CardiologyHD #31

LATEST PRODUCT NEWS

THE FACTSBehind the Headlines

CARDIOLOGIST HOT TOPICMore Testi ng for CE Marks?

MANAGEMENT HOT TOPICCCU Nurses replacing Physiologists?

UK SITE VISITWexham Park Hospital

MANAGEMENT Understanding Integrity

ECG Educati onLessons 1 & 2

Cardiology

- Connecti ng Professionals

HYBRID DESIGN + INNOVATION + LESS TREES : INTEGRATING WEB & PRINT

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CARDIAC CATH • EP • CRM • ECHO • CT/MRI

Issue 31 • Jul/Aug 2011Subscribe FREE OnlineCardiologyHD.com

www.pcrlondonvalves.com

London 201116th-18th October

VALVES FOR THE HEART TEAM

11TXXXX_PCRLONDON_PUB_CORONARY_HEART_JUIN 16/06/11 17:37 Page1

www.cardiologyhd.com Jul/Aug 2011 3

ECG Educati on + ECG Answer

Disclaimer:Coronary Heart should never be regarded as an authoritati ve peer reviewed medical journal. Coronary Heart has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the diff erent techniques used by others around the world. Whilst all care is taken in reviewing arti cles obtained from various companies and contributors, it is not possible to confi rm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publicati on should be carefully checked themselves, by either contacti ng the companies involved or speak-ing to those with skills in the specifi c area. Readers should always re-check claims made in this publicati on before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their insti tuti on, Coronary Heart Publishing Ltd or the editorial staff .

Copyright © 2006 - 2011 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing. The publicati on of an adverti sement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.


Latest Product News

Round UpCardiac Stent TrialsACUSON SC2000 from Siemens

Healthcare off ers advanced cardiac imagingNuffi eld Health Leeds Hospital is one of the fi rst hospitals in the UK to have installed an ACUSON SC2000™ ultrasound system from Sie-mens Healthcare. The SC2000 is situated in the cardiology depart-ment, one of only two in the Nuffi eld Health group, and is being used to carry out all echocardiograms as well as being the main ultrasound machine for all invasive and non-invasive tests.

The SC2000 is among the fi rst systems in the world to acquire non-sti tched, real-ti me full-volume images of the heart in one single cycle. At Nuffi eld Health Leeds Hospital it replaced an older system and there are potenti al plans for it to be used in the future for 3D ultrasound and 3D transesophageal echocardiograms.

“We chose the SC2000 because it off ers the latest technology and it has allowed us to cut the ti me taken to do a standard echocardi-ography exam and consequently see more pati ents,” said Matt hew Howland, Cardiac Services Manager at Nuffi eld Health Leeds Hospital.

ONLINE DISCUSSION FORUM

Have your say. Membership is free.

Latest Topics from our members

Hand Saniti zers - Do we need to make them secure?I just read about a man who drank six bott les of hand saniti zer at the Alfred Hospital in Melbourne, giving him a blood alcohol reading of 0.271 per cent. The 45 year old man had been undergoing treatment for alcohol-related gastriti s when he drank the 375ml bott les of saniti ser, which have an ethanol content of 66 per cent.

New Data Confi rms Safety of BioMatrix™ at One Year e-BioMatrix post-marketi ng surveillance (PMS) registry informati on presented at EuroPCR 2011 has confi rmed that BioMatrix™, Biosensors’ Biolimus A9™-eluti ng stent sys-tem with abluminal biodegradable polymer, is safe over a 12-month period in a “real-world” pati ent populati on. The prospecti ve, multi -centre, observati onal registry, ini-ti ated in March 2008, is assessing the outcomes of 1,102 pati ents across a broad range of inclusion criteria from nine European study sites over a fi ve-year period. Enrol-ment was completed in September 2009. Only 74 pati ents (6.7%) experienced a clinical adverse event that could be included in the primary endpoint of the registry, MACE (a composite of cardiac death, MI and clinically-driven TVR) at 12 months. The registry will also examine a range of secondary end-points, includ-ing primary and stent thrombo-sis over several periods; MACE at intervals up to fi ve years; and death and MI rates for up to fi ve years.

For more informati on please visit www.biosensors.com

The registry will also examine a range of secondary end-

to fi ve years; and death and MI rates for up to fi ve years.

6 Jul/Aug 2011 www.cardiologyhd.com

New Test for Residual Platelet Reacti vityAccumetrics, Inc., developer of the VerifyNow® System, the fi rst rapid and easy-to-use point-of-care system for measuring platelet reacti v-ity to multi ple anti platelet agents, announced today that the VerifyNow P2Y12 Test is now CE marked for prognosti c use in identi fy-ing pati ents with high residual platelet reacti vity (also termed poor responders) on anti platelet therapy (e.g. clopidogrel) who are at greater risk for future cardiovascular events.

Studies comprising over 3,000 pati ents, uti lizing the VerifyNow P2Y12 Test, have shown a correlati on to clinical outcomes based on PRU (P2Y12 Reacti on Units) results, concluding that an on-treat-ment PRU of ≥230 identi fi es pati ents at signifi cantly greater risk for future cardiovascular events including death, heart att ack and stent thrombosis. “Researchers, such as myself, have long been studying the relati on-ship between platelet reacti vity while on anti platelet therapy and the risk of recurrent ischemic events in our cardiovascular pati ents,” stated Robert F. Storey, MD, Professor of Cardiology at the Univer-sity of Sheffi eld, England. “The achievement of a prognosti c claim will reinforce its applicati on to risk strati fi cati on, potenti ally guiding therapy in pati ents undergoing coronary stenti ng.”

The VerifyNow System is widely used in various clinical setti ngs where anti platelet medicati ons are prescribed to reduce the occurrence of future thromboti c events such as heart att ack and stroke.

For more informati on contact:ELITech UK LimitedTel: +44 (0) 1442 86 93 20Email: [email protected]

Recruitment Services

Fresh faces, fresh fundraising, fresh success!The fi rst few months of 2011 have been busy ones for the medical and scienti fi c recruitment specialists, Kirkham Young.

Following the growth of the team at the end of 2010, the company was delighted to reveal it’s new look website as part of it’s ongoing programme of progression.“We all had great fun with the photo shoot at the offi ces” commented Scienti fi c Manager Alan Dias. “It is always a litt le unnerving being followed around by a photographer for the day but I think it’s really important that our customers can see us as naturally as possible. People are the foundati on of our business and searching for a new role can be a daunti ng prospect – being able to visualise who is on the end of the phone should help to alleviate some of that apprehension!”

Kirkham Young are also delighted to support a range of chariti es again this year with fundraising events, corporate donati ons and sponsorship of local junior sports teams.

For more informati on please visit www.kirkhamyoung.co.uk

ExoSeal™ Vascular Closure Device - available now in 5, 6 & 7 FrenchThe ExoSeal™ Vascular Closure Device from Cordis Johnson & Johnson makes use of key techno-logical developments to support the clinical safety* and effi cacy

of the closure procedure. In the ECLIPSE Trial, the extravascular plug placement was associated with no embolisati on, infecti on or other major adverse events, compared to manual compression despite the signifi cantly shorter ti me to ambulati on for ExoSeal™. The bioabsorbable PGA-plug (Poly-glycolic Acid), is designed to close the femoral artery puncture site with minimal or no infl ammati on. It is fully reabsorbed in 60-90 days. PGA is a trust-ed non-collagen plug material that is metabolized to carbon dioxide and water. A system of deploy-ment through the existi ng procedural sheath makes ExoSeal™ quick and easy to use and increases physician convenience by minimising or eliminati ng the need for sheath exchange during the procedure. The device uses visual indicators to help the physician to

correctly deploy the device. This visual feedback also promotes pati ent comfort during deployment and the ‘lock-out’ system of ExoSeal™ helps ensure that only extra-vascular plug placement can take place. ExoSeal™ is available in 5, 6 and 7 French.

*Clinical data from the ECLIPSE trial indicates safety in terms of ves-sel injury, access site-related bleeding, infecti on or nerve injury, new ipsilateral lower extremity ischemia or serious adverse events (SAE).


‘Heart repair pill’ sti ll years away“A drug that makes hearts repair themselves has been used in research on mice,” BBC News has reported.

The news is based on an early set of laboratory and animal experi-ments. Researchers identi fi ed cells in the outer layer of the heart that can develop into mature heart cells and replace injured heart ti ssue aft er being treated with a specifi c protein. These “progeni-tor cells” have the ability to develop into new heart muscle cells in embryos, but cannot normally do so in adults. However, researchers have found that dormant progenitor cells can be acti vated in adult mice by injecti ng them with a specifi c protein. When these mice were induced to have a heart att ack, some of the treated progeni-tor cells developed into new heart muscle cells, integrati ng into the heart ti ssue and functi oning as part of the organ.

This research is at a very early stage, and further studies on the eff ecti veness and safety of such treatment in animals will be needed before human studies can be carried out. In parti cular, if the biologi-cal mechanisms discovered also apply to humans, research will need to establish if the protein could have an eff ect if administered months or years before a heart att ack, or even aft er one. This study mainly looked at administering the protein before heart damage occurred. Overall, despite the possibiliti es presented by this early research, a pill that can regenerate human hearts is sti ll some years off .

The study was carried out by researchers from University College London, Children’s Hospital Boston, Harvard Medical School, the Chinese Academy of Science and Imperial College London. It was funded by the Briti sh Heart Foundati on. The study was published in the peer-reviewed scienti fi c journal Nature.

Behind The Headlines

The Facts

The following articles are courtesy of NHS Choices

Staying Healthy

Confusion over new salt research“Salt is GOOD for you,” according to claims in the Daily Mail. The newspaper challenged conventi onal health advice by suggesti ng that “eati ng more could even lower the chances of heart disease”.

However, these claims are somewhat unjusti fi ed as they are based on a study that actually looked at a one-off measure of salt in people’s urine rather than in their diet. The research looked at 3,700 people’s urinary salt levels and then followed them for nearly eight years to look at their risk of high blood pressure, cardiovascular disease (CVD) and related deaths.

