Yearly Archives: 2013

Highlights from HRC 2013

Br J Cardiol 2014;21:12–3 Leave a comment
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First published online December 20th, 2013

The Heart Rhythm Congress (HRC) remains the largest and fastest growing heart rhythm meeting in the UK, providing education and training to promote diversity and improved technology for all involved in the treatment of cardiac arrhythmia patients. We report highlights from this year’s meeting, HRC 2013, held in Birmingham from September 20–23, 2013.

What’s in a name

Last year’s meeting saw Heart Rhythm UK (HRUK) change its title to the British Heart Rhythm Society (BHRS). Explaining the change, BHRS President Elect Dr Nick Linker (South Tees Hospitals NHS Foundation Trust) said that this made things more flexible for the future, and will also avoid confusion with any other organisation using the abbreviation HRUK.

Ectopy in low- and high-risk patients

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Angela Hall (James Cook University Hospital, Middlesbrough)

When are palpitations benign and when do they signal high risk? This thorny issue was addressed by Mrs Angela Hall, Lead Cardiac Rhythm Management (CRM) Specialist Nurse (James Cook University Hospital, Middlesbrough) and Dr Elijah Behr (St George’s  Hospital, London) who looked at how to predict high risk in patients with palpitations.

Speaking to the BJC, Mrs Hall said: “Palpitations are a common presentation and a frequent reason for cardiology referral. They are, however, often benign, with less than half of patients suffering from an arrhythmia. Many patients will suffer from low-risk palpitations, however, this can still cause considerable stress and anxiety to both patients and healthcare professionals. The key to assessment is identifying patients with a significant heart rhythm abnormality at risk of adverse outcome that may require treatment.”

She described how such patients could be identified: “This can be achieved by carrying out a detailed history, electrocardiogram (ECG), echocardiogram, and clinical examination. Investigating symptoms in the form of ambulatory monitoring and event recorders will provide symptom correlation, which is important in reassuring patients of an underlying cause. Vital to the assessment is ruling out any structural heart abnormality and significant family history. Recording an ECG and acting on abnormal findings is paramount. An explanation of the mechanism behind the palpitations, reassurance and lifestyle advice is often all that is required in terms of management for low-risk palpitations. In some cases medical management may also be considered to enable the patient’s symptoms to be managed at an acceptable level.”

Behr
Dr Elijah Behr (St George’s Hospital, London)

How to predict high risk in patients with palpitations, was addressed by Dr Behr. First, what sort of palpitations are they? Are there uncomplicated ectopics, characterised by irregular, forceful beats, he asked? High-risk markers include known cardiac (including structural) or genetic disease, or family history of sudden cardiac death (SCD). Similarly, is there pre-syncope, or exertionally induced syncope? “Youth is not a reassuring factor,” he said.

Investigations include a 12-lead ECG, echocardiogram, and cardiac magnetic resonance imaging (MRI) for structural heart disease, possibly with gadolinium contrast to detect scarring. Also, an exercise ECG may be revealing, along with Holter monitoring, or implantable loop recorder, and, ultimately, an electrophysiological (EP) study, “the refuge of the undiagnosed”.

Non-sustained ventricular tachycardia (VT) on Holter monitoring in a young patient with cardiomyopathy can be ominous. Sustained VT is also a potential high-risk marker, especially in the presence of reduced ejection fraction, warranting referral. Atrial fibrillation (AF) is a “high-risk arrhythmia”, which doubles risk of mortality. If a patient is on anti-arrhythmic therapy they should be monitored, as such treatment can be pro-arrhythmic.

Exercise

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Dr Matt Fay (Westcliffe Medical Centre, Yorkshire)

Chairman Dr Matt Fay (Westcliffe Medical Centre, Yorkshire) suggested that “cardiology involves ongoing layers of risk stratification”. Not all patients may require an echo, sometimes B-type natriuretic peptide (BNP) testing may help. Questions arose on what advice should be offered regarding exercise in ‘at-risk’ patients. “These are best assessed on a case-by-case basis,” and it depends on the aetiology (phenotype), said Dr Fay.

If, for example, the arrhythmia is adrenergically driven, then sports exercise is inadvisable. Arrhythmogenic right ventricular cardiomyopathy (ARVC) may be partly induced by exercise. Deaths in Brugada syndrome, however, characteristically occur at rest, and exercise is not necessarily limited. Some long QT syndrome patients are more at risk than others and exercise is often restricted, although the evidence base is not great. Better rapport is needed between secondary and tertiary cardiac centres, particularly where cascade screening of families is concerned. A meeting following the forthcoming Association of Inherited Conditions (AICC) will address aspects of Specialist Commissioning, funding for such investigations. Dr Fay concluded that SCD in an athlete is, fortunately, “a rare but highly visible tragedy”.1

Dr Fay also discussed results from the Birmingham group in the SAFE (Saline versus Albumin Fluid Evaluation) study,2 from which “we know that one in 10 of the over 65 population will have an irregular pulse on clinical examination – however, the minority have AF and many of the others have ectopy. This is a large population for primary care to risk stratify and some direction on when further expert advice is required would assist the primary care clinicians”.

Young Investigator’s Award

Molecular autopsy was the topic addressed by Dr Hari Raju (St George’s Hospital, London) who was the winner of the Young Investigator’s Award (Basic Science). He describes this fast-developing field (see box on molecular autopsy).

The other Young Investigator’s Award (Clinical Science) was awarded to Dr Fozia Ahmed (Manchester Heart Centre) for his work on the clinical utility of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography as a diagnostic tool in patients with non-valvular cardiac device-related infection.

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Dr Hari Raju (St George’s Hospital, London)

What is a molecular autopsy? The HRC Young Investigator Award

Premature sudden deaths that remain unexplained, despite complete autopsy including toxicological examination, are referred to as sudden arrhythmic death syndrome (SADS). Approximately 500 annual SADS deaths occur in the UK, and half are associated with previously undiagnosed inherited arrhythmia syndromes, such as the long QT (LQT), Brugada (BrS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) syndromes, with phenotypically mild cardiomyopathies contributing a small minority.3 This is evidenced by the familial diagnoses identified on cardiological investigation of first-degree blood relatives; evaluation of blood relatives is advocated following a SADS death in Chapter 8 of the National Service Framework (NSF) to identify surviving family members who remain at risk.

Given the genetic aetiology of these conditions, molecular autopsy, or direct genetic evaluation of the SADS case provides an alternative avenue to establish post-mortem diagnoses. However, the differential diagnosis includes multiple conditions, each of which is associated with rare mutations affecting one of many risk-genes. Moreover, modern science has not yet identified all risk-genes for these conditions, thereby limiting the yield further.

Thus, despite a recent joint European and US consensus statement acknowledging the utility of molecular autopsy as a class 2A recommendation,4 its widespread adoption in the UK is limited by the cost and workload implications of offering such investigation, and the inability to target specific risk-genes. To our knowledge, neither the coronial services, nor the NHS, are offering routine molecular autopsy in the UK, except in the presence of a definitive familial phenotype, at present.

Next-generation sequencing (NGS) is an emerging research technology that offers the potential for the parallel study of large multi-gene panels, in many cases, at once. NGS is frequently utilised for whole genome and whole exome sequencing, although smaller gene panels can be equally cost-effective. Our study utilised an NGS panel of five major LQT and BrS risk-genes, in addition to the major CPVT risk-gene. Mutation-detection was optimised by post-sequencing bioinformatic adjustments, with subsequent replication in a second patient series, demonstrating validity of the molecular autopsy findings.

Overall, we demonstrated a molecular diagnostic yield of up to 13% (n=20/151), lower than other large published series,3 but complementary to familial evaluation. We believe that NGS panels may facilitate establishment of genetic testing at lower cost with higher throughput as part of a tiered molecular autopsy strategy in SADS.

NOACs in DC cardioversion

There is considerable interest in the role of the novel oral anticoagulants (NOACs) in direct current cardioversion (DCCV) of AF compared with warfarin. Patients often struggle to maintain therapeutic international normalised ratio (INR) leading to rescheduling of their DCCV appointments, which is frequently very inconvenient.

Dr Wai Kah Choo and colleagues (Raigmore Hospital, Inverness) presented data from their nurse-led DCCV clinic, which was set up in 2006, and replaced warfarin with dabigatran where possible, from December 2011.

They evaluated 242 DCCVs, performed in 193 patients over a 36-month period. Patients were divided into two cohorts. Cohort A included cases in the 22-month period prior to the introduction of dabigatran. Cohort B included cases in the 14-month period after the introduction of dabigatran. In cohort B, 48.4% received dabigatran; the other patients were established and stable on warfarin or had reasons for taking warfarin (e.g. metal heart valve).

They found a significantly larger number of patients from cohort A were rescheduled due to subtherapeutic INRs compared with cohort B (42% vs. 15%, p<0.001). Those who received dabigatran also had significantly lower rates of rescheduling compared with those who received warfarin (9.7% vs. 34.4%, p<0.001). The length of time between initial clinic assessment and DCCV was 22 days shorter in patients taking dabigatran compared with warfarin (p=0.0015). Outcomes in achieving and maintaining sinus rhythm were comparable in both cohorts and anticoagulants (p>0.05). There were two cases of transient ischaemic attack (TIA) in the warfarin group, both within therapeutic INR range. There was one case of TIA in the dabigatran group.

The authors conclude that use of dabigatran in patients undergoing DCCV reduced rescheduling and improved efficiency compared to warfarin. Dabigatran may bring significant cost savings, if results are extrapolated to the rest of the country, the authors conclude. The full paper for this study is published in this issue (doi: 10.5837/bjc.2014.002).

Anticoagulate, yes or no?

Dr Matt Fay provided insight into a field that warrants the view, “complacency about AF-related stroke is not acceptable”. AF-related strokes are typically more severe, and warfarin has been shown to consistently reduce the risk of stroke or systemic embolism by about two thirds compared with no treatment, and by 30–40% compared with aspirin in high-risk AF patients. The CHADS2 score system is a simple way to assess risk, but when compared with the CHADS2 score, CHA2DS2-VASc performs better in predicting patients at high risk; and those categorised as low risk by CHA2DS2-VASc are truly at low risk for thromboembolism.

