Pathology: the heart of modern healthcare Welcome and introduction to speaker Please add your name and institution if you wish.

When people think of pathology they often think of television programmes like CSI or Silent Witness and think that all pathologists spend all day solving crimes and performing autopsies. Reality couldn’t be further from the truth, most pathologists work only with the living. There are 19 different pathology specialties, staffed by dedicated doctors and scientists to provide diagnoses and treatments for millions of people every year.

Hearts are everywhere, if you look around your home you’ll probably have something heart-shaped. But have you ever thought about what your heart does and how to keep it healthy?

Broken heart Young at heart With all my heart Heart to heart My heart sank Hand on my heart Queen of hearts Heart and soul As well as seeing hearts every day, we use the word heart in many expressions – but how do these relate to the organ that sits in our chests and keeps us alive?

Heart fact: coronary heart disease is the biggest cause of death in the UK Nearly 100,000 people die from coronary heart disease in the UK every year. CHD is one of the main causes of premature death.

Heart fact: 1 in 5 deaths in the UK are from coronary heart disease

It pumps blood around the body The heart is a muscle It pumps blood around the body The heart has 4 chambers, 2 on the right and 2 on the left Bit of background – adapt to audience.

Oxygen added to blood in lungs Oxygen delivered to body by blood Dual circulation Left high pressure Right low pressure Oxygen added to blood in lungs Oxygen delivered to body by blood How the heart works – quick review of the circulation and movement of oxygen in blood – can be pitched at level of audience

Heart fact: nearly 70,000 men and 50,000 women have a heart attack in the UK each year

How can doctors look at the heart? Scanners X-rays ECG Echocardiography A digital image of the heart and ways in which the heart can be studied with imaging techniques

Heart fact: heart disease costs the economy £9 billion each year

How do pathologists investigate the heart? Blood tests Biopsies Genetic tests Blood cultures Autopsies Examples of investigations done by pathologists.

R L Transverse section of lower part of heart to show the two ventricles. Slice of heart shows thicker muscle on the left than the right. Explain that’s because the left side of the heart has to pump blood to the rest of the body, the right side only has to pump blood to the lungs. R

Atheroma Fatty deposits reduce blood flow through artery The cause of CHD is narrowing of the vessels supplying blood to the heart by fatty material called atheroma. Fatty deposits reduce blood flow through artery Normal artery wall Blood within the artery Fatty deposits in wall of artery

Fatty deposits reduce blood flow through artery Atheroma The arteries are like pipes that get furred up by atheroma so blood can’t flow so easily through them. The narrowing also increases the chance of blood clots forming and blocking the vessel. Fatty deposits reduce blood flow through artery Normal artery wall

Artery blocked by blood clot A coronary artery blocked by a blood clot. This cuts off the blood supply to part of the heart and causes a heart attack. Artery blocked by blood clot

What a heart attack looks like – there is bleeding into the wall of the left ventricle in the area of muscle supplied by the blocked blood artery. This person didn’t survive – this slice of heart was photographed following an autopsy.

Risk factors for CHD Smoking Obesity Lack of exercise Diet High cholesterol High blood pressure

Heart fact: smoking doubles your risk of having a heart attack

You can say as much or as little about smoking here as you like. Many people think that smoking is just bad for the lungs, but it’s one of the worst things you can do to your heart, and it causes lots of other diseases as well.

Heart fact: stopping smoking reduces your risk of having a heart attack by a third This is the good news – your body can repair much of the damage done and your risk of having a heart attack comes down gradually if you stop smoking.

Heart fact: almost half of all heart attacks are caused by high fat levels in the blood We all know that we should eat a diet that’s low in saturated fat – not only does it make us put on weight, it’s bad for the heart as well.

Picture to illustrate cholesterol and saturated fat – egg and cheese. One fat you might have heard of is cholesterol – this is found in some foods but is also made in the body.

Heart fact: if you have a high cholesterol level, you are three times more likely to have a heart attack than someone with a normal level You can’t tell who has a high cholesterol level just by looking at them – someone slim might have a high level. The only way to know is to have a blood test. Some causes of high cholesterol run in families and diet alone is not enough to bring the level back to normal. Drugs are available to help lower cholesterol levels and reduce the risk of heart attacks.

Heart fact: around 30% of heart disease is due to not eating enough fruit and vegetables People might start to notice that the stats are adding up to more than 100% - this is because most people have several risk factors, not just one.

Guidelines suggest that we should eat 5 portions of fruit and vegetables every day.

You might prefer to use this slide to the previous one – or you can use both. It’s good to have a range of colours – different coloured fruit and veg contain different nutrients. 28

Heart fact: around 20% of heart disease is caused by not doing enough exercise

Government guidelines say that adults should all do at least 30 minutes moderate exercise at least five times a week. That doesn’t mean sprinting, it could be something like walking or swimming. Children should aim for an hour every day.

