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Irish Cardiac Society Annual Scientific Meeting 2016

Patient education website is ‘life’s legacy’ of world-renowned cardiologist

The past-President of the European Society of Cardiology (ESC) has told the Medical Independent (MI) that a patient/caregiver website on cardiac care will be his “life’s legacy”.

Prof Kenneth Dickstein, a world-renowned authority on heart failure and Chairman of the Task Forces for both the ESC 2008 Guidelines on Heart Failure and the 2010 update of ESC guidelines on device therapy, built the www.heartfailurematters.org website as an education tool for heart failure patients. The site includes explanations and practical advice on living with the condition, as well as charts to help monitor heart failure (HF), an animated ‘journey’ through the condition, polls and patient video testimonies.

He explained that the website is a worldwide initiative and has been translated into a number of languages, with more translations being planned. “I can’t sit down with a patient and tell them in three minutes what heart failure is all about; that’s too superficial,” he told MI. “I direct them to the site, which is all about living with heart failure… it’s not designed to be cutting-edge. We don’t want patients going to their doctor and saying, ‘why am I not having a CRT?’ It’s all about lifestyle, letting patients know what their drugs do for them, and so on.”

He explained that often, patients think of their heart as “something from a Valentine’s Day card” and so animations were created to educate and inform HF patients. “The global usage of the site is striking, and in areas of the world that were surprising,” he explained. “Even aside from [chairing and drafting] guidelines, there’s nothing I feel better about, knowing that 40,000 or 50,000 people a day are getting onto this site and seeing that HF doesn’t have to be such a scary thing.”

For more information or to refer patients to the site, see www.heartfailurematters.org.

Brexit ‘will not affect’ cross-border cardiovascular care

The new President of the Irish Cardiac Society (ICS) has said the ramifications of Brexit will not affect cross-border cardiac services and continuity of care will be maintained.

Speaking to the Medical Independent (MI) at the recent ICS Scientific Sessions 2016 in Kilkenny, Dr Albert McNeill, Consultant Cardiologist at Altnagelvin Hospital, Derry, said: “I don’t think Brexit will affect cross-border co-operation in cardiac care. In practical terms, the pathways will be set up; I think that will continue [after Brexit] and I don’t see that as a problem.”

Describing how he is “delighted to be given the role” of ICS President, he told MI: “I work right on the border. In the past months, we have started to provide services for Donegal patients coming to us and we are hoping to roll that out for other services too.

“Cardiac and paediatric patients are coming to the south… we are a small island with five or six million people — we should be working together to maximise services on both sides of the border.”

He continued: “The ICS has come on in leaps and bounds, certainly during my career. I think if you look at the standard of speakers at this event, you find international speakers who are really at the cutting-edge of their various fields — interventional work, heart failure, and so on, and next year we will have an equally impressive line-up, such as the President of the European Society of Cardiology and the incoming President of the American College of Cardiology.

“For a society from a small country to attract that calibre of speakers really says something for the esteem in which the Society is held.”

He also touched on the need for the ICS to play a greater role in advocacy. “In the North, cardiologists have formed a network over the past seven or eight years,” he told MI. “As part of that network, we have liaised very closely with the commissioning body, the Health and Social Care Board, on rolling out services such as primary angioplasty, which is now established in my own centre. 

“We are probably a few years ahead of the south in that type of advocacy work but we really need to be there as the professional voice, advising civil servants, advising politicians on the best way to deliver services. This can involve difficult decisions but it’s important that the professional voice is there, to avoid politicians being left in a kind of knowledge vacuum.”

Also speaking to MI in Kilkenny, outgoing ICS President Prof Ken McDonald said that while he enjoyed the challenges of his time in the role, he will continue his endeavours to improve care delivery. “I don’t think anyone who has held an office should think that when their term ends, they can wash their hands of their duties to the society. 

“We all have an ongoing duty and the ordinary Society member, which I am now, needs to contribute to the Society as much as he or she can. It’s not because of my term, but I think the ICS is now beginning to exert a little more influence on cardiovascular care, but there is still an awful lot more to do.”

He also noted that close to half of Irish patients with heart failure (HF) do not receive specialist services, and that GPs should be better resourced to manage these patients. 

“Also, the interaction between primary and secondary care almost needs to be revolutionised. St Vincent’s and the Heartbeat Trust held an eHealth conference recently, where we looked very closely at the novel ways of directing primary and secondary care interaction and certainly, on the ground, there is experience in heart failure with what we call ‘virtual consultation’.”

He explained that in the St Vincent’s University Hospital, Dublin, catchment area, this has led to highly effective interaction between primary and secondary care and is also being used in other parts of Ireland with other conditions.