Among the main results the researchers observed 84 CVD-related deaths. Surprisingly, they found that there were 50 CVD-related deaths in the third of parti cipants with the low-est salt levels, and just 10 deaths in those passing the most salt. This would initi ally seem to challenge the conventi onal wisdom that salt raises blood pressure and, therefore, the risk of heart problems. However, this study is not straightf or-ward to interpret, parti cularly as the single urinary sodium measure analysed is not necessarily a direct indicator of how much salt a person eats. For example, it may indicate how hydrated a person is or how well their kidneys are fi ltering sodium.

The limitati ons of this study mean that, on its own, it does not challenge the accepted associati on between salt intake, blood pressure and related disease, and certainly does not suggest that eati ng more salt is good for you.

The study was carried out by investi gators from the European Project on Genes in Hypertension (EPOGH), a research pro-ject based in Belgium and supported by various European study and research grants. The study was published in the peer-reviewed Journal of the American Medical Associati on.

The Daily Mail’s headline implying that eati ng salt is good for you is a rather simplisti c conclusion from this complex study, and the study cannot be interpreted in this way. Crucially, it should be remembered that a single measure of someone’s urinary salt excreti on does not necessarily equate to the level of salt they consume. Health recommendati ons are unlikely to change based on this study alone.


With over 30 companies showcasing their version of coronary stents at EuroPCR this year:

Dr Doug FraserConsultant CardiologistManchester Heart CentreManchester Royal Infi rmaryMANCHESTER

Is there any need for additi onal stents on the market, or is the latt er already saturated?Design of workhorse stents by the major companies is conti nuing and new designs will conti nue to bring improvements. These incre-mental improvements will be less than the major advances we have seen in the past and it is uncertain whether major breakthroughs in design such as dissolving platf orms will work. Design and testi ng of workhorse stents is likely to remain with the larger companies. Stents designed for niche applicati ons such as dedicated bifurcati on, STEMI and left main stents will conti nue and do show promise. We may therefore see more development here. To answer your questi on, there is litt le point in hav-ing many more platf orms that do the same as cur-rent ones but advances in design will conti nue, per-haps parti cularly in the niche designs.

Should there be more rigorous testi ng before CE Marks are handed out? To require a mega-trial before adopti on of eve-ry new stent platf orm would exclude smaller companies from devel-oping niche stents and so would sti fl e innova-ti on so there needs to be balance – but I do agree that the CE marking pro-cess could be more rigor-ous and certainly bett er standardized.

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ChallengeCharles Bloe Training’s ECG

HistoryA 68 year old man with history of hypertension and ischaemic heart disease but no previous MI. Presenti ng with a 2 hour history of central chest pain and dyspnoea. This episode of pain awakened him from his sleep this morning. He felt very afraid and was sweati ng profusely. He lives on a croft that is 85 miles from his nearest hospital.Vital signs recorded by the Paramedics:BP 90/55 mmHg. Pulse 60 per minute and regular. Respiratory rate: 24 per minute. Temperature 36.8oC. Oxygen saturati ons were 93% and he was commenced on 3 litres of oxygen via nasal cannula.

What is your conclusion?

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Journals

Risks and Benefi ts of Anti coagulati on

Bad news for Vitamin K loving electrophysiologists. The twin risks of stroke and bleeding associated with AF ablati on have exercised operators since the technique has been practi sed. Over the years, an increasing proporti on have seen it as the lesser of two evils to perform the procedure on warfarin, rather than risk periods of procoagulabil-ity and/or the greater post procedural bleeding risk of heparinoids. In this retrospecti ve series, tamponade in the group therapeuti cally anti coagulated throughout the ablati on were no harder to manage than those with an INR<2 at the ti me of the complicati on.R Latchamsett y and others, Heart Rhythm. 2011;8:805– 808.

Another nail in the coffi n of the heparin bridging Luddites. In this underpowered, randomised trial of warfarin conti nuati on vs. stop-ping/bridging, all of the complicati ons occurred in the disconti nua-ti on group. Although not stati sti cally signifi cant, taken together with previous non randomised data, the message is clear: when it comes to implanti ng devices, warfarin is safe, heparin is poison.A Cheng and others, Heart Rhythm. 2011;8:536 –540.

In stroke preventi on for atrial fi brillati on, the cost effi cacy compari-son between warfarin, dabigatran and aspirin depends on three fac-tors: stroke risk, bleeding risk and the ti me that pati ents on warfarin spend within therapeuti c range. A model devised in this paper sug-gests possible subsets of pati ents with combinati ons of high stroke and bleeding risk and a high proporti on of non therapeuti c INRs that may benefi t suffi ciently enough from dabigatran for this to be a cost eff ecti ve opti on.V Shimoli and others. Circulati on. 2011;123:2562-2570.

Doctors seem to love a standardised defi niti on and Cardiologists are no diff erent. We already have defi niti ons for a myocardial infarcti on and for stent thrombosis. Now we have one for bleeding, produced by the Bleeding Academic Research Consorti um (BARC) – a collabo-rati on of expert groups. This consists of bleeding types 1 to 5 and is an att empt to move away from subjecti ve terms, such as ‘minor’ and ‘major’ bleeding. Commendable stuff , but will need validati on in outcome trials to gain widespread acceptance.R Mehran and others. Circulati on. 2011;123:2736-2747.

Implantable Devices

Sub group analyses on two diff erent trials (REVERSE and MADIT CRT) reveal that those NYHA I-II pati ents who reverse remodel with CRT appear to have a lower incidence of ventricular arrhythmias. As well as providing another rati onale to off er a left ventricular (LV) lead to minimally symptomati c pati ents receiving an ICD beyond heart fail-ure event reducti on, this expands the target for those who argue that some primary preventi on pati ents should be off ered CRT in place of, rather than in additi on, to an ICD.

A slight sti ng in the tail is a trend toward a higher rate of arrhythmias in low responders to CRT, compared with ICD only recipients.A Barshshet and others. J Am Coll Cardiol 2011; 57:2416–23.

M Gold and others. Heart Rhythm 2011;8:679–684.

A counterbalance to any headlong rush to LV leads for all is the well known increase in complicati ons associated with CRT, as compared with simpler devices. Among over 3000 Italian CRT recipients, LV lead displacements occurred at a rate of 2.3% per year with a four year incidence of lead revision at 14%, compared with 4% and 9% in single and dual chamber devices. The annual infecti on rate in CRT pati ents was 1% and was signifi cantly predicted by additi onal proce-dures. Predictably, CRT devices also required a box change for bat-tery depleti on sooner than other devices.M Landolina and others Circulati on. 2011;123:2526-2535.

There is more evidence of the high risk of infecti ons with box changes from the Danish registry of over 46 000 implants. Box changes were almost three ti mes as likely to be complicated by infecti on within the fi rst year post as new implants (12.1 vs. 4.8 per 1000). Late infecti ons were also more prevalent aft er more than one procedure (3.3 vs 1.1 per 1000 pati ent years). Systemic anti bioti cs at implant were associ-ated with a reducti on in incidence of infecti on in new implants (HR 2.3 for no anti bioti cs).JB Johansen and others. European Heart Journal (2011) 32, 991–998.

Dr John PaiseyJournal ReviewerConsultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundati on Trust

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundati on Trust

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Coronary Heart_HeartStation -May-June 2011_Final.pdf 1 20/04/2011 11:31:46


THE

FAC

TS

What are your special interests within cardiology?

My special interests are in percutaneous coronary interventi on (PCI) and cardiac CT imaging. I also have an interest in trans oesophageal echocardiography.

What do you fi nd most rewarding about your career?

I enjoy managing complex pati ents, and dealing with the acutely unwell pati ent - seeing these pati ents go home aft er recovery from their acute illness is the biggest reward of all.

What stage are you at with your training?

I am a fi nal year trainee in cardiology, working in the North West Deanery. I will shortly be able to apply for consultant posts.

Do you have any advice for trainees wishing to pursue a career in interventi on?

Be sure that interventi on is what you are passionate about, be realisti c about the challenges you will face, and you will fi nd the hard work part of the job is much easier. Spend ti me before the procedure evaluati ng the pati ent, and be sure to review them aft erwards. These aspects are at least as important as the procedure itself in ensuring opti mal care of the pati ent.

Are there any parti cular challenges for female trainees in your sub-speciality?

I have not encountered any problems as a female trainee in interventi on. My predecessors I am sure may have in years gone by, but this is not an issue in current day practi ce.

How do you relax aft er a long day?

Aft er a long day, it is important to clear my head and my way of switching off is to hit the road for a run. In the last year, I have parti cipated in the London Marathon, Barcelona Half-Marathon and am currently training for the Great North Run.

Dr Cara Hendry Specialist RegistrarBlackpool Teaching Hospitals NHS Foundati on Trust

Cardiologist InterviewStudy looks at fear aft er heart att ack“Pati ents who feel scared of dying during heart att ack symptoms may be more likely to suff er another,” the Daily Mirror has reported.

The news is based on a small study in 208 people who were admitt ed to hospital with chest pain. The pati ents were asked three questi ons designed to assess their level of fear, whether they thought they might die and feelings of stress. Researchers com-pared their answers to the results of blood tests, taken when the pati ents were admitt ed to hospi-tal, that measured levels of a chemical associated with infl ammati on, as well as heart rate or stress hormones three weeks later. Infl ammati on is known to both damage the heart and occur in response to heart damage.

The study found that people who were more dis-tressed when admitt ed to hospital had higher levels of infl ammati on markers as well as lower levels of stress hormones three weeks later. However, the study had several limitati ons. Principally, it did not assess the risk of a second heart att ack, but only looked at markers of infl ammati on at the start of the study. Also, about 50% of parti cipants chose not to take part in the follow-up tests three weeks aft er hospital admission. These were mainly people who were unmarried and from poorer backgrounds. This means that the data from this study need to be interpreted cauti ously.

Given the limited scope of this early research, a link between infl ammatory markers in the blood and emoti onal distress needs further investi gati on.