Heart fact: only 40% of men and 28% of women meet the guidelines for physical activity 30 minutes of moderate exercise 5 times a week

Heart fact: being overweight doubles your chance of having a heart attack

Use this with or instead of the next slide. Could talk about BMI.

Fatty foods like pizza and chips contain a lot of fat – which provides calories we might not be able to burn off, particularly if we’re not doing much exericse.

Heart fact: diabetes increases your chance of having a heart attack and increases the effect of other risk factors

Some facts about diabetes: adapt as necessary for audience. Diabetes develops when the level of sugar (glucose) in the blood is too high. Glucose is produced when you eat sugary foods or carbohydrates such as rice or potatoes. Glucose is carried to the cells by the blood to be used as fuel. The hormone insulin helps glucose enter the cells. Insulin is made in the pancreas. In diabetes either the pancreas does not produce insulin or the cells lose the ability to use it. Cells become starved of glucose and because it’s not being used up, the glucose in the blood goes up and up. People with diabetes inject themselves with insulin or take tablets to help get glucose into their cells and out of their blood.

Heart fact: the heart is formed during the first 12 weeks of pregnancy All the structures of the heart are formed in the first 12 weeks of pregnancy, after that the heart grows as the baby does.

A heart from a 12 week old fetus is fully formed – but very small.

Heart fact: over 4,500 babies are born with congenital heart disease in the UK each year The audience might have heard of blue babies or hole in the heart.

Babies can be born with heart problems or they might develop them during the first few weeks of life as the circulation switches from the one in the womb, where oxygen-containing blood comes from the placenta, to the one outside the womb, where oxygen-containing blood comes from the lungs.

Heart fact: over 80% of babies with congenital heart disease now survive to adulthood There are many successful treatments for congenital heart disease now and most babies survive to adulthood.

Pathology fact: over 70% of diagnoses in the NHS involve pathology Moving onto the role of pathology in heart disease – it is interesting to know that over 70% of all diagnoses in the NHS involve pathology. If you’ve ever had a blood or urine test, a cervical smear or biopsy, your result will have been provided by the pathology department.

Pathology fact: over 700 million pathology tests are performed in the NHS each year Figures for England alone. That’s 14 tests for every man, woman and child every year.

Will now look at the role of some of the pathology specialties in the prevention, diagnosis, treatment and monitoring of different types of heart disease. Many people work in pathology – some are doctors and others are scientists. They work together, often in laboratories but also on hospital wards, in outpatient clinics and in the community.

The study of disease in human tissue Histopathologists: Are doctors Look at cells and tissues removed in clinic or during an operation Diagnose diseases including cancer Work as part of teams Some perform autopsies

When someone has a heart transplant, histopathologists look at the heart to find out what was wrong with it They also look at biopsies from transplanted hearts to see if they are being rejected If someone dies of heart disease a histopathologist might examine the heart to find out what happened A lot of the statistics we have about heart disease and its causes come from pathologists.

An example of heart disease diagnosed at autopsy. This person was found dead in bed. An autopsy was performed to find out why they died. This is their heart. It may not be obvious what’s wrong with it.

Dilated cardiomyopathy If we compare the heart of the person who died suddenly (right) with a normal heart (left), we can see that the left ventricle, the part that pumps blood around the body, is thinned and dilated. This is called dilated cardiomyopathy – the heart becomes weak and cannot pump blood effectively. DCM can be caused by infection, alcohol abuse and pregnancy, among other things, but sometimes the cause is not known. Dilated cardiomyopathy

Histopathologists in England look at 13 million slides each year Histopathologists in England look at 13 million slides each year. If you’ve had a mole removed or your appendix out, the tissue will have been looked at under a microscope by a histopathologist.

The study of chemicals in the blood and body fluids Clinical biochemists Are scientists Chemical pathologists Are doctors Both work in outpatient clinics, on hospitals wards and in the lab. Some tests are now done by patients at home.

Clinical biochemists: Measure cholesterol levels in the blood Measure the levels of heart enzymes in the blood Diagnose and treat diabetes Measure chemicals in the blood that indicate how well the heart is working Can talk about heart enzymes – chemicals released when the heart is damaged, for example by a heart attack. After several hours/days the level can be measured to give an idea of how much damage has been done to the heart and to confirm that it was actually a heart attack.

500 million biochemistry tests are performed in England each year. And it’s not just blood tests – chemicals are measured in urine samples, joint fluid, fluid from around the brain etc.

The study of infectious diseases Microbiologists can be doctors or scientists They perform tests to find out which antibiotics will be effective against an infection And make sure that infections don’t spread from one patient to another They work with patients and in the lab. 50 million microbiology tests are performed each year.

