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Irish Cardiac Society 2017 Annual Scientific Meeting and AGM

The Irish-American connection in providing cardiac care to patients

The President of the American College of Cardiology delivered a revealing address to the Irish Cardiac Society 2017 Annual Scientific Sessions, addressing pharmacotherapy, innovative devices and the lack of data on HFpEF patients

he opening address at the Irish Cardiac Society (ICS) Scientific Sessions 2017, held in Derry from 5 to 7 October, was delivered by renowned cardiologist Dr Mary Norine Walsh, President of the American College of Cardiology (ACC), who was introduced by consultant cardiologist and founder of The Heartbeat Trust Prof Ken McDonald. 

Dr Walsh delivered a talk titled ‘Heart Failure: Current Therapies and New Horizons’ and addressed the latest trends in mechanical circulatory support in cardiac transplantation.

She pointed out that in Europe and North America, between 1-to-2 per cent of the population have heart failure. “However, it’s not always the same type of heart failure encountered by GPs and cardiologists,” she told the attendees. “It’s also important to remember that the prevalence of heart failure goes up with age primarily because of HFpEF [heart failure with preserved ejection fraction] and this affects more women than men in general.

“What drives the prevalence of heart failure worldwide, overall, are diabetes and hypertension and in the elderly, we are seeing a lot of patients with HFpEF rather than HFrEF [heart failure with reduced ejection fraction].”

She pointed out that approximately 50 per cent of heart failure patients have preserved ejection fraction and these patients account for more than half of all heart failure hospitalisations.

“But importantly, we really don’t have a lot of clinical trial data on this patient population,” Dr Walsh pointed out. “As helpful as our newer heart failure therapies are, half of our heart failure patients [with HFpEF] are really not as healthy as the HFrEF population.”

Newer therapies

Dr Walsh went on to discuss the latest heart failure therapies and outlined the more recent ACC/American Heart Association guidelines: “These were just recently released and is a really straightforward way to look at our heart failure patients,” she explained. “Step one is simply diagnosing the patient with heart failure; step two is considering the various therapies; step three is individualising those therapies; and importantly, thereafter, we reassess and perhaps re-image the patient and reassess their LV [left ventricular] function and then look at further therapies. I call this to your attention because I think this is the most important piece of our new guidelines.”

She also referenced the PARADIGM-HF trial, as well as the newest heart failure therapy and its influence on survival rates. “This is the angiotensin receptor blocker valsartan and neprilysin inhibitor sacubitril… the PARADIGM trial brought this therapy to us an option for patients,” said Dr Walsh, who also outlined the study design and end-points. “When we compare this combination therapy to an angiotensin receptor blocker and ACE inhibitor, we get a 20 per cent additional reduction in mortality for our patients with heart failure, so this really is a blockbuster drug.”

Mechanical support

Dr Walsh pointed out the growing use of mechanical circulatory support for the indication of both bridge-to-transplantation and destination therapy. “This is a device that you can take ‘off the shelf’ and patients don’t have to wait for a donor heart, for example,” she said. “In people listed for transplant, they fare best in the current generation of therapies and even the people who are not eligible for transplant have improved survival compared to the previous era… more people are doing well on these devices.”

She explained that the newer versions of these devices are smaller and are fully magnetically-levitated, which decreases the amount of exposure to a patient’s blood, thereby reducing the risk of thrombo-embolic complications.

Speaking to the Medical Independent (MI) at the Sessions, Dr Walsh explained that despite its modest size relative to other organisations, the ICS is held in high esteem internationally.

“The ACC has had a very close working relationship with the ICS for years and has also partnered with it for various chapter activities around the world; the ICS has been a very active partner of ours.”

Diaspora

Dr Walsh, who is Irish-American, referred to the large Irish diaspora of physicians in the US. “Our ancestors left Ireland and came to the US, and now we have the US — not just cardiologists, but other doctors — coming back to the homeland to find our relatives, which is wonderful.”

In terms of modern advances in heart failure treatment, Dr Walsh highlighted a number of areas. “Pharmacotherapy has seen two or three new agents in recent times, but we also now have ventricular assist devices, not to mention the growing use of resynchronisation therapy,” she said.