The study was carried out by researchers from Uni-versity College London, the University of Sti rling, the University of Bern and St George’s Hospital in London. It was supported with grants from the Brit-ish Heart Foundati on, the Medical Research Council and the Swiss Nati onal Foundati on. The research paper was published in the peer-reviewed European Heart Journal.

The Daily Mirror uncriti cally reported the research-ers’ main fi ndings. The BBC included quotes that highlighted some of the study’s limitati ons.

Edwards Lifesciences Irvine, USA I Nyon, Switzerland I Tokyo, Japan I Singapore, Singapore I São Paulo, Braziledwards.com

Edwards transcatheter heart valves: The life-changing innovation that improves quality of lifeTo date, thousands of high-risk patients in Europe have received Edwards transcatheter heart valves as an effective therapy. Along with improved rates of survival,1 the landmark clinical study—The PARTNER Trial—demonstrated a 25-point improvement in quality-of-life scores for patients receiving an Edwards SAPIEN balloon-expandable transcatheter aortic valve compared to the standard treatment control group at one year.2

For more information & to find a TAVI center near you please visit edwards.com/eu/products/transcathetervalves

References: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607. 2. Data on file, Edwards Lifesciences Corporation. 2. Data on file, Edwards Lifesciences Corporation.

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation.Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation.

© 2011 Edwards Lifesciences Corporation. All rights reserved. E2064/05-11/THV

A new option for your high-risk patients with aortic stenosis

Publication: Coronary Heart Size: A4 Trim: 210 mm X 297mm Bleed: 3mm

an innovation of


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Mitral Isthmus Ablati on

Linear ablati on at the mitral isthmus is oft en performed in the context of left atrial ablati on of atrial fi brillati on and related arrhythmias. The commonest anatomical strategy is to create a line of block between the mitral valve and left pulmonary veins. Is it safe and feasible aft er mitral valve surgery? Yes, in a small series of post surgical pati ents compared with matched non surgical pati ents. The success rate in achieving block was modest at 71% in both groups, but no signifi cant complicati ons were observed.S Mountantonakis and others Heart Rhythm 2011;8:809–814.

One of the challenges with achieving block is the cooling eff ect of the coronary sinus (CS). It is well recognised that ablati on within CS is oft en necessary, but some operators are keen to avoid this and even with CS ablati on in the best hands there are some instances of failure to achieve block.

An alternati ve strategy to avoiding the cooling eff ect is to occlude the distal CS with an air fi lled balloon. In a randomised trial of 46 pati ents undergoing mitral isthmus ablati on deployment of a balloon was pos-sible in 20/23 pati ents with a reducti on CS ablati on requirements and reduced radiofrequency (RF) and procedure ti mes to achieve block. Acute procedural success was no diff erent in the balloon occlusion or control groups (87 vs. 91%).K Wong and others. Heart Rhythm 2011;8:833– 839.

Valves

The big news in interventi onal cardiology this month is the publica-ti on of the PARTNER A study. In typically perverse fashion, PARTNER B was published fi rst (September 2010), demonstrati ng that trans-cutaneous aorti c valve implantati on (TAVI) using the Edwards Sapien valve inserted via the femoral route improved survival (20% absolute risk reducti on at 12 months) in pati ents deemed unsuitable for sur-gery, when compared with best medical care. PARTNER A compared TAVI using the same balloon expandable valve to conventi onal sur-gery in high risk pati ents with severe aorti c stenosis. At 1 year follow up, mortality was shown to be non-inferior with TAVI, with more vas-cular complicati ons (that will be the big sheath in the femoral artery then) and less bleeding complicati ons. There was a trend towards increased stroke and more paravalvular regurgitati on with TAVI and longer follow-up is needed to see whether these will cause trouble further down the line. We anti cipate that the PARTNER trials are a gamechanger in the management of severe aorti c stenosis.CR Smith and others. NEJM 2011;364:2187-2198.

Endocarditi s is bad for you. Staphylococcus aureus, development of heart failure and periannular complicati ons are all associated with worse outcomes. No surprise there then.Javier Lopez and others. Heart 2011;97:1138-1142.

Stents

Old stents with long term data. 5 year pooled results for Taxus paclitaxel-eluti ng stents (PES) confi rm no signifi cant diff erences in mortality or MI compared to bare metal stents (BMS) in simple and complex lesions, with a signifi cant reducti on in ischaemia-driven tar-get lesion revascularisati on, as expected. Interesti ngly, the rates of cardiac death, MI or stent thrombosis were greater with PES than BMS between 1 and 5 years.

Also, 5 year results from the SIRTAX LATE study comparing the fi rst generati on Cypher sirolimus-eluti ng (SES) vs. PES show no signifi -cant diff erences in clinical or angiographic outcomes. Of note, tar-

get lesion revascularisati on occurred at a rate of 2% a year, with a stent thrombosis rate of 0.65%, confi rming previous data. There are a number of newer stents with bett er data, though only 3 year follow up is currently available.

G Stone and others. J Am Coll Cardiol Intv. 2011;4:530-542.L Raber and others. Circulati on 2011 10.1161/CIRCULATIONAHA.110.004762

Another trial with an old stent conti nues to produce infant papers. HORIZONS AMI now has 3 year follow up data, showing that the Taxus PES is as safe as a bare metal stent in STEMI, with less need for ischaemia-driven target lesion revascularisati on. However, the stent thrombosis rate of 5% seen in both arms is of concern. The other part of the trial conti nues to demonstrate the benefi ts of bivalirudin vs. heparin and a glycoprotein IIBIIIA inhibitor in STEMI pati ents, due to signifi cantly reduced major bleeding and adverse clinical events.G Stone and others. Lancet 2011; DOI:10.1016/S0140-6736(11)60764-2

STEMI

Yet another off spring from HORIZONS AMI has looked for an expla-nati on for the no-fl ow phenomenon seen in some pati ents undergo-ing percutaneous coronary interventi on. This phenomenon is poorly understood and is thought to relate to a combinati on of distal embo-lisati on, capillary occlusion, coronary spasm and various vasoacti ve factors. It is seen in a signifi cant minority of STEMI pati ents and is a concern for interventi onists and their pati ents.

Previous retrospecti ve studies have shown that att enuated plaque i.e. mixed atheroma or hypoechoic plaque, demonstrated on intra-vascular ultrasound, is associated with no-refl ow. This paper has confi rmed that the amount of att enuated plaque strongly correlates with no-refl ow. This is interesti ng to know, but unlikely to eff ect clini-cal practi ce.X Wu and others. J Am Coll Cardiol Intv. 2011;4:495-502

CABG

We suspect that most senior clinicians are good at talking through the major risks associated with angioplasty or coronary artery bypass graft ing (CABG), including death, heart att ack, stroke and ‘major’ bleeding, though no-one is ever assessed on this. We would be par-ti cularly interested to know whether we are accurate at explaining the other complicati ons that may occur. This study from New York of 33,936 pati ents undergoing CABG has shown a 30-day readmission rate of 16.5%, for various reasons including infecti on, heart failure and arrhythmias. Predictors for readmission include age, high BMI, receiving a saphenous venous graft and African American descent.E Hannan and others. J Am Coll Cardiol Intv. 2011;4:569-576.

Telemedicine

Is telephonic transmission of data associated with any measurable improvement in heat failure outcomes? No.F Koehler and others. Circulati on. 2011;123:1873-1880.

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ContentsJuly / August 2011


Management: Understanding IntegrityMs Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

AssistanceManagement

I wouldn’t like to suggest that I am the sort of person that takes great value in the words of fi cti onal TV characters, but there is a quote I heard from Jack Bauer in the program 24 which I think is

excellent.

As Jack Bauer is a bit of a legend, fi cti onal as he may be, I am happy to share these words with you without being too ashamed. I quote:

‘You can look the other way once, and it’s no big deal, except it makes it easier for you to compromise the next ti me. And prett y soon that’s all you’re doing: compromising--because that’s the way you think things are done. You know those guys I busted? You think they were the bad guys? Because they weren’t, they weren’t bad guys; they were just like you and me. Except they compromised....once.’

This leads me to integrity in the workplace. You see there are two types of standards - those that people set for you and those that you set for yourself. The standards that are set for you will be those of your professional bodies, from nati onal guidelines, local policies and from your manag-er. These standards are given to you so that the work you do is safe, effi cient, and with minimal risk for you and your pati ents. It ensures that your work is evidence based, audited, reviewed, quality assured and amended in line with what is proven or agreed by consensus to be bett er practi ce.

The standards you set for yourself describe your integrity. Integrity is a concept of consistency of acti ons, values, methods, measures, prin-ciples, expectati ons, and outcomes. Ethically integrity is regarded as the honesty and truthfulness or accuracy of one’s acti ons.

It is your own integrity that will ensure that you work to the stand-ards set for you, to honour those standards and your integrity that will ensure that those around you meet these standards too.

The Insti tute of Business Ethics conducted a nati onal survey1 in 2008 to assess ethical standards and it found that compared to the previ-ous survey in 2005:

• Briti sh full-ti me workers are generally less tolerant of unethical practi ces in the workplace.

• Fewer employees feel pressured to compromise ethical standards.

It also identi fi ed that in a supporti ve culture employees appear to be more willing to report misconduct they are aware of, and are gen-erally more ethical in their atti tudes towards a range of workplace practi ces Conversely that in an unsupporti ve culture, employees experience more pressure to compromise ethical standards and are more likely to feel that honesty is rarely or never practi ced

As a manager, you must set the standards and support your staff in maintaining them. You must ensure that your department abides by evidence based practi ce, and your system allows change, encourages improvement and supports high ethical standards.

Whether you are a manager or an employee one thing is certain. You must not compromise......not even once.

References:1. http://www.serco.com/Images/IBE_Ethics_at_work_

survey_2008_tcm3-30664.PDF

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• Something has to give!• The Festi ve Season• Three Top Tips• Listening to Staff • Set Your Boundaries• Sick Leave

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Before we begin I’d like you to answer the following questi ons regarding the practi ce of acquiring a resti ng 12-lead ECG.

