Mater Private Network hosted its third annual Cardiology Masterclass webinar for GPs on 26 March, which featured presentations from a number of its leading cardiologists on the latest management approaches across a range of cardiology topics.
The meeting was divided into three main sessions, each of which was chaired by a GP – Dr Róisín Lyons, Dublin; Dr Mike Thompson, Cork; and Dr Ken Fitzpatrick, Dublin.
The Masterclass was opened by Prof Robert Byrne, Director of Cardiology at Mater Private Hospital, Dublin, and Chair of Cardiovascular Research at the RCSI, who welcomed everyone and said the main aim of the meeting was sharing knowledge and continuing to strengthen the relationship with colleagues in primary care.
He briefly outlined details of the Cardiovascular Research Institute Dublin, a collaboration between Mater Private Network and the RCSI, which is currently carrying out a number of outcomes-based research projects, including an open clinical trial on treatment of resistant hypertension, which GPs can refer suitable patients to, with full details available at www.cvridublin.ie.
“We hope to be one of the first, if not the first, hospital in Ireland to publish the outcomes of all patients undergoing cardiac procedures on our website in a publicly accessible manner, so patients and referring doctors can inform themselves exactly what the outcomes of patients undergoing procedures are. There are also a number of clinical trials we are happy to collaborate with GPs on,” Prof Byrne said.
Session one: Heart failure and structural heart disease
The first speaker of Session One was Prof Jim O’Neill, Consultant Cardiologist, Mater Private Network, Dublin, and Clinical Professor, RCSI, who spoke about heart failure, which he described as “truly a multisystem disease” with an array of treatment options to enable patients to live well, even if not ‘cured’.
He said that contemporary management of heart failure is the synthesis of all that is good in modern medicine, and in particular, cardiology. Unfortunately, it has an image problem, which possibly originates from the title ‘heart failure’ that is by its very nature the epitome of negativity, “This is troubling for a variety of reasons – it is a frightening term for our patients and flies in the face of the fact that we can do an enormous amount for our patients – who should really be referred to as ‘patients with cardiomyopathy’. We don’t call diabetes ‘pancreas failure’, we use the correct term, which is understood by all.”
Multidisciplinary care and a nuanced, individualised approach with good communication is the cornerstone of treating cardiomyopathy patients, according to Prof O’Neill, and he especially praised the role of the heart failure nurse.
The key treatment approaches can be summarised as the ‘3 Ds’ – “Diet (everything we do by way of advice to the patient), Drugs (of which we have many new ones), and Devices (an ever-complex world of increasingly minimally invasive approaches with amazing outcomes).”
Prof O’Neill also spoke about the need for clinicians to have a “heart failure conscience” so that every time they meet their cardiomyopathy patients, even if they are feeling well, they take the opportunity to assess and uptitrate their medicines. “Know the four pillars” – beta blockers (BBL), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor-neprilysin inhibitors (ANRI), mineralocorticoid receptor antagonists (MRA), and SGLT-2 inhibitors.
A red flag to look out for in cardiomyopathy patients is unexplained weight loss, while cachexia is another potential red flag that should not be ignored. Prof O’Neill said that digoxin can be useful in certain acute situations, and sacubitril-valsartan can be (very carefully) used with low BP.
Once cardiomyopathy patients have improved, even with normalisation of cardiac function, disease-modifying agents should not be stopped, Prof O’Neill stressed, as cardiomyopathy is never ‘cured’ as such.
Concluding, Prof O’Neill said that community cardiology services being rolled out by the HSE nationally will provide a vital link to strengthen shared care. The Mater already operates a Virtual Community Cardiology Clinic, which he said is continuing to work very well in optimising care for patients and reducing hospitalisation.
The next speaker in this session was Dr James Dollard, Consultant Cardiologist, Mater Private Network, Cork, who spoke about resistant hypertension. He began by reminding the audience of the huge prevalence of hypertension, which increases with age; “so about 50 per cent of people by the age of 50 have it, and 70 per cent at 70, and so on.” However, hypertension remains significantly underdiagnosed in Ireland, “at about 50 per cent,” and therefore untreated. Even among those who are diagnosed, treatment is suboptimal said Dr Dollard, quoting TILDA data (2015) showing that of those who were aware of their hypertension diagnosis, only 50-to-65 per cent were on treatment and 50 per cent were controlled.
Dr Dollard thus stressed the importance of screening, which should be done opportunistically, and in the presence of symptoms, being conscious of the potential for masked or white coat hypertension. There has been a move towards more widespread use of 24-hour BP monitoring in recent years to get a more complete, accurate picture, he noted.
