The British Cardiovascular Society (BCS) annual conference returned to the Manchester Central Convention Complex on the 5th–7th June 2023. The focus this year was on workforce, resilience, sustainability and multi-disciplinary working. Dr J. Aaron Henry reports selected highlights from BCS 2023.
What is the future of cardiovascular health?
NHS Medical Director Professor Sir Stephen Powis opened the conference by outlining the growing need to provide high quality cardiovascular care. With a quarter of deaths in England attributable to cardiovascular disease and a wider cost to the economy of £15.8 billion per year,1 there is an urgent need for innovative care pathways and new technologies.
He showcased virtual wards as one example of innovation, with over 100,000 patients having been managed remotely in 2022.2 In Liverpool, a Telehealth team has successfully utilised a medical monitoring app to manage patients at home, leading to a 10% decrease in all-cause readmissions and a 10% decrease in 30-day all-cause mortality. Similar initiatives are being implemented across the country.
Professor Powis emphasised the importance of preventive medicine. Data from 2019 reveal that 42% of poor health and premature deaths in England were linked to modifiable risk factors, such as diet, alcohol, and tobacco.3 He urged local health leaders to prioritise dedicated secondary prevention programmes to address hypertension, dyslipidaemia, obesity and atrial fibrillation. Such programmes have already shown promise, with a 7% decrease in the incidence of type 2 diabetes observed in practices implementing the NHS diabetes prevention program.
Finally, Professor Powis emphasised the importance of research and innovation in cardiovascular health. Artificial intelligence (AI) is already impacting the field, with 86% of stroke units using AI-assisted image analysis and new technologies such as CaRiHeart being developed to harness AI-image analysis to predict coronary event risk.
Can precision medicine become medicine?
This year’s BCS lecture was delivered by Professor Dame Anna Dominiczak (University of Glasgow). She discussed how genetics has revolutionised our understanding of hypertension, with over 30 genes associated with monogenic hypertension and over 1,477 single nucleotide polymorphisms (SNPs) identified as polygenic risk factors.4 Such knowledge may be utilised in generating polygenic risk scores to predict risk of disease or to identify patients who may respond to certain therapies. The ongoing BHF UMOD trial seeks to achieve the latter by investigating a genotype-based treatment strategy for loop diuretic use in hypertension.5 Professor Dominiczak outlined that with the increasing amounts of multi-omic data and network modelling techniques, precision medicine may simply become routine medical practice.
Can genetics give promise to CureHeart?
In the Thomas Lewis BCS Lecture, Professor Hugh Watkins (University of Oxford) presented the CureHeart project, winner of the British Heart Foundation (BHF) Big Beat Challenge and £30 million in funding to find a cure for inherited cardiomyopathies. The project is a multinational collaboration of principally eight research groups with expertise in cardiomyopathy genetics and emerging gene editing techniques.
Professor Watkins outlined the two broad categories of challenges the project would seek to overcome.
Firstly, identifying who to treat, when to treat them and how to monitor treatment effects, given that patients with similar genetic mutations have a heterogeneous clinical presentation and disease progression. A combination of rare variant mutations, polygenic risk scores and family history are being utilised to inform patient identification. Advances in cardiac magnetic resonance imaging (CMR) techniques such as myocardial energetics and blood oxygenation dependent (BOLD) imaging are currently showing promise in detecting biofilament defects before changes in volumes.
Secondly, there is a need for gene editing techniques to allow gene supplementation or silencing, with the team investigating both reversible (e.g. antisense) and one-time (e.g. editing) approaches for each. One promising approach is that of base editing, with recent work showing that a single intrathoracic injection of an adenosine base editor prevented hypertrophy and fibrosis in a mouse model of hypertrophic cardiomyopathy.6
New frontiers in interventional cardiology
Is RDN the cure for hypertension?
Hypertension is the leading modifiable risk factor for mortality but only half of those affected are aware of their condition, and only half of those receive adequate treatment.7 Professor Andrew Sharp (University Hospital of Wales, Cardiff) highlighted the need for alternative strategies to address hypertension, such as renal denervation (RDN).
First attempted over 70 years ago, sympathectomy procedures result in significant reductions in blood pressure but also a high side-effect burden. This led to more selective strategies to target renal innervation. A randomised, sham-controlled trial, SYMPLICITY HTN-3, investigated RDN for resistant hypertension, and whilst finding a significant decrease in blood pressure in those undergoing RDN, this was similar to the reduction in the sham procedure group.8 More recently, however, a meta-analysis of three sham-controlled ultrasound RDN trials (RADIANCE II, SOLO, TRIO) showed the reduction in ambulatory blood pressure at two months was greater in those undergoing RDN.9 New National Institute of Health and Care Excellence (NICE) guidance is now in place permitting RDN in cases of resistant hypertension under special arrangement.10
Tricuspid intervention – the forgotten valve?
