Editorial articles

Access to echocardiography represents the main current barrier to early detection of heart valve disease in the UK. One-third to two-thirds of outpatient echocardiography requests are made to investigate a murmur,^1–3 and almost a fifth of cases have moderate or severe heart valve disease.³ In early 2022, 155,000 people were waiting for outpatient echocardiography in the UK,⁴ with up to 91,450 likely to have a murmur, and up to 16,461 likely to have moderate or severe heart valve disease. Delayed diagnosis causes delay in management with potential negative consequences on patient outcome. Consequently, the British Heart Valve Society (BHVS) recommends easy access to echocardiography for patients with suspected heart valve disease; it also recommends that echocardiography departments have a system of alerts for detected significant heart valve disease.

Aortic dissection is often thought of as a rare condition with a poor prognosis and to be the provenance of a few medical specialists. Beyond this misconception, there are further challenges; half of the people who suffer an acute aortic dissection die before reaching hospital,¹ and the number of sufferers is set to double by 2050.¹ As many people suffer an aortic dissection each year as are diagnosed with a brain tumour,² and 7% of people who have an out-of-hospital cardiac arrest do so due to an aortic dissection.³

While treatment of patients with an acute dissection is usually undertaken by a few medical specialists, a wide range of healthcare professionals may interact with patients with an aortic dissection. As well as cardiac and vascular surgeons, pre-hospital clinicians, emergency medicine, acute medicine, cardiology and general practice are all likely to encounter patients with aortic dissection.

Education and pathway improvement are key elements of improving outcomes for patients with aortic dissection. It is a great pleasure to share three articles as a partnership between The Aortic Dissection Charitable Trust and British Journal of Cardiology, and in collaboration with the UK-Aortic Society.

The first article is written by Dr Karen Booth who is a Consultant Cardiac Surgeon at Freeman Hospital, Newcastle upon Tyne, and focuses on the epidemiology, pathophysiology and natural history of acute aortic dissection.

Chronic kidney disease (CKD) and heart failure with preserved ejection fraction (HFpEF) commonly co-exist. Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently emerged as key disease-modifying therapies for both conditions. In the second half of 2022, EMPA-KIDNEY (Empagliflozin in Patients with Chronic Kidney Disease) and DELIVER (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure) – two large placebo-controlled trials conducted in these populations – published their main results and expanded the evidence base in patients with and without diabetes. About one-half of each of the trials’ respective populations did not have diabetes at recruitment.^1,2 Importantly, EMPA-KIDNEY represents patients with low levels of kidney function: mean estimated glomerular filtration rate (eGFR) of 37 ± 14 ml/min/1.73 m². Both trials’ main reports were accompanied by meta-analyses in The Lancet, ensuring the new results could be reviewed in the context of the totality of evidence.

Calcific aortic valve stenosis (aortic stenosis [AS] characterised by progressive fibro-calcific leaflet remodelling) leading to blood flow restriction is the most frequent structural heart disease, with mortality rates increasing across Europe since 2000. Symptoms are insidious at onset and development of any of the three cardinal symptoms of angina, syncope, or heart failure portend a poor prognosis, with aortic valve replacement (AVR) showing a consistent improvement for both symptom-free and overall survival.

Current guidelines recommend AVR in symptomatic severe AS but the role of AVR in patients with asymptomatic severe or moderate stenosis is evolving. In the last decade the rapid adoption of transcatheter AVR (TAVR) has raised new treatment paradigms for AVR across the spectrum of risk. Opportunities to improve outcomes include earlier diagnosis and a reconsideration of intervention timing in the asymptomatic severe and moderate categories of AS, along with a reconsideration of the patient lifelong aortic valve care plan.

International guidelines recommend multi-disciplinary ‘Heart Teams’ as the preferred clinical method in decision-making¹ for multi-dimensional, pre-procedural work-up: surgical risk evaluation; clinical assessment; multi-modality valve imaging; and coronary disease management. Heart Teams have evolved central to the process, and bear responsibility for offering each patient a tailored approach.² With approximately 5,000 AS patients having not received treatment, over eight months in 2020, following the COVID-19 outbreak (UK TAVR Registry and the National Adult Cardiac Surgery Audit),³ there is a need to meet increasing demands and reverse the drop in SAVR/TAVR activity. The authors have reviewed what the future holds for AS management.

