquid in order to circulate, yet it is also chock-full of tiny platelet cells, and a soluble chemical, fibrinogen, that will solidify into a clot at a moment’s notice. Blood vessels are lined with the biological equivalent of Teflon – the vascular endothelium – which ensures this clotting potential is held in check. Any breach in this endothelium activates the platelets, causing them to clump together in great numbers and to convert fibrinogen into its insoluble cousin, fibrin, which coagulates into a matted web.

This clotting cascade is vital in trauma, sealing damaged vessels and limiting blood loss; but when it is triggered in other circumstances, it can have catastrophic effects.

Cholesterol-rich plaques in arterial walls – the “furring up” of popular discourse – can swell and rupture the vascular endothelium. The ensuing clot may block the vessel entirely, causing death to the tissues downstream. If this occurs in a coronary artery, heart muscle dies – a myocardial infarction (MI), or heart attack. In the brain, the result is a stroke.

In the UK, deaths due to MI halved between 2002 and 2010. Some of this dramatic drop is because heart disease is becoming less common, thanks to the decline in smoking, and improvements in diet and exercise. The NHS has also become better at identifying and offering preventative medication to those at high risk. But around 50 per cent of the astounding increase in survival comes down to the transformation in treatment of those who have the misfortune to suffer a heart attack.

The management of MI has been revolutionised by techniques to unblock occluded coronary vessels, thereby salvaging as much of the blood-starved heart muscle as possible. The earliest attempts used “clot-buster” drugs known as thrombolytics, which cause the fibrin in the offending clot to dissolve. Thrombolytics still have an important place, but surgical approaches are ever more commonplace.

Angioplasty, where a wire is threaded up to the coronary vessels from an artery in the groin, has become the first-line emergency treatment for the most serious types of MI. A balloon at the end of the wire, or an implantable wire cage called a stent, can be deployed to reopen the blocked vessel.

Time is of the essence: the earlier that perfusion can be restored, the less heart muscle will die, and the better the outcome (in some cases, MI can actually be aborted). Ambulance services, and A&E and cardiology departments, have refined protocols for fast-tracking suspected MI sufferers, and “door-to-needle” or “door-to-balloon” times have been reduced substantially.

Stroke medicine has also undergone a revolution in recent years. Thanks to a sustained research effort led by the Stroke Association, much more is understood about maximising recovery following stroke, and most sufferers will now be treated in a dedicated stroke unit, which significantly improves outcomes.

The holy grail, though, would be comparable success in re-perfusing blood-starved tissue after stroke to what cardiologists are achieving in MI.

Stroke is different in a number of ways. Angioplasty is not useful in the majority due to the small size of the vessels within the brain. Thrombolysis should, in theory, be successful – but whereas re-perfusion can salvage heart muscle up to 12 hours after the onset of symptoms, brain tissue has a much narrower window of opportunity, probably around three to four hours.

And not all strokes are caused by clot. Around one in ten occur when a blood vessel ruptures and bleeds into the surrounding brain; you most certainly don’t want to give clot-busting drugs in those cases. They can be identified on a scan, but more challenging to predict are those patients suffering a clot-induced stroke who go on to bleed into the damaged neural tissue, something thrombolytics also make catastrophically worse.

The balance between benefit and harm is a fine one, and some experts have recently called for thrombolysis in stroke to be confined to clinical trials until the evidence to justify its use is clarified.

For now, at least, we continue to rescue the heart more successfully than the head.

Phil Whitaker is an award-winning novelist and a working doctor

Doctors treat a heart attack patient in Berlin, Germany. Image: Getty

This article first appeared in the 30 October 2013 issue of the New Statesman, Should you bother to vote?

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Andy Burnham and Sadiq Khan are both slippery self-mythologisers – so why do we rate one more than the other?

Their obsessions with their childhoods have both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

Andy Burnham is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s widely seen as an unprincipled flip-flopper.

Sadiq Khan is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s the hugely popular mayor of London, the voice of those who’d be proud to think of themselves as the metropolitan liberal elite, and is even talked of as a possible future leader of the Labour party.

