Editorial articles

When I first arrived at Whitby Group Practice (WGP) in the middle 80s, my surgery was next to Whitby Hospital Outpatients, where Anthony Bacon conducted his cardiology clinic. Dr Bacon’s article on aortic stenosis was in our previous issue.¹ In this issue, Tariq Enezate and colleagues add to our knowledge of managing this condition.²

Women are underrepresented in cardiology and there is a focus on increasing entry to the specialty and understanding how to overcome challenges. At the British Cardiovascular Society (BCS) annual conference 2019, there was a session dedicated to discussing barriers faced by women in cardiology and progress made in this area, making a ‘call to action’ for change. Representing and supporting women in cardiology is a priority of the BCS and the British Junior Cardiologists’ Association (BJCA). The BJCA has undertaken commendable work exploring challenges and proposing potential solutions: much of the data discussed in this article are from their annual survey or was reported at BCS 2019.

The All-Party Parliamentary Inquiry¹ into heart failure reported in September 2016. The inquiry’s aim was to understand what the key issues were in heart failure and what needs to happen to address deficiencies. Data presented to the inquiry highlighted the significant impact of the role played by the heart failure specialist nurse (HFSN). The evidence-base behind the role of the HFSN has shown that these highly skilled individuals have been able to reduce morbidity, mortality and provide patients and carers with holistic and effective care.² The patients that contributed to the inquiry spoke of the immense support and care that they received from their HFSN. However, further data emphasised that access to a HFSN was inequitable, with anecdotal experience suggesting that services are being decommissioned as a result of reorganisation of services and nurse retirement.

The concept of nurse-led angiography was first introduced in the UK just over two decades ago. This was in response to concerns raised following implementation of the Calman report.¹ The Calman report recommended a structured training programme for cardiology registrars, thus, achieving clinical competence at a faster rate, with a view to filling anticipated consultant vacancies. However, it was presumed that this would negatively impact clinical service delivery. One particular concern was that there would be a reduced number of registrars available and able to perform coronary angiography. There was a fear that this shortfall would lead to reduced throughput within cardiology centres. Boulton et al. described a potential solution to this shortfall: the training of a clinical nurse specialist to perform coronary angiography.² The aim was to teach the nurse-angiographer the technical skills to undertake coronary angiography, with a head-to-head comparison of procedural time, radiation exposure, and complication rate. The results were impressive with the nurse-angiographer demonstrating a numerical reduction in complication rate and fluoroscopy time. These results were similar to those of DeMots et al., who trained a physician assistant in Portland, Oregon to perform coronary angiography with a view to reducing the workload of trainee cardiologists.³

In this issue of the British Journal of Cardiology Yasin et al. describe the implementation of nurse-led angiography at Wycombe Hospital. Although not novel, the findings are certainly interesting. They performed a comparison of nurse-led coronary angiography with registrar-led angiography in an observational study of 200 patients. They examined procedural time, radiation exposure, contrast load and complication rates. Albeit small numbers, they demonstrated that nurse-led angiography was associated with a reduction in radiation and contrast load, concluding that a non-medical operator can be taught the technical skills required to perform coronary angiography safely. However, the observational nature of this study limits the conclusions that can be drawn. Although appropriate at an early level of training, the patients that underwent nurse-led angiography were a highly select ‘safe’ patient group, and, without baseline characteristics, it is not possible to determine if one arm of the study had more comorbidities than the other.

Atrial fibrillation (AF) and diabetes are chronic conditions, which are increasing in prevalence. Stroke is a recognised complication of both conditions and can often be prevented through detection and appropriate intervention. Screening for disease has also improved over the last few decades through a plethora of tools and advances in technology. AF impacts physically, psychologically, socially and economically, and does not always present with symptoms. AF can be detected through electrocardiogram (ECG) monitoring and pulse checks, with high-risk groups typically targeted. When AF is detected, medication to control heart rate and anticoagulation can be started to reduce subsequent risks. AF is underdiagnosed in the community, particularly in the elderly, and the condition lends itself to screening.¹

A review of the evidence for AF screening demonstrates a lack of homogeneity, with different target populations. High-risk groups have varied and include those with hypertension, stroke, myocardial infarction, older age and diabetes. Although the pathophysiological relationship between AF and diabetes is not entirely understood, there is an acceptance that the coexistence imposes greater risk to the patient in terms of comorbidities including stroke.

