Editorial articles

“Alone we can do so little, together we can do so much.” Helen Keller

The links between kidney disease and cardiovascular disease have been reported as far back as 1827 with Richard Bright describing the changes in the left ventricle associated with kidney disease, and subsequently, Frederick Akbar Mahomed reporting increased arterial stiffness in patients with Bright’s disease.¹ Over the last two to three decades it has become increasingly apparent that kidney disease is the most important predictor of outcomes in all cardiology diseases and that cardiovascular disease is the leading cause of death in patients with chronic kidney disease.² In 2008, a systematic approach to the bi-directional interactions of heart and kidney diseases, or cardiorenal syndromes (table 1), was proposed.³ Cardiorenal syndromes can be broadly defined as disorders of the heart and kidney whereby acute or chronic dysfunction in one organ can induce acute or chronic dysfunction in the other.⁴ This was followed by increasing efforts to develop strategies to manage patients with combined heart and kidney dysfunction, as demonstrated by an increasing number of publications on cardiorenal syndromes.⁵

In 2015 one of my patients in the Fourier PCSK9 inhibitor trial asked me if I would like to attend his ‘bespoke’ total knee replacement operation. I said yes and witnessed an amazing procedure.

When the extent of the coronavirus threat became clear, it was an obvious imperative to close down elective catheter lab work for all cases except for patients at the highest level of clinical urgency. The effect of this action is illustrated by the national survey reported by Adlan and colleagues.¹

Above and beyond the immediate, unarguable imperative to limit elective work, a range of other equally immediate challenges relating to patient care were apparent, and generated strong but divergent opinion within the interventional cardiology community. Firstly, the optimal treatment plan for patients presenting with ST-elevation myocardial infarction (STEMI)… should primary percutaneous coronary intervention (PCI) remain the default strategy, or should it now be to adopt thrombolysis as a default, as recommended by hastily constructed care pathways in other countries which were affected by COVID-19 earlier than the UK? Secondly, what level of personal protective equipment (PPE) should cardiologists and cath lab staff wear for the cases who did make it to the lab? Finally, how should patients admitted to hospital with severe symptomatic aortic stenosis be treated?

The current President of the United States once stated that “the kidney has a very special place in the heart”; despite the questionable anatomical reference, the truth is that the kidneys and heart are intertwined, affected by common pathophysiological processes and sharing many of the same disease-causing risk factors. Ronco and colleagues have previously classified the complex array of inter-related derangements that simultaneously involve both organs, and this serves as a useful starting point in understanding their important physiological and pathophysiological inter-dependence.¹

Cardiac surgery for adults became widely available around 50 years ago, due mainly to the introduction of relatively safe cardiopulmonary bypass. Initially, mortality rates were quite high, even for relatively young and fit patients, and, therefore, patients and carers focused on this outcome measure. Moreover, it was easy to define and record. Local and national registries developed into databases that allowed comparison of mortality rates and were then further refined with risk modelling.

As the odds of survival after cardiac surgery improved, sicker and older patients were offered cardiac surgery, including octogenarians and extending to nonagenarians.

Clearly, surviving cardiac surgery is very important – but is survival the top priority for the 92-year old after bypass surgery who becomes unable to live independently again and who’s quality of life is insufferable? Should quality of life be the main factor driving therapeutic decisions for the frail and elderly?

The use of immune checkpoint inhibitors (ICIs) has transformed the treatment landscape for a number of tumour types over the past decade. Targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4; ipilimumab), programmed cell death protein 1 (PD1; nivolumab, pembrolizumab), and programmed death-ligand 1 (PD-L1; atezolizumab, avelumab, or durvalumab), as monotherapy or in combination, activates the immune system to recognise and target cancer cells via a T-cell-mediated immune response and can lead to improved survival in the metastatic setting in a number of malignancies, as well as improved recurrence-free survival when utilised in multi-modality radical treatment paradigms in melanoma and non-small cell lung cancer (NSCLC).^1,2 The systemic activation of T-cells can also lead to auto-immune toxicity, affecting any body system; most commonly skin, gastrointestinal, liver and endocrine toxicities.³

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.