Morgan Lee-Stephens noticed she was becoming increasingly out of puff walking uphill to pick up her grandchildren from school.
She also had some chest pain and felt momentarily dizzy.
‘The walk was on a slight incline, but I’m a fit gym-goer — I went three times a week, including a boxing class — so it wasn’t normal for me to be so breathless,’ says Morgan, 65.
The accommodation advisory consultant, who lives in Loughton, Essex, with partner Lee, 61, a black cab driver, adds: ‘I thought I was in pretty good health. The breathlessness and central chest pain would soon disappear after I stopped at the school gates and I’d be fine walking back.
‘I was always in a rush, dashing there from work, so I just put it down to that and not exercising as much during lockdown.’
So instead of seeing her doctor, Morgan started the NHS’s Couch to 5k programme — a running app for beginners that you can download for free. But within a few minutes of jogging, she was breathless, nauseous and dizzy.
Morgan Lee-Stephens was fortunate that her GP picked up a heart murmur immediately with the stethoscope, telling her it was so severe she needed to go straight to A&E
‘I was so out of breath, and felt so horrible I had to give up on the first day,’ says Morgan.
‘I told myself I’d have to do more walking.’
Still, she didn’t think her condition was serious enough to bother a doctor — especially when GP appointments were so hard to come by after the pandemic.
Six months later though, in January last year, Morgan had a GP phone consultation about an unrelated bacterial infection and was offered antibiotics over the phone.
‘I insisted that I wanted to be seen face-to-face as I felt I needed an examination, partly because I hadn’t seen a doctor in person in a long while. It was Lee who said I should also mention the breathlessness,’ says Morgan.
Luckily, she got an appointment the same day and was asked by the GP if there was anything else she wanted to talk about.
‘I mentioned my breathlessness and she listened to my heart with a stethoscope — a decision that saved my life,’ says Morgan.
Through the stethoscope, the doctor picked up a loud ‘whooshing’ sound — the distinctive sound of a heart murmur and a symptom of severe aortic stenosis, where the aortic valve narrows, restricting blood flow.
The whooshing noise is caused by turbulent blood flow through the narrowed valve.
Left untreated, it can cause heart failure or sudden cardiac death.
Aortic stenosis is highly treatable, if spotted quickly. ‘If you have a severe aortic stenosis diagnosis, treatment needs to be rapid — within a two to three-month window, but eight weeks ideally,’ says Dr Jonathan Byrne, a consultant cardiologist at King’s College Hospital NHS Foundation Trust in London.
But he says anecdotal evidence from cardiologists around the UK suggests average waits for treatment are often four to five months.
That’s if you even manage to get a diagnosis — some experts fear too many cases are being missed because GPs are not routinely examining people with that simple tool of the trade: a stethoscope.
To help tackle the hidden toll of heart valve disease, a bus run by the Valve for Life initiative, and the charity Heart Valve Voice, has been touring 11 UK cities in the past 18 months offering stethoscope and pulse checks (stock image)
The aortic valve is one of four in the heart and controls blood flow from the left side of the heart to the aorta, the large artery that takes oxygen-rich blood to vital organs and around the body.
Symptoms include breathlessness, chest pain brought on by physical activity, dizziness, and fainting.
In severe cases it can lead to complications such as heart failure — where the heart is unable to pump properly, and cardiac arrhythmia (irregular heartbeat). Severe aortic stenosis that causes symptoms affects an estimated 200,000 people in the UK, mainly those over 65. It’s usually due to wear and tear of the valve and calcium build-up in the ‘leaflets’ — or flaps — of the valve (the calcium is the body’s response to damage to the leaflets).
Other causes include inflammation and cholesterol deposits on the valve. Younger people can get it, too, but usually due to a congenital problem caused by having two flaps instead of the usual three in the aortic valve.
Other symptoms can include a rapid fluttering heartbeat, swollen ankles or feet — caused by fluid build-up, and sleep problems.
‘One of the key symptoms in older people is exertional breathlessness, particularly when walking uphill,’ says Dr Byrne, who is the UK lead for Valves for Life, a European Society of Cardiology initiative to improve access to valve treatment.
‘The key to diagnosing it is listening to the heart with a stethoscope and hearing a whooshing sound.
‘Yet I often see patients in my clinic who tell me they didn’t get their heart listened to with a stethoscope.’
He says a face-to-face stethoscope examination remains the most straightforward method to detect aortic valve disease.
‘The fact that it’s become more difficult to see a GP face to face means this assessment is done less frequently,’ says Dr Byrne.
‘But even when patients do have a face-to-face appointment, it’s not that common that a GP picks up a stethoscope and listens to the heart. The basic skills are being lost and drowned out with the volume of workload.’
Referrals for valve disease fell during the pandemic and have yet to recover, which is concerning, says Dr Byrne.