Data collection remains ‘bugbear’ of National ACS Programme

Delegates at the recent Irish Cardiac Society (ICS) Scientific Sessions 2016 heard that data collection is a stumbling block in effective delivery of the HSE’s Acute Coronary Syndrome (ACS) Programme.

Prof Kieran Daly, Consultant Cardiologist, University Hospital Galway, delivered a talk on progress in the ACS Programme, of which he is the Clinical Lead, and said: “Data collection remains a bugbear. To have a high-quality system is fine, but in each unit, you need an individual with sole responsibility in terms of data collection.

“We have tried for the past four years to have this put into every service line and have it delivered, and that’s one of the failures of the Programme, that we have not persuaded… every time we get close, we are told that there is a national data system coming into play and all of this will be covered. But for a programme like this, you need an individual in each unit whose responsibility is training and data collection.”

He continued: “Three years ago, I put a very strong suggestion to the powers-that-be that money should follow the patient to incentivise hospitals, but also that it is one of the best ways of ensuring data collection, but the money does not follow the patient unless the complete dataset is there. The only thing that has changed in the three years is the name — ‘money follows the patient’ is now ‘activity-based funding’. That’s one of the frustrations of where we are now with the Clinical Programmes.”

He also told ICS delegates that while ECG transmission has been an issue, he expects this to be resolved in the coming months, which should help interventional cardiologists “to feel more comfortable”. He also stated that cardiac rehabilitation “needs to be revised”. 

Prof Daly told the meeting that the number of non-STEMIs is approximately four times the number of STEMIs and pointed out that it is not as easy to build a protocol for delivery of services with non-STEMIs. “This needs to be put in place in terms of delivery of services,” he said. “We are all aware of patients waiting for a week in a hospital for an angiogram… what none of the guidelines seem to focus on is that a significant proportion of these patients would probably do very well on conservative management. 

“I still think that the gut reaction to a troponin figure in an elderly patient postoperatively is angiography and I think we need to look at that.”

Prof Daly said for the past two years, he has been attending meetings to discuss progress in delivering the HSE’s Clinical Programmes: “A suggestion from the powers-that-be was that one individual would be over the cardiology programmes — I felt there should be at least four. We have gone back to two and they are now looking at changing it to a hospital-based, acute disease programme and that would involve acute coronary syndromes, perhaps electrophysiology delivered nationally, structural heart disease delivered nationally — these are the major questions that are coming down the line and we need to be involved in those decisions.”

However, he described a “major sense of frustration” in terms of programme delivery. “The Clinical Programmes, rather than going in a straight line, have seemed to expand and sag in the middle,” he concluded. “They are constantly being revised and that’s a major frustration to those of us who have been involved in them. The decision making is going to lie between the ICS, the College of Physicians and the HSE and I think it’s absolutely essential to this Society that it is very much involved in this decision making. 

“We are not necessarily in a particularly great place in terms of where the Programmes are. It needs to be clarified and structured quickly and I think the ICS should push very hard to make sure this happens.”

Many TAVI procedures now carried out without anaesthetic

The cost of transcatheter aortic valve implantation (TAVI) is impacting the number of these procedures being carried out in Irish public hospitals, while a shortage of anaesthetic nurses means many are carried out without anaesthesia, the recent ICS Scientific Sessions 2016 heard. 

Dr Darren Mylotte, Consultant Cardiologist, University Hospital Galway, delivered an update on TAVI trends and data at the meeting.

He said there are “significant limitations” in performing such procedures, particularly in public hospitals in Ireland, and noted that approximately 50 per cent of all TAVI procedures done in Ireland are carried out privately because there is no central reimbursement for the cost of the devices. 

“Not only is the cost of the devices an issue, but we also usually need buy-in from other sub-specialties, such as anaesthesia and the time involved in this for that sub-specialty can be challenging,” he said.

Dr Mylotte told the meeting that TAVIs have now become much more simplified and the vast majority of procedures are now carried out under local anaesthesia. “Because we have difficulty getting anaesthetic nurses, and some anaesthetic consultants are reluctant to come to the cath lab without these nurses, we also do a significant amount of our TAVIs with no anaesthesia,” said Dr Mylotte. 

He described the last year as “very significant” in terms of TAVI. “Of course, this technology is not necessarily something for elderly, dying, frail patients who have no other choice and can’t have the gold standard of surgery,” Dr Mylotte told the meeting, adding that “many of the advancements in TAVI have come from the huge scope of valve designs and different techniques that have emerged in the last 10 years”.

