Editorial articles

The arrival of sodium-glucose cotransporter type 2 (SGLT2) inhibitors has ushered in a new era in the management of cardiometabolic diseases. These innovative agents, initially developed for glycaemic control in type 2 diabetes, have unexpectedly demonstrated significant cardiovascular benefits, revolutionising cardiologists’ approach to the prevention and treatment of heart failure and cardiovascular events.¹

Cardiovascular disease remains the leading cause of death for women, responsible for over a third of all deaths.¹ In contrast, women remain widely under-represented in cardiovascular trials,² as well as in their roles as physicians and trialists.³

The scarcity of female representation in cardiology carries broad consequences, affecting patient care quality, workplace diversity, and the inclusion of women in clinical trials. Engaging more women in academia and industry collaborations can boost their professional visibility, career opportunities, and increases the likelihood of female patients to receive guideline-based therapies, all of which highlights the need for gender diversity in cardiology.⁴

A quiet revolution without fanfare took place at a meeting, witnessed by over 1,000 people both in London and live streamed across the globe on 31 January 2024. It was unprecedented, going against received wisdom. That, it was possible to treat atherosclerotic coronary artery disease with an updated Andreas Grüntzig’s balloon alone, without the safety net and comfort of implanting a single stent. Three interactive cases were treated with the drug-coated balloon and all patients were same-day discharged. Seemingly a show of simplicity, parsimony and bravado, but dive a little deeper, the skill set for stent-free coronary intervention has been meticulously studied over the last 20 years by pioneers and early adopters alike. The sacred cow slayed on this historic day was that balloon-inflicted coronary dissection rarely leads to occlusion, having effective antiplatelet therapy on board. And, potentially occlusive dissection is, not only predictable, but this method can be used in the ambulatory care setting. Thus, saving hospital bed stays. This event will be remembered as the tipping point at which a paradigm shift has occurred, but going back to embracing Grüntzig’s lessons. This is timely too, considering that two decades of systematic stenting has led to stent failures comprising nearly a third of daily interventional workload.

There is little doubt that demand on the National Health Service (NHS) has exceeded supply. Given the rhetoric of no more money, no new workforce, and no new estates, it is incumbent on us all to make better and more efficient use of the limited resource we do have, improve how we work together as one integrated health, community and social care ecosystem, and increase the value of every action we take. Cardiovascular services are no exception.

Training and development of cardiology trainees in the UK at a local level, is usually delivered through senior supervision by a consultant cardiologist. This training is overseen by clinical and educational supervisors, whose role is to set goals in line with existing training curricula. This is crucial to ensuring trainee development and attainment of skills in line with a pre-determined ‘gold standard’ for independent practice.

“In spite of the accumulating evidence of their efficacy, established treatments for maintaining renal function remain woefully underutilized. Clinicians and health care systems must be encouraged to make use of these treatments.”¹

The above was written in an editorial by Thomas Hostetter¹ that accompanied three landmark nephrology trials published in 2001.^2–4 The studies will be well-known to nephrologists and demonstrated that angiotensin-receptor blockers (ARBs) had anti-proteinuric effects and/or slowed the decline of kidney function in patients with diabetic kidney disease. These trials added weight to the evidence that supported the use of both angiotensin-converting enzyme inhibitors (ACEi) or ARBs in diabetic kidney disease and chronic kidney disease (CKD), particularly in patients with proteinuria.⁵ The evidence-base supporting the use of these drugs for patients with heart failure and cardiovascular diseases is unquestioned, and given the inter-related nature of the heart and the kidneys, the hope and optimism around these drugs was understandable. Dr Hostetter, however, was right to be cautious in his appraisal of the impact these medications might have on outcomes for patients with CKD, not because of the quality or compelling nature of the trial data, but because of the difficulties overcoming clinical and systems-related inertia to achieve effective implementation of the drugs. His predictions have proved cogent.