1. Are you a certi fi ed practi ti oner? 2. Have you had regular refresher training and assessment since

your initi al ECG training?3. How regularly do you perform resti ng 12-lead ECGs in line with

your duti es?

Now think about or enquire of the person(s) that have trained you, and ask the same questi ons of them.

Taking a resti ng 12-lead ECG is the most fundamental and rudimenta-ry part of the pati ents care pathway through Cardiology – and many other disciplines besides. Whether for an acute or a routi ne presen-tati on, this is the test that starts the whole diagnosti c ball rolling and to me this demonstrates one of the most remarkable contradicti ons about ECG training:

Because, for the majority:

1. You will not be a certi fi ed ECG practi ti oner, and nor will your trainer.

2. You will not have had regular refresher training, and nor would your trainer.

3. Yet, you will perform plenti ful numbers of ECGs in line with your duti es.

If you and your trainer are accredited, and if you undergo regular training and assessment and are able to show this then you must be commended, because it is so important for ensuring that there is standardised practi ce across all centres. The Society of Cardiologi-cal Science and Technology are the professional body that accredit cardiac physiologists and cardiographers in the acquisiti on and inter-pretati on of the resti ng 12-lead ECG, so despite any training course or ECG workshops you, or your trainer, may have done, it is the SCST accreditati on that is considered the gold standard.

Lesson 1.

Accreditati on, certi fi cati on and training.

The training that you receive, at any stage of your career, should be measureable. You should know who is teaching you, and what qualifi es them to do so. You should know that the informati on you receive is evidence based and accurate. Realisti cally asking all those that teach you what their qualifi cati ons are will probably not warm people to you, and you should be able to gauge by the positi on they hold what skills they are likely to be able to pass down. However, anyone that is delivering training should not mind disclosing their credenti als. Those that do not, will not or can not you should perhaps be more cauti ous of.

Therefore, or the purpose of this training I disclose to you my level of training, practi ce and accreditati on relevant to ECGs below:

I am an RCCP registered Clinical Cardiac Physiologist with 12 years experience working as a clinical cardiac physiologist. I am a mem-ber of the Society of Cardiological Science and Technology accred-ited with both my part 1 and part 2 SCST exams. I am a practi cing work based assessor – which means I regularly assess trainee clinical cardiac physiologists in all aspects of their cardiology training, and I am also an SCST examiner providing assessment at the part 1 and 2 SCST exams for cardiac physiologists and cardiographers nati onally. I am on the SCST educati on committ ee and SCST council and I work at West Hertf ordshire Hospitals NHS Trust as the Principal Clinical Cardiac Physiologist.

To fulfi l all these duti es I am an accredited and certi fi ed practi ti oner for recording resti ng 12-lead ECGs, as well as certi fi ed to assess those doing ECGs in the workplace, and at the professional body exam. To do this I am regularly assessed and regularly practi cing.

EducationSophie Blackman’s ECG

ECG Educati on: Lessons 1 and 2Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust


October 2-5HRC 2011Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October 7-8Briti sh Society of Echocardiography Annual Meeti ngEdinburgh Internati onal Conference CentreEdinburgh, Scotlandwww.bsecho.org

October 14-15Cardiac Risk in the Young (CRY) Internati onal Conference The Cavendish Conference CentreLondon, Englandwww.c-r-y.org.uk

October 16-18PCR London Valves 2011London Englandwww.pcrlondonvalves.com

October 23SADS UK - Heart to Heart Conference 2011Royal College of Pathologists London, Englandwww.sadsuk.org

November 24-25Briti sh Society for Heart Failure 14th Annual Autumn Meeti ngQueen Elizabeth II Conference CentreLondon, Englandwww.bsh.org.uk

November 29The Sixth UK Stroke Forum ConferenceSECCGlasgow, Scotlandwww.ukstrokeforum.org

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Like our educati on topics? We have some of the best cardiology professionals writi ng easy-to-understand educati onal arti cles. Discover them all on our website today.

Here are just some of our great writers

Lesson 2.

Preparing the room and preparing the equipment.

Before I even get onto the bit about where the electrodes should be stuck, and more importantly why, I need to concentrate on the bits you need to know before you even have a pati ent to do an ECG on.

In order to accurately record a resti ng 12-lead ECG you will need to ensure you have the correct equipment available:

1. A clean and fully functi onal electrocardiograph (ECG machine) should be plugged into the mains (where applicable) with its date and ti me set accurately.

2. The electrograph cables and module – clean and in good conditi on.

3. There should be an electrical safety test sti cker on the ECG machine to demonstrate that it has been electrically tested and is safe for use.

4. A manual for the electrocardiograph should be available. 5. An investi gati on couch that is in a recumbent positi on, that is

wide enough and long enough to support the pati ent’s limbs.6. Suffi cient paper, electrodes and spare leads for the ECG machine. 7. Skin preparati on equipment, including razors, skin-friendly alco-

hol wipes, abrasive tape designed for skin exfoliati on, gauze, ti s-sues etc.

8. A sharps bin.9. A clinical waste bin, a refuse bin, and a confi denti al waste bin. 10. Disposable towelling for the bed. 11. Clean gowns and clean sheets and a laundry bin.

You must remember that you will be asking the pati ent to remove all garments from their upper body and in line with this the room should be of an appropriate temperature.

The clinical area must be clean, and ti dy. The investi gati on couch should be clean with a clean strip of disposable towelling upon it, and the ECG machine and its components should be clean and ready for use.

ECG Challenge AnswerQuesti on Page 12

12 Lead ECG discussion.• The rhythm is sinus rhythm rate approx. 60 per minute. • Normal cardiac axis• There is signifi cant ST elevati on in V1-V4 and aVL

(anterior septal leads) of up to 12 mm. There is also ST depression in the inferior leads II,

• III and aVF.

In the context of his clinical presentati on this ECG would sug-gest an Anterior Septal ST elevati on myocardial infarcti on (STEMI).

There is no evidence of T-wave inversion or pathological Q wave development on the leads aff ected by ST elevati on. This would suggest a recent, hyperacute presentati on. This wouldfi t with the very recent onset of symptoms.

Ian Sophie Stuart


Highly specialised CCU Nurses are experienced with ECG rhythms, IABP’s, and temporary pacing wires. With additi onal training and lab experience, do you believe their skills would be suitable to replace cardiac physiologists in an on-call situati on covering Primary PCI’s, where a lack of physiologist staffi ng is an issue?

CCU Nurses replacing Physiologists?

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Like to have your say to this question? Just go to this article on our website and scroll to the bottom of the page.

Management

Hot Topic

It seems I always get asked the controversial questi ons and I’m only allowed 250 words for my answer!I can answer this questi on in one of two ways, one with my physiologist

hat on and one with my manager’s hat on.

As a physiologist of 20 years I’m very protecti ve of my profession and am keen to see our various roles strengthened and not diluted, and the idea of nurses directly replacing physiologists in the cath lab is not something that I would readily endorse, in fact it horrifi es me! Over the years we have seen the idea of a generic cath lab worker to address staff shortages come and go, and I think the majority of centres realise that a good invasive physiolo-gist needs to be exposed to all areas of the cath lab, and if physiologists are replaced by nurses for primary PCI this will have a detrimental eff ect.

As a manager I have to think of service need, and if I didn’t have enough physiologists to provide a day ti me and primary PCI service, then I would have to look to see if any services (including primary PCI) could be sup-ported by other staff groups and not just by CCU nurses, but possibly radi-ographers as well. Ulti mately the local needs of the pati ent have to be met, and each hospital will have to look how best to achieve this including the provision of out of hours services. If that means uti lising nurses instead of physiologists to run a primary PCI service, then that’s what will need to happen. I hope any centre that is proposing using nurses instead of physi-ologists in the catheter lab due to recruitment issues is putti ng in place an acti on plan, for example recruitment of a number of students to address future needs.

I could write another 10 pages on how MSC (modernising scienti fi c careers) wont address the shortages of physiologists, or perhaps the SCST just needs to endorse the registrati on of invasive physiologists as with other physiologist specialiti es, so that trusts would be more obliged to fund the appropriate level of physiologist infrastructure that is necessary to provide primary PCI……I bett er shut up now!

Stuart AllenPrincipal Cardiac Physiologist, Manchester Heart Centre, Manchester Royal Infi rmaryUnited Kingdom

Marti n ReganCharge Nurse

Acute CCUWythenshawe Hospital

Joanne Forster - Chair Educati on Committ ee,

Society of Cardiological Science and Technology

(SCST)

We have more responses to this questi on on our website. Read them today.


The role of a Cardiac Physiologist during a PCI is rapidly changing, from one of a member of the team sitti ng in a control

room, watching the haemodynamic systems and noti ng balloon infl ati on ti mes, to a fully integrated, pivotal member of the team who has knowledge of all facets of the procedures and pati ent care.

The Physiologist is essenti al in a PPCI, not only because of their knowledge of haemodynam-ics, IABP and pacing, but also because of their in-depth background knowledge of cardiac physiology, coupled with their exposure and experience of the PCI procedure.

A CCU nurse could be trained to use a haemo-dynamics system; but this would suggest that the only role of a Cardiac Physiologist in a PPCI

is to interpret unstable rhythms, and operate an IABP and pacing equipment when things go wrong, and this I reject. It would surely be more cost eff ecti ve for a basic Physiologist to receive the same training to perform this spe-cialist role, and leave CCU nurses to staff CCU.

If there is a trust planning to provide a PPCI on-call service without the appropriate staff then this may be an example of a trust putti ng reve-nue before safety. The current austerity meas-ures should NOT compromise pati ent care. If a trust sti ll pursued this course and used non-specialised CCU nurses, then the procedure would become less safe and this would do the pati ent, having an MI and putti ng their life in our hands, a huge disservice.