He also spoke about the importance of patient selection and the effect this can have on all-cause mortality. “We tend to less frequently treat the 95-year-old and tend to treat the 75-year-olds more often… the mortality benefits were recently demonstrated in a meta-analysis of randomised, controlled trials, which was the pinnacle of evidence that we have in this day and age.

“It demonstrates from four randomised trials that TAVI reduces mortality and therefore there is a need to have TAVI as a class 1A indication in next year’s European heart valve disease guidelines,” said Dr Mylotte. “TAVI also reduces the incidence and significance of atrial fibrillation by 50 per cent, acute kidney injury by 50 per cent, major bleeding by 50 per cent and also patient prostheses.”

Describing these figures as “the good news,” he went on to say that TAVI has “significant limitations”, pointing out that “our surgical patients sometimes require pacemakers too”.

Dr Mylotte also referred to the PARTNER 1 trial, which suggested that stroke risk is much higher in TAVI compared to traditional surgery: “But that’s not necessarily the case,” he explained. “The five-year PARTNER data shows that there’s no difference in stroke. What is probably more important is that when you start looking at stroke, the end-point was assessed by the individual who is looking after the patient, so a surgeon or interventional cardiologist might call a stroke… because of these discrepant stroke rates, future trials decided to have an independent neurological assessment of stroke rates, pre- and post-TAVI.  

“What we have learned from clinical trials is that TAVI is less invasive than surgery, mortality rates are better than in surgery, the stroke rate is probably lower, and a lot of complications have been addressed. What remains an issue, but will continue to improve as time goes on, is the cost of the devices. That’s just a matter of time.”

HF diagnosis and treatment needs to get ‘priority boarding’ health status

Prof Ken McDonald, outgoing President of the ICS, addressed the recent ICS Scientific Sessions 2016 and delivered a talk titled ‘Guidelines for Heart Failure Diagnosis in the Community’. He presented data from an ICS-GP collaborative group looking at the trends in diagnosis, treatment and physician attitudes to heart failure (HF).

Prof McDonald presented an overview of data showing that access to care is a significant issue. “There have been comments from GPs to the effect that they could do serial vitamin D on patients every week of the year in Ireland, but they can’t get access to natriuretic peptide.” 

He presented map data representing access to natriuretic peptide in Ireland, showing such access to be sporadic and inconsistent, as well as limited access to echocardiography, which he described as “not a comfortable situation for patients to be in, in terms of accurate and timely diagnosis”. 

“This is probably a conservative estimate but around 40 or 45 per cent of HF patients never get to see a specialist and never get worked up,” he told delegates. 

“A lot of HF care resides with the GP, so, how comfortable is the GP in managing HF? The answer is probably that they are not very comfortable,” Prof McDonald said. “GPs were probably more comfortable 20 years ago but HF care is more complicated nowadays… it can be a very difficult diagnosis to make in the community without access to diagnostic tools and even with a correct diagnosis, if you don’t investigate it, you fail to phenotype and you fail to communicate the advantages of self-care in a group of physicians who are understandably not that confident in the complex management of heart failure these days.”

Prof McDonald pointed out that if a diagnosis is delayed for six months, for example, risk of hospitalisation is increased by 25 per cent and he emphasised that each hospitalisation takes its toll on a patient’s life expectancy. 

He also told attendees of the need to align the southern-northern approaches to “create algorithms of care so that we are all singing from the same hymn sheet”.

“We need a diagnostics-driven strategy for the diagnosis of community heart failure… this is driven by the GP initially identifying symptoms that suggest heart failure, driven by the diagnostic tests and in particular natriuretic peptide and an absolute minimum time for review by echocardiography and specialist involvement.”

He continued: “We have a six-month waiting list for a lot of cardiology appointments and it’s about time that HF got, as Ryanair would say, ‘priority boarding’, and easier access to diagnostics to make it easier to take the route from diagnosis to management. Once you diagnose, there is an awful lot to be done for these patients, which consumes a lot of time.”

He explained that the ICS-GP collaborative group took the Northern Ireland treatment algorithm and refined the natriuretic peptide levels, emphasising the need to identify the correct natriuretic peptide cut-points within an algorithm.

“The ICS is taking on an advocacy role in this and other areas… we have said the we need to put a bit of ‘muscle’ behind this and to get the resources to provide this kind of service for patients with HF,” Prof McDonald told the meeting. “At the ICS meeting in Derry next year, we hope to be talking about a national pilot.”

The 30-year journey for aspirin

The recent ICS Scientific Sessions 2016 heard a comprehensive overview of the evolution and changing role of aspirin in cardiac patients by Prof Magnus Ohman, Professor of Medicine and Associate Director at the Duke Heart Centre and Senior Investigator at the Duke Clinical Research Institute, US.