“Seek simplicity and distrust it.”
Alfred North Whitehead (1861–1947), English philosopher and mathematician

The metric ejection fraction (EF) is widely employed to evaluate ventricular pumping performance, used for heart failure (HF) classification, and its calculation is simple.^1–3 For example, with end-systolic volume (ESV) =50 ml and end-diastolic volume (EDV) =100 ml, the EF=50%. Unfortunately, its correct interpretation received insufficient attention. As EF is a ratio-based number (or percentage) without physical unit(s), it cannot provide unique information. The underlying problem, and also a logical solution, can be shown by the ventricular volume domain representation (figure 1A) that relates ESV to EDV. Volumes may be indexed (i) for body surface area, if appropriate. Focusing on ESVi and EDVi is important, as this combination is associated with the familiar pressure–volume (PV) loop description, which, in turn, connects with clinically relevant characteristics, such as stroke work and myocardial oxygen consumption (MVO₂).¹

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide, causing around 17.9 million deaths annually, a third of whom are adults aged <70 years.¹ In addition to genetic and behavioural risk factors (unhealthy diet, physical inactivity, and tobacco and alcohol abuse), inhaling airborne pollutants, such as fine particulate matter (<2.5 µm [PM_2.5] and <10 µm [PM₁₀]), ultrafine particles (UFPs; <100 nm), nitrogen dioxide (NO₂), ozone (O₃), and sulphur dioxide (SO₂), are associated with ASCVD among adults.²

Air pollution has been referred to as “the single most important environmental factor presenting a risk to health and represents a greater disease burden than polluted water, soil contamination and occupational exposures combined”.³ Air pollution is a silent killer and was highlighted as a significant public health concern in the recently published European Society of Cardiology (ESC) guidelines.⁴

The impact of urbanisation on air pollution levels is a critical concern for countries like Malta, which have adopted a city model to bolster their economies. Despite efforts to stimulate economic growth, the rise in urbanisation can pose risks to air quality. In London, mean PM_2.5 concentrations stood at approximately 12.7 µg/m³ in 2017, 12.0 µg/m³ in 2018, and 11.4 µg/m³ in 2019.⁵ Conversely, Valletta, Malta’s capital, recorded mean PM_2.5 concentrations of about 14 µg/m³ in 2017, 14.4 µg/m³ in 2018, and 14 µg/m³ in 2019.⁶ While both have seen improvements in their aggregated annual mean PM_2.5 concentrations compared with the concentration levels recorded in the past decade, they still exceed the World Health Organisation (WHO) annual air quality guideline value by approximately 1.14 to 1.4 times, highlighting the persistent challenge of air pollution in urban environments.

At the Association of Cardiovascular Nursing & Allied Professions conference in June, Professor Tiny Jaarsma called for a pillar of self-care to be added to heart failure (HF) care guidelines.¹ Taylor et al.² agree that HF care needs an additional pillar and suggest cardiac rehabilitation. Currently, the HF pillars are focused on medications shown to improve the outcomes of people with heart failure with reduced ejection fraction (HFrEF),³ but other key non-pharmacological interventions are not considered. Also, the pillars of care do not provide guidance for people with heart failure with preserved ejection fraction (HFpEF), which represent 50% of the HF population.⁴ While these pillars focus on a single important aspect of care, they do not capture the totality of HF management or illness types. A focus on interventions to improve HF management is welcome but can obscure the challenges that treatment – as well as illness – impose on patients and their carers.

Twenty years ago, Wald and Law¹ hypothesised that, if a combination pill could be made including aspirin, folic acid, a statin, and a low-dose diuretic, beta blocker and angiotensin-converting enzyme (ACE) inhibitor (thus, allowing for the simultaneous modification of four different risk factors: low-density lipoprotein [LDL]-cholesterol, blood pressure, homocysteine, and platelet function), and administered to everyone with existing cardiovascular disease and everyone over 55 years old, there would be an 88% reduction in ischaemic heart disease events, and an 80% reduction in stroke. One third of people over the age of 55 years would benefit by gaining an average of 11 years free from a cardiac event or stroke (subsequently termed the vaccination approach). They called this pill the ‘Polypill’, and concluded that treatment would be acceptably safe and, with widespread use, would have a greater impact on the prevention of disease in the Western world than any other single intervention. They noted that, while such a preventative strategy was radical, if such a formulation existed that prevented cancer and was safe, it would be widely used. “It is time to discard the view that risk factors need to be measured and treated individually if found to be abnormal. There is much to gain and little to lose by the widespread use of these drugs.” While subsequent works have shown that folic acid is not prognostically beneficial in preventing cardiovascular disease,² and that aspirin may not be beneficial overall in primary prevention settings,³ the concept of the combination pill was awakened in the public eye.