Rob EdwardsLead EP Senior Chief Cardiac PhysiologistHarefi eld HospitalUnited Kingdom


Wexham Park HospitalWexham, SloughBerkshire, SL2 4HL

Website: www.heatherwoodandwexham.nhs.uk

Wexham Park Hospital: Cardiac Investi gati ons Unit

Above: Liezl Bernales

Site VisitUnited Kingdom


Wexham Park Hospital is part of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust, and is located in the city of Slough, just beyond the M25, west of London. The hospital has 521 beds and offers a full range of services, including a large A&E department, an angiography suite, and an 8 bed Coronary Care Unit accompanied by a 6 bed Post Coronary Care Unit, which acts as a step down unit. The hospital has excellent transport links for staff and patients due to its proximity to London, with regular rail and bus services, as well as the M40, M4, and M25 close by. Heathrow Airport is located only a 20min drive away.

We spoke with Suzanne Jordan, CIU Manager about her department.

What are the sizes of the Cardiac Investigations Unit and Hospital?We have investigation units in Wexham and Heatherwood and pro-vide diagnostic support to clinics at St Marks and Chalfont which are classed as satellite clinics.

What is the geographical intake area and population served by your hospital? 500,000

How many staff? Roles? Band 8a (x1), Band 7 (x2), Band 6 (x5), Band 5 (x5), and one Band 3. Admin (x7) and secretaries (x2).

Types of studies? ECGs, 24 hr ambulatory monitoring inc event monitoring, exercise tolerance testing, echocardiography (TTE and TOE), pacing follow-up inc complex devices. Pacing and complex device implants. We also provide diagnostic angiograms, PCI and a Primary PCI service. Car-dioversions, Radi pressure wire studies and IVUS.

Types of equipment used? GE echo machines, Quest exercise machine, Spacelabs, Toshiba lab with Siemens reporting system.

Above: Mohammed Malik

SITE

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SITE

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How many studies are performed a year? Echo (TTE) 14,700 over 3 sites

What new procedures / techniques have you implemented into the department recently?Working towards implementi ng a paperless pacing clinic and providing dyssynchrony service for our pati ents at Wexham.

What are the benefi ts to pati ents att ending your facility? We off er a one-stop non invasive diagnosti cs for clinics held at Wexham, Heatherwood and St Marks. We are a friendly, professional and enthusiasti c team.

What measures has the department implemented to cut costs?To encourage multi skilling for the Cardiac Physiologists, reducing agency spend by suc-cessfully recruiti ng overseas.

What kind of training can new employees expect to receive?Training / support from Senior physiologists, courses, conferences.

What kinds of competency checks do staff have to undergo once employed? All staff undergo mandatory training, all staff are required to be updated yearly for device training. Students are required to keep a log.

How do you deal with late fi nishing of cases? Physiologists take ti me back in lieu. This is formally recorded.

What is the best part of working at your facility? Friendly down to earth professional team who really do support each other to ensure that the service works.

SITE VISITS ONLINE

Cardiac Investigation Unit Staff

Mukbinder Jassal, Theo Rosales, Harmesh Lyal, Raquel Tango, Barbara Smith, Suzanne Jordan, Mohammed Malik, Michael Phillips, Fatama Khatun, Theresa Smith, Poonam Chaudhary, Mark Curson, Liezl Bernales

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Pharmaceuti cal EditorHead of Clinical Pharmacy, Royal Berkshire Foundati on Trust & Nati onal Non-medical Prescribing Facilitator, Nati onal Prescribing Centre.

Mr Tim LarnerDirector / FounderPrevious Cardiac Radiographer Manager in Australia, & Senior Radiographer at multi ple sites in the UK.

Dr Magdi El-OmarLead Consulti ng EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundati on Trust

Dr Richard EdwardsConsulti ng EditorConsultant Cardiologist, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

Mr Ian WrightEP Consulti ng EditorTechnical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust



Prof Simon RedwoodConsulti ng EditorConsultant Cardiologist & Director of the Cath Labs at Guy’s & St Thomas‘ NHS Foundati on Trust

Dr Rodney FoaleConsulti ng EditorConsultant Cardiologist, Imperial College Healthcare NHS Trust

Mr Adam LunghiEcho Consulti ng EditorSenior Echo ManagerCVS - CardioVascular Services, Australia

Mr Dennis SandemanNursing Consulti ng EditorChest Pain Nurse SpecialistNHS Fife, Trustee of the Scotti sh Heart and Arterial Risk Preventi on (SHARP) charity.

Ms Sophie BlackmanManagement & CRM Consulti ng EditorHead of Clinical Cardiac Physiology, West Hertf ordshire NHS Trust


Latest Product News

Round UpCardiac Stent TrialsACUSON SC2000 from Siemens

Healthcare off ers advanced cardiac imagingNuffi eld Health Leeds Hospital is one of the fi rst hospitals in the UK to have installed an ACUSON SC2000™ ultrasound system from Sie-mens Healthcare. The SC2000 is situated in the cardiology depart-ment, one of only two in the Nuffi eld Health group, and is being used to carry out all echocardiograms as well as being the main ultrasound machine for all invasive and non-invasive tests.

The SC2000 is among the fi rst systems in the world to acquire non-sti tched, real-ti me full-volume images of the heart in one single cycle. At Nuffi eld Health Leeds Hospital it replaced an older system and there are potenti al plans for it to be used in the future for 3D ultrasound and 3D transesophageal echocardiograms.

“We chose the SC2000 because it off ers the latest technology and it has allowed us to cut the ti me taken to do a standard echocardi-ography exam and consequently see more pati ents,” said Matt hew Howland, Cardiac Services Manager at Nuffi eld Health Leeds Hospital.

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Hand Saniti zers - Do we need to make them secure?I just read about a man who drank six bott les of hand saniti zer at the Alfred Hospital in Melbourne, giving him a blood alcohol reading of 0.271 per cent. The 45 year old man had been undergoing treatment for alcohol-related gastriti s when he drank the 375ml bott les of saniti ser, which have an ethanol content of 66 per cent.

New Data Confi rms Safety of BioMatrix™ at One Year e-BioMatrix post-marketi ng surveillance (PMS) registry informati on presented at EuroPCR 2011 has confi rmed that BioMatrix™, Biosensors’ Biolimus A9™-eluti ng stent sys-tem with abluminal biodegradable polymer, is safe over a 12-month period in a “real-world” pati ent populati on. The prospecti ve, multi -centre, observati onal registry, ini-ti ated in March 2008, is assessing the outcomes of 1,102 pati ents across a broad range of inclusion criteria from nine European study sites over a fi ve-year period. Enrol-ment was completed in September 2009. Only 74 pati ents (6.7%) experienced a clinical adverse event that could be included in the primary endpoint of the registry, MACE (a composite of cardiac death, MI and clinically-driven TVR) at 12 months. The registry will also examine a range of secondary end-points, includ-ing primary and stent thrombo-sis over several periods; MACE at intervals up to fi ve years; and death and MI rates for up to fi ve years.

For more informati on please visit www.biosensors.com

The registry will also examine a range of secondary end-

to fi ve years; and death and MI rates for up to fi ve years.


New Test for Residual Platelet Reacti vityAccumetrics, Inc., developer of the VerifyNow® System, the fi rst rapid and easy-to-use point-of-care system for measuring platelet reacti v-ity to multi ple anti platelet agents, announced today that the VerifyNow P2Y12 Test is now CE marked for prognosti c use in identi fy-ing pati ents with high residual platelet reacti vity (also termed poor responders) on anti platelet therapy (e.g. clopidogrel) who are at greater risk for future cardiovascular events.

Studies comprising over 3,000 pati ents, uti lizing the VerifyNow P2Y12 Test, have shown a correlati on to clinical outcomes based on PRU (P2Y12 Reacti on Units) results, concluding that an on-treat-ment PRU of ≥230 identi fi es pati ents at signifi cantly greater risk for future cardiovascular events including death, heart att ack and stent thrombosis. “Researchers, such as myself, have long been studying the relati on-ship between platelet reacti vity while on anti platelet therapy and the risk of recurrent ischemic events in our cardiovascular pati ents,” stated Robert F. Storey, MD, Professor of Cardiology at the Univer-sity of Sheffi eld, England. “The achievement of a prognosti c claim will reinforce its applicati on to risk strati fi cati on, potenti ally guiding therapy in pati ents undergoing coronary stenti ng.”

The VerifyNow System is widely used in various clinical setti ngs where anti platelet medicati ons are prescribed to reduce the occurrence of future thromboti c events such as heart att ack and stroke.

For more informati on contact:ELITech UK LimitedTel: +44 (0) 1442 86 93 20Email: [email protected]

Recruitment Services

Fresh faces, fresh fundraising, fresh success!The fi rst few months of 2011 have been busy ones for the medical and scienti fi c recruitment specialists, Kirkham Young.

Following the growth of the team at the end of 2010, the company was delighted to reveal it’s new look website as part of it’s ongoing programme of progression.“We all had great fun with the photo shoot at the offi ces” commented Scienti fi c Manager Alan Dias. “It is always a litt le unnerving being followed around by a photographer for the day but I think it’s really important that our customers can see us as naturally as possible. People are the foundati on of our business and searching for a new role can be a daunti ng prospect – being able to visualise who is on the end of the phone should help to alleviate some of that apprehension!”

Kirkham Young are also delighted to support a range of chariti es again this year with fundraising events, corporate donati ons and sponsorship of local junior sports teams.

For more informati on please visit www.kirkhamyoung.co.uk

ExoSeal™ Vascular Closure Device - available now in 5, 6 & 7 FrenchThe ExoSeal™ Vascular Closure Device from Cordis Johnson & Johnson makes use of key techno-logical developments to support the clinical safety* and effi cacy

of the closure procedure. In the ECLIPSE Trial, the extravascular plug placement was associated with no embolisati on, infecti on or other major adverse events, compared to manual compression despite the signifi cantly shorter ti me to ambulati on for ExoSeal™. The bioabsorbable PGA-plug (Poly-glycolic Acid), is designed to close the femoral artery puncture site with minimal or no infl ammati on. It is fully reabsorbed in 60-90 days. PGA is a trust-ed non-collagen plug material that is metabolized to carbon dioxide and water. A system of deploy-ment through the existi ng procedural sheath makes ExoSeal™ quick and easy to use and increases physician convenience by minimising or eliminati ng the need for sheath exchange during the procedure. The device uses visual indicators to help the physician to

correctly deploy the device. This visual feedback also promotes pati ent comfort during deployment and the ‘lock-out’ system of ExoSeal™ helps ensure that only extra-vascular plug placement can take place. ExoSeal™ is available in 5, 6 and 7 French.

