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Irish Cardiac Society Annual Scientific Meeting 2015

Medical professionals ‘should not resist patient empowerment’ in sharing information on outcomes

Cardiologists and cardiac surgeons should be open to sharing information about their clinical and surgical outcomes, according to Consultant Cardiac Surgeon at the University Hospital of South Manchester, UK, Mr Ben Bridgewater.

Mr Bridgewater, who delivered a presentation on cardiac care in the digital age to the Irish Cardiac Society’s Annual Scientific Meeting in Killarney, said that the experience of publishing national clinical audits in the UK has been difficult because of significant resistance from the medical community.

However, Mr Bridgewater believes that the audits, which promote greater transparency and patient empowerment, should be embraced by the profession.

“This has been very fiercely argued, particularly by people who fall the wrong side of the monitoring system,” according to Mr Bridgewater.

“But I would argue very much that these are just speed bumps in the road… to where we are going with open data and patient empowerment and we need to accept these are speed bumps and actually get over them.”

Mr Bridgewater argued that the publication of the data has helped improve patient outcomes and has led to more considered behaviour by surgeons.

“One of the reasons that I think the results are better is that it focuses the decision-making on these high-risk patients,” he said. “I think in the past, people would just get on with it. Now, there are much better-configured discussions.”

Regarding cardiac care, Mr Bridgewater said that doctors need to be thinking a lot more about lifetime risk, rather than merely focusing on procedural outcomes.

“We need to be empowering patients, not just about the choices in the treatment they get, but also about doing the right things to minimise their lifetime risk,” he said.

Although Mr Bridgewater acknowledged that the implementation of the audits has been challenging, he insisted it was part of a new doctor/patient paradigm that is emerging.

“There will be big changes in cardiac care delivery,” he said.

“The relationship is changing due to pressure from the public and we should embrace that and we should work with it because it will not be in anyone’s interests to fight against that.

“This whole interconnected digital world gives us real opportunities in many, many different ways and consumers will be seeking this information and we need to understand what they want and try to give it to them as best we can.”

Heart failure is now ‘being cured’ – Prof Cleland

In the 2015 Stokes Lecture at the Annual Scientific Meeting of the Irish Cardiac Society in Killarney, Prof John Cleland, Professor of Cardiology at Imperial College London, rejected the contention that heart failure is an incurable condition.

Prof Cleland’s presentation largely focused on the developments in the field since 2008, the last time that heart failure was the subject of the lecture.

He declared that there was plenty of evidence to show that some types of heart failure are being cured, and that others could be cured in the future.

“An awful lot of people say that heart failure can’t be cured,” Prof Cleland told the Medical Independent (MI) after delivering his lecture.

“I think they are wrong. I think that we do it with our current therapies. We have to select the right patient and the right therapy of course, but we have made a start. And once you have made a start, then we should be able to expand from that bridgehead.”

Prof Cleland pointed out that a significant proportion of patients classified as having stages 3 or 4 heart failure with dilated cardiomyopathy, a “broad” QRS, moderate mitral regurgitation and an ejection fraction of 25/30 per cent, will be cured.

“They will come off their diuretic, their ejection fraction will normalise, they will be asymptomatic with the intervention,” he argued.

Prof Cleland said that it was important to start looking at heart failure not as the statistical average response, but rather at the proportion of patients being cured.

“It is certainly not everybody,” he said.

“We estimate that perhaps about 15 per cent of patients get dramatic response to CRT [cardiac resynchronisation therapy] but it also occurs with beta blockers, it occurs with ivabradine, we occasionally see it with cardiac surgery; correcting valve disease can also do it. So we actually cure, or at least drive heart failure into remission, much more commonly than we are given credit for.”

TAVI procedures have become safer and more beneficial for patients, ‘with dramatic gains’

There have been dramatic gains in the outcomes of patients who have had transcatheter aortic valve implantation (TAVI) procedures in the last number of years, according to Dr Martin Quinn, Consultant Cardiologist, St Vincent’s University Hospital, Dublin.

In an update on the procedure, Dr Quinn said that the PARTNER trial in 2012 showed there was a one-year mortality of 24 per cent associated with TAVI.

However, the Sapien S3 Trial, the results of which were published this year, showed one-year mortality to be 8.4 per cent, with a 2.1 per cent stroke rate.