About 5% of the population over 65 years has AF and even subclinical (asymptomatic) AF increases stroke risk, while paroxysmal AF appears to carry similar risk to persistent/permanent AF. Yet there are barriers to anticoagulation – including age, falls, dementia, poor INR control, permanent versus sustained AF – which should not be barriers, and it is often the patients who are denied anticoagulation who have the most to gain. It has been shown, for example, that the benefits of anticoagulation outweigh the risk of falls.

Dr Fay asked why with such an evidence base, adoption of stroke prevention strategies in this population remains inconsistent. After looking at the evidence for level of risk for intervention, paroxysmal compared with consistent AF, and risks of falls as barriers – among other topics – he ended with a reminder: “If the profession does not resolve this issue, then 5,000–10,000 people will suffer a possibly avoidable AF-related stroke each year.”

What are the pros and cons of the NOACs? Clearly they are convenient, and have a predictable and rapid onset/offset. Conversely, there are no reversal agents, no routine monitoring (anticoagulation assessment), and there are risks associated with missed dosing. Caution is required in relation to renal dysfunction, although cost may be the paramount issue. The NOACs are “very cost effective but not affordable in an NHS without very much money”, Dr Fay contends. However, as data emerge, showing benefit with the NOACs, “these are all part of the solution”.

AF: ablate, medicate or leave alone?

Dr-Tim-Betts-photo
Dr Tim Betts (John Radcliffe Hospital, Oxford)

This intriguing topic was addressed by Dr Tim Betts (John Radcliffe Hospital, Oxford). AF accounts for about 1.1–3.6% of emergency department (ED) visits. Just over 3% of these patients are haemodynamically unstable. There is a 48-hour ‘window’ for cardioversion and after this there is an increased thromboembolic risk. There is a high rate of spontaneous reversion to sinus rhythm, however, there is a choice between rhythm or rate control. While flecainide has high cardioversion rates between 2 and 8 hours, it can be pro-arrhythmic and should be only used in structurally normal hearts with a low likelihood of ischaemic heart disease. Digoxin is “the least effective rate controller”, and beta blockers and rate-lowering calcium antagonists are the drugs of choice for rate control. There is no role for amiodarone, he said, which takes 24 hours to work as a rate controller and is no better than placebo at acute pharmacological conversion in the ED.

If sinus rhythm is not restored, what is the next outpatient option? The goals are to address the stroke risk, to reduce symptoms and improve quality of life and to avoid tachycardia-induced cardiomyopathy, which can occur with persistent AF. The ‘pill in the pocket’ approach with flecainide is useful in paroxysmal AF, the downside being that AF may become flutter.

The treatment strategy depends on the relative contribution of rapid rate and loss of atrial contractility. “Although long-term sinus rhythm is very difficult to achieve, if successful it’s better than AF”. DCCV may be worth undertaking as a ‘diagnostic tool’ to see whether the patient differentiates between AF and sinus rhythm. AF ablation has been practiced for many years. It takes 2–3 hours with a success rate of about 80–90%, but the Achilles heel is that one in three patients “need more than one go”.  Also, the only role for ablation is in symptomatic treatment – “ablation has not yet been shown to reduce stroke risk”. While it is useful to see patients through all the ‘drug steps’ first, ablation is an increasingly popular option, especially in younger and more active patients.

Preventing deterioration in LVSD

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Dr Andrew Turley (James Cook University Hospital, Middlesbrough)

Dr Andrew Turley (James Cook University Hospital, Middlesbrough) reviewed how preventing deterioration in left ventricular systolic dysfunction (LVSD) can be achieved with interventions such as cardiac resynchronisation therapy (CRT). While not much has changed in considering implantable cardioverter defibrillators (ICDs), there has been a big evolution in who qualifies for CRT. And the CRT guidelines are “evolving rapidly”, so much so that the NICE (National Institute for Health and Care Excellence) guidelines are now significantly outdated (although may have a new iteration in the spring). Evolving indications include use in patients with AF, non-left bundle branch block, bradycardic pacing indications (irrespective of QRS duration), and minimally symptomatic patients (NYHA I/II) with a broad QRS complex.

The ECHO CRT (Echocardiography Guided Cardiac Resynchronisation Therapy) study was stopped for futility, but the study did reveal that if the QRS is less than 130 ms, then “don’t bother with CRT”, Dr Turley advised. CRT does not improve clinical outcome in patients with a QRS <130 ms.

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Table 1. North of England Cardiovascular Network referral criteria for ICD/CRT

Within the UK, implant rates for life-saving cardiac devices (i.e. ICD and CRT) remain among the lowest in Europe. Severe LVSD should be an automatic referral for consideration of an ICD device and/or CRT.  Useful online resources for guidance include www.arrhythmiaalliance.org.uk and www.screenlinkcalculator.com. Table 1 shows the North of England Cardiovascular Network referral criteria for ICD/CRT

The next Heart Rhythm Congress will be held at the International Convention Centre, Birmingham from October 5–8 2014. For more information, please visit http://
www.heartrhythmcongress.com/

Acknowlegement

We thank the following, who all contributed to this article:

  • Dr Elijah Behr (St George’s Hospital, London)
  • Dr Tim Betts (John Radcliffe Hospital, Oxford)
  • Dr Wai Kah Choo (Raigmore Hospital, Inverness)
  • Dr Matt Fay (Westcliffe Medical Centre, Yorkshire)
  • Ms Angela Hall (James Cook University Hospital, Middlesbrough)
  • Dr Hari Raju (St George’s Hospital, London)
  • Dr Andrew Turley (James Cook University Hospital, Middlesbrough)

References

1. Chandra N, Bastienen R, Papadakis M, Sharma S. Sudden cardiac death in young athletes. J Am Coll Cardiol 2013;61:1027–40. http://dx.doi.org/10.1016/j.jacc.2012.08.1032

2. Mant J, Fitzmaurice DA, Hobbs FDR, et al. Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial. Br Med J 2007;335:380. http://dx.doi.org/10.1136/bmj.39227.551713.AE

3. Raju H, Behr ER. Unexplained sudden death, focussing on genetics and family phenotyping. Curr Opin Cardiol 2013;28:19–25. http://dx.doi.org/10.1097/HCO.0b013e32835b0a9e

4. Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS Expert Consensus Statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes. Heart Rhythm 2013;29:e75–e106. http://dx.doi.org/10.1016/j.hrthm.2013.05.014

Introduction: Cardiovascular health and disease prevention in clinical practice

Br J Cardiol 2013;20(suppl 3):S1–S19 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

Promoting cardiovascular health is central to the national strategy to reduce premature mortality in our population. In this supplement, we offer a new approach to cardiovascular disease (CVD) prevention through the MyAction preventive cardiology programme, developed by Imperial College London. This nurse-led, multi-disciplinary, family-centred service embraces all patients with atherosclerotic disease – coronary heart disease, stroke and peripheral arterial disease – together with those identified through Health Checks to be at high risk of developing CVD in one community-based programme. In this supplement, we describe the studies that compiled the rationale for MyAction, our experience in delivering this programme in different communities and our approach to education and training through our Imperial College Masters degree programme in preventive cardiology: cardiovascular health and disease prevention. All health professionals are welcome to visit MyAction and join us in our ambitions to achieve excellence in preventive care for all our patients.

The ASPIRE-2-PREVENT study was partly funded through an unrestricted educational grant by MSD and the DYSIS study was sponsored by MSD. These studies were conducted together and we thank all the participants, local clinical staff and the scientific committee members.

Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

MyAction and the new cardiovascular outcomes strategy

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s03 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

Introduction

Cardiovascular diseases (CVDs) are a single family of diseases with common antecedents requiring a holistic approach to prevention. This is the central theme of the new cardiovascular outcomes strategy for NHS England.1 Atherosclerosis is ubiquitous in the population, manifesting itself in different ways – acute coronary syndromes, transient cerebral ischaemia or claudication – but linked by a common pathology and underlying causes in terms of lifestyle and related risk factors. Many with one expression of this disease commonly suffer from another, and yet each is managed in silos of care through cardiology, stroke and vascular services, and while appropriate for acute disease, not so for prevention. All these patients require a professional lifestyle intervention, risk factor and therapeutic management to reduce risk of disease progression, the need for further hospitalisation, revascularisation, and, ultimately, prevention of recurrent events leading to greater life expectancy.

If true of manifest disease, it is even truer for the antecedents of atherosclerosis, namely hypertension, hypercholesterolaemia, diabetes and chronic kidney disease. These very terms also lead to silo approaches for risk factor assessment and management in primary prevention, now replaced by the new paradigm of total cardiovascular risk, central to the national Health Checks programme. Those at highest multi-factorial risk, including all those with type 2 diabetes mellitus, also require an integrated prevention programme, but are commonly signposted to silo services for smoking cessation, weight management, exercise referral schemes, as well as specialist clinics in hypertension, lipids and diabetes. Dividing the patient into all these specialist areas leads to uncoordinated care, multiple visits to different health professionals and services, which can offer confusing and contradictory advice.

The patient should be at the centre of preventive care, based on holistic assessment and management. As stated in the national strategy a “more coordinated and integrated approach is needed to assessment, treatment and care to improve outcomes”. The report recommends developing and evaluating service models to manage CVD as “a single family of diseases” applicable to both manifest atherosclerotic disease and those at high multi-factorial risk of developing this disease. In the context of prevention, distinguishing secondary from primary prevention is, to a large extent, artificial, as all patients require lifestyle, risk factor and therapeutic management to reduce their overall risk of developing, or having recurrent, disease.

MyAction

MyAction is an innovative, nurse-led, multi-disciplinary programme, which manages cardiovascular disease as “a single family of diseases” and integrates secondary and primary prevention in one community-based service.2 It is founded on the principles of EUROACTION – a nurse-led, multi-disciplinary programme evaluated in a cluster randomised-controlled trial in hospital and general practice across eight European countries.3 MyAction accepts all patients with coronary artery disease, with transient cerebral ischaemia or minor stroke and with claudication. At the same time, MyAction takes high-risk patients identified through the Health Checks programme because of a CVD score of ≥20% over 10 years, diabetes or chronic kidney disease. The MyAction team comprises full-time specialist cardiac nurses, full-time dietitians and full-time physiotherapists or physical activity specialists, supported by a psychologist and a community cardiologist and led by a central team at Imperial College London. Patients are recruited together with their partners because there is concordance for lifestyle – smoking, eating habits and physical activity levels – and achieving healthy lifestyle changes is more likely if the intervention is offered to the whole household rather than the patient in isolation. The MyAction programme is located in community leisure centres, rather than hospital or general practice, as the facilities in these centres provide a more conducive health-promoting environment.

