Editorial articles

The National Institute for Health and Care Excellence (NICE) has made an important change to Clinical Guideline 64 (CG64)¹ adding the word ‘routinely’ to Recommendation 1.1.3: “Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures”. In a letter about the change,² Sir Andrew Dillon, CEO of NICE, confirmed that “… in individual cases, antibiotic prophylaxis may be appropriate”. 

Compared with other diseases, cardiovascular diseases (CVD) are responsible for the greatest burden of disease both globally¹ and in the UK.² Drugs for CVD and its risk factors have always been represented in the list of international blockbuster drugs. Important research innovations, such as ‘learning health systems’, ‘precision medicine’ and electronic health record (EHR)-based trials, have been led by professionals in the field of cardiology. Cardiovascular scientists from the UK have a long and strong history of research contributions with international impact. Training in cardiology is critical, not only in preparing and mentoring the clinical and academic cardiologists of the future, but also in shaping how the specialty is perceived from inside and outside. Global health and data science are overarching themes that offer new lenses through which to view CVD and cardiology. However, cardiology training in the UK barely pays lip service to either of these issues, when their implications have never been greater or more acute on our specialty. 

The coronary artery calcium (CAC) score is widely believed to be an important tool in determining the risk of developing heart disease. The measurement of this score has traditionally been based on using electrocardiography triggered computed tomography (CT). This confers an advantage over non-gated CT scanning by acquiring images during diastole, which reduces motion artefact and avoids missing areas of coronary artery calcification. Radiologists are, therefore, cautious when reporting CAC on non-gated CT scans due to concerns that it may not be accurate. This means that there is currently no obligation, from a radiology perspective, to report on the degree of CAC on non-gated CT scans. While this has been acceptable for a long time, emerging evidence may force us to change our practise. 

Refractory angina (RA) is an increasingly common, chronic, debilitating condition, which severely reduces quality of life. It can severely impact on physical, social and psychological wellbeing. RA should be considered in patients with known coronary artery disease, who continue to experience frequent angina-like symptoms, despite surgical or percutaneous revascularisation and optimal medical therapy. Objective evidence of reversible ischaemia should also be demonstrated. Treatment is challenging and often not delivered adequately. Management should ideally be provided by a specialist multi-disciplinary team, but national provision of such services is extremely limited. As a result, patients with RA commonly enter a downward spiral of long-term local review, cycling between the outpatient department and Accident and Emergency (A&E). Consequently, a disproportionately high proportion of healthcare resource is consumed in the management of these patients due to high attendance rates in primary and secondary care, unscheduled hospitalisation, prolonged hospital stays, investigations and polypharmacy. This may be improved by the implementation of more appropriate models of care delivery.

Deaths from congenital heart disease in childhood have fallen 83% in the last 25 years.¹ This dramatic change has led to a significant increase in the numbers of adults with congenital heart disease (ACHD) requiring care, and prevalence is not expected to plateau until 2050.² Even patients with extremely complex pathophysiology are now expected to survive well into adult life, and will have significantly higher rates of utilisation of all hospital services than the general population.^3,4 

I first started using the V scan myself over four years ago, and I have found this hand-held mobile device extremely useful for providing rapid and important diagnostic information at the bedside. The quality of the images of the V scan are usually of sufficiently high quality to make a useful clinical assessment. It is usually possible to make a fair assessment of systolic function of the left ventricle. I have also found that the identification of a dilated right heart has often been very useful for diagnosing massive pulmonary emboli – quite frequently when this diagnosis would not otherwise have been suspected. Valve lesions of significance are invariably pretty obvious and the images are usually adequate to identify vegetations as well. Pericardial effusion is readily detected.

Cardiac implantable electronic devices (CIEDs) have an unquestionable evidence base in patients with reduced left ventricular ejection fraction (LVEF), already on optimal medical therapy. Implantable cardioverter defibrillators (ICDs) effectively treat ventricular arrhythmias, which account for up to 50% of mortality in patients with reduced LVEF.¹ Likewise in appropriately selected patients, cardiac resynchronisation therapy (CRT) reduces hospitalisation rates, improves symptoms and prolongs life-expectancy.²

The Government is soon to publicly disclose a league table for cardiac surgical units within National Health Service (NHS) England. While this information may be useful and raise questions as to why one unit may be better or worse than another, we are also to be made aware of surgeons who are performing significantly better or worse than expected in terms of risk-adjusted mortality. But are patient deaths following surgery caused exclusively by the surgeon, as surgeon-specific mortality data (SSMD) would imply? And is the surgeon with the lowest operative mortality the best doctor? In my opinion the answer to both these questions is a resounding no.

Life-expectancy is now approaching 90 years, and it won’t stop there. Healthy life-expectancy is also extending, so that the average 60 year old can expect a further 11 years of healthy life. Currently, 35% of the UK population is over 50 years, and growing – and on the whole they are healthier, more skilled, better educated and more dynamic than ever before.

Contemporary guidelines have lowered the threshold for statin use in primary prevention (7.5% risk of a cardiovascular event over 10 years in the USA,¹ 10% risk according to National Institute for Health and Care Excellence [NICE] guidelines in the UK).² Applying these thresholds, the majority of men over 50 years and more than half of women over 60 years will qualify for statin use. Countering the more widespread uptake of statin use in primary prevention advocated by these guidelines are claims, popularised by the lay press and uncritically published in some medical journals,^3,4 that statin use is accompanied by an unacceptable incidence of side effects that adversely compromise lifestyle and which challenge whether the small absolute benefits in some lower risk groups are worth the intolerance of the statin.