Also, data from the German registry, which is due to be published imminently, shows one-year mortality to be closer to 4 per cent.

“So mortality is reducing dramatically,” commented Dr Quinn.

“I think this is mainly due to the population we are treating, in addition to improvement in techniques, where the population is getting fitter and younger and the mortality is coming down in association.”

Dr Quinn said that there are now fewer cases of aortic incompetence, which used to be the “Achilles heel” of the procedure, as a result of the introduction of newly-developed valves, while the number of vascular complications has also been reduced.

He added that there is increasing evidence of the cost effectiveness of TAVI interventions. “We are seeing reduced cost, there is less ICU stay, there is less bed stay, there is less complexity,” he said.

However, Dr Quinn stressed that the procedure is not suitable in certain instances and must be performed appropriately. “The ones who do need the procedure are the ones who are fit and healthy and that is why the assessment of their overall frailty index is very important,” he said.

The number of people having the procedure is also significantly increasing, according to Dr Quinn, who cited data showing that in Ireland, there are 20-to-25 cases performed per million, although this is at the lower end of the European spectrum.

Dr Quinn predicted that the number of people requiring TAVI is set to increase in the near future and said the fact that the procedure will soon be available in Cork, in addition to the existing five national centres, is to be welcomed.

MRI is predicted to play an increasing role in detecting heart transplant problems

MRI has an increasingly important role to play in the diagnosis and management of patients suffering from heart failure and those who have had a heart transplant, according to Knight Professor of Cardiac Imaging in Northwestern University and the Feinberg School of Medicine, US, Dr James Carr.

Speaking at the Irish Cardiac Society Annual Scientific Meeting, Dr Carr, who originally hails from Ireland, said that T2 scans, which measure inflammation by showing the amount of water in the heart, are very useful in examining transplant patients.

“Right now, our standard of practice, and it is the same all over the world, is to do biopsies to detect inflammation or rejection of the transplant heart,” Dr Carr told MI.

“That is very invasive and very costly. We can just do T2 to detect inflammation or rejection. It is much better, it is going to be much cheaper and much easier on the patient.”

Dr Carr said that such techniques are not yet contained in guidelines, though he believes this will happen in the near future.

“There is a lot of data now appearing in the literature supporting the use of this,” he said.

“I don’t think you are going to see, for example, T2 MRI completely replace biopsy but what it might do is replace the number of biopsies done, and that just means fewer complications for patients, less cost to the health system and overall, a better way of managing problems.”

T1 images are also a good way to detect interstitial fibrosis in the myocardium.

“While you may not see any change in function or any actual visual change, you know because the numerical value is abnormal, that it is abnormal, then you can proceed accordingly and then, similarly, if you put patients on therapy, you can follow that number,” according to Dr Carr.

“It is much easier to follow a number rather than to follow the appearance of an organ, so if you can follow that number and see it normalise over time, you can see your therapy is working.”

Overall, Dr Carr said that MRI plays an important role in the work-up of non-ischaemic cardiomyopathy by helping characterise the pathology.

Treatment for congenital heart disease is now becoming increasingly more complex

The successful treatment and survival of patients with congenital heart disease has created a new group of patients with complex requirements, according to Dr Kevin Walsh, Consultant Cardiologist, Mater Hospital, Dublin.

In his talk to the Irish Cardiac Society’s 2015 Annual Scientific Meeting, entitled ‘Adult congenital heart disease — success creates its own problems’, Dr Walsh said that these patients require specialist follow-up and often complex multidisciplinary management and interventions.

“I think the patients with single ventricles would probably need the most care going into the future because they have a significant number of complications later on and many of them will need transplantation, which is a scarce resource and it is about trying to keep them in as good a condition as possible, yet have as normal a life as possible,” Dr Walsh told MI.

Repeat surgery is often a requirement for patients with problems relating to complex congenital heart disease.

“Medication, repeat procedures in terms of catheter intervention and then repeat surgeries such as Fontan conversion surgery and also the possible need for transplantation are often required,” he said.

“But most of the complex diseases need further surgery, whether it is the Fallot tetralogy group needing pulmonary valve replacement, the Mustard operation patients needing atrial arrhythmia ablation, and you would have other patients needing valve replacement, so the complex group needs a lot more surgery.”

A major complicating factor with the condition is that it ends up affecting multiple organs, which makes interventions more difficult, Dr Walsh noted.