Microbiologists: Detect organisms in the blood that might cause infection of the heart muscle or valves Prevent, diagnose and treat the infections that are risk factors for coronary heart disease Prevent infections in people with congenital heart disease or transplants

An infected heart valve with vegetations on the valve cusps

The study of the blood and bone marrow Haematologists: Are doctors Diagnose and treat anaemia, leukaemia and lymphoma Work in outpatients clinics, on hospital wards and in the lab. 130 haematology tests are performed in England each year.

The branch of pathology concerned with transfusion of blood and its components Makes sure that blood transfusions are safe Makes sure that donor and recipient blood groups match

Haematologists diagnose and treat anaemia, which can have an effect on the heart They also measure blood clotting to try and prevent blood clots which might cause a heart attack You might need a transfusion after heart surgery to replace blood lost

There are 4 blood groups; Group O is the most common in the UK 2.1 million blood donations were collected in 2008 from 1.6 million donors There are 4 blood groups; Group O is the most common in the UK 2.1 million blood donations were collected in 2008 from 1.6 million donors. It may sound a lot but that’s only 4% of the population. Donated blood only lasts 5 to 35 days (depending on which part of the blood is being used) so new donations are required every day to meet demand.

The study of DNA and how diseases are inherited Geneticists are usually scientists, some also have a medical degree Technological advances in the last 20 years have had a huge impact on genetics Technological advances allow understanding of an ever expanding host of inherited and congenital disorders. Patients and their families can be given accurate testing and prenatal diagnosis to help them make critical choices about their lives and planning their families.

Diagnose inherited forms of heart disease Screen family members following unexpected cardiac death Look at inherited risk factors for heart disease e.g. high cholesterol Working on tests and treatments for inherited heart disease

This is a form of heart disease that can run in families This is a form of heart disease that can run in families. Can you spot what’s wrong with this heart?

Hypertrophic cardiomyopathy If you compare the diseased heart (right) to the normal heart (left), you can see that the wall of the left ventricle is much thicker in the diseased heart. This is hypertrophic cardiomyopathy – the heart muscle is thick and disorganised. This can cause sudden death in someone who was previously healthy, often a young, fit person. Hypertrophic cardiomyopathy is inherited as an autosomal dominant trait, which means that the children of someone with the disease have a 50% chance of inheriting the disorder. Hypertrophic cardiomyopathy

The study of disorders of the immune system e.g. allergies, immunodeficiency disorders Most immunologists run clinics, provide advice on the wards and work in the lab.

The study of inherited aspects of immunity Support stem cell and organ transplants Usually scientists

Immune disorders can affect the heart e. g Immune disorders can affect the heart e.g. autoimmune anaemia, Grave’s disease, lupus Heart transplants could not be performed without careful tissue typing to match the donor and recipient Top photo = grass, the most common cause of hay fever Lower photo= pollen grains, the cause of hay fever = one of the most common allergies

Heart transplants have only become possible with advances in immunology The first heart transplant was performed in 1967 It takes up to 10 hours to perform a heart transplant People have survived over 20 years following heart transplants

The study of diseases of fetuses and babies Paediatric pathologists are doctors They perform post mortems to find out why babies have died They also diagnose diseases in babies and children

Paediatric pathologists provide information about heart defects This helps families plan future pregnancies

The investigation of suspicious deaths Perform post mortems to find out how people died The most high profile of all pathology specialties but accounts for less than 1% of pathologists in the UK

As well as performing autopsies, forensic pathologists give evidence in court and give advice to families, police and lawyers Often investigate sudden death due to heart disease e.g. distinguishing between death due to drugs, inherited conditions, trauma or disease

The study of the effects of drugs and chemicals Measure levels of drugs in the blood and other body fluids May work for industry, in hospitals, with forensic cases or on the environment

Ecstasy can trigger heart attacks, increases heart rate and blood pressure, can cause heart failure Heroin lowers blood pressure, can make the heart rate slow and irregular, injection increases risk of heart valve infection, additives can cause blood clots Just 2 of the many drugs that can affect the heart.

Pathology as it applies to other animals All the different branches of pathology are found in veterinary medicine as well

Animals have heart disease too Dogs can have inherited or acquired heart disease, just as humans do In dogs the problems are often with the heart valves or muscle

Cardiomyopathies are common in cats, particularly hypertrophic cardiomyopathy Cats and dogs do not develop coronary heart disease

Pathology is involved in the Prevention Diagnosis Treatment Monitoring of heart disease So we have seen that pathology plays an essential role in caring for people with heart disease: Prevention e.g. measuring cholesterol levels so that changes to diet and lifestyle can be made to avoid a heart attack Diagnosis e.g. measuring heart enzyme levels to confirm that someone has had a heart attack Treatment e.g. blood transfusion after an accident or operation Monitoring e.g. keeping an eye on blood sugar levels in someone in diabetes to prevent them developing complications

This has been an introduction to heart disease, the role that pathology plays in its diagnosis and treatment and some of the careers available in the different pathology specialties.