*Clinical data from the ECLIPSE trial indicates safety in terms of ves-sel injury, access site-related bleeding, infecti on or nerve injury, new ipsilateral lower extremity ischemia or serious adverse events (SAE).

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Coronary Heart_HeartStation -May-June 2011_Final.pdf 1 20/04/2011 11:31:46


‘Heart repair pill’ sti ll years away“A drug that makes hearts repair themselves has been used in research on mice,” BBC News has reported.

The news is based on an early set of laboratory and animal experi-ments. Researchers identi fi ed cells in the outer layer of the heart that can develop into mature heart cells and replace injured heart ti ssue aft er being treated with a specifi c protein. These “progeni-tor cells” have the ability to develop into new heart muscle cells in embryos, but cannot normally do so in adults. However, researchers have found that dormant progenitor cells can be acti vated in adult mice by injecti ng them with a specifi c protein. When these mice were induced to have a heart att ack, some of the treated progeni-tor cells developed into new heart muscle cells, integrati ng into the heart ti ssue and functi oning as part of the organ.

This research is at a very early stage, and further studies on the eff ecti veness and safety of such treatment in animals will be needed before human studies can be carried out. In parti cular, if the biologi-cal mechanisms discovered also apply to humans, research will need to establish if the protein could have an eff ect if administered months or years before a heart att ack, or even aft er one. This study mainly looked at administering the protein before heart damage occurred. Overall, despite the possibiliti es presented by this early research, a pill that can regenerate human hearts is sti ll some years off .

The study was carried out by researchers from University College London, Children’s Hospital Boston, Harvard Medical School, the Chinese Academy of Science and Imperial College London. It was funded by the Briti sh Heart Foundati on. The study was published in the peer-reviewed scienti fi c journal Nature.

Behind The Headlines

The Facts

The following articles are courtesy of NHS Choices

Staying Healthy

Confusion over new salt research“Salt is GOOD for you,” according to claims in the Daily Mail. The newspaper challenged conventi onal health advice by suggesti ng that “eati ng more could even lower the chances of heart disease”.

However, these claims are somewhat unjusti fi ed as they are based on a study that actually looked at a one-off measure of salt in people’s urine rather than in their diet. The research looked at 3,700 people’s urinary salt levels and then followed them for nearly eight years to look at their risk of high blood pressure, cardiovascular disease (CVD) and related deaths.

Among the main results the researchers observed 84 CVD-related deaths. Surprisingly, they found that there were 50 CVD-related deaths in the third of parti cipants with the low-est salt levels, and just 10 deaths in those passing the most salt. This would initi ally seem to challenge the conventi onal wisdom that salt raises blood pressure and, therefore, the risk of heart problems. However, this study is not straightf or-ward to interpret, parti cularly as the single urinary sodium measure analysed is not necessarily a direct indicator of how much salt a person eats. For example, it may indicate how hydrated a person is or how well their kidneys are fi ltering sodium.

The limitati ons of this study mean that, on its own, it does not challenge the accepted associati on between salt intake, blood pressure and related disease, and certainly does not suggest that eati ng more salt is good for you.

The study was carried out by investi gators from the European Project on Genes in Hypertension (EPOGH), a research pro-ject based in Belgium and supported by various European study and research grants. The study was published in the peer-reviewed Journal of the American Medical Associati on.

The Daily Mail’s headline implying that eati ng salt is good for you is a rather simplisti c conclusion from this complex study, and the study cannot be interpreted in this way. Crucially, it should be remembered that a single measure of someone’s urinary salt excreti on does not necessarily equate to the level of salt they consume. Health recommendati ons are unlikely to change based on this study alone.


THE

FAC

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What are your special interests within cardiology?

My special interests are in percutaneous coronary interventi on (PCI) and cardiac CT imaging. I also have an interest in trans-oesophageal echocardiography.

What do you fi nd most rewarding about your career?

I enjoy managing complex pati ents, and dealing with the acutely unwell pati ent - seeing these pati ents go home aft er recovery from their acute illness is the biggest reward of all.

What stage are you at with your training?

I am a fi nal year trainee in cardiology, working in the North West Deanery. I will shortly be able to apply for consultant posts.

Do you have any advice for trainees wishing to pursue a career in interventi on?

Be sure that interventi on is what you are passionate about, be realisti c about the challenges you will face, and you will fi nd the hard work part of the job is much easier. Spend ti me before the procedure evaluati ng the pati ent, and be sure to review them aft erwards. These aspects are at least as important as the procedure itself in ensuring opti mal care of the pati ent.

Are there any parti cular challenges for female trainees in your sub-speciality?

I have not encountered any problems as a female trainee in interventi on. My predecessors I am sure may have in years gone by, but this is not an issue in current day practi ce.

How do you relax aft er a long day?

Aft er a long day, it is important to clear my head and my way of switching off is to hit the road for a run. In the last year, I have parti cipated in the London Marathon, Barcelona Half-Marathon and am currently training for the Great North Run.

Dr Cara Hendry Specialist RegistrarBlackpool Teaching Hospitals NHS Foundati on Trust

Cardiologist InterviewStudy looks at fear aft er heart att ack“Pati ents who feel scared of dying during heart att ack symptoms may be more likely to suff er another,” the Daily Mirror has reported.

The news is based on a small study in 208 people who were admitt ed to hospital with chest pain. The pati ents were asked three questi ons designed to assess their level of fear, whether they thought they might die and feelings of stress. Researchers com-pared their answers to the results of blood tests, taken when the pati ents were admitt ed to hospi-tal, that measured levels of a chemical associated with infl ammati on, as well as heart rate or stress hormones three weeks later. Infl ammati on is known to both damage the heart and occur in response to heart damage.

The study found that people who were more dis-tressed when admitt ed to hospital had higher levels of infl ammati on markers as well as lower levels of stress hormones three weeks later. However, the study had several limitati ons. Principally, it did not assess the risk of a second heart att ack, but only looked at markers of infl ammati on at the start of the study. Also, about 50% of parti cipants chose not to take part in the follow-up tests three weeks aft er hospital admission. These were mainly people who were unmarried and from poorer backgrounds. This means that the data from this study need to be interpreted cauti ously.

Given the limited scope of this early research, a link between infl ammatory markers in the blood and emoti onal distress needs further investi gati on.

The study was carried out by researchers from Uni-versity College London, the University of Sti rling, the University of Bern and St George’s Hospital in London. It was supported with grants from the Brit-ish Heart Foundati on, the Medical Research Council and the Swiss Nati onal Foundati on. The research paper was published in the peer-reviewed European Heart Journal.

The Daily Mirror uncriti cally reported the research-ers’ main fi ndings. The BBC included quotes that highlighted some of the study’s limitati ons.


With over 30 companies showcasing their version of coronary stents at EuroPCR this year:

Dr Doug FraserConsultant CardiologistManchester Heart CentreManchester Royal Infi rmaryMANCHESTER

Is there any need for additi onal stents on the market, or is the latt er already saturated?Design of workhorse stents by the major companies is conti nuing and new designs will conti nue to bring improvements. These incre-mental improvements will be less than the major advances we have seen in the past and it is uncertain whether major breakthroughs in design such as dissolving platf orms will work. Design and testi ng of workhorse stents is likely to remain with the larger companies. Stents designed for niche applicati ons such as dedicated bifurcati on, STEMI and left main stents will conti nue and do show promise. We may therefore see more development here. To answer your questi on, there is litt le point in hav-ing many more platf orms that do the same as cur-rent ones but advances in design will conti nue, per-haps parti cularly in the niche designs.

Should there be more rigorous testi ng before CE Marks are handed out? To require a mega-trial before adopti on of eve-ry new stent platf orm would exclude smaller companies from devel-oping niche stents and so would sti fl e innova-ti on so there needs to be balance – but I do agree that the CE marking pro-cess could be more rigor-ous and certainly bett er standardized.

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SEE OUR PREVIOUS HOT TOPICS

We have 15 Hot Topics available on our website with responses from leading cardiologists from across the UK and around the world.

Hot TopicCardiologist

Questions designed by Dr Magdi El-Omar and Tim Larner

Edwards Lifesciences Irvine, USA I Nyon, Switzerland I Tokyo, Japan I Singapore, Singapore I São Paulo, Braziledwards.com

Edwards transcatheter heart valves: The life-changing innovation that improves quality of lifeTo date, thousands of high-risk patients in Europe have received Edwards transcatheter heart valves as an effective therapy. Along with improved rates of survival,1 the landmark clinical study—The PARTNER Trial—demonstrated a 25-point improvement in quality-of-life scores for patients receiving an Edwards SAPIEN balloon-expandable transcatheter aortic valve compared to the standard treatment control group at one year.2

For more information & to find a TAVI center near you please visit edwards.com/eu/products/transcathetervalves

References: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607. 2. Data on file, Edwards Lifesciences Corporation. 2. Data on file, Edwards Lifesciences Corporation.

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation.Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation.

© 2011 Edwards Lifesciences Corporation. All rights reserved. E2064/05-11/THV

A new option for your high-risk patients with aortic stenosis

Publication: Coronary Heart Size: A4 Trim: 210 mm X 297mm Bleed: 3mm

Register as a member for FREE on our site and get access to a variety of free and discounted online courses from Charles Bloe Training Ltd.


