Editorial articles

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.

It is no secret that the National Health Service (NHS) is currently screaming along in fifth gear just to stay on a country lane: and we haven’t yet reached the motorway that lies ahead.

The NHS long-term plan couldn’t be more current, but it could perhaps have been more timely.¹ Successive governments have watched our population changing shape and ageing over the last 20 years, but a powerful response to that looming ‘motorway’ of healthcare demand has only now materialised. The backlash of COVID-19 and the realisation of the impact of Brexit on NHS staff has become the ‘speed camera’ the NHS needed.

In 2022, the British Society of Echocardiography (BSE) commissioned Professor Alison Leary, Chair of Workforce Modelling at London South Bank University, to design a workforce survey that would allow us to fully understand the challenges facing the echocardiography workforce. This report and the policy report, which models solutions onto these data, can be read in full through our website (bsecho.org).^2,3

This is my viewpoint on the messages contained within these gold-dust documents painted within the landscape of three years of fascinating conversations with many members of our profession and the national agencies we interact with.

Hypertension affects over a billion people worldwide and is a leading cause of premature death and disability. However, it continues to remain a silent epidemic, with the majority of patients undiagnosed or untreated. The World Health Organisation reports that only 42% of individuals with hypertension receive a diagnosis and appropriate treatment. Furthermore, only one in five adults have their blood pressure under control.¹ These statistics reflect a grave failure in identifying and managing a condition that has far-reaching health consequences. The misdiagnosis and undertreatment of blood pressure pose substantial risks to individuals and impose a tremendous burden on healthcare systems worldwide.

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.