Prof Ohman delivered the annual Stokes Lecture on the topic, ‘The Role of Aspirin in Acute Coronary Syndromes: A 30-Year Journey’ and the packed auditorium heard how early on, far-sighted physicians were promoting the benefits of self-care and exercise in patients. 

Prof Ohman also paid tribute to the late Prof Risteard Mulcahy: “Risteard was all about diet and lifestyle and smoking prevention [Prof Mulcahy published his first paper on the link between smoking and heart disease in 1963] and I think he might have been pleased with the topic I’m talking about today, namely, should we revisit the idea of the value of aspirin for secondary prevention in patients with ischaemic heart disease?”

Describing aspirin as a “truly old drug”, Prof Ohman presented data from a range of trials and charted the evolution of aspirin from the 1700s, explaining that the first trial on aspirin took almost 80 years to complete. In 1982, the Nobel Prize was awarded for the discovery of aspirin as a mechanism for blocking formation of prostaglandins, but the first large-scale trial to show a major clinical benefit for aspirin (ISIS-2) was not published until 1988, Prof Ohman told the ICS delegates.

“It took almost two more decades before we actually had a trial that looked at two different doses, so this is, briefly, the entire history of aspirin — almost 200 years of trial and error,” he said.

Prof Ohman presented slides to illustrate the mechanism of action in blocking thromboxane A2 and provided a brief outline of the results from the ISIS-2 trial. He singled out the relatively minor risk of bleeding and suggested that this was acceptable in the context of reductions in overall mortality rates. 

“But moving away from the acute phase post-myocardial infarction to the chronic phase, there were actually only seven trials published on aspirin,” he stated. “There was only a 13 per cent reduction in mortality [compared to 20 per cent in the acute phase].”

Addressing the issue of gastrointestinal (GI) bleeding, he added: “Data from trials of aspirin vs control show a 54 per cent increase in GI bleeding when data from studies are correlated. Many of you may not have seen this data because it only appears in the supplement part of The Lancet.”

He charted the journey to dual and triple therapy and noted that bleeding events often occurred when high-dose aspirin was used in combination therapy. 

“So what can we conclude from this journey, starting with ISIS-2 and finishing with all the subsequent trials?” Prof Ohman summarised. “I think that combining more than two antithrombotic therapies is associated with more severe bleeding so in some ways, we have reached the ceiling of what we can do. Some of the studies show clinical benefit but we really have to dial-back the therapies. Replacing aspirin with more targeted therapy is very attractive, but can we maintain that therapeutic benefit?”

Brian Maurer Young Investigator Award goes to research on contrast-induced nephropathy

Delegates at the recent ICS Scientific Sessions 2016 heard presentations from four physicians vying for the Brian Maurer Young Investigator Award (YIA). The judges of the Award were Prof Kenneth Dickstein, Chairman of the Task Forces for both the ESC 2008 Guidelines on Heart Failure and the 2010 update of ESC guidelines on device therapy; and Dr Magnus Ohman, Professor of Medicine and Associate Director at the Duke Heart Centre and Senior Investigator at the Duke Clinical Research Institute, US.

In a session chaired by outgoing ICS President Prof Ken McDonald, attendees heard presentations on topics ranging from the psychosocial wellbeing in patients with congenital heart disease, to blood pressure control, to comparison of HFrEF and HFpEF and costs in the first year of hospitalisation. 

The winner of the Young Investigator Award was Dr Michael Connolly, who presented on the topic ‘Prediction of Contrast-Induced Nephropathy using Novel Biomarkers Following Elective Contrast Coronary Angiography’.

Dr Connolly, who currently works in Antrim, undertook the study as part of his MD project in Craigavon Area Hospital. 

“Currently, the only widely-available biomarker that we have is creatinine and we have known for some time that this has its problems — it’s indirect, it’s insensitive, but more important for our day-case PCI, it’s a delayed marker, taking at least 48 hours to rise following a nephrotoxic insult.”

He explained that if a patient develops contrast-induced nephropathy as an inpatient, the mortality risk is high “and even if a patient is successfully discharged from hospital, there remains a significant risk of death or cardiac abnormality within five years”, he told the meeting.

Dr Connolly outlined the study design and stressed that when a patient is discharged, there is a need for awareness among the cardiology team, nursing staff and patients and their families on the indications of acute kidney injury (AKI). 

Speaking to the Medical Independent (MI), Dr Connolly said: “Winning the Award was a actually a bit of a shock — I certainly wasn’t expecting it. There were three other great presentations, so I think it really could have been awarded to any one of us.”