The concept of the MyAction programme meets the requirements of the new cardiovascular outcomes strategy to improve outcomes for people with or at risk of CVD. We are managing CVDs as a single family of diseases with common antecedents – through complete integration of secondary and primary prevention – a new paradigm for cardiovascular prevention compared with traditional service models of cardiac rehabilitation, limited to those following myocardial infarction or coronary revascularisation, and silo services for smoking cessation, weight management, exercise prescription, hypertension, lipids and diabetes. If we are to reduce premature mortality from CVD, reduce inequalities and improve quality of life we need to take an innovative holistic approach to cardiovascular prevention.

References

  1. Department of Health. Cardiovascular disease outcomes strategy: improving outcomes for people with or at risk of cardiovascular disease. London: DoH, 5th March 2013. Available from: https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy
  2. Connolly S, Holden A, Turner E et al. MyAction: an innovative approach to prevention of cardiovascular disease in the community. Br J Cardiol 2011;18:171–6. Available from: https://bjcardio.co.uk/2011/08/myactionaninnovativeapproachtothe
    preventionofcardiovasculardisease/
  3. Wood DA, Kotseva K, Connolly S et al.; on behalf of EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008;371:1999–2012.
    http://dx.doi.org/10.1016/S0140-6736(08)60868-5
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

What is cardiac rehabilitation achieving for patients with CHD? The ASPIRE-2-PREVENT results

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s04 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

The main objective of cardiovascular prevention and rehabilitation in clinical practice is to reduce the risk of future vascular events, to improve quality of life and increase life expectancy. Cardiac rehabilitation (CR) is recommended by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR).1 This second edition of the Standards and Core Components (SCC) for Cardiovascular Disease Prevention and Rehabilitation from the BACPR, define CR through seven standards and seven core components for assuring a quality service of care using a multi-disciplinary biological and psychosocial approach.2

S5However, the implementation of secondary prevention of coronary heart disease (CHD) in the UK is still far from optimal. The results of the ASPIRE-2-PREVENT (Action on Secondary Prevention through Intervention to Reduce Events) (A-2-P) survey showed poor lifestyle and risk factor management in patients with established coronary disease.3

The aim of this paper is to describe lifestyle and risk factor management, and the use of cardioprotective drug therapies in a representative sample of coronary patients participating in a cardiac rehabilitation programme (CRP) compared with those who did not.

Methods

Detailed description of study design and principal results has been published in detail elsewhere.3 Briefly, A-2-P survey was conducted in 19 randomly selected hospitals in 12 geographical regions in England, Northern Ireland, Wales, and Scotland. Consecutive patients, men and women younger than 80 years of age, with one or more of the following diagnoses: elective or emergency coronary artery bypass surgery (CABG), elective or emergency percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), unstable angina (UA) and exertional angina (EA), were identified retrospectively, and interviewed and examined at least six months after their index event or procedure.

Data collection was conducted by centrally trained research nurses and was based on retrospective review of individual medical notes, and interview and examination of patients at least six months and at most three years after the recruiting coronary event or procedure, using standardised methods and instruments. Venous blood was drawn for serum total cholesterol, high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and plasma glucose. Fasting time was recorded. The low-density lipoprotein cholesterol (LDL-C) was calculated using the Friedewald formula. The central laboratory was the School of Clinical and Laboratory Sciences, Faculty of Medical and Human Sciences, University of Manchester, UK. The laboratory takes part in the Lipid Standardization Program organised by CDC, Atlanta, USA. Data management was undertaken by the Euro Heart Survey department of the European Society of Cardiology, European Heart House, Sophia Antipolis, Nice, France.

The main outcome measures were the proportions of coronary patients achieving, at interview, the lifestyle, risk factor and therapeutic targets as defined in the Joint British Societies (JBS2) guidelines for cardiovascular disease (CVD) prevention.4 Patient demographics were summarised as counts and percentages, or means and standard deviations, as appropriate. These demographics were presented for those who were advised to participate and according to participation, both for those who were advised and of the whole study group. Logistic regression was used to identify patient demographic variables and risk factors associated with participation in a CRP. Unadjusted and adjusted p values were reported, with adjustment for age at index event, sex and index event.

Results

A total of 1,522 medical records (26.1% women) were reviewed and 676 patients were interviewed, of whom 663 (74.5% men and 25.5% women) had valid information about their participation in a CRP and are included in the present analysis. Patients were interviewed at a median interval of 13 months (interquartile range [IQR] 10–16 months) after the recruiting index coronary event. The characteristics of patients who were advised and participated in a CRP by age, gender and diagnostic category are presented in table 1. Overall, 466 (70.3%) patients were advised to participate in a CRP and 345 (74.0%) of them attended at least half of the sessions (52.0% of the whole study population). Participation rates ranged from 19.4% in the exertional angina group to 71.3% in the CABG group. Table 2 shows patients characteristics and risk factor prevalence and control at interview according to participation in a CRP. There were significant differences by age, gender, diagnostic category, educational level, prevalence of diabetes, smoking, obesity, achieving physical activity target, total cholesterol control, and use of antiplatelets, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and calcium channel blockers (CCBs).

Table 1. Proportion of patients advised to attend a cardiac rehabilitation programme (CRP) and participation, by age, sex, index event and educational level among those advised (n=466), and among the whole study group with valid CRP information (n=663)
Table 1. Proportion of patients advised to attend a cardiac rehabilitation programme (CRP) and participation, by age, sex, index event and educational level among those advised (n=466), and among the whole study group with valid CRP information (n=663)

Table 2. Patient characteristics and risk factor prevalence and control at interview according to participation in a CRP for the whole study group with valid CRP information (n=663)
Table 2. Patient characteristics and risk factor prevalence and control at interview according to participation in a CRP for the whole study group with valid CRP information (n=663)

Discussion

There is a wealth of scientific evidence from randomised-controlled trials and meta-analyses that comprehensive CR can reduce the risk of future cardiovascular events in patients with CHD and improve survival.5-8 A systematic review of 47 studies randomising 10,794 patients showed that a structured exercise-based CR, compared with usual care, was associated with a reduction in overall and cardiovascular mortality (relative risk [RR] 0.87, 95% confidence interval [CI] 0.75–0.99; and 0.74, 95% CI 0.63–0.87, respectively), and in hospital admissions (RR 0.69, 95% CI 0.51–0.93).5 Secondary prevention, including blood pressure, cholesterol and glucose management and the use of cardioprotective medication, now also forms an integral part of an effective CRP.6 A meta-analysis of the effectiveness of secondary prevention programmes of 63 randomised-controlled trials, including 21,295 patients, showed a summary risk ratio for all-cause mortality of 0.85 (95% CI 0.77–0.94) and for recurrent myocardial infarction of 0.83 (95% CI 0.74–0.94).7 In the systematic review of trials of secondary prevention, multi-disciplinary disease management programmes led to a reduction in hospital admissions and a trend towards improved symptom scores, exercise tolerance, or quality of life.8

However, despite the strength of scientific evidence, CR in the UK is underused with a low participation rate. The A-2-P results presented here show that just over two-thirds of patients with CHD were advised to follow a CRP and just over half of all patients actually participated in some form of CR. Yet, of those who were advised, nearly four-fifths did so. The referral and participation rates in A-2-P (70.3% and 52.0%, respectively) were higher than in the EUROASPIRE III survey in 22 countries (44.8% and 36.5%, respectively).9 In the A-2-P survey, age, gender, diagnostic category and educational level were associated with the reported advice to attend a CRP. Those who were younger, men, with higher educational status, and those who had had CABG and PCI were more likely to be advised to participate in a CRP. Importantly, angina patients may gain potentially more from CR than other diagnostic groups, and they, therefore, need lifestyle and risk factor management as much as those revascularised by CABG and PCI. Similarly, patients who attended a CRP were more likely to be younger, men, and with a higher educational level. Those who had had CABG and PCI as recruiting index event were more likely to attend a CRP than those with UA and EA.

Patients who reported attending a CRP had a significantly lower prevalence of persistent smoking, obesity and elevated total cholesterol. Significantly higher proportions of patients attending a CRP achieved the physical activity target and were on antiplatelets and ACEIs/ARBs. However, despite the higher use of ACEIs/ARBs, there was no significant difference in blood pressure control according to participation in a CRP. The control of total cholesterol in those on lipid-lowering medication was significantly better in those who attended a CRP. Importantly, more than 90% in both groups were on lipid-lowering medication, mainly statins, so the better cholesterol control may be probably explained by healthier lifestyle management and by up-titrating or switching to more potent statins in a CRP group.

The findings of this survey must be considered within the context of study strengths and limitations. An important strength of the A-2-P survey is that, in order to obtain a representative sample, participating centres were randomly selected from a geographically stratified sample of hospitals in the UK. Data collection was not based just on information from medical notes, but also on face-to-face interviews and examinations using standardised methods and instruments, including central laboratory measurements for lipids and glucose.

A-2-P showed considerable differences in the profile of patients who were advised, as well as in those who attended a CRP. In this context, the differences in lifestyle and risk factor management at interview should be interpreted with caution, as it is unclear whether they are related to the effectiveness of the CRP or to the selection of patients in the respective groups. These differences may influence the results not only in this study, but in the other studies that evaluate the effectiveness of CRPs.

CR has been identified in two of the indicators of the Quality and Outcomes Framework (QOF), which either currently exist or are part of the 2013–2014 planned guidelines from the National Institute for Health and Care Excellence (NICE; http://www.nice.org.uk). The two QOF indicators are the secondary prevention of coronary heart disease and the management of chronic congestive heart failure, with a special focus on improving early uptake and adherence to CR. The seven core components for cardiovascular disease prevention and rehabilitation of the BACPR include lifestyle (smoking cessation, diet and physical activity) and medical risk factor management, cardioprotective drug therapies, health behaviour change and education, psychosocial health, long-term management, audit and evaluation.2

In conclusion, the results of A-2-P survey show that CR in the UK is underused and only just over half of all coronary patients reported attending a CRP. There is a difference between characteristics of patients advised to attend and in those who participated in a CRP. Although the control of smoking, obesity and cholesterol was significantly better in those who attended a CRP many patients had not achieved lifestyle and risk factor targets. Better strategies are required to ensure that patients with CHD receive adequate lifestyle and risk factor management. The recent EUROACTION randomised-controlled trial and the new MyAction programme for the NHS have shown that a nurse-led multi-disciplinary programme can achieve a high standard of preventive care for patients with CHD and their families.10,11 Cardiovascular prevention and rehabilitation must be integral to any modern cardiology service. There is an urgent need of comprehensive, multi-disciplinary rehabilitation programmes addressing all aspects of the lifestyle and risk factor management for all patients with coronary or other atherosclerotic disease.