Acute coronary syndrome (ACS) is one of the leading causes for morbidity and mortality in the world despite advances in treatment as shown by both short- and long-term studies.¹ Studies demonstrate that factors responsible for increased risk of future cardiovascular events are often ignored resulting in increased morbidity and mortality.^1,2 Despite the significant reduction of in-hospital mortality in patients with ACS, the overall mortality and morbidity remains high due to missed opportunities to optimise treatment.³ The Global Registry of Acute Coronary Events (GRACE) conducted in centres in Belgium and the United Kingdom (UK) shows a long-term signal of recurrent events, such that in-hospital mortality was 3%, 4% and 5% at five-year follow up and that mortality was 15% and 18% for Belgium and UK patients, respectively.⁴ The GRACE study showed that patients with a higher GRACE score were at higher risk compared to low and moderate scores, and 68%, 86% and 97% deaths occurred in patients with ST-elevation myocardial infarction (STEMI), ACS and unstable angina, respectively, after initial hospital discharge. Patients with non-ST segment elevated myocardial infarction (NSTEMI) were found to have poor prognosis at six-month follow up, compared to STEMI patients, which was most likely due to patients being on less-than-optimal treatment. Medication compliance among patients is highest in the first month after ACS and Cheng et al., reported that from patients discharged on aspirin, beta blocker and statins, 34% patients had stopped at least one medicine and 12% had stopped all three medications a month after ACS.⁵ Only 40–45% patients were adherent with beta blocker or statins one to two years following ACS.

Some healthcare professionals may see the idea of ‘joint working’ between NHS Trusts and pharmaceutical companies as anathema – a bridge too far in the direction of private interests perhaps? However, when the needs of patients, the health system and the company are aligned, it can bring significant benefits for everyone.

At the Leeds Teaching Hospitals NHS Trust (LTHT), we have recently entered into a joint working partnership with Boehringer Ingelheim.¹ This arrangement is helping us to develop a patient-centred clinic specifically focused on reducing cardiovascular (CV) risk in individuals with diabetes recently discharged from LTHT following a myocardial infarction (MI). Initiated in September 2021, the clinic is run jointly by the cardiology department at Leeds General Infirmary and the diabetes services at the Trust. It is shared funded by the Trust and by Boehringer Ingelheim.

Nutrition is underrepresented in the medical curriculum; this has always been the case, but recently there has been a focus on trying to change this. A ‘call for action’ by the independent organisation Nutritank CIC and the Nutrition Implementation Coalition has led the way for this. New recommendations for curriculum changes have been proposed, but no mandatory changes are yet in place.

Significant pharmacologic, interventional and surgical strategies in the management of coronary syndromes, together with evolving surgical and non-surgical innovations for valvular disease and improved care of congenital heart disease, have ensured that patients live longer and better lives. With these advancing therapies for cardiac disease, the number of patients surviving to develop end-stage heart failure continues to increase exponentially. While the heart as an organ has evolved to demonstrate remarkable resilience in the setting of disease, death from cardiovascular causes remains the most common cause of death in many parts of the world. Given the significant morbidity and mortality associated with end-stage heart failure, the last half century has been notable for a concentrated effort on developing therapies for the failing heart.

In this issue, Professor Stephen Westaby (see https://doi.org/10.5837/bjc.2022.021) provides an insightful personal perspective on a laudable life-long pursuit in the development of mechanical circulatory support with the ultimate goal of a fully implantable device. His long career has been punctuated by a number of seminal achievements, which have led to incremental improvements in a challenging area.

On the 31^st March 2021, the German Health Ministry – on the advice of the Standing Committee on Vaccination (STIKO) – declared that the Astra Zeneca/Oxford Vaxzevria vaccine against SARS-CoV-2 (COVID-19), based on a chimpanzee adenovirus genetic scaffold, henceChAdOx1, would no longer be administered to those under the age of 60 years. In its hands were details of 31 cerebral venous sinus thrombosis (CVST) cases provided by the Paul Ehrlich Institute. These cases, of whom 19 had platelet deficiency, were seen after 2.7 million first and 767 second vaccine doses.

The paper by Gall et al., published in this issue (see https://doi.org/10.5837/bjc.2022.003), is timely and important; the largest case series from the UK, and among the largest globally detailing the clinical characteristics of patients affected with postural tachycardia syndrome (PoTS) developing after a COVID-19 infection. It brings empirical stature to the anecdotal reports of PoTS developing post-COVID-19. It articulates that this presents in a form indistinguishable from PoTS precipitated by other events.