“But one of the concerns about the healthcare system here in Northern Ireland is the average waiting time of six months for an echocardiogram,” she told MI. “In the US, a patient can get an echocardiogram sometimes in the same day, or certainly within the same week for a patient who needs a diagnosis. So time to diagnose is pretty long here and we don’t see that so much in the US.”

However, one thing cardiac physicians across the island of Ireland have in common with their US counterparts is the increased emphasis on prevention and increasing public awareness in this area. “In the US, for the primary risk factors for developing heart failure and cardiovascular disease, there is a big push to ‘know your numbers’,” she explained. “This means knowing your blood pressure, knowing your blood sugar levels and knowing your cholesterol levels. When we see treatment of hypertension improving in any community, we see a decline in the prevalence of heart failure so having either community screening or people knowing their numbers and going to see their GP are all issues that we really push hard.

“What I notice about Ireland is that, while people can’t smoke indoors, there are many, many more people smoking outside compared to the US; the smoking rate is still higher overall here.”

Rise in US heart transplants is due to ‘opioid epidemic’

The President of the American College of Cardiology Dr Mary Norine Walsh revealed data that shows a significant rise in the rates of cardiac transplantation in the US and Canada, and a significant factor in this is an epidemic of opioid use.

Dr Walsh was addressing the ICS Scientific Sessions 2017, which was held recently in Derry. “The number of patients waiting for transplant who have cardiomyopathy that is not ischaemic is growing,” said Dr Walsh. “Our therapies for ischaemic heart disease are very effective and fewer patients are being transplanted for that disease. Cardiomyopathy continues to be the driving diagnosis in adult cardiac patients per transplantation.”

However, she added: “The increase in cardiac transplantation over the past five years has been seen in men more than women… the reason that there are more donors is because of anoxia and this is directly related to the opioid epidemic in the US.

“So the sad outcome of this opioid epidemic is that there are more solid-organ transplants being done.”

Dr Walsh added that a decrease in US donor rates due to head trauma is due to improved public safety measures, such as motorcycle helmet and seat-belt laws. “Head trauma is still the number-one reason [for donations] but that is on the down-swing, but on the up-swing is the number of patients with anoxia as a diagnosis.”

Another interesting statistic, said Dr Walsh, is the rise in the number of US patients over the age of 65 years who are being transplanted. “This is not simply because there are more patients aged over 65 with cardiomyopathy — although that is true — but we have become much more comfortable with transplantation over the years and are transplanting patients with older donor hearts,” she told the attendees.

“When I started in this field, we would have never accepted a donor heart over the age of even 40. Now, if a 50- or 52-year-old donor heart is available, with a normal coronary angiogram, we would consider that a suitable donor for someone over the age of 65. Many centres are now transplanting patients in the age group between 65 and even 70 or 72 years.”

Inappropriate drugs being used in long-term care heart failure population

During the ICS Scientific Sessions 2017, held recently in Derry, delegates heard data from pharmacist Ms Margaret Birmingham of Cork University Hospital (CUH) showing that many heart failure patients are having inappropriate medicines prescribed for their condition.

Ms Birmingham presented data on behalf of Mr Seif El Hadidi of the School of Pharmacy at CUH relating to the prescribing of potentially inappropriate medicines to patients residing in long-term care facilities in Ireland. While there is some disparity in the data available on patients with heart failure in such facilities, using data from the US and Northern Europe, Ms Birmingham estimated the prevalence to be approximately 33 per cent among such residents, although “this prevalence may be underestimated,” she pointed out.

“There are a couple of reasons for this,” she explained, “including the atypical presentation of heart failure in very elderly patients and the role of comorbidities — our long-term care population tends to be highly comorbid and this presents problems in terms of diagnosis.”

Ms Birmingham told the attendees that recent studies in Northern Europe used natriuretic peptide screening to identify heart failure patients in long-term care facilities and found that the proportion of this population with low levels and who receive a clinical diagnosis of heart failure is very low, compared to the population with highly-elevated natriuretic peptide levels.