ChallengeCharles Bloe Training’s ECG

HistoryA 68 year old man with history of hypertension and ischaemic heart disease but no previous MI. Presenti ng with a 2 hour history of central chest pain and dyspnoea. This episode of pain awakened him from his sleep this morning. He felt very afraid and was sweati ng profusely. He lives on a croft that is 85 miles from his nearest hospital.Vital signs recorded by the Paramedics:BP 90/55 mmHg. Pulse 60 per minute and regular. Respiratory rate: 24 per minute. Temperature 36.8oC. Oxygen saturati ons were 93% and he was commenced on 3 litres of oxygen via nasal cannula.

What is your conclusion?

AVAILABLEONLINE

Answer Page 25

BONUS ECG CHALLENGE ONLINE ONLY

Every month on our website will be a new ECG Challenge, joining the other 20+ ECG Challenges already available online.

You can even rate and comment on each ECG.

an innovation of


WebsiteCardiologyHD Community

Website Overview

CardiologyHD.comOur new website has been specially designed with you in mind. Over six months in development our site integrates a modern, easy to use community to allow for easy networking with other professionals around the world. To make it even easier we have linked our community with several cardiology societi es and groups who now call our site home for their members to discuss topics and relay latest informati on.

All of our arti cles can be commented on and rated, to assist other users looking for relevant topics. Integrated Google maps operate seamlessly within the dynamic layout to provide you with relevant informati on quickly. With a growing list of new members, we hope you can join us soon. Registrati on is free and easy.

Our Home Page is your fi rst port of call. Use the sliders to scroll through the latest site visits and catalogue products, see the latest events happening around the world, and keep an eye on the latest forum discussions. All of our latest arti cles are also promoted here.

Once registered you will have your own

secure profi le page. Upload a new photo of yourself and keep track

of what is happening throughout the

community. Your forum posts, comments, and

favourites are all listed here in a very easy to

use dynamic layout.

Like an arti cle? Make it social with integrated Google +1, Twitt er, & Facebook butt ons.


Mobile Devices

iPad & iPhone Compati bleCardiologyHD.com has been opti mised to work on the latest mobile devices, including iPad and iPhone

We are conti nually updati ng our site features so that you get maximum enjoyment wherever you are located.

Within the community is a list of several societi es and groups that are integrated within the site. Members from each group can interact with a dedicated forum for their society to stay up-to-date with the latest news and upcoming

events. You will also fi nd other informati on such as membership details and who to contact.

One of our favourite secti ons is the Site Visits. Now even

easier to use. Either click on the map or scroll through the

list of hospitals to show the one you are aft er. Use the

handy search bar in the right column on many pages to

speed up your search. At the bott om of site visit pages you

will also fi nd extra Google Maps with Street View as

well as departmental photos.

The forum is the main hub of acti vity within the community and allows you to post and discuss topics across a wide range of interests.


Journals

Risks and Benefi ts of Anti coagulati on

Bad news for Vitamin K loving electrophysiologists. The twin risks of stroke and bleeding associated with AF ablati on have exercised operators since the technique has been practi sed. Over the years, an increasing proporti on have seen it as the lesser of two evils to perform the procedure on warfarin, rather than risk periods of procoagulabil-ity and/or the greater post procedural bleeding risk of heparinoids. In this retrospecti ve series, tamponade in the group therapeuti cally anti coagulated throughout the ablati on were no harder to manage than those with an INR<2 at the ti me of the complicati on.R Latchamsett y and others, Heart Rhythm. 2011;8:805– 808.

Another nail in the coffi n of the heparin bridging Luddites. In this underpowered, randomised trial of warfarin conti nuati on vs. stop-ping/bridging, all of the complicati ons occurred in the disconti nua-ti on group. Although not stati sti cally signifi cant, taken together with previous non randomised data, the message is clear: when it comes to implanti ng devices, warfarin is safe, heparin is poison.A Cheng and others, Heart Rhythm. 2011;8:536 –540.

In stroke preventi on for atrial fi brillati on, the cost effi cacy compari-son between warfarin, dabigatran and aspirin depends on three fac-tors: stroke risk, bleeding risk and the ti me that pati ents on warfarin spend within therapeuti c range. A model devised in this paper sug-gests possible subsets of pati ents with combinati ons of high stroke and bleeding risk and a high proporti on of non therapeuti c INRs that may benefi t suffi ciently enough from dabigatran for this to be a cost eff ecti ve opti on.V Shimoli and others. Circulati on. 2011;123:2562-2570.

Doctors seem to love a standardised defi niti on and Cardiologists are no diff erent. We already have defi niti ons for a myocardial infarcti on and for stent thrombosis. Now we have one for bleeding, produced by the Bleeding Academic Research Consorti um (BARC) – a collabo-rati on of expert groups. This consists of bleeding types 1 to 5 and is an att empt to move away from subjecti ve terms, such as ‘minor’ and ‘major’ bleeding. Commendable stuff , but will need validati on in outcome trials to gain widespread acceptance.R Mehran and others. Circulati on. 2011;123:2736-2747.

Implantable Devices

Sub group analyses on two diff erent trials (REVERSE and MADIT CRT) reveal that those NYHA I-II pati ents who reverse remodel with CRT appear to have a lower incidence of ventricular arrhythmias. As well as providing another rati onale to off er a left ventricular (LV) lead to minimally symptomati c pati ents receiving an ICD beyond heart fail-ure event reducti on, this expands the target for those who argue that some primary preventi on pati ents should be off ered CRT in place of, rather than in additi on, to an ICD.

A slight sti ng in the tail is a trend toward a higher rate of arrhythmias in low responders to CRT, compared with ICD only recipients.A Barshshet and others. J Am Coll Cardiol 2011; 57:2416–23.

M Gold and others. Heart Rhythm 2011;8:679–684.

A counterbalance to any headlong rush to LV leads for all is the well known increase in complicati ons associated with CRT, as compared with simpler devices. Among over 3000 Italian CRT recipients, LV lead displacements occurred at a rate of 2.3% per year with a four year incidence of lead revision at 14%, compared with 4% and 9% in single and dual chamber devices. The annual infecti on rate in CRT pati ents was 1% and was signifi cantly predicted by additi onal proce-dures. Predictably, CRT devices also required a box change for bat-tery depleti on sooner than other devices.M Landolina and others Circulati on. 2011;123:2526-2535.

There is more evidence of the high risk of infecti ons with box changes from the Danish registry of over 46 000 implants. Box changes were almost three ti mes as likely to be complicated by infecti on within the fi rst year post as new implants (12.1 vs. 4.8 per 1000). Late infecti ons were also more prevalent aft er more than one procedure (3.3 vs 1.1 per 1000 pati ent years). Systemic anti bioti cs at implant were associ-ated with a reducti on in incidence of infecti on in new implants (HR 2.3 for no anti bioti cs).JB Johansen and others. European Heart Journal (2011) 32, 991–998.




Mitral Isthmus Ablati on

Linear ablati on at the mitral isthmus is oft en performed in the context of left atrial ablati on of atrial fi brillati on and related arrhythmias. The commonest anatomical strategy is to create a line of block between the mitral valve and left pulmonary veins. Is it safe and feasible aft er mitral valve surgery? Yes, in a small series of post surgical pati ents compared with matched non surgical pati ents. The success rate in achieving block was modest at 71% in both groups, but no signifi cant complicati ons were observed.S Mountantonakis and others Heart Rhythm 2011;8:809–814.

One of the challenges with achieving block is the cooling eff ect of the coronary sinus (CS). It is well recognised that ablati on within CS is oft en necessary, but some operators are keen to avoid this and even with CS ablati on in the best hands there are some instances of failure to achieve block.

An alternati ve strategy to avoiding the cooling eff ect is to occlude the distal CS with an air fi lled balloon. In a randomised trial of 46 pati ents undergoing mitral isthmus ablati on deployment of a balloon was pos-sible in 20/23 pati ents with a reducti on CS ablati on requirements and reduced radiofrequency (RF) and procedure ti mes to achieve block. Acute procedural success was no diff erent in the balloon occlusion or control groups (87 vs. 91%).K Wong and others. Heart Rhythm 2011;8:833– 839.

Valves

The big news in interventi onal cardiology this month is the publica-ti on of the PARTNER A study. In typically perverse fashion, PARTNER B was published fi rst (September 2010), demonstrati ng that trans-cutaneous aorti c valve implantati on (TAVI) using the Edwards Sapien valve inserted via the femoral route improved survival (20% absolute risk reducti on at 12 months) in pati ents deemed unsuitable for sur-gery, when compared with best medical care. PARTNER A compared TAVI using the same balloon expandable valve to conventi onal sur-gery in high risk pati ents with severe aorti c stenosis. At 1 year follow up, mortality was shown to be non-inferior with TAVI, with more vas-cular complicati ons (that will be the big sheath in the femoral artery then) and less bleeding complicati ons. There was a trend towards increased stroke and more paravalvular regurgitati on with TAVI and longer follow-up is needed to see whether these will cause trouble further down the line. We anti cipate that the PARTNER trials are a gamechanger in the management of severe aorti c stenosis.CR Smith and others. NEJM 2011;364:2187-2198.

Endocarditi s is bad for you. Staphylococcus aureus, development of heart failure and periannular complicati ons are all associated with worse outcomes. No surprise there then.Javier Lopez and others. Heart 2011;97:1138-1142.

Stents

Old stents with long term data. 5 year pooled results for Taxus paclitaxel-eluti ng stents (PES) confi rm no signifi cant diff erences in mortality or MI compared to bare metal stents (BMS) in simple and complex lesions, with a signifi cant reducti on in ischaemia-driven tar-get lesion revascularisati on, as expected. Interesti ngly, the rates of cardiac death, MI or stent thrombosis were greater with PES than BMS between 1 and 5 years.

Also, 5 year results from the SIRTAX LATE study comparing the fi rst generati on Cypher sirolimus-eluti ng (SES) vs. PES show no signifi -cant diff erences in clinical or angiographic outcomes. Of note, tar-

get lesion revascularisati on occurred at a rate of 2% a year, with a stent thrombosis rate of 0.65%, confi rming previous data. There are a number of newer stents with bett er data, though only 3 year follow up is currently available.