‘The shift towards virtual appointments, which has continued long after the pandemic, is a contributor to the declining numbers. This condition, if left untreated, can have life-threatening consequences.’
Yet severe aortic stenosis can be cured with a valve replacement operation — either via open-heart surgery or keyhole surgery (in a procedure known as a transcatheter aortic valve implantation, or TAVI) — where a replacement aortic valve is fixed over the old valve, via a catheter (a thin tube) inserted into a blood vessel in the upper leg or chest. TAVIs are performed by specialists called interventional cardiologists in cardiac catheter labs.
Some experts fear too many cases are being missed because GPs are not routinely examining people with that simple tool of the trade: a stethoscope (stock image)
‘The problem is the waiting time for surgery — and even before that, you can wait months for clinic appointments, then for tests and multi-disciplinary team meetings to decide on the best surgery for the individual patient,’ says Dr Byrne.
‘One year after diagnosis of severe aortic stenosis up to 50 per cent of patients will have died if they don’t get a valve replacement,’ he warns.
NHS England data published in July revealed a record 392,698 people were on cardiac waiting lists at the end of May — up 68 per cent since February 2020, just before the pandemic began.
Dr Byrne calculates that the NHS operates on only 10 to 20 per cent of the 200,000 patients who have severe aortic stenosis that causes symptoms.
And the number of those affected is expected to rise: a study by the National Institute for Health Research at Oxford University Hospital Foundation Trust, published in the European Heart Journal in 2016, predicted an ’emerging epidemic’ of heart valve disease in the UK, doubling from 1.5 million cases between that year and 2046.
The rise is due mainly to the ageing population.
In a survey by the charity Heart Valve Voice and the All-Party Parliamentary Group on Heart Valve Disease, published a few weeks ago, 72 per cent of catheter lab staff said they believed that patients were dying simply because there wasn’t enough capacity in the NHS to treat them.
These are needless losses, as Dr Byrne points out: ‘Every centre faces the same battle to help their patients, and staff sadly watch while patients are denied life-saving treatment due to a lack of capacity.
‘A fast-track pathway for severe aortic stenosis, along with increased, ring-fenced, catheter lab capacity to treat the disease, is the first step to increase access to this life-saving treatment.’
Severe aortic stenosis affects between 2 and 5 per cent of over-65s, but many are diagnosed with late-stage disease says Dr Stephen Dorman, a consultant cardiologist at University Hospitals Bristol.
‘We keep finding people who arrive with severe aortic stenosis with their heart in failure, when ideally, we’d have caught them five to ten years earlier and had them under a surveillance programme and have been able to time their intervention in a better manner,’ says Dr Dorman.
‘Another factor is that people dismiss their symptoms as just being down to getting older. While understandably people do ‘decondition’ as they age, if you’ve always been fit and kept yourself in good shape, and you’ve noticed a distinct change in your exercise tolerance or breathing, that is significant, and worth a doctor listening to your heart with a stethoscope.’
Dr Margaret Ikpoh, the vice chair of professional development at the Royal College of GPs, says: ‘GPs and their teams are working flat-out to deliver safe, timely and appropriate care, and are seeing millions more people every month than before the pandemic.
‘But we are doing this with 930 fewer GPs than we had at the end of 2019.’
To help tackle the hidden toll of heart valve disease, a bus run by the Valve for Life initiative, and the charity Heart Valve Voice, has been touring 11 UK cities in the past 18 months offering stethoscope and pulse checks. Around 10 per cent of those screened have needed further investigations for cardiac problems, including heart murmur and irregular heart beat.
Morgan was fortunate that her GP picked up a heart murmur immediately with the stethoscope, telling her it was so severe she needed to go straight to A&E. ‘I couldn’t believe what I was being told,’ says Morgan. ‘Although I’d felt breathless and had some slight chest pain, it didn’t seem possible that I had such a serious condition. I just thought: ‘It couldn’t be that bad, surely?’ ‘
A face-to-face stethoscope examination remains the most straightforward method to detect aortic valve disease, according to Dr Jonathan Byrne
At the hospital her heart was checked with a stethoscope again, and she underwent blood tests to rule out a heart attack. A heart murmur was confirmed, and she was referred for an echocardiogram, but was told it could take six weeks. Morgan decided to pay £600 for a private echocardiogram as the couple had booked a holiday in the U.S. for Lee’s 60th birthday.
‘I wanted to get the test out of the way so we could get insurance cover for the holiday — I was still hoping it wouldn’t be anything major,’ she says.
But the news was bad — she had severe aortic stenosis and wouldn’t be going on holiday as she needed prompt open-heart surgery to replace the valve.
‘I was in shock,’ says Morgan. ‘A heart surgeon later told me I’d have had only 18 months left if I didn’t have the operation.’