Ms Birmingham explained that the research looked at studies on inappropriate prescribing in general in long-term care facilities, one of which (O’Sullivan, 2011) revealed that the ‘STOPP-START’ tool, an Irish-developed tool to identify inappropriate prescribing, showed that up to 71 per cent of residents in long-term care facilities were being prescribed at least one inappropriate medication.

“We sought to use a heart failure-specific tool to identify the patient factors associated with the prescribing of inappropriate medicines in this patient population,” Ms Birmingham told the attendees.

In the retrospective, observational study, patients in the Cork area were looked at, including their comorbidities, medications and long-term care records, with prescription of a loop diuretic used as a surrogate marker of heart failure. The team also utilised the ‘Potentially Inappropriate Medicines in Heart Failure’ (PIMHF) tool, first published in the European Journal of Heart Failure in 2014, specifically designed to identify medicines that can in fact cause more harm than good to heart failure patients.

“There were 732 patients in 14 long-term care facilities from whom the data was collected,” said Ms Birmingham. “Ninety-nine of those patients — or 13.5 per cent — had heart failure reported in their nursing home records. However, in total from that 732, 232 patients were prescribed a loop diuretic, so that’s over 30 per cent.

“For the purposes of the study, we compared the heart failure patients and the loop diuretic patients and we found that there were no significant differences between the two groups in the long-term care facilities… comparing that 265 patients to the non-heart failure population, we see that they are older, have a greater number of medicines prescribed and have more cardiovascular comorbidities. Interestingly, they had a lower rate of dementia than other patients,” said Ms Birmingham.

She continued: “In terms of heart failure medicines prescribed, about 87 per cent of the population were prescribed a loop diuretic and over 50 per cent were prescribed a loop diuretic alone — they were not prescribed a typical, disease-modifying heart failure therapy. Just 24 per cent were prescribed an ACE [inhibitor] and just 22 per cent were prescribed a beta-blocker.”

Ms Birmingham explained that six of the 11 items on the assessment tool were identified, meaning that 25 per cent of the patient population had at least one potentially inappropriate medicine prescribed to them, primarily NSAIDs.

“Looking at the difference between those who were prescribed an inappropriate medicine and those who were not, key differences were that those prescribed an inappropriate medicine were more likely to be taking a greater number of medicines, were more likely to have diabetes and were less likely to be prescribed a loop diuretic,” she told the conference. “In terms of diabetes, this reflects the type of medicines that are listed on the PIMHF tool.”

Ms Birmingham concluded: “Heart failure patients in long-term care are at risk of being prescribed inappropriate medicines, in particular agents that may worsen heart failure symptoms. Pharmacists have a key role in providing medicines optimisation for long-term care patients, however, medicines optimisation is hampered by the fact that there are difficulties in confirming heart failure diagnosis in this patient population, as we see from the disparity in prescribing, in particular of loop diuretics.

“Quite interestingly, it seems that in those who are looking at medicines in this population, the loop diuretic is leading their decisions in the prescribing of medicines, rather than the diagnosis of heart failure, and which seems to be a marker of heart failure in this patient population.”

Virtual consultations on heart failure represent ‘a viable model’ of care for both GPs and patients

Attendees at the recent ICS Scientific Sessions 2017 in Derry heard a report on the use of ‘virtual consultations’ between GPs and specialist cardiac physicians, and were told that this represents a viable model of care that could save travel and time for a vulnerable and potentially frail patient population.

Dr Stephanie James informed the meeting about a new platform to help deal with heart failure in the community via ‘virtual consultations’, which was conducted from the Heart Failure Unit in St Vincent’s University Hospital, Dublin, and has been running since May 2014.

“As we know, the traditional referral pathway for any chronic disease can take six-to-nine months. These can often be vulnerable, elderly patients who will typically present to the GP in the meantime,” said Dr James. “This project involved using teleconferencing to mentor and educate primary care physicians in the community in the management of heart failure.”

Between May 2014 and November 2016, there were 152 consultations in total, she explained, divided into three types: New diagnostic cases; patients with known heart failure who are at risk of decompensating in the community; and therapeutic management queries. The main, typical comorbidities among these patients included heart disease, chronic kidney disease, diabetes, anaemia and COPD. Around 40 per cent of these cases required a follow-up review via virtual consultation.