It is widely known that physical activity provides strong physical, psychological and cognitive health benefits, with over 20 different conditions showing prevention and treatment effects,¹ including mortality reductions comparable with drug treatments in heart failure and stroke.² Economic effects are important, with physical inactivity responsible for approximately 13.4 million disability-adjusted life-years worldwide, over $100 billion in healthcare expenditure in the US,³ and £0.9 billion in the UK,¹ annually. Yet, despite this, around 40% of UK adults report being insufficiently active for health, worse with increasing age and socio-economic deprivation.¹ Objectively measured findings are much worse, only 5% achieve guidelines by accelerometry, compared to 50% by self-report.⁴

Over the last few decades there has been a steady increase in life-expectancy leading to an increase in the ageing population, placing significant demands on health and social care.¹ Among the several healthcare issues that confront older people, frailty has emerged as an important entity, and tackling frailty has assumed greater significance.² There is currently no single agreed definition of frailty, but it is widely accepted as a condition characterised by reduced response to stressors consequent to decline in multiple physiological systems associated with ageing. Prevalence of frailty in community-dwelling older adults is estimated to be around 10–14%, but figures between 4% and 49% have been quoted in various populations.^3,4 Prevalence also varies with age, with around 7% in adults over 65 years, increasing up to 25% in those aged 80 years and above.⁵ There are a number of tools to detect frailty, and the most commonly used tool is the criteria proposed by Fried and colleagues based on data from the Cardiovascular Health Study, which assesses five domains, namely weight loss (≥5% weight loss in the past year), exhaustion (effort required for activities), slow walking speed (>6–7 s per 15 feet), weakness as measured by grip strength and decreased physical activity (kilocalories/week: male <383, female <270), with the presence of three or more of these fulfilling the criteria for frailty.⁵

The paradigm for glucose control in type 2 diabetes has been based on historic and landmark studies demonstrating the unquestionable microvascular benefits of good glycaemic control.^1-3 However, whether better control improves survival and prevents cardiovascular events has been less consistently shown, with one notable study, ACCORD (Action to Control Cardiovascular Risk in Type 2 Diabetes), showing an increased risk of cardiovascular death with tight control.² Over the past few years, a number of randomised, placebo-controlled, cardiovascular outcome trials (CVOTs) testing novel glucose-lowering agents have demonstrated beneficial effects on mortality and cardiovascular events. This has prompted a change in emphasis away from solely targeting glycaemic control in diabetes, and focusing on reducing cardiovascular events and improving survival.

Twitter is a web-based micro-blogging service in which messages called ‘Tweets’, which may include visual media, are shared with followers of the account. Benefits include continuing education, networking and personal branding. This article examines the current use of Twitter among UK-based cardiologists, and General Medical Council guidance on social media interaction.

UK cardiologists using Twitter were identified by reviewing the Twitter accounts followed by the British Cardiovascular Society using an analysis programme (Twitonomy). An iterative process of tracing accounts followed by UK cardiologists was then undertaken. The last 20 Tweets of the 10 UK cardiologists most followed by other cardiologists were then reviewed for content.

There were 301 UK cardiologists identified. The most common location was London, the sub-specialty intervention, and the majority were consultants. Most had tweeted within the past month, and over 100 times. Content analysis of Tweets revealed 64% were cardiology-related, and 80% related to cardiology/medicine/science.

In conclusion, Twitter has been adopted by a relatively small group of UK cardiologists, but evidence suggests that those who have find it useful. While professionalism and patient confidentiality remain valid concerns, Twitter should be promoted as a location-independent, time-efficient way to network, and keep pace with current research and practice.

Congenital heart disease (CHD) is the most common congenital anomaly, with an estimated prevalence of eight per 1,000 births.¹ However, reliable data on long-term survival for this heterogeneous group of patients are still lacking. Previous population-based studies from the US reported age-standardised mortality rates secondary to CHD of 1.2 per 100,000.² Mortality was highest during infancy (48.1% of all deaths occurred under the age of one year), however, the majority of the remaining deaths occurred outside of childhood, following transition to adult care. Yet, while it is accepted that individuals with CHD may have a higher mortality compared with the general population, the wide spectrum of disease means interpretation of population-based mortality rates for individual lesions is difficult. Additionally, a significant number of studies report only on short-term follow-up, meaning that long-term outcomes are unknown. A previous systematic review reported pooled survival estimates for common CHD lesions, however, it only included studies from hospital-based cohorts with survival estimates calculated from the time of surgical repair.³ It, therefore, does not account for those patients who do not need surgical intervention and may not be representative of all patients with CHD. Knowing the expected mortality rates for CHD is not only important for family counselling, but also in service planning.