“Often, to have the kidneys treated you also need to have the heart treated, and vice versa, so you end up with patients with really significant care needs,” he said.

“Sometimes it is possible to get everything done; sometimes it is not possible. But they certainly need a lot more consultant manpower, nursing support, technician support, you need to buy more valves and there are lots of things that are required to effectively look after this group,” Dr Walsh concluded.

Number of patients who are dying on waiting lists for cardiac surgery is ‘unacceptably high’

There are an “unacceptably” high number of deaths on the waiting list for cardiac surgery in Northern Ireland, according to a study presented to the Irish Cardiac Society Annual Scientific Meeting.

Over the two-year period covered by the study in the Royal Victoria Hospital, Belfast, 36 patients who were on the waiting list for cardiac surgery died prior to the procedure.

Of these patients, 15 were categorised as urgent inpatients; four were urgent outpatients; and 17 were routine outpatients.

Lead author of the study and Consultant Cardiac surgeon and Clinical Director in the hospital, Mr Alastair Graham, told the Medical Independent (MI) that the issue has been a problem in Northern Ireland for the past 30 years.

“There has been significant underfunding of cardiac surgery and it has been a recurring problem that essentially hasn’t changed for many, many years,” according to Mr Graham.

He explained that there had been an expectation that cardiac surgery would eventually be made obsolete as a result of new medications and interventions, such as stents, but this has not turned out to be the case.

“The average cardiac operation on average costs £20,000 (€26,800),” he said.

“That sounds a lot up-front, but it is actually very, very cheap because you can actually fix these people and they are out of hospital and they get a lasting result and a major improvement in their quality of life. So I think the problem is essentially one of commissioning — that is the core issue.”

According to the results of the study, which were presented by the waiting list co-ordinator in the hospital, Ms Aileen Cassidy, patients awaiting aortic valve surgery and coronary artery bypass grafting have the highest risk and should, therefore, be prioritised accordingly.

Speaking from the floor, Prof Mahendra Varma, Consultant Cardiologist, South West Acute Hospital, Enniskillen, said it was “appalling” that these patients were dying while awaiting surgery.

Gaps in heart failure management in primary care due to a lack of specialist involvement

The lack of specialist involvement in heart failure diagnosis has left concerning gaps in the management of the condition, according to a presentation delivered during the Annual Scientific Meeting of the Irish Cardiac Society.

Previous research has identified that patients with a diagnosis of heart failure in the community frequently have not had previous heart failure specialist assessment.

The new study examined the records of patients with a coded diagnosis of heart failure or those on loop diuretics, who had no previous record of cardiology specialist assessment, across 13 general practices in the Republic and Northern Ireland.

In total, 111 patients met the inclusion criteria: 76 in Northern Ireland and 35 in the Republic. Of those in the North, only 50 per cent had ever had an echocardiogram (ECHO) performed; 22 per cent had an ECHO in the last five years; and 36 per cent had their NT-PRO BNP measured.

In the Republic, 40 per cent had an ECHO performed; five per cent had an ECHO in the last five years; and 42 per cent had their NT-PRO BNP measured.

“When comparing these figures to the 2013 national heart failure audit, you can see that the community rates of echocardiography fall significantly short of the figure of 91 per cent of all patients who were admitted to hospital with an unscheduled admission secondary to heart failure,” according to Dr Jonathan Mailey, medical trainee in the heart Centre, Royal Victoria Hospital, Belfast, who made the presentation.

In terms of therapeutics for this cohort, the use of beta-blockers was 54 per cent in the North and 63 per cent in the Republic; the use of ACE inhibitors and angiotensin receptor blockers was 57 per cent in the North and 63 per cent in the Republic; while mineralocorticoid receptor antagonists were used by 9 per cent of patients in the North and none in the Republic.

“Overall, we have shown low rates of both diagnostic investigation and the prescription of medical therapy within community heart failure patients,” Dr Mailey said.

“This demonstrates poor adherence to current evidence-based practice. The benefit of heart failure pharmacological therapy is well documented and, therefore, poor adherence to current clinical guidelines will result in an increase in morbidity and mortality, but also [lead] to an increased cost to the health service relating to higher admission rates to hospital and longer inpatient stays. The low rates of diagnostic investigations and specialist referral will also inevitably have an impact on the identification of heart failure aetiology, diagnosis of diastolic heart failure and potentially on the implementation of device therapy in appropriate patients.”