“The challenges from our point of view were data protection and patient confidentiality, Internet connectivity and coverage and ease-of-use for the GP,” said Dr James. “We awarded CME points for the GPs who do these virtual consultations, as it involves 10 or 15 minutes of education update and knowledge exchange for the GP… our survey with primary care physicians indicates that they see the service as excellent and easy to use and patients are happy too because their cases are discussed with a specialist — almost all GPs said they would recommend the platform to their colleagues.”

GPs also said they felt the system took some pressure off them and helped them to feel more confident in dealing with heart failure patients, she said. The system began as one session per week and has now increased in frequency to two sessions each week.

“The heart failure virtual consult is a feasible model and is helpful to patients who may find it difficult to travel because of their age or comorbidities and they might sometimes be in long-term care,” concluded Dr James. “We also found that these consultations can lead to early diagnosis and also help GPs to initiate guideline-based therapy for patients.”

‘Common sense will prevail’ on cross-border care following Brexit

Dr James Crowley, a consultant cardiologist based in Galway, has said that despite widespread anxiety over the future of cross-border care following Brexit, there will be little or no disruption to care pathways.

Speaking to the Medical Independent (MI) at the ICS Scientific Sessions 2017  in Derry recently, Dr Crowley said: “For example, with regard to the Primary PCI [percutaneous coronary intervention] Programme — where angioplasty is performed for patients with acute ST elevation — the Donegal patient population are receiving their primary PCI in Altnagelvin.

“Doctors on both sides of the border are very keen to maintain that programme — in the interests of patient care, it’s the best thing to do. Derry is the nearest primary PCI hospital for people in Donegal, and people in Donegal are too far away from Galway to get their primary PCI there.”

In practical terms, this would present serious complications for a significant number of patients, said Dr Crowley. “That [transporting patients to Galway] would be out of the time-frame, whatever way we would try to plan it; even with the use of helicopters, and so on, we would only get a very small number of the patients in Donegal who present with a STEMI to Galway on time,” he told MI.

“The way we work now is the solution to that. The Saolta Group wants us to continue this way; also, the patients and cardiologists in the hospital in Altnagelvin are very happy with it and are very keen to continue the programme, so the only issue will be with regard to the border and how that will be managed, so we would hope that people will reach a solution to this.

“There is no problem at the moment, but we would hope that if a problem did arise, we could resolve it and allow these services to be maintained… common sense will prevail, I believe. Everybody wants that, and I can’t see legal issues getting in the way.”

On a separate issue, MI asked Dr Crowley if, in terms of research, there is a dearth of knowledge on heart failure with preserved ejection fraction (HFpEF) patients, in comparison to those with reduced ejection fraction (HFrEF), and whether this patient population is in some way being left behind in terms of evidence-based research.

“I think there is a lot of research now going on into the HFpEF population — what we do know now is that a lot of the traditional strategies that have been developed for patients with HFrEF are probably not as effective in patients with HFpEF, so we still need a lot more information on that,” he said.

“It’s really only a few years ago that we began to recognise that there is a substantial proportion of patients with HFpEF and their mortality is actually as high as those with HFrEF,” he told MI. “People are focusing more now on HFpEF and recognising that this population may require different strategies and therapies. There is a lot going on in this area, it’s just that treatments have not yet been established. We have established therapies for HFrEF, but it seems that some of those are not as effective in HFpEF.

“But it is good that there is a lot more recognition of the problem now and a lot more drug therapies that we are trying to use to treat the problem. We are definitely catching up.”

In terms of higher specialist training, in which Dr Crowley is National Specialty Director, as is Prof Brendan McAdam, he noted: “It’s always great to see the SpRs who are training abroad come back to Ireland to present at these meetings. We are glad to say that virtually all of the SpRs in training here go abroad.

“I think it’s a sign of the quality of the programme and the quality of the trainees that virtually all of them become established in world-class centres across the globe. These people are working in the best centres in the world, but are still interested in coming back here to work.”