Oh, and also they were both born in 1970. So that’s a thing they have in common, too.

Why it is this approach to politics should have worked so much better for the mayor of London than the would-be mayor of Manchester is something I’ve been trying to work out for a while. There are definite parallels between Burnham’s attempts to present himself as a normal northern bloke who likes normal things like football, and Sadiq’s endless reminders that he’s a sarf London geezer whose dad drove a bus. They’ve both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

And yes, Burnham apparent tendency to switch sides, on everything from NHS privatisation to the 2015 welfare vote to the leadership of Jeremy Corbyn, has given him a reputation for slipperiness. But Sadiq’s core campaign pledge was to freeze London transport fares; everyone said it was nonsense, and true to form it was, and you’d be hard pressed to find an observer who thought this an atypical lapse on the mayor’s part. (Khan, too, has switched sides on the matter of Jeremy Corbyn.)

 And yet, he seems to get away with this, in a way that Burnham doesn’t. His low-level duplicity is factored in, and it’s hard to judge him for it because, well, it’s just what he’s like, isn’t it? For a long time, the Tory leadership’s line on London’s last mayor was “Boris is Boris”, meaning, look, we don’t trust him either, but what you gonna do? Well: Sadiq is Sadiq.

Even the names we refer to them by suggest that one of these two guys is viewed very differently from the other. I’ve instinctively slipped into referring to the mayor of London by his first name: he’s always Sadiq, not Khan, just as his predecessors were Boris and Ken. But, despite Eoin Clarke’s brief attempt to promote his 2015 leadership campaign with a twitter feed called “Labour Andy”, Burnham is still Burnham: formal, not familiar. 

I’ve a few theories to explain all this, though I’ve no idea which is correct. For a while I’ve assumed it’s about sincerity. When Sadiq Khan mentions his dad’s bus for the 257th time in a day, he does it with a wink to the audience, making a crack about the fact he won’t stop going on about it. That way, the message gets through to the punters at home who are only half listening, but the bored lobby hacks who’ve heard this routine two dozen times before feel they’re in the joke.

Burnham, it seems to me, lacks this lightness of touch: when he won’t stop banging on about the fact he grew up in the north, it feels uncomfortably like he means it. And to take yourself seriously in politics is sometimes to invite others to make jokes at your expense.

Then again, perhaps the problem is that Burnham isn’t quite sincere enough. Sadiq Khan genuinely is the son of a bus-driving immigrant: he may keep going on about it, but it is at least true. Burnham’s “just a northern lad” narrative is true, too, but excludes some crucial facts: that he went to Cambridge, and was working in Parliament aged 24. Perhaps that shouldn’t change how we interpret his story; but I fear, nonetheless, it does.

Maybe that’s not it, though: maybe I’m just another London media snob. Because Burnham did grow up at the disadvantaged end of the country, a region where, for too many people, chasing opportunities means leaving. The idea London is a city where the son of a bus driver can become mayor flatters our metropolitan self-image; the idea that a northerner who wants to build a career in politics has to head south at the earliest opportunity does the opposite. 

So if we roll our eyes when Burnham talks about the north, perhaps that reflects badly on us, not him: the opposite of northern chippiness is southern snobbery.

There’s one last possibility for why we may rate Sadiq Khan more highly than Andy Burnham: Sadiq Khan won. We can titter a little at the jokes and the fibs but he is, nonetheless, mayor of London. Andy Burnham is just the bloke who lost two Labour leadership campaigns.

At least – for now. In six weeks time, he’s highly likely to the first mayor of Greater Manchester. Slipperiness is not the worst quality in a mayor; and so much of the job will be about banging the drum for the city, and the region, that Burnham’s tendency to wear his northernness on his sleeve will be a positive boon.

Sadiq Khan’s stature has grown because the fact he became London’s mayor seems to say something, about the kind of city London is and the kind we want it to be. Perhaps, after May, Andy Burnham can do the same for the north – and the north can do the same for Andy Burnham.

Jonn Elledge edits the New Statesman's sister site CityMetric, and writes for the NS about subjects including politics, history and Daniel Hannan. You can find him on Twitter or Facebook.