In terms of initiating treatment, Dr Dollard said to have a low threshold (as per the European Society of Cardiology (ESC) guidelines algorithm). Lifestyle advice (diet, smoking cessation, physical activity) is the first step, with pharmacotherapy also needed in most cases, to be initiated on a stepwise approach.
If the patient is not controlled despite using a number of agents they could have resistant hypertension (representing 10-to-21 per cent of total hypertension), which can significantly increase their risk of cardiovascular-related complications/events and deaths.
Resistant hypertension is defined (American Heart Association definition) as BP in a hypertensive patient that remains elevated above goal despite concurrent use of three antihypertensive agents of different classes (RAASi, calcium channel blockers (CCB) and a diuretic), at maximum tolerated doses, with the exclusion of therapy non-adherence and white coat hypertension.
These patients are more likely to be male, obese, and have chronic kidney disease and obstructive sleep apnoea. It is important to investigate potential medication (contraceptive pill, etc) or lifestyle causes (dietary sodium, obesity, liquorice, alcohol, and activity), as well as secondary causes (sleep disorders, endocrine conditions, renal disease, vascular disease, and intracranial causes).
In relation to managing resistant hypertension, as well as trying to deal with the underlying causes and salt sensitivity, Dr Dollard said the guidance advises maximum therapy with three agents and the addition of a fourth agent if needed (such as spironolactone).
The final speaker of this session was Prof Mark Spence, Head of Structural Heart and Consultant Cardiologist, Mater Private Network, Dublin, and Professor of Structural and Interventional Cardiology, RCSI, who discussed ‘structural heart disease’, a term which has become common-place over the last 20 years and encompasses those non-coronary related cardiology conditions for which transcatheter therapies now exist.
Prof Spence said this field is growing quickly due to increasing patient numbers (ageing population), continued innovations, and the development of new treatments, and many research studies that have given the international cardiology guideline committees the confidence to recommend these treatments.
During his talk he outlined several case vignettes of patients with structural heart problems treated according to the most recent guideline recommendations, with procedures including transcatheter aortic valve implantation (TAVI), and he stressed the importance of patient-centred care and a multidisciplinary team approach
Session 2: Cardiac arrhythmia
The first speaker of the second session was Dr Usama Boles, Cardiologist and Electrophysiologist, Mater Private Network, Dublin, who discussed atrial fibrillation (AF) and supraventricular tachycardia (SVT) guidelines. He pointed out that AF represents a growing burden in medical practice – it is the most common cardiac arrhythmia, and up to one-in-four people has AF at the age of 80 years.
Stroke prevention is recommended (ESC guidelines) in mild- to moderate-risk AF patients (CHA2DS2-VASc). Direct oral anticoagulants (DOACs) are now accepted as first-line agents, but there is no role for antiplatelets (eg, aspirin) in CV thromboembolic events prevention with AF, he said.
Ablation is now emerging as the most accepted approach in the majority of arrhythmias, according to Dr Boles; “ablation for AF is feasible, curative and has a quite low risk for complications.” He said that AF ablation/rhythm strategies would be a good option for younger patients, those with relatively recent diagnosis of AF, controlled risk factors, non-tolerant to medications, development of reduced systolic function, and/or valvular cardiac disease.
Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common type of SVT encountered in practice, after AF, Dr Boles said, and treatment with ablation is well-established with a very high success rate >95 per cent.
As per the 2019 ESC recommendations, electrophysiology studies (EPS) and ablation should be considered in a wide range of patients with accessory pathways (AP) (antidromic atrioventricular re-entry tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome). Examples include patients who are very active, athletes, rapidly conducting AP in EPS, worsening LV systolic function with chronic pre-excited ECG and AF with pre-excitation.
Atrial flutter (typical or atypical) should also be referred for consideration for ablation, he advised. Atrial flutter anticoagulation should follow the same role as AF, with careful consideration to bleeding risk, Dr Boles concluded.
The next speaker was Dr Jim O’Brien, Consultant Cardiologist, Mater Private Network, Dublin, whose presentation focused on recognising different types of atrial arrhythmias. He noted that atrial arrhythmias are common and can be due to re-entry: AVNRT, AVRT, flutter; and automaticity: AT, AF.
Medication therapy (beta blockers, NDCC, amiodarone, adenosine) comes up a lot for all atrial arrhythmias, he said, adding that if there any concerns when an ECG has a delta wave, or if there is a broad complex tachycardia, adenosine should be avoided.
Catheter ablation now has class I/IIa recommendations for almost all atrial arrhythmias – all SVTs, most flutters, and paroxysmal AF/persistent AF when symptomatic or in heart failure, Dr O’Brien noted, so referral to an appropriate service should be considered.