On the matter of continuing doctor emigration and its effects, Dr Crowley said: “In terms of delivering cardiology consultants to the population of Ireland, at least the trainees who decide to return home are exceptionally well trained, to the highest calibre worldwide. With regards to the HSE getting the highest-quality people returning, and in the private sector, they are trained to the highest standards worldwide, and that’s a credit to the HSE and the Government for allowing these programmes to be developed.

“If you look at the trainees and where they are training, you will see they are in the top-10 institutions in the world and they will be delivering the highest-quality care to the people of Ireland in the years to come.”

Dr Crowley will take up office as the ICS President at next year’s Scientific Sessions in Galway and he paid tribute to current President, Dr Albert McNeill. “This year has been a very successful meeting,” he told MI. “Attendances have been up and the number of submissions for presentation has also increased. The venue [the Millennium Forum] has been brilliant and we’ve had a great experience here in Derry, including the President’s dinner in the historic Guildhall, which was also a fantastic occasion.”

‘Male dominance’ in Irish cardiology

Dr Noel Fitzpatrick delivered a presentation titled ‘The Who, Where and What of Irish Cardiology Higher Specialist Training Scheme: 1998-2017’ to the ICS Scientific Sessions 2017, held recently in Derry, and presented a real-world picture of where cardiology SpRs go following their training programme.

Among the aspects of Dr Fitzpatrick’s retrospective review, he and his co-authors looked at gender balance in Irish cardiology, “or perhaps that could be better described as ‘gender imbalance’,” Dr Fitzpatrick told the conference. He delivered his presentation on behalf of his co-authors, who included ICS Executive Administrator, Ms Barbra Dalton, whom Dr Fitzpatrick described as “one of the hardest-working people in Irish cardiology”.

Analysing the number of cardiology trainees since 1998, Dr Fitzpatrick noted a “male dominance” in the field.

“Looking at those who have qualified, 72 per cent are male; however, we are swinging-back somewhat in terms of equality if you look at the people currently in training, with 57 per cent male and 43 per cent female. This is in remarkable contrast to HSE schemes across Ireland in general, where you have a 55 per cent female dominance and notably different to the trend across European Society of Cardiology (ESC) training, where at the moment 70 per cent of trainees are female.”

Dr Fitzpatrick and his colleagues also looked at subspecialty training and locations and found that in previous years, there was a prominent preference among trainees to travel to North America, but recent years have seen parity with Europe as a preferred destination.

“Overall, some 53 per cent of trainees who qualified ended up with a post in Ireland,” said Dr Fitzpatrick. “Notably, there is a trend towards less appointments in Ireland over the past five years or so.”

With regards to private vs public appointments in Ireland, Dr Fitzpatrick said: “Most noticeably, in the past five years there has been a huge increase in private-only posts coming online in Ireland.

“My main conclusions from this is that there is huge disparity in the gender balance in Ireland in cardiology trainees and those who qualified versus other medical specialties throughout Ireland and Europe in general. There has also been a shift in the trend from doing subspecialty training exclusively in North America and in the rise in private-only posts,” he concluded.

“It would be good to include Northern Ireland trainees in this data and a comparison with the UK, so this is something we might update in the future.”

Lowering the bar on cholesterol levels

The recent ICS Scientific Sessions 2017, held in Derry, heard a presentation from Prof Francois Mach, Head of Cardiology at University Hospital Geneva, Switzerland, on the topic ‘LDL-C in High-Risk Patients: From ‘High is Bad’ to ‘Lowest is Best’’.

Prof Mach told the conference: “We used to say ‘high is bad’, but I hope to convince you that the ‘lowest is the best’… there are some unmet needs in the cardiovascular field — roughly 50,000 deaths per day mainly due to cardiovascular disease. This is a far higher death toll than from cancer or AIDS.”

Most of the risk factors for cardiovascular disease are modifiable, Prof Mach pointed out, with the exceptions of age and genetics, but certainly diabetes, overweight and obesity and smoking, which he described as “a disaster”.

“When we talk about lipids, the fact is that it is almost impossible to develop atherothrombosis or atherosclerosis without cholesterol,” said Prof Mach. “There is always a correlation — the higher the cholesterol, the greater the risk of heart attack, stroke, or other atherothrombotic disease.”