He concluded that strategies to reach this patient group need to be developed to confirm diagnosis and to implement appropriate medical device management.

Cardiologists debate value for money of ICDs

Dr Joe Galvin, Consultant Cardiologist, Connolly Hospital, Blanchardstown, won the debate at the 2015 Annual Scientific Meeting of the Irish Cardiac Society on the subject of the value of implantable cardioverter defibrillators (ICDs).

Dr Galvin spoke against the motion: ‘Given the ongoing orchestrated promotion by the industry of ICDs throughout Europe and in the current economic environment in Ireland, primary prevention ICD implantation on the basis of low ejection fraction alone provides poor value for money and with significant long-term complications and accumulative costs, resources should be better spent in Ireland on higher risk patient populations.’

Dr Galvin said that there was an epidemic of cardiac arrests in Ireland, and that ICDs were a vital intervention for this group.

He noted that the number of ICDs implanted in Ireland was relatively small and was probably in the region of 810 a year.

“Implanted defibrillators do not treat populations, they treat individuals,” he said.

Dr Galvin pointed out that the cost of the devices had come down substantially in recent years, despite improvements in their functionality, with the batteries of ICDs now lasting about 10 years.

“If you look at the technological improvements that have taken place in terms of the size of devices and how small they have become, and if you look at all these additional beneficial functions of ICDs that have occurred over the last 25 years, it is incredible that the cost has actually come down,” according to Dr Galvin. “Our first implant in the Mater in 1993 cost £34,000 punts (€42,000) and we are now down to about €12,000, despite all these additional functions.”

Dr Galvin said that it was important that the appropriate patients be implanted with the devices.

“For prior myocardial infarction, an ejection fraction of less than 30 per cent is the cut off, not the less than 35 per cent that a lot of people in Ireland are using,” he stated. “So we need to stick to that and not be putting in ICDs inappropriately.”

However, he argued that ICDs, when used correctly, provide major benefits to patients in terms of relative, and even absolute, risk reductions.

“These are for primary prevention ICDs,” he said. “They are really unparalleled in medicine.”

Prof James O’Neill, Consultant Cardiologist in Connolly Hospital, who defended the motion, said that despite reductions in cost, ICDs were still an extremely expensive intervention.

“We put in too many primary prevention ICDs; I don’t think there’s enough CRTs,” Prof O’Neill said.

“I think we’ve been bullied into a culture of being afraid to say ‘no’, not having the conversation and not concluding that the ICD isn’t indicated in individual patients…We all need to use more than ejection fraction, we need to use our heads, we need to use clinical judgment and we need to use the newer tools that have been developed.”

New lipid therapies are a promising  approach for patients who are statin-intolerant

There is a significant unmet need for lipid therapies in high-risk groups, according to Dr Susan Connolly, Consultant Cardiologist at Imperial College Healthcare NHS Trust, London, UK.

Dr Connolly, who delivered a presentation entitled ‘Injectable lipid-lowering, therapies — ready for prime time?’ at the Annual Scientific Meeting of the Irish Cardiac Society, stated that PCK9 inhibitors are a promising new approach, with a consistent LDL-c lowering of between 50 and 60 per cent, and are well tolerated.

Speaking to MI, Dr Connolly said that the effects of these medications, two of which, evolocumab and alirocumab, have recently been licensed, are “remarkable”, although further studies are necessary to assess their safety.

“They seem very clean and have a lack of side-effects,” Dr Connolly explained. “But we are seeing LDL cholesterol levels so low that we haven’t seen before because, on top of statins, they bring it down another 60 per cent. So we are seeing cholesterol levels like you have in a baby and we don’t know if that’s safe.”

Dr Connolly said larger studies are currently ongoing to examine the safety and efficacy of the medications.

The medications are designed to be useful for people who are statin intolerant, yet Dr Connolly contended that true statin intolerance is over-reported. “Studies have clearly shown, as we have shown in our clinic, that [in] patients who come and see us and have been told they are statin intolerant, the vast majority can tolerate some form of statin, even if it is low dose,” she said.

“But it does leave patients who can’t tolerate high-dose statins, who will still have high lipid levels and will need additional cholesterol-lowering drugs. Then you have the patients with the genetically high lipids who need cholesterol-lowering drugs more than statins, and this is where these new drugs will come in.”

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