Tricuspid regurgitation (TR) is increasing in prevalence and has a significant morbidity and mortality, as does tricuspid valve surgery. Dr Rob Smith (Royal Brompton and Harefield Hospitals, Harefield) outlined the current transcatheter intervention options, including leaflet devices, coaptation devices, annuloplasty systems, caval valve implantation and tricuspid valve replacement. Particular focus was paid to the transcatheter edge-to-edge repair (TEER) procedure. In the randomised, controlled TRILUMINATE study, TEER reduced the severity of TR and improved quality of life compared to medical therapy.11 Further work must be conducted to identify which patients should be offered treatment, and whether we should intervene at an earlier stage in lower-risk patients.
Should a cardiologist offer MT in acute ischaemic stroke?
Currently only 3% of patients in the UK receive emergency mechanical thrombectomy (MT) due to limited staffing and training. Dr Helen Routledge (Worcestershire Acute Hospitals NHS Trust, Worcester) discussed the possible role for interventional cardiologists in providing this service, with a General Medical Council credentialling service for acute stroke interventions being finalised. This is particularly important given the limited effectiveness of thrombolysis for those with large vessel occlusions, and that MT has a number needed-to-treat of 2.6 for a 1-unit improvement in the modified Rankin scale.12
How to manage epidemics: innovative primary care service models
Innovative primary care service models were discussed in a session looking at how to manage the epidemics of atrial fibrillation (AF), heart failure and dyslipiadaemia in primary care.
Professor Ahmet Fuat (GPSI, Darlington; and Durham University) outlined the ‘Detect, Protect, Perfect’ pathway for AF.
- Detect – raising public awareness and targeted detection using a pulse check
- Protect – ensuring those who would benefit from anticoagulation receive it
- Perfect – ensuring those requiring anticoagulation are on the correct dose
He highlighted the use of a stroke prevention in AF tool – Oberoi SPAF – in Darlington which can identify patients with AF in the medical record and optimise their anticoagulation treatment.
Mr Jaya Authunuri (Clinical Pharmacist, Bridlington Primary Care Network) promoted pharmacist-led in-practice heart failure clinics for uptitration of prognostic medicines and patient education. These have brought:
- Regular liaison with the heart failure multidisciplinary team (MDT) for challenging cases
- Planning for this to be replicated across surgeries in the primary care network.
Dr Peter Carey (South Tyneside and Sunderland NHS Foundation Trust) showcased the use of electronic patient records to identify those at high risk of familial hypercholesterolaemia. This has led to the development of a Northern England Evaluation and Lipid Intensification (NEELI) guideline to ensure those undergoing lipid-lowering therapy are treated to target.
Michael Davies Early Career Award
Professor Vanessa Ferreira (University of Oxford) received the Michael Davies Early Career Award for her work on quantitative tissue characterisation using CMR imaging. CMR T1 mapping techniques can be used to non-invasively detect particular changes in myocardial water content, which can occur in ischaemia and fibrosis. Professor Ferreira’s early work focused on the development of a Shortened Modified Look-Locker Inversion (ShMOLLI) recovery method of generating T1 maps, shortening the breath hold to 10s and therefore allowing wider clinical applications.13 Subsequent work has shown the utility of the technique in detecting infarction and myocarditis, and also subclinical myocardial inflammation in systemic conditions such as rheumatoid arthritis, systemic sclerosis and systemic lupus erythematosus.
Professor Ferreira’s more recent work has focused on the development of contrast-free CMR techniques. Using an AI-based, deep-learning model trained on contrast-free T1 maps and cine images, Professor Ferreira and her team developed a virtual native enhancement imaging technology. This allowed generation of ‘virtual’ late gadolinium images with lower costs, quicker scan times and without the need for gadolinium.14 This technique has now been validated in ischaemic and non-ischaemic pathologies, with future work planned in different patient populations.
Young Investigator Award
Five candidates gave excellent presentations in the competition for the Young Investigator Award.
Ms Konstantina Amoiradaki (King’s College London) presented work using fibrosis-specific MR contrast agents to quantify cardiac fibrosis in a mouse model of myocardial infarction. She also showed that intramyocardial delivery of a novel cardioprotective and antifibrotic factor, Chrdl1, was able to reduce infarct size, fibrosis area and preserve cardiac function.
Dr Maddalena Ardissino (University of Cambridge; Imperial College London) presented work on modelling the predicted effect of lowering low-density lipoprotein cholesterol (LDL-C) in pregnancy on congenital malformations. Using Mendelian randomisation, Dr Ardissino found an association between LDL-C lowering via PCSK9 inhibition with congenital malformations, providing evidence to support the avoidance of PCSK9 inhibitors in pregnancy.