In the past five or 10 years, trials with statins show that the lower the cholesterol level achieved, the lower the risk in patients, he said. He also raised the possibility of reducing or repairing genetic mutations that might contribute to risk in the years ahead. 

“For very high-risk patients, the target value is 1.8mmol per litre, according to the guidelines. We should try to achieve this with statins…” he said, referencing clinical trials involving evolocumab, ezetimibe, atorvastatin and simvastatin. “Whatever time you start the statin after an acute myocardial infarction, the better the prospects for survival.

“If you lower LDL with a statin by 1mmol, you reduce the relative risk to 20-to-25 per cent,” he said. “Still, after 25 years, we do not know the answer to the question: ‘What is a normal LDL cholesterol level?’ We were all born with a cholesterol level of about 1.2mmol. Does this mean that this is the level we need to achieve throughout life? Probably not. But, for example, I am 56 years old — but we still can’t exactly identify the target value for a ‘normal’ individual.

“But we do know that if everybody in this room takes a statin and measures LDL 24 hours afterwards, there is a broad response… and of course, we all absorb cholesterol differently.”

Presenting more data, Prof Mach explained that less-than-optimal results achieved in lowering LDL levels among hospital patients is often linked to poor patient compliance and approximately 10 per cent of cardiovascular events in Europe could be associated with poor patient compliance with statins.

This could be improved with patient awareness, he added, pointing out that if statin therapy is not sufficient, guidelines suggest that physicians can consider the addition of a PCSK9 inhibitor, possibly in combination with monoclonal antibodies, which data shows lowers the risk of future cardiovascular events.

“The future may lie in silencing the RNA,” Prof Mach concluded. “If you silence the RNA in the cell, you block the full production of the machinery needed to get PCSK9,” he said.

“The beauty here is that it could be injected only two or three times per year and will cost almost nothing, compared to a PCSK9 antibody.

“Phase 1 and 2 trials show that patients respond nicely and phase 3 is being launched now.

“In the early 1990s, high cholesterol was ‘bad’; then we had all the trials since then to show that ‘average is not good’; then ‘lower is better’; and now clearly, if this very low level in patients is confirmed, this will help us to change the guidelines and the target for very high-risk patients.”

‘No strategic plan’ in place for Irish cardiology appointments

Dr James (Jim) Crowley, Clinical Lead for Saolta University Health Care Group, told attendees at the recent ICS Scientific Sessions 2017 in Derry that the current system of cardiology appointments is far from ideal and is subject to an “amorphous” process.

Dr Crowley made his comments as he chaired a session at the conference on cardiology education and training.

Answering a question from the floor on the ease of access to information, or otherwise, for doctors practising abroad who may want to return to Ireland, Dr Crowley described the current system as “ad-hoc”.

Answering the point that there is “no easy way of making contact” for these doctors, Dr Crowley responded: “To my knowledge, there is no register at all of jobs that may be coming up. It seems to be very ad-hoc in the public and private sectors. Certainly, from my experience working in the Saolta Group, the way we arrive at the need for an appointment is… we tend to press management and have to demonstrate the need for an appointment and present a business case and eventually, through some amorphous, magical approach, the post becomes approved and advertised. That’s how it seems to happen all the time.”

He continued: “There does not seem to be a strategic plan for the appointment of cardiologists, or [general] physicians for that matter, across the country; that’s my understanding of it. That’s why it’s impossible to match-up trainee-to-needs, and so on, across the country.”

He pointed out the number of cardiologists per head in Ireland falls far short of the European average and is a lower ratio than almost every other country in the EU. “Despite the fact that there have been a number of appointments over the past 10 years, there is still a significant need for an increase in the number of cardiologists in Ireland. It would be great if we had a strategic plan of the where, when and what type of cardiologists we are going to need over the next five or 10 years.”

He also drew attention to an impending need for dual-accredited cardiologists in the coming years outside tertiary referral hospitals. “This does highlight a problem that’s going to hit Ireland in the next few years,” said Dr Crowley. “How do you deliver cardiology services to, say, medical assessment units or hospitals other than tertiary referral hospitals — who will take care of these cardiology patients if they require dual-accredited physicians? Do we need to restructure these types of jobs?”