The final speaker of this session was Dr Mahesh Pauriah, Consultant Cardiologist and Cardiac Electrophysiologist, Mater Private Network, Cork, who discussed when rhythm control is superior to rate control in AF, citing his preference in patients who are supposedly asymptomatic and patients with heart failure. He noted how the use of catheter ablation in AF, particularly cryoablation and radio frequency ablation, has continued to increase, with higher success rates and less risk or side-effects now as technology and techniques have evolved.
Session 3: Coronary disease and device management
The first speaker of this session was Dr Ronan Margey, Clinical Director, Mater Private Network, Cork, and National Clinical Lead, Irish Heart Attack Audit, National Office of Clinical Audit, who discussed the impact of the Covid-19 pandemic on heart attack hospital admissions and out-of-hospital cardiac arrest. The impact included a reduction in recorded STEMIs and non-STEMIs presenting to hospital, less admissions from nursing homes, less inter-hospital transfers, and an increased time from first medical contact to reperfusion.
Dr Margey highlighted the difficulty of accessing data from separate systems (HiPE, etc) in Ireland and the need for better data collection resourcing and sharing. He stressed the importance of public health messaging regarding recognition of MI symptoms and early access to primary percutaneous coronary intervention (PPCI) regardless of the pandemic. Pre-hospital delays remain too long and deteriorated during the pandemic, he acknowledged, adding that particular focus should be given to reducing door-in door-out times from non-PCI hospitals to PPCI sites. Some changes introduced during the pandemic should remain, however – Dr Margey said ED bypass protocols should be widely adopted post-pandemic, and cardiac rehab programmes should continue virtually.
The next speaker was Ms Grainne Pelly, Chief II Cardiac Physiologist, Mater Private Network, Dublin, who gave an overview of practical issues in the management of implantable cardiac devices (ICDs) in the community. Cardiac rhythm management devices include pacemakers, implantable cardioverter defibrillators and loop recorders. The function of these devices is to perform bradycardia pacing, monitoring for arrhythmias, cardiac resynchronisation for heart failure, defibrillation, and anti-tachycardia pacing for tachyarrhythmias. Potential (rare) issues can include malfunction, infection, erosion, shocks, and the need to be aware of the risk from MRI machines.
As patients age, their heart failure burden progresses, or they develop other life-limiting conditions (cancer, dementia) focus can turn to the benefit of the ICD being turned on, and healthcare/palliative care services can discuss with the patient about having it switched off, Ms Pelly explained.
If a patient dies with their ICD in place it is vital that it is deactivated before post-mortem to prevent mortuary workers getting an electric shock from an activated device, and to ensure the information from the ICD is extracted, she said. If death is unexpected, device interrogation can confirm if the patient died due to an arrhythmia, device malfunction, or other cause.
ICDs must also be explanted prior to cremation due to the risk of lithium battery explosion. If a patient with a cardiac device dies suddenly, Ms Pelly said that emergency deactivation can be achieved by placing a magnet over the device and putting adhesive tape over it. This is a temporary measure until the cardiology team can come.
The final speaker of this session was Dr Róisín Colleran, Consultant Interventionalist Cardiologist, Mater Private Network, Dublin, who discussed the management of left main coronary artery disease; when to use bypass surgery or stenting. During her talk, she outlined the main recommendations of the 2018 Joint ESC/EACTS Guidelines on Myocardial Revascularisation, which are based in part on overall anatomic complexity.
“In stable patients with significant left main stem disease, with coronary anatomy suitable for both PCI and coronary artery bypass graft (CABG), with a low predicted surgical mortality, and with low to intermediate anatomic disease complexity, both treatment options are reasonable,” she summarised.
The totality of the evidence shows similar results for overall mortality at five years, without evidence of a difference in trials with follow-up extended to 10 years, Dr Colleran said.
There is a higher rate of spontaneous MI with PCI (absolute risk difference of 3.5 per cent; number need to treat with CABG to prevent one MI of 29).
Similar rates of stroke are seen with both treatments, although there is an excess risk of stroke of 1.0 per cent in the first year with CABG, she noted.
Repeat revascularisation is more common after PCI (absolute risk difference of 7.6 per cent over five years; with a number needed to treat with CABG to prevent one repeat revascularisation of 14), Dr Colleran concluded.
Each session was followed by a Q&A session where questions were put to the expert panel, including when to initiate particular therapies, what therapies were suitable for pregnant and breastfeeding patients, what diagnostic tests should be ordered for particular patients (eg, when to use calcium scoring), and what procedure would be advised for certain ages, etc. Attendees were also provided with the speaker presentations after the event. It is hoped the 2023 Masterclass will be held in person.
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