Editorial articles

The burden of hypertension in the UK is profound.¹ It is the leading modifiable risk factor for cardiovascular disease, chronic kidney disease and vascular dementia, affecting approximately 30% of adults, with an estimated 4.2 million remaining undiagnosed – an alarming figure that underscores longstanding gaps between evidence and implementation in routine care.^2–5 Against this backdrop, the British and Irish Hypertension Society (BIHS), in partnership with the British Heart Foundation Clinical Research Collaborative (BHF‑CRC), has developed the first national, consensus‑driven effort to define future research priorities in hypertension.⁶ This represents a landmark initiative: a structured attempt to align research, policy, and clinical services with the realities of modern hypertension care.

Over eight million UK citizens are at unnecessary risk of the avoidable consequences of hypertension because of inadequate blood pressure (BP) control.¹ Improving this is a key objective of the Department of Health and Social Care, and is one of the five major priorities in the NHSE Core20PLUS5 approach to reducing healthcare inequalities.² The national emphasis on hypertension case finding and management requires a significant increase in the availability of specialist advice and management, which can improve control and outcomes.

“There’s a ghost in the library”

Documentation in medicine has transformed in the last 10 years: notes no longer scatter across the floor to reveal hurriedly scribbled ward rounds without signature or ownership. In the digital era, we can proudly say that ‘if it wasn’t written down it didn’t happen’. By extension, in the modern world of acute echocardiography, if it wasn’t ‘uploaded and reported’, it didn’t happen. These ‘ghost studies’ roam hospital corridors ready to interfere with patient care in maverick ways. All we are left with clinically is a rumour that a study possibly happened. There should be zero ‘ghost studies’ in our library. But, evidently, the ghosts are yet to be busted.

Cardiovascular medicine is undergoing transformation driven by machine learning (ML) technologies.¹ Algorithms now assist in imaging interpretation, electrocardiogram (ECG) analysis, and outcome prediction, with increasing sophistication.^1,2 The adoption of ML-powered diagnostic tools in cardiology is growing, yet training programmes remain largely unchanged, creating a disconnect between skills taught and those required in contemporary practice.^1–4

Despite rigorous clinical preparation, many cardiology trainees complete their education with insufficient knowledge of the ML technologies increasingly present in clinical workflows.^5,6 As these applications become more prevalent, training programmes must integrate relevant ML education to ensure cardiologists can effectively evaluate, implement, and collaborate with artificial intelligence (AI) systems, rather than merely function as passive end-users of increasingly sophisticated technology.

Every week, patients present to emergency departments (EDs) following an episode of transient loss of consciousness (TLoC) due to syncope. It is common, affecting 40% of the population, and it constitutes 1–3% of ED visits and up to 6% of all hospital admissions.^1,2 The US Society for Academic Emergency Medicine – Guidelines for Reasonable and Appropriate Care in the Emergency Department (SAEM GRACE) review found that among ED patients, up to 50% remain undiagnosed after initial evaluation, that hospitalisation rates were highly variable, and approximately one-third of admitted patients are discharged without a definite diagnosis.³ Along with this, patients are subjected to unnecessary investigations, which contribute to escalating healthcare costs.⁴

Syncope is common, disabling, and, if mismanaged, potentially dangerous, both in terms of missed diagnoses or needless and harmful stays in hospital. Yet across health systems, it continues to fall between the cracks. It is time to build bridges: connecting emergency care, cardiology, neurology, geriatrics and acute medicine, through cohesive pathways that are early, equitable, efficient, and delivered by experts.

As Sutton and de Lange remind us, syncope is a symptom, not a diagnosis, and must be taken seriously.⁵ It should no longer be the orphan condition with no home. Despite not belonging in one specialty, a coordinated approach and collaboration should be forged between specialties.

Ischaemic heart disease remains the number one cause of mortality worldwide, with chest pain being one of the most common presentations to both primary care and cardiology services. Suspected angina referral pathways have become well established within NHS practice through rapid access chest pain clinics (RACPC), allowing prompt specialist assessment. While the expansion of access to noninvasive imaging has significantly enhanced risk stratification and management of patients with obstructive coronary artery disease (CAD), questions remain about the suitability of this rule-in/rule-out approach for all individuals referred to RACPC.

Most cardiologists view themselves as strong, hardened clinicians with a broad knowledge-base, alongside (sometimes very) specialist expertise. As clinicians we are seen to embody the quintessential type A stereotype, impervious to most emotional traumas, managing and coping with frequent, both sudden and slow, demises and challenging, complex and often time-pressured, scenarios.

I am no stranger to the demands of a profession that requires precision, composure, and resilience. Yet, behind the façade of clinical and academic competence, lies a reality that many of us, including myself, are reluctant to confront: the personal and professional toll that psychiatric illness can take on physicians.

Cardiovascular disease (CVD) is one of the leading causes of death and disability in the UK. The implications for the NHS are profound, as increasing hospital admissions strain resources and escalate wait times. Currently, people with one or more long-term conditions use 50% of all general practitioner (GP) appointments, 64% of all outpatient appointments, and 70% of hospital beds.¹ With CVD now the cause of one in four premature deaths² in the UK, transforming the way CVD is prevented and care is provided, is becoming increasingly crucial.

With National Health Service England (NHSE) recently publishing their 2025/26 priorities and operational planning guidance,³ there is a need for systems to address inequalities and shift towards prevention. To address this challenge in the West Midlands, a transformative approach to CVD prevention and management was taken that included early diagnosis, effective management and comprehensive education. The work was led by Health Innovation West Midlands (HIWM) and colleagues from primary and secondary care across all six integrated care systems (ICSs).

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) represent major global health burdens, collectively affecting hundreds of millions worldwide.¹ COPD is projected to become the third leading cause of death globally by 2030, while CVD remains the primary cause of mortality worldwide.² Historically viewed as distinct entities, a paradigm shift is underway as mounting evidence reveals a complex, bi-directional relationship between these conditions.^3,4 This growing recognition extends beyond shared risk factors like smoking, encompassing common pathophysiological mechanisms, such as systemic inflammation and oxidative stress.⁵ The interplay between COPD and CVD presents unique challenges and opportunities, necessitating a re-evaluation of traditional management approaches and calling for more integrated, multi-disciplinary care strategies.

Hypertension is the most important single modifiable risk factor for cardiovascular disease prevention. An estimated 1.28 billion adults aged 30–79 years have hypertension worldwide.¹ Around 16 million adults in the UK suffer with hypertension, which is roughly a third of the adult population.² The benefits of lowering blood pressure (BP) are firmly established down to 140/90 mmHg. More recently, several randomised-controlled trials (RCTs) have assessed the benefits of lowering targets further to <120 mmHg systolic. ACCORD, SPRINT, RESPECT, ESPRIT and BPROAD RCTs compared a systolic blood pressure (SBP) target of <120 mmHg versus <140 mmHg.^3–7 The ACCORD trial recruited patients with diabetes, and RESPECT recruited patients with stroke.^3,4 Both of these RCTs demonstrated no significant difference in their pre-specified primary outcomes of major cardiovascular events in ACCORD, and recurrence of stroke in RESPECT. The ACCORD trial found more serious adverse events with intensive BP targeting, and the RESPECT trial ended early due to slow recruitment and funding.^3,4 Both had a relatively small number of participants, which may have contributed to the negative result seen in these studies.