He added that the HSE needs guidance from the ICS in terms of the direction cardiology care should take in the years ahead. “We can’t lay the blame with Government all the time,” he said. “If we are not saying what we think needs to be done, it’s very hard for Government to come back and tell us what they are going to deliver on. This is probably something that we need to look at over the next couple of years, in terms of trying to define what is needed for the population of Ireland, particularly with the generalists and the subspecialties.”

ICS building ‘year-on-year’

ICS President Dr Albert McNeill described the continued growth in quality and attendance at each year’s conference as “remarkable”. Delivering his closing address at the ICS Scientific Sessions 2017 in Derry recently, Dr McNeill told attendees: “In terms of infrastructure and the type of infrastructure we have, year-on-year this Society builds; it builds in technology, it builds in scientific merit and it builds in the quality of speakers we have.

“I was really quite blown away — there must be few societies in the world that can attract this calibre of speakers. Things will be different in Galway [at next year’s Sessions] and we have a 70th anniversary coming up in two years, when Dr [James] Crowley will be President, but year-on-year, things change and improve because of the work people have put in at all levels.”

Brian Maurer Young Investigator Award: Finalists and winner

Finalist – Dr Matthew Barrett, Cardiology SpR, currently completing fellowship training in Chicago, US.

‘The Inferior Vena Cava — A Reproducible and Clinically-Useful Tool in the Monitoring and Treatment of Heart Failure Which Deserves Greater Clinical Prominence’

1M Barrett, 2M Iacoviello, 2F Monitillo, 2D Grande, 2C Rizzo, 3A Patle, 3R Fox, 1Patricia Campbell, 3Rory O’Hanlon, 1Kenneth McDonald.

1. St Vincent’s University Hospital, Dublin.

2. Polyclinic Hospital of Bari, Italy.

3. St Michael’s Hospital, Dublin.

Finalist – Dr Ashraf Hamarneh, Cardiology Trainee from Northern Ireland.

‘The Effect of Remote Ischaemic Conditioning and Glyceryl Trinitrate on Perioperative Myocardial Injury in Cardiac Bypass Surgery Patients: The ERIC-GTN Study’

1A Hamarneh, 2E Hardman, 2P Wicks, 2H Shanahan, 1H Bulluck, 1M Ramlall, 1R Chung, 1R Bell, 2R Cordery, 1D Yellon, 1,2,3,4D Hausenloy.

1. Hatter Cardiovascular Institute, University College London, UK.

2. Bart’s Heart Centre. Health NHS Trust, UK.

3. National Heart Research Institute, Singapore, National Heart Centre, Singapore.

4. Cardiovascular and Metabolic Disorders Programme, Duke-National University of Singapore, Singapore.

Finalist – Dr Barry Hennigan, Consultant Cardiologist based in Cork.

‘A Randomised, Controlled Trial in Stable Intermediate Coronary Lesions and Grey-Zone FFR Values with Evaluation of the Diagnostic Utility of Invasive Coronary Physiological Indices with Perfusion MRI: The GZFFR Study’

1,3B Hennigan, 2,3C Berry, 2,3D Collison, 2,3D Corcoran, 3J McClure, 2H Eteiba, 3K Mangion, 2R Good, 2M McEntegart, 2KG Oldroyd.

1. The Mater Private Cork, Cork.

2. Golden Jubilee National Hospital, West of Scotland Heart and Lung Centre, Glasgow, UK.

3. University of Glasgow, UK.

Finalist and Winner – Dr Grace O’Carroll, Cardiology SpR currently based in Wexford.

‘Subclinical Diastolic Dysfunction is Prevalent in Diabetes, Progresses Over Time and May Reflect a Handicap in Natriuretic Peptide Function.’

G O’Carroll, S Zhou, L McDonald, P Barrett, C Watson, M Ledwidge, V Harkins, J Gallagher, C Keane, K McDonald.

St Vincent’s University Hospital, Dublin.

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