Funding

The A-2-P survey was supported by Merck Sharp & Dohme (MSD) with an unrestricted educational grant to Imperial College London, and is part of a wider international survey called DYSIS (Dyslipidaemia International Survey). The sponsor had no role in the ASPIRE-2-PREVENT design, data collection, data analysis, data interpretation, and writing of this report. The authors had full access to all data and had final responsibility for the decision to submit the manuscript for publication.

References

  1. Buckley JP, Furze G, Doherty P et al.; on behalf of BACPR. BACPR scientific statement: British standards and core components for cardiovascular disease prevention and rehabilitation. Heart 2013;99:1069–71. http://dx.doi.org/10.1136/heartjnl-2012-303460
  2. British Association for Cardiovascular Prevention and Rehabilitation (BACPR). The BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012. London: BACPR, 2012. Available from: http://www.bacpr.com/resources/8BZ_BACPR_Standards_and_Core_Components_2012.pdf [accessed November 2012].
  3. Kotseva K, Jennings CS, Turner EL et al.; on behalf of the ASPIRE-2-PREVENT Study Group. ASPIRE-2-PREVENT: a survey of lifestyle, risk factor management and cardioprotective medication in patients with coronary heart disease and people at high risk of developing cardiovascular disease in the UK. Heart 2012;98:865–71. http://dx.doi.org/10.1136/heartjnl-2011-301603
  4. British Cardiac Society, British Hypertension Society, Diabetes UK et al. JBS2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(suppl 5):v1–v52. http://dx.doi.org/10.1136/hrt.2005.079988
  5. Heran BS, Chen JMH, Ebrahim S et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011;(7):CD001800. http://dx.doi.org/10.1002/14651858.CD001800.pub2
  6. Perk J, De Backer G, Gohlke H et al.European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012;33:1635–701. http://dx.doi.org/10.1093/eurheartj/ehs092
  7. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005;143:659–72. http://dx.doi.org/10.7326/0003-4819-143-9-200511010-00010
  8. McAlister FA, Lawson FME, Teo KK, Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001;323:957–62. http://dx.doi.org/10.1136/bmj.323.7319.957
  9. Kotseva K, Wood D, De Backer G, De Bacquer D. Use and effects of cardiac rehabilitation in patients with coronary heart disease: results from the EUROASPIRE III survey. Eur J Prev Cardiology 2013;20:817–26. http://dx.doi.org/10.1177/2047487312449591
  10. Wood DA, Kotseva K, Connolly S et al.; on behalf of the EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008;371:1999–2012. http://dx.doi.org/10.1016/S0140-6736(08)60868-5
  11. Connolly S, Holden A, Turner E et al. MyAction: an innovative approach to the prevention of cardiovascular disease in the community.
    Br J Cardiol 2011;18:171−6. Available from: https://bjcardio.co.uk/2011/08/myactionaninnovativeapproach tothepreventionof cardiovasculardisease/
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

Dyslipidaemia and atherosclerotic vascular disease: DYSIS results in the UK

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s05 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

Background

Statins are first choice for treatment of dyslipidaemia in both secondary and primary cardiovascular disease prevention. For every 1.0 mmol/L reduction in low-density lipoprotein cholesterol (LDL‑C), the risk of coronary heart disease (CHD) mortality decreases by 19% and overall mortality decreases by 12%.1 Despite statin treatment, a substantial number of cardiovascular events still occur, and one reason may be persistent lipid abnormalities including total cholesterol and LDL-C not at target, or low levels of high-density lipoprotein cholesterol (HDL-C) or elevated triglycerides. Results from the DYSlipidaemia International Study (DYSIS) in 22,063 statin-treated patients across 11 European countries and Canada, assessed the prevalence and types of persistent lipid abnormalities in patients receiving statin therapy, in both secondary and primary care settings.2 In this paper we report the UK results.

Figure 1. Participating centres in the UK
Figure 1. Participating centres in the UK

Methods

DYSIS was a multi-centre, cross-sectional, observational study of the lipid profile of statin-treated outpatients and the study design, methods and principal results are published.2 Outpatients under the care of a specialist or primary care physician were eligible for inclusion if they were ≥45 years old, had been receiving statin therapy for ≥3 months, and had ≥1 documented fasting blood lipid profile performed while on statins. Consecutive patients, fulfilling these inclusion criteria, who visited their specialist or primary care physician for whatever reason during a six‑month recruitment period were invited to participate. Routinely collected data from patient medical records were used, including the most recently recorded lipid parameters from the previous 6–12 months for total cholesterol, LDL-C, HDL‑C, and triglycerides.

Results

Table 1. Patient characteristics
Table 1. Patient characteristics

A total of 1,277 statin-treated patients with a clinical diagnosis of coronary or other atherosclerotic disease, or at high risk of developing cardiovascular disease (CVD), were recruited from 19 hospital and 19 primary care centres across the UK (figure 1).The patient characteristics are presented in table 1: 44.3% of patients had a history of coronary artery disease, 5.4% cerebrovascular disease and 3.4% peripheral artery disease.

Lipid-lowering treatment

All patients were taking a statin.

Lipid abnormalities

The distribution of single and combined lipid abnormalities in patients with a total lipid profile is shown in figure 2: 25.3% of patients had no lipid abnormalities and the rest had either an elevated LDL-C (≥2.0 mmol/L) or low HDL-C (<1.0 mmol/L men and <1.2 mmol/L women) or elevated fasting triglycerides (≥1.7 mmol/L) or a combination of these abnormalities. Overall, 56.1% of patients had LDL-C ≥2.0 mmol/L, 35.7% had low HDL-C and 35.6% had an elevated triglyceride level. In addition, 25.1% had a total cholesterol/HDL-C ratio ≥4.0. The proportion of patients at the total and LDL-C goals, the proportion with normal HDL-C and the proportion with normal triglycerides are shown in figure 3. 

Figure 2. Distribution of single and multiple combined lipid abnormalities in patients with total lipid profile (n=1,128)*
Figure 2. Distribution of single and multiple combined lipid abnormalities in patients with total lipid profile (n=1,128)*

Figure 3. Total and LDL-cholesterol at goal/normal lipid levels in patients with total lipid profile
Figure 3. Total and LDL-cholesterol at goal/normal lipid levels in patients with total lipid profile

Discussion

Joint British Societies’ guidelines (JBS2) defined the same lipid targets for patients with atherosclerotic vascular disease, and those at high risk of developing CVD, namely a total cholesterol of <4.0 mmol/L and <2.0 mmol/L for LDL-C.3 The same targets for coronary patients were subsequently recommended by the National Institute for Health and Care Excellence (NICE) lipid guidelines, although not for primary prevention. Yet a majority of these coronary and high-risk patients, despite being actively treated with a statin, are not achieving these targets. In addition, a substantial minority also have either low HDL-C and/or elevated fasting triglycerides, further increasing cardiovascular risk.

In ASPIRE-2-PREVENT, 92.8% of coronary patients were taking a statin and, yet, 56.1% were above the LDL-C target of <2.0 mmol/L. In high-risk patients, only 61.2% were taking a statin and 74.8% were above the same LDL-C target.4 Therapeutic control in those taking a statin was also poor with only 44.7% of coronary patients below the LDL-C target, and 36.8% of high-risk patients for the same target.

In conclusion, these results continue to demonstrate the need for more intensive and comprehensive lipid management, especially of LDL-C, and where the target is not achieved with a high-intensity statin then combination lipid-lowering therapy should be considered. Other aspects of dyslipidaemia, including low HDL-C and elevated triglycerides, may also require a therapeutic strategy beyond statins, but this requires further evidence from randomised-controlled trials.

References

  1. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371:117–25. http://dx.doi.org/10.1016/S0140-6736(08)60104-X
  2. Gitt AK, Drexel H, Feely J et al. Persistent lipid abnormalities in statin-treated patients and predictors of LDL-cholesterol goal achievement in clinical practice in Europe and Canada. Eur J Prev Cardiol 2012;19:221–30. http://dx.doi.org/10.1177/1741826711400545
  3. British Cardiac Society, British Hypertension Society, Diabetes UK et al. JBS2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(suppl 5):v1–v52. http://dx.doi.org/10.1136/hrt.2005.079988
  4. Kotseva K, Jennings CS, Turner EL et al.; ASPIRE-2-PREVENT Study Group. ASPIRE-2-PREVENT: a survey of lifestyle, risk factor management and cardioprotective medication in patients with coronary heart disease and people at high risk of developing cardiovascular disease in the UK. Heart 2012;98:865–71. http://dx.doi.org/10.1136/heartjnl-2011-301603
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

The principles of MyAction

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s06 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

The programme is implemented according to national evidence-based guidelines and local policies.

The programme integrates primary and secondary prevention in one programme and recruits all those who will benefit the most, i.e. patients with vascular disease, those at high risk of developing disease, and the close family members of the above, and takes into account the groups in which the prevalence of cardiovascular disease and risk factors is the highest.

The programme is family centred and so recruits the spouse and/or others close to the patient in order to maximise the potential for adoption of positive healthy behaviours.

Wherever possible, the programme is based in a community setting and adopts a flexible approach, which allows easy access to the people from the community targeted for the intervention, especially when that community includes vulnerable and deprived groups.

The focus of the programme is on the promotion of healthy lifestyle habits using behavioural strategies and expertise from a multi-disciplinary team (nursing, dietetics, physiotherapy, exercise, psychology, cardiology).

Effective prescribing of cardioprotective medications is ensured with the use of protocols to facilitate the management of blood pressure, lipids and diabetes to goal, and also with dedicated nurse prescribers, cardiologists and general practitioners.