Dr Amrit Chowdhary (University of Leeds) presented work using advanced CMR imaging to investigate the effect of liraglutide on myocardial function in patients with type 2 diabetes. Dr Chowdhary showed that liraglutide improved myocardial stress perfusion, myocardial energetics and six-minute walk distance.
Dr Krishnaraj Rathod (Queen Mary University of London) presented work from the NITRATE-OCT study investigating the effects of dietary nitrate on stent restenosis in patients with stable angina. In this randomised control trial of 300 patients, Dr Rathod found that a once-daily shot of beetroot juice for six months resulted in a significant reduction in late lumen loss and a trend towards a reduction in major adverse cardiovascular events at two years.
Dr Arunashis Sau (Imperial College London) presented work utilising neural networks to identify ECG morphological features associated with adverse outcomes. From 1.6 million ECGs, three phenogroups emerged, with one phenogroup being associated with a poorer prognosis, even when only ECGs designated as normal were included.
Congratulations to the final winner Dr Arunashis Sau, and to all candidates for their excellent work and presentations.
Top 10 trials
The top 10 recent cardiovascular trials were discussed at the meeting and summarised in table 1.
Table 1. Top 10 trials discussed at the BCS
|Take home message
|In patients with severe ischaemic left ventricular dysfunction, revascularisation by PCI did not reduce all-cause death or heart failure hospitalisation
|In patients with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to delayed complete revascularisation, and associated with a lower risk of MI
|Acetazolamide in addition to loop diuretics in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion
|A rapid uptitration of heart failure medication following an acute admission improved quality of life and reduced the 180-day all cause death or heart failure readmission
|After five years, undergoing comprehensive cardiovascular screening did not significantly reduce all-cause mortality, but did reduce a composite end point of death, stroke or MI by 7%
|In patients with persistent AF, atrial low-voltage myocardium ablation in addition to pulmonary vein isolation (PVI) was superior to PVI alone in reducing atrial arrhythmia recurrence
|In heart failure patients with non-ischaemic cardiomyopathy and left bundle branch block, left bundle pacing demonstrated a greater improvement in LVEF than biventricular pacing
|In patients with stable chest pain and an intermediate pre-test probability of CAD, the risk of death, stroke and MI was similar between those undergoing a CTCA vs. invasive coronary angiogram
|National Trends in Coronary Artery Disease Imaging23
|CTCA is increasing in use and its greater regional use is associated with fewer hospitalisations for MI and a more rapid decline in CAD mortality
|In statin-intolerant patients with or at high risk of atherosclerotic CVD, bempedoic acid was associated with reduced major adverse cardiovascular events
|Key: AF = atrial fibrillation; CAD = coronary artery disease; CTCA = computed tomography coronary angiography; LVEF = left ventricular ejection fraction; MI = myocardial infarction; PCI = percutaneous coronary intervention
Training the next generation at BCS
This year the conference featured:
- An imaging village for transthoracic echocardiography (TTE), transoesophageal echocardiolography (TOE), computed tomography (CT), CMR and nuclear
- a simulator village for transcatheter aortic valve implantation, percutaneous coronary intervention, pacing and pericardiocentesis
- sessions on cardiac laboratory emergency medical simulations (CLEMS); introductory nuclear and CT courses and lifelong learning interactive sessions.
Much discussion was had at the conference on the new curriculum for cardiology. These discussions focused on the most notable change, namely the requirement to dual accredit in general internal medicine (GIM) and the difficulty in finding GIM supervisors. Concerns were raised as to how this requirement would impact upon trainees’ ability to obtain sufficient competencies in cardiology. The British Junior Cardiologists’ Association (BJCA) encouraged trainees to make use of their newly developed GIM calculator to prospectively monitor time spent on GIM rotas (https://bjca.tv/gim-training-time-calculator/).
The BJCA also announced the results of the 2023 trainee survey. This was the 19th year of the survey, generating over 400 responses from trainees across the UK. Headline figures were:
- 30% of trainees stated that the new curriculum has made them less likely to consider academia
- 20% of trainees felt burnt out, with GIM requirement being the most common reason
- 11% of trainees reported that they had been bullied, the majority by consultant cardiologists.
Next year’s BCS meeting will be held on the 3rd–5th June 2024 in Manchester Central Convention Complex.