He explained: “When I started as a registrar in 2011, contrast-induced nephropathy was not very well known about at that point and was not really something that we talked about much as a profession. In our cath lab at Craigavon, I started to notice that the rates of nephropathy were very high, which led to an audit and that became the main focus of my research.”

This audit revealed a 12 per cent prevalence of contrast-induced nephropathy AKI in patients after coronary angiography. 

Describing the research as a personal “learning experience”, Dr Connolly explained that his work can translate into better outcomes for patients. “We re-audited our results after my MD and showed a significant reduction in the amount of people developing AKI, so the benefits are already becoming manifest and we are very happy with that,” he told MI.

“I’d like to acknowledge Craigavon and Queen’s University Belfast, they were both brilliant.” 

Too many cooks? — taking the heart team concept to task

An entertaining, engaging and often light-hearted debate took place at the recent ICS Scientific Sessions 2016, which posed the question, ‘Is There a Need for a Heart Team?’ The debate, chaired by new ICS President Dr Albert McNeill, featured Prof William Wijns, Co-Director of the Cardiovascular Centre in Aalst, Belgium, who argued that the heart multidisciplinary team (MDT) is a necessary component in cardiac care. Opposing him was Prof Keith G Oldroyd, Consultant Interventional Cardiologist NRS Champion for CV Disease, West of Scotland Regional Heart and Lung Centre, Glasgow, Scotland.

Before the debate, a show of hands was called for by Dr McNeill, which revealed that all but three people at the session were in favour of a heart team in cardiac care.

Prof Wijns opened by saying: “The composition of the heart team varies, but the key is to have the patient at the centre, particularly patients with complex disease and comorbidities. With those patients, it’s common sense that the more people you bring to the bedside to discuss the pros and cons of various treatment options, the better. In the area of cancer, this approach has been used quite successfully for many years.”

He said that people have highlighted the need for evidence in favour of a heart team, but he said “there is evidence in common sense also… parachutes decrease the risk of injury in people jumping out of planes. There is no randomised trial to prove this, but it’s common sense”.

Prof Wijns presented tables from 2014 guidelines to support his argument and commented: “One of the criticisms of the heart team is that some people feel it delays treatment. In fact, I once heard a colleague in Britain say the meaning of the acronym MDT is ‘mostly delays treatment’ but this is not the intention at all.

“People from the outside world are also looking at what the heart team does and there is increasing emphasis on patient preference, and carers and patients are becoming active stakeholders in the heart team process.”

He pointed out that the heart team process is embedded in the design of many trials and as such, will help to form the basis of best practice for many years to come. 

“It is so obvious that progress is going to come from joint efforts between interventional colleagues, clinicians and surgeons. There are many pros to the heart team but one I would like to single out is mutual dedication between non-invasive colleagues, interventionalists and surgeons. If we continue to live in silos, we are going to miss great opportunities for patients.”

Prof Oldroyd retorted by suggesting that the evidence to support the heart team concept included in guidelines is weak: “There are no references to support any recommendation for the heart team… I totally agree that the patient has to be involved in the decision-making process, but I don’t think you necessarily need an MDT for that. 

“I can tell you, we have never brought a patient into an MDT meeting yet. When we start doing that, then the MDT might have a role, but I can tell you that it would be difficult to bring a patient in on that discussion and if we did, we would have to modify our behaviour big time,” he joked.

He also contended that while physicians need to keep up to date with developments, an MDT is not necessary for this. Prof Oldroyd also set about dismantling the evidence presented in favour of a heart team, citing a lack of evidence-based recommendations and a lack of consensus among the team on many occasions.

“I can tell you, what we have in our hospital is ‘heart team mania’,” he told attendees. “It’s out of control,” he said, stating that there are various MDT meetings almost each day of the week. “The poor guy who is on at night has to prepare their cases, we have a full-time co-ordinator on a cardiac surgeon’s schedule, a consultant who chairs everything, a cardiac surgeon, we have e-referral and recording of outcomes through the cath lab database, we have teleconferencing and video-conferencing for off-site clinicians — this is out of control.

“The cardiologists send patients to the MDT, even when it’s a straightforward decision. The surgeons won’t accept a case unless it’s been through the MDT and even then, sometimes, even when they accept a case they send it back again — they even accept patients from other MDTs off-site and bring them back to our MDT to discuss it,” said Prof Oldroyd, to laughter from the ICS delegates. 

The attendees warmly applauded both presentations. Remarkably, when a post-debate show of hands was called for, the for/against opinion was divided exactly evenly, with Dr McNeill light-heartedly declining to cast the deciding vote.

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