The MyAction model of preventive cardiology care
The MyAction model of preventive cardiology care
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

Delivering the MyAction programme in different populations: NHS Westminster, London

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s07 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

MyAction Westminster: background

In response to the Department of Health (DoH) policy document Putting Prevention First,1 NHS Westminster launched its Health Checks programme in primary care in 2009. The MyAction Westminster programme was concomitantly commissioned by NHS Westminster so that those individuals identified to be at high cardiovascular disease (CVD) risk through the Health Checks could access, with their families, an effective vascular prevention programme that would help them achieve measurably healthier lives. Imperial College Healthcare NHS Trust were successful in becoming the providers of the programme with an annual budget of £1.3 million for three years, and the programme is delivered in partnership with Imperial College.

The Borough of Westminster

Westminster has a population of over 230,000, although the weekday daytime population may swell to as high as one million. Cardiovascular disease is the leading cause of premature death (below age 75 years) in Westminster, and is also the principle contributor to a 10-year gap in life expectancy that exists between the most affluent and most deprived areas (the borough is ranked 72 out of 354 local authorities in England in terms of deprivation).2 In addition, the borough is an ethnically and culturally diverse area with an estimated 29% of the population belonging to black and minority ethnic groups (BME) and over 100 different languages are spoken throughout the borough. The largest BME groups are South Asian, Arabic and Black, respectively. South Asian Indians in the UK are well recognised as having a much higher incidence of coronary heart disease, whereas black patients have a higher risk of stroke.3,4 The reasons for increased CVD risk in these ethnic groups remain incompletely understood, although traditional cardiovascular risk factors are still recognised to play an important role, as well as cultural and lifestyle factors.3

Structure of MyAction Westminster programme

The programme is led by a central coordinating team based in Imperial College Healthcare NHS Trust. The programme is delivered in three community-based hubs in the north, south and west of the borough (figure 1), with deliberate siting of several of the hubs in areas of social deprivation where there are large BME communities. Each hub includes a full multi-disciplinary team, which consists of two cardiovascular nurse specialists, a full-time dietitian, physical activity specialist and administrator, supported by a visiting cardiologist (Dr Kornelia Kotseva) and clinical psychologist. The teams were trained by the MyAction Imperial College academic team, who also provide regular mentoring and quality assurance visits to ensure that the programme is delivered to preset protocols and standards.

Figure 1. The MyAction Westminster sites superimposed on a map of Westminster stratified by Index of Multiple Deprivation whereby the darker the colour the higher the deprivation score
Figure 1. The MyAction Westminster sites superimposed on a map of Westminster stratified by Index of Multiple Deprivation whereby the darker the colour the higher the deprivation score

A truly panvascular prevention programme

The setting up of the programme was seen as an ideal opportunity to streamline preventive cardiovascular care across the borough, with the subsequent integration of the existing hospital-based cardiac rehabilitation programme into the community-based MyAction Westminster programme. In addition, as patients with other forms of atherosclerosis, such as transient ischaemic attack (TIA) or peripheral arterial disease (PAD), rarely have access to effective prevention programmes, despite being at even higher cardiovascular disease risk,5,6 referral pathways from the acute stroke and vascular surgical services were also formalised. Referrals from primary care are principally through the NHS Health Checks service. From 2013 all primary care practices in Westminster have been offered an electronic ‘Preventative Medicine Pod’, which is specifically designed to assist in practice public health interventions (including the Health Check) and enables automatic electronic referral to the MyAction programme. The ‘inclusive nature’ of the MyAction programme, whereby all individuals with either established atherosclerotic disease or who are at high risk for developing disease are managed in the community by the same service with all their risk factors being addressed under the one roof, is what makes MyAction Westminster truly unique – and an excellent example of what the recent CVD Outcomes strategy aspires to.7

What are the MyAction Westminster service aims and objectives?

  • To help individuals and their families reduce their risk of vascular disease through healthy lifestyle changes (stopping smoking, making healthy food choices, engaging in regular physical activity), management of their medical risk factors (blood pressure, lipids and glucose) and also the promotion of psychological well-being.
  • To help reduce health inequalities by focusing efforts in areas of social deprivation and where there is a high prevalence of ethnic minorities, identified by NHS Westminster.
  • To deliver a programme:
  1. That is tailored to meet the needs of individual patients and their families
  2. That is socially and culturally appropriate
  3. That is located in the heart of these communities.
  • To help ensure that changes made during the programme are maintained in the longer term:
  1. Through use of proven self-efficacy techniques for behaviour change
  2. Completion of a one-year follow-up
  3. Signposting of the use of appropriate exit strategies
  4. Provision of a dedicated phase IV exercise service.
Figure 2. The MyAction supervised exercise class
Figure 2. The MyAction supervised exercise class

The MyAction weekly timetable

Following referral, patients and their partners are invited to attend a comprehensive baseline initial assessment at one of the MyAction centres (figure 2). At the end of the programme, the patients will have a further assessment, which is repeated at the end of one year. MyAction Westminster offers both morning and afternoon appointments in one of the 14 clinics that run during the week. The patients are then invited to attend the weekly health promotion session, which includes a review of progress, supervised exercise plus an education/health promotion component. Each session lasts approximately two hours and patients are encouraged to attend for a maximum of 16 weeks. At present, there are nine health promotion sessions running across the borough that take place in the morning, afternoon and evening to provide maximum access to the programme.

Measuring clinical activity and patient satisfaction

MyAction Westminster has its own dedicated web-based secure database where patient records are held, including demographics and clinical measurements. This permits audit of the programme’s activity and clinical outcomes on a regular basis, the latter being benchmarked against existing national targets. Data (on coronary patients only) are also electronically ‘patched’ to the National Audit of Cardiac Rehabilitation so that double entry of data is not required. Patient satisfaction is tracked through an electronic tablet device that patients fill in after each visit. This contains generic questions that are Trust-specified, and also questions that are specific to the MyAction programme.

Figure 3. The MyAction weekly education class
Figure 3. The MyAction weekly education class

Challenges faced in setting up the programme

The identification of suitable community venues where all the programme’s requirements could be met, including the provision of adequate clinical and exercise space, was challenging, particularly as Westminster contains some prime London property spots. Ultimately, however, suitable community hubs were established, two of which are co-located with other primary care services, and the three exercise venues are ideally located in public leisure facilities (figure 3).

Another challenge that was overcome was the interfacing of the MyAction database with Trust data services, and the provision of secure communications lines (e.g. NHS N3) in community sites, ensuring that the MyAction database met Trust IT governance requirements.

Initially, to help engage primary care colleagues, the MyAction teams assisted with the delivery of Health Checks in primary care. This helped to establish relationships and engage the programme’s largest stakeholder. Engaging with patients from BME groups was also key and achieved through training of staff to be culturally appropriate (e.g. the dietitians were trained in details of typical South Asian and Afro-Caribbean diets), provision of an interpreter at all appointments (including the exercise class), provision of British Heart Foundation materials in the patients’ language, and particularly through establishing links with community groups who were able to promote the programme locally in their communities.

Progress to date

Figure 4. Ethnicity of patients attending the MyAction programme
Figure 4. Ethnicity of patients attending the MyAction programme

Over 3,000 have been received to date by the programme, with approximately 60% being from primary care and 40% from secondary care. Uptake of the programme is high at ~75% of those referred. Of those who attend for an initial assessment, one in two are from BME groups (principally South Asian, Arabic and Black), showing that the programme is indeed engaging with priority groups (figure 4). The principle results of the programme to date, in terms of clinical and patient-reported outcomes, will be published in a peer-reviewed paper shortly.

References

  1. Department of Health. Putting prevention first. NHS Health Check: vascular risk assessment and management.
    Best practice guidance. London: DoH, April 2009. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098410.pdf
  2. Public Health England. Local health. Available from:http://www.localhealth.org.uk/#sly=ltla_2012_DR;z=514455,199252,26082,36873;sid=325;l=en;v=map8 [accessed September 2013].
  3. Cappuccio FP. Ethnicity and cardiovascular risk: variations in people of African ancestry and South Asian origin. J Hum Hypertens 1997;11:571–6.
  4. Khunti K, Samani NJ. Coronary heart disease in people of South-Asian origin. Lancet 2004;364:2077–8. http://dx.doi.org/10.1016/S0140-6736(04)17563-6
  5. Alberts MJ, Bhatt DL, Mas JL et al. Three-year follow-up and event rates in the international REduction of Atherothrombosis for Continued Health Registry. Eur Heart J 2009;30:2318–26. http://dx.doi.org/10.1093/eurheartj/ehp355
  6. Mechtouff L, Touze E, Steg PG et al. Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease. J Intern Med 2010;267:621–33. http://dx.doi.org/10.1111/j.1365-2796.2009.02198.x
  7. Department of Health. Cardiovascular disease outcomes strategy: improving outcomes for people with or at risk of cardiovascular disease. London: DoH, March 2013. Available from: https://www.gov.uk/government/publications/cardiovascular-disease-outcomes-strategy-improving-outcomes-for-people-with-or-at-risk-of-cardiovascular-disease
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

Delivering the MyAction programme in different populations: Galway, Republic of Ireland

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s08 Leave a comment
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Authors:
Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

Background

Cardiovascular disease (CVD) is the single most common cause of death in Ireland, with diseases of the circulatory system accounting for 33.5% of deaths.1 While there has been a significant decline in death rates over the last 30 years, CVD mortality rates in Ireland remain high in comparison with European averages.2 There is compelling evidence that managing risk factors through lifestyle intervention and cardioprotective drug management can reduce cardiovascular morbidity and mortality by up to 90%.3 In Ireland, high-risk approaches to prevention have traditionally targeted those with established heart disease, yet there are many asymptomatic individuals with multiple risk factors whose risk is similar to those who have overt heart disease but go unrecognised. With a high prevalence of risk factors in the Irish population,4,5 the need to develop an effective model of prevention that would include asymptomatic individuals at high multi-factorial risk was urgent. In response to this need, Croí, an Irish heart and stroke charity, wanted to develop an effective, evidence-based intervention that would help individuals reduce their CVD risk. In 2009, following a successful business case submission to Galway Primary Community and Continuing Care, HSE (Health Service Executive) West, ‘Croí MyAction’ a nurse-led, community-based, multi-disciplinary CVD prevention programme was established in Galway on the West coast of Ireland.

What is ‘Croí MyAction’?

‘Croí MyAction’ is a 12–16 week vascular prevention programme with an emphasis on lifestyle modification (smoking cessation, healthy food choices and physical activity), medical risk factor management (blood pressure, lipids and glucose) and the prescription of cardioprotective medication, where appropriate. The programme is coordinated by a specially trained multi-disciplinary team (MDT), which includes a nurse specialist, dietitian, physiotherapist, physical activity specialist and physician.