Conflicts of interest
J. Aaron Henry
Academic Foundation Doctor
Oxford Centre for Clinical Magnetic Resonance Research
University of Oxford
1. British Heart Foundation. Heart & Circulatory Disease Statistics 2023. https://www.bhf.org.uk/what-we-do/our-research/heart-statistics/heart-statistics-publications/cardiovascular-disease-statistics-2023 (last accessed 5th July 2023)
2. O’Dowd A. Virtual wards: Staffing gaps threaten national plan, warn leaders. BMJ 2023;381:1205. https://doi.org/10.1136/bmj.p1205
3. Institute for Health Metrics and Evaluation (IHME). United Kingdom Profile. Data from Global Burden of Disease Study 2019. https://ghdx.healthdata.org/gbd-2019
4. Padmanabhan S, Dominiczak AF. Genomics of hypertension: the road to precision medicine. Nat Rev Cardiol 2021;18:235–50. https://doi.org/10.1038/s41569-020-00466-4
5. McCallum L, Brooksbank K, McConnachie A, et al. Rationale and design of the Genotype-Blinded Trial of Torasemide for the Treatment of Hypertension (BHF UMOD). Am J Hypertens 2021;34:92–9. https://doi.org/10.1093/ajh/hpaa166
6. Reichart D, Newby GA, Wakimoto H, et al. Efficient in vivo genome editing prevents hypertrophic cardiomyopathy in mice. Nat Med 2023;29:412–21. https://doi.org/10.1038/s41591-022-02190-7
7. Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol 2020;16:223–37. https://doi.org/10.1038/s41581-019-0244-2
8. Bhatt DL, Kandzari DE, O’Neill WW, et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014;370:1393–1401. https://doi.org/10.1056/nejmoa1402670
9. Kirtane AJ, Sharp ASP, Mahfoud F, et al. Patient-level pooled analysis of ultrasound renal denervation in the sham-controlled RADIANCE II, RADIANCE-HTN SOLO, and RADIANCE-HTN TRIO trials. JAMA Cardiology 2023;8:464. https://doi.org/10.1001/jamacardio.2023.0338
10. National Institute for Health and Care Excellence (NICE). Percutaneous transluminal renal sympathetic denervation for resistant hypertension. Interventioanl procedures guidance (IPG 754). Published 1 March 2023. https://www.nice.org.uk/guidance/ipg754 (last accessed 5th July 2023)
11. Sorajja P, Whisenant B, Hamid N, et al. Transcatheter repair for patients with tricuspid regurgitation. N Engl J Med 2023;388:1833–42. https://doi.org/10.1056/nejmoa2300525
12. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723–31. https://doi.org/10.1016/s0140-6736(16)00163-x
13. Piechnik SK, Ferreira VM, Dall’Armellina E, et al. Shortened Modified Look-Locker Inversion recovery (ShMOLLI) for clinical myocardial T1-mapping at 1.5 and 3 T within a 9 heartbeat breathhold. J Cardiovasc Magn Reson 2010;12:69. https://doi.org/10.1186/1532-429x-12-69
14. Zhang Q, Burrage MK, Lukaschuk E, et al. Toward replacing late gadolinium enhancement with artificial intelligence virtual native enhancement for gadolinium-free cardiovascular magnetic resonance tissue characterization in hypertrophic cardiomyopathy. Circulation 2021;144:589–99. https://doi.org/10.1161/circulationaha.121.054432
15. Perera D, Clayton T, O’Kane PD, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022;387:1351–60. https://doi.org/10.1056/nejmoa2206606
16. Diletti R, Den Dekker WK, Bennett J, et al. Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial. Lancet 2023;401:1172–82. https://doi.org/10.1016/s0140-6736(23)00351-3
17. Mullens W, Dauw J, Martens P, et al. Acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med 2022;387:1185–95. https://doi.org/10.1056/nejmoa2203094
18. Mebazaa A, Davison B, Chioncel O, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet 2022;400:1938–52. https://doi.org/10.1016/s0140-6736(22)02076-1
19. Lindholt JS, Søgaard R, Rasmussen LM, et al. Five-year outcomes of the Danish cardiovascular screening (DANCAVAS) trial. N Engl J Med 2022;387:1385–94. https://doi.org/10.1056/nejmoa2208681
20. Huo Y, Gaspar T, Schönbauer R, et al. Low-voltage myocardium-guided ablation trial of persistent atrial fibrillation. NEJM Evid 2022;1. https://doi.org/10.1056/evidoa2200141
21. Wang Y, Zhu H, Hou X, et al. Randomized trial of left bundle branch vs biventricular pacing for cardiac resynchronization therapy. J Am Coll Cardiol 2022;80:1205–16. https://doi.org/10.1016/j.jacc.2022.07.019
22. Maurovich-Horvat P, Bosserdt M, Kofoed KF, et al. CT or invasive coronary angiography in stable chest pain. N Engl J Med 2022;386:1591–1602. https://doi.org/10.1056/nejmoa2200963
23. Weir-McCall JR, Williams MC, Shah ASV, et al. National trends in coronary artery disease imaging: associations with health care outcomes and costs. JACC Cardiovasc Imaging 2023;16:659–71. https://doi.org/10.1016/j.jcmg.2022.10.022
24. Nissen SE, Lincoff AM, Brennan D, et al. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients. N Engl J Med 2023;388:1353–64. https://doi.org/10.1056/nejmoa2215024