The radical theory about heart attacks – and the common gout drug that may help ...Middle East

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One of the ways doctors explain how heart attacks happen is through a metaphor about plumbing. The arteries to the heart get furred up with cholesterol-laden plaques, narrowing and eventually blocking off the blood supply, like the way that water pipes get coated inside with limescale.

But another theory says that the plumbing idea of heart disease is misleading, or at least, is not the whole story.

Rather than a physical blockage of our arteries, the main cause of heart attacks is actually inflammation, a process involving the immune system.

This theory has been gaining ground for some years, leading to several new scans and tests for heart disease.

And last week, new evidence emerged that an existing gout medicine, which combats inflammation, could become the next new treatment to stop heart attacks.

“It’s rapidly moving from being just an experimental idea to a serious adjunct in [heart attack] prevention for selected patients,” said Professor Ramzi Khamis, a cardiologist at the National Heart & Lung Institute in London.

Plaques blocking pipes – and how they lead to clots

The plumbing idea developed in the last century, as new scanning techniques allowed us to see plaques partially blocking arteries in people with chest pains, often a forerunner to heart attacks.

As the fatty substance cholesterol is one of the main components of these plaques, this led to the idea that we should cut saturated fat from the diet to try to slow the furring up. It also led to the use of statins, medicines designed to cut blood cholesterol levels.

Those ideas are not wrong, but they are missing some of the picture, Professor Khamis said.

Inflammation comes in because scientists say it not only contributes to the growth of plaques but also can cause the crucial event when the plaque “bursts”, causing blood clots that are the final trigger for the heart attack.

We tend to be most familiar with inflammation when it happens to the outside of the body. For instance if we get an infected cut, the area becomes red and swollen, and there may be visible pus, an accumulation of immune cells gathering to kill bacteria.

But inflammation is going on in artery plaques too. We now know that plaques aren’t just a uniform layer of cholesterol coating the inside of our arteries.

Imagine a cross-section through a plaque: cholesterol is at the core, while its thick walls are made of muscle cells and immune cells, and it has a thin fibrous cap. How active those immune cells in the walls are – aka which inflammatory chemicals they are releasing – is what governs whether the cap bursts.

Tests could help predict heart attacks

Various techniques are in development to see which plaques in the heart’s arteries are most inflamed and at risk of bursting.

Professor Khamis has developed blood tests for inflammation that are in studies – with the ultimate aim of identifying at-risk patients earlier.

Scans are also in the works to show if a plaque’s fibrous cap is dangerously thin.

Another kind of scan can directly measure inflammation in the fat surrounding the plaque. This was shown last year to be highly predictive of someone going on to have a heart attack.

“That was an amazing study,” said Professor Khamis. “It showed that the more inflammation you have, you’re more likely to have an event, really significantly.”

Inflammation-busting drugs already exist

These kinds of tests will be most useful if we have drugs that can dampen inflammation – and there is progress there too.

It involves existing medicines used for other diseases where inflammation plays a role. Gout, for instance, is caused by inflammation of joints, which can cause excruciating pain.

A common treatment for gout is a substance called colchicine – first derived from crocus plants – and this is already approved as a heart disease treatment in the US.

It is not yet approved for this use in the UK, but specialists like Professor Khamis are already prescribing it for patients found to have high plaque inflammation.

It may become more widely used thanks to the latest study, which was a review of all previous trials of colchicine in heart disease patients. It confirmed the medicine cuts heart attacks by 26 per cent and strokes by 33 per cent. (Strokes are also caused by plaques and blood clots.)

“Reductions like this can make a real difference for patients,” said Dr Ramin Ebrahimi, co-lead author from the University Medicine Greifswald, Germany.

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