The Croí Heart and Stroke Centre
The Croí Heart and Stroke Centre

Programme recruitment

In establishing the programme, the key stakeholders were engaged from the outset, these included hospital departments (cardiology, vascular, stroke and diabetes), general practice (GPs and practice nurses), public health consultants, primary care services and representatives from relevant community groups. A standardised and efficient referral pathway was agreed, whereby high-risk individuals (score ≥5%,6 type 2 diabetes, peripheral arterial disease) are referred to the programme through a series of pathways, which include general practice and hospital departments, such as cardiology, vascular and endocrinology. Recently, the referral pathway has been expanding to include transient ischaemic attack (TIA) and stroke patients. To date, the majority of referrals come from general practice, with 80% of GPs in the catchment area of Galway referring. Developing a strong communication link has been critical to achieving these high referral rates, and this involves regular meetings and working with referral sources in identifying high-risk patients in their practice or clinic.

One of the key objectives of the programme is to address health inequalities, thus, recruitment is targeted at high-risk, lower socioeconomic groups, such as the travelling community, low income farmers and those living in rural isolation or areas of known deprivation. Using specific pre-screening criteria, opportunistic screening and health checks were offered in local community settings, e.g. supermarkets, community centres and farmers’ markets, which proved to be an effective way of reaching those most at risk. In addition, the programme was promoted using social media, radio, press, public meetings and other communication channels. This targeted approach has been successful, with 34% of patients recruited having a GMS (General Medical Scheme) card, which is a measure of socioeconomic status in Ireland.

Outcomes

The Croí MyAction programme is protocol driven, and outcomes are measured both at end of programme (16 weeks) and at one year. They include the primary end points for lifestyle, risk factor and therapeutic goals, as recommended by the European Society of Cardiology and Joint British Societies’ guidelines (JBS2) for blood pressure.6,7

The programme is successfully recruiting participants and partners with a multiple of risk factors, as is evident in table 1, and is demonstrating significant outcomes for lifestyle, biomedical measures and psychosocial indices, for both patients and partners, at end of programme and at one year.8 The uptake and retention rates are high, with 92.7% of eligible participants attending the initial assessment, 87.2% completing the programme and 93.6% of those who completed the programme attending the one-year follow-up assessment. These rates compare favourably with the 38% cardiac rehabilitation uptake rates in the UK.9 The mean age of participants was 57.5 years, with 49.4% being male. Of those who attended the initial assessment, there was a 61% uptake of partners among those who had a partner to bring.

Table 1. Characteristics of patients and partners at baseline
Table 1. Characteristics of patients and partners at baseline
Croí Nurse Coordinator Anne Marie Walsh with Croí MyAction participants
Croí Nurse Coordinator Anne Marie Walsh with Croí MyAction participants

The majority of patients attending the Croí MyAction programme are obese (table 1), with obesity levels exceeding the national figures for a similar age category in both men (49%) and women (43%) in the general population.4 The Croí MyAction programme is successfully tackling obesity as part of its multi-factorial approach to risk factor management, with significant reductions in body mass index (BMI) and abdominal obesity being achieved. There was increased adherence to the cardioprotective diet, with the observed improvements in the Mediterranean score being associated with a 9% reduction in total mortality, CVD mortality and a 6% reduction in cancer.10 The increase in those achieving physical activity targets can be associated with a 20–30% reduction in CVD events.11 The smoking quit rate compares favourably with specialist smoking cessation programmes in the UK.12 There were significant improvements in blood pressure and cholesterol, the benefits of which are well established. There were also significant reductions in anxiety levels and depression levels, demonstrating the positive effect that a healthy lifestyle can have on quality of life and symptoms of anxiety and depression.13-15 If the improvements achieved on this programme could be sustained, future CVD mortality would be reduced.

The Croí MyAction team
The Croí MyAction team

The success of Croí MyAction is due to a number of key features, which make the programme unique and innovative. Croí MyAction integrates the care of many high-risk priority patient groups for prevention and does not just care for those with established disease, as has happened in the past. This is the first time this type of ‘all-inclusive’ approach to CVD prevention has been adopted in Ireland. The programme is community-based and, thus, easily accessible to the target population, which may account for the high attendance and retention rates. Its multi-disciplinary approach places a strong emphasis on promoting healthy lifestyle habits, recognising that addressing and managing complex lifestyle behaviours requires expertise from a variety of healthcare professionals. The programme is family-based, recognising that risk factors cluster in families, and healthy lifestyle change is easier to achieve if the family changes together.16 The success of the programme as a family-based intervention was borne out by the striking similar changes achieved by partners, compared with patients, across all risk factors.

Conclusion

Croí MyAction Programme Manager, Irene Gibson
Croí MyAction Programme Manager, Irene Gibson

‘Croí MyAction’ is the first and only preventive cardiovascular programme of its kind in Ireland, and already incorporates many important principles that are recommended by the recent National Cardiovascular Health Policy.2 It is setting new standards of preventive cardiovascular care, which have been recognised through the receipt of a number of Irish Healthcare Awards. In developing excellence in CVD prevention, the programme has prompted a number of professional educational initiatives, these include the development of a specialist study module in preventive cardiology for undergraduate medical students at the National University of Ireland (NUI) Galway, short courses in diabetes and weight management, and plans are currently underway to develop a Masters programme in CVD Prevention at NUI Galway.

Acknowledgements

We are grateful for the contributions of Deirdre Henry, Croí MyAction Programme Administrator, Neil Johnson, CEO Croí, West of Ireland Cardiac Foundation, Newcastle, Galway, and Croí MyAction programme participants.

Funding

Croí MyAction is funded by Croí the West of Ireland Cardiac Foundation. Part funding has been received from HSE (Health Service Executive) West, Primary Community and Continuing Care, Galway, Ireland and through an educational grant from MSD Ireland.

References

  1. Central Statistics Office. Press release report on Vital Statistics 2009. Cork: Central Statistics Office, 2009. Available from: http://www.cso.ie/en/newsandevents/pressreleases/ 2012pressreleases/pressrelease reportonvitalstatistics2009/
  2. Department of Health. Changing cardiovascular health. National cardiovascular health policy 2010–2019. Dublin: Government Publications, 2010. Available from: http://www.headway.ie/download/pdf/changing_cardiovascular_health.pdf
  3. Yusuf PS, Hawken S, Ôunpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937–52. http://dx.doi.org/10.1016/S0140-6736(04)17018-9
  4. Morgan K, McGee H, Watson D et al. SLÁN 2007 survey of lifestyle, attitudes and nutrition in Ireland. Main report. Dublin: Government Publications, 2008. Available from: http://www.dohc.ie/publications/slan07_report.html [accessed August 2013].
  5. Gibson I. Heart Smart. A two year report on a community based cardiovascular disease prevention programme in the West of Ireland. Galway: Croí West of Ireland Cardiology Foundation, 2008. Available from: http://www.croi.ie/sites/files/croi/HeartSmartReport.pdf [accessed 29 August 2013].
  6. Perk J, De Backer G, Gohlke H et al.European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012;33:1635–701. http://dx.doi.org/10.1093/eurheartj/ehs092
  7. British Cardiac Society, British Hypertension Society, Diabetes UK et al. JBS2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(suppl 5):v1–v52. http://dx.doi.org/10.1136/hrt.2005.079988
  8. Gibson I, Flaherty G, Cormican S et al. Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland. Eur J Preventive Cardiol 2013;published online. http://dx.doi.org/10.1177/2047487313498831
  9. British Heart Foundation. The National audit of cardiac rehabilitation. Annual statistical report 2009. London: BHF, 2009. Available from: http://www.cardiacrehabilitation.org.uk/docs/2009.pdf
  10. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008;337:a1344. http://dx.doi.org/10.1136/bmj.a1344
  11. Manson JE, Greenland P, LaCroix AZ et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716–25. http://dx.doi.org/10.1056/NEJMoa021067
  12. The NHS Information Centre, Lifestyle Statistics. Statistics on NHS Stop Smoking Services: England, April 2009–March 2010. London: The Health and Social Care Information Centre, 2010. Available from: https://catalogue.ic.nhs.uk/publications/public-health/smoking/nhs-stop-smok-serv-eng-2009-2010/nhs-stop-smok-serv-eng-2009-2010-rep.pdf
  13. Conn VS. Depressive symptom outcomes of physical activity interventions: meta-analysis findings. Ann Behav Med 2010;39:128–38. http://dx.doi.org/10.1007/s12160-010-9172-x
  14. Conn VS. Anxiety outcomes after physical activity interventions: meta-analysis findings. Nurs Res 2010;59:224–31. http://dx.doi.org/10.1097/NNR.0b013e3181dbb2f8
  15. Kuczmarski MF, Cremer SA, Hotchkiss L, Cotugna N, Evans MK, Zonderman AB. Higher Healthy Eating Index-2005 scores associated with reduced symptoms of depression in an urban population: findings from the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) study. J Am Diet Assoc 2010;110:383–9. http://dx.doi.org/10.1016/j.jada.2009.11.025
  16. Pyke SDM, Wood DA, Kinmonth AL, Thompson SG. Change in coronary risk and coronary risk factor levels in couples following lifestyle intervention. The British Family Heart Study. Arch Fam Med 1997;6:354–60. Available from: http://triggered.stanford.clockss.org/ServeContent?url=http%3A%2F%2Farchfami.ama-assn.org%2Fcgi%2Freprint%2F6%2F4%2F354
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

Training opportunities in preventive cardiology: MSc, Diploma and Certificate in Preventive Cardiology

Br J Cardiol 2013;20(suppl 3):S1–S19doi:10.5837/bjc.2013.s09 Leave a comment
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Sponsorship Statement: MSD provided financial support for this publication. The supplement was conceived by the authors. Content and articles were fully developed and written by the authors except the DYSIS article, which was written in collaboration with MSD. Full editorial control of the supplement rested with the authors. The ASPIRE-2-PREVENT study and the Croi MyAction programme, Ireland, were partly funded though unrestricted educational grants by MSD UK and MSD Ireland, respectively. DYSIS was an MSD sponsored study. The supplement was reviewed by MSD for ABPI compliance only.

