Editorial articles

We share Professor Brady et al.’s opinion¹ that stroke prevention is the single greatest priority in the management of patients with atrial fibrillation (AF). It is reasonable to say that highlighting the inappropriately low levels of anticoagulant uptake as a major public health issue and seeking to improve anticoagulant uptake nationwide was uppermost in the minds of the Guideline Development Group (GDG) members.

The heart beats 120,000 times a day pumping 7,000 litres. Ischaemia or inflammation decimate this workload causing end organ dysfunction. New National Institute for Health and Care Excellence (NICE) guidelines for acute heart failure (AHF) acknowledge very high early mortality. Of 67,000 acute admissions, 11% die in hospital, 50% are readmitted and 33% are dead within 12 months.^1,2 When cardiogenic shock ensues, prognosis is poor.^3-5 Most patients are elderly but several thousand deaths occur in those under 65 years. Many are salvageable using advanced resuscitation techniques. When the prospectively randomised-controlled trial (RCT) IABP-SHOCK II trial (Intra-Aortic Balloon Pump in Cardiogenic Shock II) revealed the intra-aortic balloon pump (IABP) as ineffective, a New England Journal of Medicine (2012) editorial stated “we must move forward understanding that a condition with 40% mortality at 30 days remains unacceptable”.^3,4 So do the guidelines help with this? 

Cannabis has been employed medicinally and recreationally for thousands of years,^1,2 but it was not until the 1960s that the structure and pharmacology of its primary phytocannabinoid components, cannabidiol (CBD)³ and tetrahydrocannabinol (THC)⁴ were identified, and another generation before the nature and function of the endocannabinoid system (ECS) were elucidated (see reference 5 for a comprehensive review). The ECS consists of endogenous cannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), their biosynthetic and catabolic enzymes, and their receptors: CB₁, which is psychoactive, analgesic, neuromodulatory and the most abundant G-protein coupled receptor in the brain, and CB₂, which is non-psychoactive, immunomodulatory and anti-inflammatory. The ECS may be thought of as a grand homeostatic regulator of chordate physiological functions, whose roles have been summarised as: “relax, eat, sleep, forget and protect”.⁶ Those actions closely describe the effects of THC and AEA, which are both weak partial agonists at CB₁ and CB₂. 

We know that people with advanced heart failure have unmet supportive and palliative care needs, and the burden of these concerns is comparable with people with cancer.^1–2 Palliative care services in the UK and elsewhere have grown up around oncology services. Randomised controlled trials (RCTs) have confirmed that early integration of palliative care, alongside cancer treatment, improves patient outcomes.^3–7 In contrast, experience of and the evidence base for integration of palliative care alongside heart failure treatment has been slow to develop. However, this is changing. A pilot RCT comparing the addition of a palliative care intervention to usual care for people with advanced heart failure has reported benefit in health-related quality of life, symptom control and health service utilisation (reduced hospital admission)⁸ and several phase three RCTs are ongoing. 

Hypoglycaemia is defined as a lower than normal level of blood glucose, and in patients on glucose-lowering therapy, defined as glucose levels less than 4 mmol/L. In the UK, it is usually classified as ‘mild’, if the episode is self-treated, or ‘severe’, if the individual requires third-party assistance. However, the American Diabetes Association definition of hypoglycaemia is different.¹ They classify hypoglycaemia into five categories. These are shown in table 1. 

Non-adherence to medication for chronic conditions, whether this involves tablets, inhalers, injections or other drug delivery systems, is a serious healthcare problem resulting in poor clinical outcomes and high costs. Here, we review the extent of the problem and the development of a novel evidence-based digital tool to support healthcare professionals (HCPs) in assessing and potentially improving the adherence of chronic patients. 

HCPs are increasingly focusing on developing interventions to address this problem. However, the development of effective adherence interventions is challenging; it involves finding the individual root causes of non-adherence, with the added difficulty of introducing and maintaining behavioural change, and offering tailored solutions that address the specific needs of a particular patient.

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) has expanded exponentially since it was first described 12 years ago, with around 100,000 procedures performed worldwide.^1,2 Randomised controlled trials have established TAVI as the treatment of choice for severe AS in patients of prohibitive surgical risk and as a viable alternative to surgical aortic valve replacement (SAVR) in high-risk candidates.^3–5 The feasibility and safety of TAVI is further supported by a large body of ‘real-world’ data from multi-centre registries with 93% 30-day and 79% one-year survival in the UK.⁶ Moreover, with growing operator experience and evolving valve technology, TAVI continues to expand beyond those populations originally studied, to include those with severe left ventricular dysfunction and those with failing surgical homografts (so called ‘valve-in-valve’ TAVI), for example.^7,8

Lowering serum cholesterol with statins has consistently shown benefits on cardiovascular outcomes. A 1 mmol/L reduction in low-density lipoprotein (LDL)-cholesterol is associated with approximately one-third fewer coronary events and one-fifth fewer ischaemic strokes.¹ However, despite these impressive results, there remains a substantial residual risk of cardiovascular (CV) events despite optimal statin therapy.² From pooled analyses of randomised-controlled trials of statins, there is a clear relationship between the achieved level of LDL-cholesterol and the number of coronary heart disease (CHD) events. This observation applies to both primary and secondary prevention trials.³ 

Today’s patient is potentially very different compared with only just a few years ago. So much has changed there is even a new word to describe them, the ‘e-patient’. The ‘e’ can stand for one of many things, equipped, enabled, empowered, engaged or even electronic to cover the internet-savvy approach taken by these patients. Increasing numbers of patients are ever more knowledgeable than in the past and are keen to take control of their own health as much as they can. Many walk in to your consulting room no longer just up to speed on what could be wrong with them, but also with strong opinions on the latest treatments.

The introduction of high-dose statin therapy, more potent statins and the corresponding clinical trial results have led to new treatment targets in secondary prevention of cardiovascular disease (CVD).¹ Most guidelines recommend that for secondary prevention patients require a treatment goal of less than 1.8 mmol/L low-density lipoprotein (LDL)-cholesterol (LDL-C).² While the use of high-dose atorvastatin therapy is expected to become more widespread now that atorvastatin is available as a generic drug,³ in practice, poor compliance seriously impacts effective treatment.⁴ Only 1.9% of patients in the Treating to New Targets (TNT) study reduced the randomised treatment of 80 mg atorvastatin to 40 mg,¹ whereas, in practice, the mean dose prescribed is 32 mg per day.⁵ For statins, there appears to be a road-block to implementing the results of large randomised-controlled trials (RCTs), similar to the issue of treating hypertension, another ‘silent’ disease.