But the backlog from Covid meant a four to six-month wait for surgery on the NHS.
‘I don’t think I would have survived that wait — the stress and toll on my mental health would have been too great aside from the valve problems,’ she added.
Morgan paid privately for the £45,000 operation, cashing in a pension, and had open-heart surgery seven weeks later in April.
She says phlegmatically: ‘My life savings actually saved my life, so I’m not bitter and I certainly don’t regret it. My surgeon told me afterwards that my valve was really badly affected and that I probably wouldn’t have lasted much longer had I waited.’
The surgery has been transformative; within eight weeks, Morgan was able to walk up hills without becoming breathless.
‘It has made such a difference,’ she says. ‘But it’s horrendous that people are dying while they wait for these operations.
‘My advice for anyone experiencing breathlessness is not to ignore it or accept a phone consultation if you have new symptoms — see your doctor face to face and get your heart checked. If I hadn’t, I wouldn’t be here today.’
DR MARTIN SCURR: High-tech gadgets can’t replace this old-fashioned skill
Not long ago, I was shocked to read an eminent GP colleague’s comments — in the British Medical Journal, no less — opining that training medical students in how to examine patients is a waste of time.
The suggestion was that it’s a hangover from the long-distant past, since thanks to high-tech CT and MRI scans, ultrasound and echocardiography, no one needs to learn how to check a patient’s mouth and tongue with a depressor stick, or palpate their abdomen, for instance — let alone use a stethoscope to examine their heart.
For all our fascination with modern medical gadgetry, even at three score years and ten, I continue to believe that my most treasured skill is my training in medical diagnosis. A cornerstone of that is the craft of physical examination.
As medical students we learned to examine patients correctly, in lecture theatres and in hospital outpatient clinics. Once the consultant had taken the history of a patient with a small team of students in attendance, there would be a demonstration of the clinical signs to look for and, one by one, the students all had a turn — to listen to the heart or lungs, or feel the pulse, or examine the abdomen, or a use a pinprick test or other methods (to check nerve sensitivity), or a ‘patella hammer’ for reflexes.
Using a stethoscope is a vital early step in diagnosis — to be frank, waiting for an echocardiogram (a type of ultrasound used to examine the structure of the heart) might be too late for too many patients
We learned how to examine the thyroid gland, from behind the patient using two hands, asking them to swallow to feel the gland move; to carefully check the skin for abnormalities — such as the stretch marks on the trunk and legs that may be a sign of Cushing’s syndrome — or any other of a whole range of other tests.
And as part of our exams, we had to examine several patients, for 30 seconds each, before being asked for our opinion — followed by one ‘long case’: taking a detailed history, conducting a full examination and then presenting the examiner with a diagnosis and treatment plan.
Invariably, the long case would involve a patient with aortic stenosis — a narrowed heart valve (see main story) or regurgitation (a leaky heart valve) or mitral stenosis (another type of narrowed heart valve, most often caused by rheumatic fever). Getting this wrong would result in failure. Aortic stenosis is common. And while it can cause breathlessness, at times it is a silent condition with perhaps only an occasional ‘drop attack’, i.e. sudden fainting, because not enough blood and oxygen is reaching the brain. A common complication is sudden death.
Using a stethoscope is a vital early step in diagnosis — to be frank, waiting for an echocardiogram (a type of ultrasound used to examine the structure of the heart) might be too late for too many patients.
DR MARTIN SCURR: These days, it is beginning to look as though most readers will see only a stethoscope on the photo of my esteemed Daily Mail columnist, psychiatrist Dr Max Pemberton — a reaffirmation of his status as a skilled medical doctor, both of mind and body
A stethoscope is also vital for checking a patient with a cough and a high temperature to identify pneumonia, allowing prompt administration of potentially life-saving antibiotics.
This is especially important when you consider the time it can often take to access an ambulance, transfer a patient to hospital and then wait in the queue on arrival.
The sound of ‘bronchial breathing’ of pneumonia through the stethoscope, unlike the soft and quiet sound of the air going in and out (as with healthy lungs), is very loud and clear.
Starting antibiotics at this point may avoid rapid deterioration into often-deadly sepsis. Yet some doctors merely call for the ambulance, a bit too keen to depend on the chest X-ray that will be organised once the patient gets to hospital. But that can involve a delay of hours before treatment is started.
In rejecting those examination skills for the sake of modern technology, my eminent colleague did not allow for the fact that scans can involve long waiting times.
Then there’s the chance they might be rationed by cost-cutting. And at a more banal level, what if the power is cut off for some reason?
These days, it is beginning to look as though most readers will see only a stethoscope on the photo of my esteemed Daily Mail columnist, psychiatrist Dr Max Pemberton — a reaffirmation of his status as a skilled medical doctor, both of mind and body.