Insights from the world of cardiology

Introduction

The scientific evidence for cardiovascular (CVD) disease prevention is compelling but, as demonstrated by the EUROASPIRE and ASPIRE-2-PREVENT surveys, translating this evidence into effective patient care in the real-world in clinical practice is challenging.1,2 However, the same academic group have undertaken a number of trials and have shown that it is possible to implement national and international clinical guidelines and achieve the lifestyle, medical and therapeutic targets associated with reduced cardiovascular events and improved health outcomes.3-5 In recognising the need to bridge the implementation gap for prevention and control of cardiovascular diseases, the combined research, teaching and clinical expertise at the National Heart and Lung Institute of Imperial College London launched a Masters (MSc), Postgraduate Diploma (PGDip) and Postgraduate Certificate (PGCert) in Preventive Cardiology. This programme was initiated in October 2008, offers many unique features and consequently remains the only one of its kind worldwide (box 1).

Box 1. Preventive cardiology at Imperial College London

Unique qualities creating a highly fulfilling student experience

Interdisciplinary and international:Inclusive of health professionals from a variety of backgrounds from all over the world

Flexible learning: All programmes include a taught component, which is combined with online learning, enabling students to work flexibly around other commitments. Students are able to interact with their tutors and fellow students via an advanced online virtual learning environment

Comprehensive and integrated: Our programme includes all aspects of preventive cardiology to include patients with established atherosclerotic disease, the relatives of patients with premature atherosclerotic disease, and also individuals who are asymptomatic, for example those with diabetes and those who are at high multi-factorial risk for cardiovascular disease

Knowledge, practical application and research skills acquisition:Clinical placements are completed across key areas of preventive cardiology practice, e.g. cardiovascular risk reduction clinics, cardiac rehabilitation, diabetes and heart failure, providing the opportunity to be immersed in the practicalities of current service delivery, rather than only learning the theory. The research component provides a strong foundation in practical use of research methods in preventive cardiology, and the translation of research evidence into best practice

Interaction with world leaders:Our teaching faculty comprises national and international leaders and clinical specialists from cardiology, nursing, nutrition, exercise and behavioural medicine. Our programme is based in the International Centre for Circulatory Health and, as a result, draws on considerable teaching expertise and provides high-quality research opportunities in a range of relevant subjects. We also have an expert lecture series allowing our students to interact with world leaders in the prevention and management of cardiovascular disease

Imperial College London:Imperial College has a world-renowned reputation and is currently rated in the top 10 universities worldwide

Programme content

The scientific foundation of the programme is lifestyle change (smoking cessation, healthy food choices and physical activity) through behavioural approaches, together with weight management, medical management of blood pressure, blood lipids and blood glucose, and use of cardioprotective drug therapies. All students complete a core compulsory module entitled ‘Preventive Cardiology Theory and Practice’,which includes six themes (box 2). These themes are then explored in greater detail in specialist optional modules. Students, depending on the direction of their studies, also engage in modules in clinical practice (clinical placements), research methods and complete an original research project in the field of preventive cardiology.

Box 2. Main themes of study
Box 2. Main themes of study

Blended programme

This programme aims to be flexible and accommodate each individual’s needs, this arrangement is particularly important for those who are at work and also studying in the programme. Each module starts with a block of face-to-face teaching followed by a number of purposefully designed online learning resources. All of these teaching sessions are recorded using lecture captures, giving our part-time students some flexibility to either attend or alternatively participate via our monitored virtual-learning environment at a convenient time to each individual (figure 1).

Centres of excellence in preventive cardiology

This programme aims to produce graduates equipped to fill specialist posts and set up centres of excellence in preventive cardiology by combining knowledge and skill acquisition with real-world application and research practice – ambassadors of preventive cardiology trained to ‘raise the standards of care in the prevention and management of cardiovascular disease’.

For further information contact: [email protected] or visit:
http://www1.imperial.ac.uk/medicine/teaching/postgraduate/preventivecardiology/

S19 Graduates

References

  1. Kotseva K, Wood D, De Backer G et al.; EUROASPIRE Study Group. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009;373:929–40. http://dx.doi.org/10.1016/S0140-6736(09)60330-5
  2. Kotseva K, Jennings CS, Turner EL et al.; ASPIRE-2-PREVENT Study Group. ASPIRE-2-PREVENT: a survey of lifestyle, risk factor management and cardioprotective medication in patients with coronary heart disease and people at high risk of developing cardiovascular disease in the UK. Heart 2012;98:865–71. http://dx.doi.org/10.1136/heartjnl-2011-301603
  3. Wood DA, Kotseva K, Connolly S et al.; EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008;371:1999–2012. http://dx.doi.org/10.1016/S0140-6736(08)60868-5
  4. Connolly S, Holden A, Turner E et al. MyAction: an innovative approach to prevention of cardiovascular disease in the community. Br J Cardiol 2011;18:171–6. Available from: https://bjcardio.co.uk/2011/08/ myactionaninnovativeapproachtothe preventionofcardiovasculardisease/
  5. Jennings CS, Kotseva K, De Bacquer D et al. EUROACTION preventive cardiology programme plus intensive smoking cessation with Varenicline. Eur J Cardiovasc Nurs 2012;11(suppl 1):S4. http://dx.doi.org/10.1177/1474515112441129
Disclaimer: Medinews Cardiology Limited advises healthcare professionals to consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews Cardiology Limited cannot accept responsibility for any errors in prescribing which may occur.

What’s hot in cardiorenal medicine

Br J Cardiol 2013;20:133-5 Leave a comment
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This year’s 8th Annual Scientific Meeting of the Cardiorenal Forum looked at clinical dilemmas in cardiorenal disease and co-morbidities. The meeting was held at the Royal College of Obstetricians and Gynaecologists, London, October 4th 2013, and endorsed by the Renal Association and the British Society for Heart Failure. Alice Zheng and Katy Watson report on its highlights.

Advances in imaging and diagnosis

Dr Nik Abidin (Consultant Cardiologist, Salford Royal NHS Foundation Trust) kicked off the theme of ‘Advances in diagnosis’ with a tantalising taster of the future of echocardiography, and a demonstration of what is already possible. Patients with chronic kidney disease (CKD) have a high incidence of cardiac dysfunction, with 75% of patients with significant CKD demonstrating left ventricular hypertrophy. In such patients, left ventricular dilatation occurs late with advanced disease, and left ventricular mass is an earlier predictor of cardiac mortality. An increase in left atrium size is the downstream effect of left ventricular dysfunction and is also associated with worse outcome.

Two-dimensional (2D) echocardiography relies on linear beam oscillation to measure ventricular dimensions from still 2D images to calculate ejection fraction (EF). Conventional methods of measurement and calculation e.g. Simpson’s method, or using M-mode measurements have inherent limitations and result in different EFs, allowing only a range of either mild, moderate or severe dysfunction to be reported. This lack of accuracy and reproducibility makes the follow-up of a particular patient throughout treatment difficult. Left ventricular mass can be calculated using measurements from both M-mode and 2D images, incorporated into various mathematical formulae, all based on a spherical geometrical assumption of the left ventricle, and all resulting in different values.

Three-dimensional (3D) echocardiography uses a matrix array ultrasound probe, allowing acquisition of multiple ‘pyramid’ volumes of data (see figures 1a–1d). Once processed, the virtual 3D heart can be sliced and analysed from infinite planes, allowing for the non-geometrical shape of the ventricles. Volume, particularly at the apex, traditionally lost by 2D echocardiography techniques can also be accounted for. It has been demonstrated that using 3D echocardiography to trace the epicardial and endocardial borders in different planes, an individual’s calculated left ventricular mass can be halfof that calculated using 2D techniques.

Fig 1b
Figure 1b. 3D view of closed mitral valve leaflets
Fig 1a
Figure 1a. Transthoracic echo enface view of the mitral valve leaflets, showing calcification with chronic kidney disease. 2D view of closed mitral valve leaflets
Fig 1b
Figure 1d. 3D view of open mitral valve leaflets
Fig 1a
Figure 1c. 2D view of open mitral valve
leaflets

Cardiac magnetic resonance imaging (MRI) is currently the gold standard for assessing cardiac anatomy, function and mass. Jenkins et al.1looked into the reproducibility and accuracy of echocardiography and found little difference between 3D echocardiography and cardiac MRI-measured ventricular volumes, whereas 2D echocardiography gave a variability of up to 50 ml, which potentially could alter the severity class of dysfunction. 3D echocardiography demonstrated consistently narrower variability and more reproducible results when analysed for both inter- and intra-operator variance. Limitations common to 2D echocardiography include the impairment of acoustic windows such as in patients with raised body mass index (BMI) or lung disease, i.e. chronic obstructive pulmonary disease (COPD). 3D techniques are extremely useful in the assessment of valves and foreign lines e.g. pacing wires in relation to the surrounding structures. Most machines already have 3D echocardiography capabilities, and once familiarised with the technique 3D scans are quicker to carry out than the conventional 2D technique.

3D echocardiography is new and exciting; due to its accuracy and reproducibility it has significant applicability in the research field, adding power to studies. It is a valuable assessment tool which we will be seeing more of in the future.

Advances in treatments

Renal denervation is a novel treatment for resistant hypertension. It is a minimally invasive, endovascular catheter-based procedure which uses radiofrequency ablation to target the sympathetic nerves in the adventitia of the renal arteries. The ablation is performed in a swirl pattern with a series of burns (see figure 2), thereby preventing a circular burn which theoretically could result in renal artery stenosis. Resistant hypertension is notoriously difficult to treat, often affects the younger person, and carries a high morbidity from stroke, heart failure (HF) and progressive renal impairment. Renal denervation is currently being performed at certain centres around the UK. The outcomes of the SYMPLICITY trials, and his own clinical experience, were presented by Dr Hitesh Patel, an SpR at the Royal Brompton Hospital, London.

Screen shot 2013-12-04 at 16.50.24
Figure 2. Endovascular catheter using radiofrequency ablation to target the sympathetic nerves of the renal arteries. Courtesy of Medtronic

SYMPLICITY I and II have shown very promising results at 36 months, with a mean systolic blood pressure (BP) reduction of 33 mmHg.2 Equal benefit has been seen amongst those with normal and mildly impaired renal function; however trials to date have excluded patients with an estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 cm2. SYMPLICITY I and II demonstrated from subgroup analysis that this technique was only beneficial in individuals with ambulatory BP satisfying the criteria of resistant BP (i.e. BP ≥160 mmHg systolic despite at least three antihypertensive agents, including a diuretic at maximal tolerated doses).3 These early trials, however, have not been powered for hard cardiovascular end points, and had only 36 months of patient follow-up.

The experience at the Brompton has been of patients tolerating the procedure well, with a mean admission of 24 hours. Complication rates have been low with no renal artery thrombosis. Future studies will allow for a longer follow-up and will look to include individuals with more advanced CKD.

Dr Patel introduced future studies at the Brompton & Harefield Trust with the National Institute for Health Research (NIHR) Cardiovascular Biomedical Research, which will investigate the role of renal denervation in individuals with HF and preserved EF. This is a hard-to-manage patient group with a minimal existing evidence base. Recruitment for this trial started July 2013 and preliminary findings have shown a significant reduction in left ventricular mass, left atrial (LA) volume and left ventricular filling pressure (E/E) at six months post-renal denervation.4 This study excludes individuals with an eGFR <45 ml/min/1.73 m2, contraindications to cardiac MRI, cardiomyopathy or unfavourable renal artery anatomy. Early results are promising, and we can hold out hope for this novel therapy.

Cardiorenal syndrome (CRS) is a major clinical problem for cardiologists and nephrologists, and is an indicator of poor prognosis in individuals with HF which itself carries a high mortality. Currently there is no clear evidence base with which to guide treatment. Novel approaches include renal denervation. Professor Henry Krum (Monash University, Melbourne, Australia) illustrated that in animal models with CRS, renal blood flow and renal vascular resistance improves post-renal denervation.5 SYMPLICITY-HF is a novel trial looking to investigate the role of renal denervation in systolic HF and co-morbid CKD stage II and III. This landmark trial will include those with New York Heart Association (NYHA) Class II–III, a left ventricular EF <40%, eGFR 30–75 ml ml/min/1.73 m2 and on optimal medical therapy.

Trials performed in the cardiorenal population and shortfalls

Table 1
Table 1. Trial acronyms

Cardiorenal medicine lacks well-powered trials. Renal dysfunction is a common exclusion criterion from landmark cardiovascular studies, leaving us with dilemmas in managing our patients. Professor David Goldsmith, (Consultant Nephrologist, Guy’s and St Thomas’ NHS Foundation Hospital, London) presented data from recent trials and highlighted the shortfalls and surprise findings. These included the controversial SHARP study, EVOLVE, and the dialysis trials CONTRAST, OL-HDF and ESHOL (see table 1).

SHARP looked at cardiovascular outcomes in patients treated with simvastatin/ezetimibe versus placebo in the CKD and dialysis population.6 While benefit was seen in CKD, similar to that in the general population, those on dialysis failed to show any benefit. This potentially highlights the different pathogenesis in cardiovascular disease in those on dialysis where the haemodynamic stress of dialysis itself outweighs the traditional risk factors, but it may be a shortfall of the study with this subgroup being underpowered.

EVOLVE looked at cinacalcet in the treatment of secondary hyperparathyroidism in dialysis patients.7 Secondary hyperparathyroidism itself, and its more traditional treatments, result in abnormalities in calcium and phosphate metabolism. High calcium phosphate product is associated with an increased risk for all-cause mortality and cardiovascular morbidity in the dialysis population. This mechanism is likely to be mediated by increased vascular calcification, increased arterial stiffness and left ventricular hypertrophy. This was a landmark trial being the first well-powered randomised control trial focussing on the dialysis population. The trial showed that cinacalcet, a calcimimetic, reduced parathyroid hormone (PTH) successfully but this did not translate to any improvement in cardiovascular outcomes, or any reduction in all-cause mortality. Disappointingly there were inadequacies in the trial design. The placebo group was permitted to continue with “flexible use of traditional therapies” to manage the hyperparathyroidism. Unfortunately, with the more widespread availability of cinacalcet, both arms of the trial were being given the drug, i.e. masking any benefit of the treatment arm and invalidating the outcome.

The three large trials comparing online haemodiafiltration to standard haemodialysis were discussed, the theory being that the more expensive haemodiafiltration enables more efficient removal of beta 2 microglobulin and other non-uraemic toxins than standard dialysis therapy, and would result in less cardiovascular morbidity. However, CONTRAST and OL-HDF failed to show any difference between primary end points despite the surrogate end point showing significant reduction of beta 2 microglobulin. ESHOL did see some benefit but this was small and deemed insufficient to outweigh the increased expense.

This session highlighted the need in cardiorenal medicine for more well-designed and well-powered randomised control trials.

Future promising areas for research

Dr Paul Cockwell (Consultant Nephrologist, Renal Institute of Birmingham) introduced the theme of advancing research in cardiorenal medicine. His work has focussed on serum-free light chains and its use as a prognostic indicator in the progression of CKD. Malignant proliferation with raised monoclonal serum light chains is seen in the plasma cell dyscrasia- light chain myeloma. When a threshold concentration of light chains is reached, overwhelming the renal tubular capacity to reabsorb these proteins, there is overspill into the urine. This phenomenon was first described by Dr Henry Bence Jones in 1847 and detection of light chains in the urine is a technique still used in the diagnosis of myeloma today. The monoclonal element can occur in both the kappa and lambda moiety leading to light chain deposition and is a common treatable cause of renal disease and end-stage renal failure.

In the absence of myeloma, in the context of inflammation or infection, titres of light chains rise. This rise is polyclonal and the ratio of kappa to lambda is unchanged. Light chains, are, in part, renally excreted with 40% kappa and 20% lambda renal clearance respectively; the remainder are cleared by the reticulo-endothelial system. In CKD, renal clearance of light chains is reduced. Increased titres of polyclonalfree light chains in the general population without plasma cell disorders have been shown by both The Mayo Clinic and the UK Haematological Referral Population to be associated with a clear increase in all-cause mortality. Dr Cockwell presented study data from three cohorts of CKD patients from Birmingham, Salford and Derby. Increased serum polyclonal free light chains were shown to be independently associated with all-cause mortality in all three cohorts, and also associated with progression of CKD to renal replacement therapy (RRT).

Serum-free light chain analysis proves to be an exciting area of immunological diagnosis with a possible future role as a biomarker to predict the risk of progression of renal impairment in CKD.

Dilemmas: treating nonvalvular atrial fibrillation in CKD

The important frequently encountered scenario of appropriate anticoagulation in individuals with atrial fibrillation (AF) and CKD was debated at the forum. AF is extremely common with a prevalence of 2% in the general population but is 10–20 times more prevalent in CKD patients. The European Society of Cardiology (ESC) issued new AF guidelines in 20128 which shifted the focus from identifying high-risk patients to identifying truly low-risk patients, i.e. those not requiring anticoagulation. It recommended the use of CHA2DS2Vasc score for thromboembolic risk assessment and the HASBLED score for bleeding risk assessment in AF. Renal impairment was, however, an exclusion criterion in clinical trials and hence risk prediction scores are not validated in CKD. Patients with CKD and AF have a higher risk of thrombotic and bleeding complications. The risk of both complications is greater in dialysis-dependent individuals.

There have been attempts to assess whether renal function itself adds to risk prediction of stroke in AF. The ROCKET AF (rivaroxaban vs. warfarin) cohort was used to validate a new risk score R2CHADS2, involving the addition of 2 points for CrCl <60 ml/min, and identified a hazard ratio (HR) of 1.085.9 Unfortunately the trial cohort was not representative and did not include a range of renal dysfunction. Conclusions from this trial were that renal impairment does not add predictive value to existing risk scores. Deteriorating renal function, however, is a strong marker of poor outcome. Guo et al. found a relative reduction in eGFR of ≥25% over two years to independently predict the risk for ischaemic stroke or death at six months.10

Warfarin has been shown to decrease stroke risk significantly in CKD patients including those on dialysis, but aspirin alone does not. Anticoagulation and aspirin both increase the risk of bleeding, particularly in patients requiring dialysis. Trials with novel anticoagulants excluded those with advanced CKD eGFR <30 ml/min/1.73m2 and aren’t licensed in this population.

Dr Amitava Banerjee (Honorary Specialist Registrar, City Hospital, Birmingham) reiterated the need for further studies of change in renal function and clinical outcomes, as well as the need for trials of novel anticoagulants in renal failure. The management of AF and the decision to anticoagulate in CKD patients, especially those on RRT, remains complex given the paucity of evidence and known significant complications, including increased bleeding risk, and calciphylaxis with use of the coumarin agents. Pending further trials, the consensus of opinion from the meeting was to carefully consider each case on an individual basis.

Future

There are still many unknowns and uncertainties in the treatment of the high-risk cardiorenal population. This year’s forum has highlighted the shortfalls, and shed light on promising future areas of progress

Dr Kathryn Watson
Specialist Registrar, Renal Medicine
([email protected])

Dr Alice Zheng
Senior House Officer, Cardiology

Queen Alexandra Hospital, Portsmouth, PO6 3LY

References

1. Jenkins C, Chan J, Bricknell K, Strudwick M, Marwick TH. Reproducibility of right ventricular volumes and ejection fraction using real-time three-dimensional echocardiography: comparison with cardiac MRI. Chest 2007;131:1844– 51. http://dx.doi.org/10.1378/ chest.06-2143

2. Esler MD, Krum H, Schlaich M, et al. Renal sympathetic denervation for treatment of drugresistant hypertension: one-year results from the Symplicity HTN- 2 randomized, controlled trial. Circulation 2012;126:2976–82. http://dx.doi.org/10.1161/ CIRCULATIONAHA.112.130880

3. Mahfoud F, Ukena C, Schmieder RE, et al. Ambulatory blood pressure changes after renal sympathetic denervation in patients with resistant hypertension. Circulation 2013;128:132–40. http://dx.doi.org/10.1161/ CIRCULATIONAHA.112.000949

4. Brandt MC, Mahfoud F, Reda S, et al. Renal sympathetic denervation reduces left ventricular hypertrophy and improves cardiac function in patients with resistant hypertension. J Am Coll Cardiol 2012;59:901–9. http://dx.doi.org/10.1016/j. jacc.2011.11.034

5. Clayton SC, Haack KK, Zucker IH. Renal denervation modulates angiotensin receptor expression in the renal cortex of rabbits with chronic heart failure. Am J Physiol-Renal 2011;300:F31–9. http://dx.doi. org/10.1152/ajprenal.00088.2010

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