G Stone and others. J Am Coll Cardiol Intv. 2011;4:530-542.L Raber and others. Circulati on 2011 10.1161/CIRCULATIONAHA.110.004762

Another trial with an old stent conti nues to produce infant papers. HORIZONS AMI now has 3 year follow up data, showing that the Taxus PES is as safe as a bare metal stent in STEMI, with less need for ischaemia-driven target lesion revascularisati on. However, the stent thrombosis rate of 5% seen in both arms is of concern. The other part of the trial conti nues to demonstrate the benefi ts of bivalirudin vs. heparin and a glycoprotein IIBIIIA inhibitor in STEMI pati ents, due to signifi cantly reduced major bleeding and adverse clinical events.G Stone and others. Lancet 2011; DOI:10.1016/S0140-6736(11)60764-2

STEMI

Yet another off spring from HORIZONS AMI has looked for an expla-nati on for the no-fl ow phenomenon seen in some pati ents undergo-ing percutaneous coronary interventi on. This phenomenon is poorly understood and is thought to relate to a combinati on of distal embo-lisati on, capillary occlusion, coronary spasm and various vasoacti ve factors. It is seen in a signifi cant minority of STEMI pati ents and is a concern for interventi onists and their pati ents.

Previous retrospecti ve studies have shown that att enuated plaque i.e. mixed atheroma or hypoechoic plaque, demonstrated on intra-vascular ultrasound, is associated with no-refl ow. This paper has confi rmed that the amount of att enuated plaque strongly correlates with no-refl ow. This is interesti ng to know, but unlikely to eff ect clini-cal practi ce.X Wu and others. J Am Coll Cardiol Intv. 2011;4:495-502

CABG

We suspect that most senior clinicians are good at talking through the major risks associated with angioplasty or coronary artery bypass graft ing (CABG), including death, heart att ack, stroke and ‘major’ bleeding, though no-one is ever assessed on this. We would be par-ti cularly interested to know whether we are accurate at explaining the other complicati ons that may occur. This study from New York of 33,936 pati ents undergoing CABG has shown a 30-day readmission rate of 16.5%, for various reasons including infecti on, heart failure and arrhythmias. Predictors for readmission include age, high BMI, receiving a saphenous venous graft and African American descent.E Hannan and others. J Am Coll Cardiol Intv. 2011;4:569-576.

Telemedicine

Is telephonic transmission of data associated with any measurable improvement in heat failure outcomes? No.F Koehler and others. Circulati on. 2011;123:1873-1880.

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Highly specialised CCU Nurses are experienced with ECG rhythms, IABP’s, and temporary pacing wires. With additi onal training and lab experience, do you believe their skills would be suitable to replace cardiac physiologists in an on-call situati on covering Primary PCI’s, where a lack of physiologist staffi ng is an issue?

CCU Nurses replacing Physiologists?

ONLINE

BONUS RESPONSES ONLINE

Like to have your say to this question? Just go to this article on our website and scroll to the bottom of the page.

Management

Hot Topic

It seems I always get asked the controversial questi ons and I’m only allowed 250 words for my answer!I can answer this questi on in one of two ways, one with my physiologist

hat on and one with my manager’s hat on.

As a physiologist of 20 years I’m very protecti ve of my profession and am keen to see our various roles strengthened and not diluted, and the idea of nurses directly replacing physiologists in the cath lab is not something that I would readily endorse, in fact it horrifi es me! Over the years we have seen the idea of a generic cath lab worker to address staff shortages come and go, and I think the majority of centres realise that a good invasive physiolo-gist needs to be exposed to all areas of the cath lab, and if physiologists are replaced by nurses for primary PCI this will have a detrimental eff ect.

As a manager I have to think of service need, and if I didn’t have enough physiologists to provide a day ti me and primary PCI service, then I would have to look to see if any services (including primary PCI) could be sup-ported by other staff groups and not just by CCU nurses, but possibly radi-ographers as well. Ulti mately the local needs of the pati ent have to be met, and each hospital will have to look how best to achieve this including the provision of out of hours services. If that means uti lising nurses instead of physiologists to run a primary PCI service, then that’s what will need to happen. I hope any centre that is proposing using nurses instead of physi-ologists in the catheter lab due to recruitment issues is putti ng in place an acti on plan, for example recruitment of a number of students to address future needs.

I could write another 10 pages on how MSC (modernising scienti fi c careers) wont address the shortages of physiologists, or perhaps the SCST just needs to endorse the registrati on of invasive physiologists as with other physiologist specialiti es, so that trusts would be more obliged to fund the appropriate level of physiologist infrastructure that is necessary to provide primary PCI……I bett er shut up now!

Stuart AllenPrincipal Cardiac Physiologist, Manchester Heart Centre, Manchester Royal Infi rmaryUnited Kingdom

Marti n ReganCharge Nurse

Acute CCUWythenshawe Hospital

Joanne Forster - Chair Educati on Committ ee,

Society of Cardiological Science and Technology

(SCST)

We have more responses to this questi on on our website. Read them today.


The role of a Cardiac Physiologist during a PCI is rapidly changing, from one of a member of the team sitti ng in a control

room, watching the haemodynamic systems and noti ng balloon infl ati on ti mes, to a fully integrated, pivotal member of the team who has knowledge of all facets of the procedures and pati ent care.

The Physiologist is essenti al in a PPCI, not only because of their knowledge of haemodynam-ics, IABP and pacing, but also because of their in-depth background knowledge of cardiac physiology, coupled with their exposure and experience of the PCI procedure.

A CCU nurse could be trained to use a haemo-dynamics system; but this would suggest that the only role of a Cardiac Physiologist in a PPCI

is to interpret unstable rhythms, and operate an IABP and pacing equipment when things go wrong, and this I reject. It would surely be more cost eff ecti ve for a basic Physiologist to receive the same training to perform this spe-cialist role, and leave CCU nurses to staff CCU.

If there is a trust planning to provide a PPCI on-call service without the appropriate staff then this may be an example of a trust putti ng reve-nue before safety. The current austerity meas-ures should NOT compromise pati ent care. If a trust sti ll pursued this course and used non-specialised CCU nurses, then the procedure would become less safe and this would do the pati ent, having an MI and putti ng their life in our hands, a huge disservice.

Rob EdwardsLead EP Senior Chief Cardiac PhysiologistHarefi eld HospitalUnited Kingdom


Management: Understanding IntegrityMs Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

AssistanceManagement

I wouldn’t like to suggest that I am the sort of person that takes great value in the words of fi cti onal TV characters, but there is a quote I heard from Jack Bauer in the program 24 which I think is

excellent.

As Jack Bauer is a bit of a legend, fi cti onal as he may be, I am happy to share these words with you without being too ashamed. I quote:

‘You can look the other way once, and it’s no big deal, except it makes it easier for you to compromise the next ti me. And prett y soon that’s all you’re doing: compromising--because that’s the way you think things are done. You know those guys I busted? You think they were the bad guys? Because they weren’t, they weren’t bad guys; they were just like you and me. Except they compromised....once.’

This leads me to integrity in the workplace. You see there are two types of standards - those that people set for you and those that you set for yourself. The standards that are set for you will be those of your profes-sional bodies, from nati onal guidelines, local policies and from your manager. These standards are given to you so that the work you do is safe, effi cient, and with minimal risk for you and your pati ents. It ensures that your work is evidence based, audited, reviewed, qual-ity assured and amended in line with what is proven or agreed by consensus to be bett er practi ce.

The standards you set for yourself describe your integrity. Integrity is a concept of consistency of acti ons, values, methods, measures, prin-ciples, expectati ons, and outcomes. Ethically integrity is regarded as the honesty and truthfulness or accuracy of one’s acti ons.

It is your own integrity that will ensure that you work to the stand-ards set for you, to honour those standards and your integrity that will ensure that those around you meet these standards too.

The Insti tute of Business Ethics conducted a nati onal survey1 in 2008 to assess ethical standards and it found that compared to the previ-ous survey in 2005:

• Briti sh full-ti me workers are generally less tolerant of unethical practi ces in the workplace.

• Fewer employees feel pressured to compromise ethical standards.

It also identi fi ed that in a supporti ve culture employees appear to be more willing to report misconduct they are aware of, and are gen-erally more ethical in their atti tudes towards a range of workplace practi ces. Conversely that in an unsupporti ve culture, employees experience more pressure to compromise ethical standards and are more likely to feel that honesty is rarely or never practi ced.

As a manager, you must set the standards and support your staff in maintaining them. You must ensure that your department abides by evidence based practi ce, and your system allows change, encourages improvement and supports high ethical standards.

Whether you are a manager or an employee one thing is certain. You must not compromise......not even once.

References:1. http://www.serco.com/Images/IBE_Ethics_at_work_

survey_2008_tcm3-30664.PDF

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Wexham Park HospitalWexham, SloughBerkshire, SL2 4HL

Website: www.heatherwoodandwexham.nhs.uk

Wexham Park Hospital: Cardiac Investi gati ons Unit

Above: Liezl Bernales

Site VisitUnited Kingdom


Wexham Park Hospital is part of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust, and is located in the city of Slough, just beyond the M25, west of London. The hospital has 521 beds and offers a full range of services, including a large A&E department, an angiography suite, and an 8 bed Coronary Care Unit accompanied by a 6 bed Post Coronary Care Unit, which acts as a step down unit. The hospital has excellent transport links for staff and patients due to its proximity to London, with regular rail and bus services, as well as the M40, M4, and M25 close by. Heathrow Airport is located only a 20min drive away.

We spoke with Suzanne Jordan, CIU Manager about her department.

What are the sizes of the Cardiac Investigations Unit and Hospital?We have investigation units in Wexham and Heatherwood and pro-vide diagnostic support to clinics at St Marks and Chalfont which are classed as satellite clinics.

What is the geographical intake area and population served by your hospital? 500,000

How many staff? Roles? Band 8a (x1), Band 7 (x2), Band 6 (x5), Band 5 (x5), and one Band 3. Admin (x7) and secretaries (x2).

Types of studies? ECGs, 24 hr ambulatory monitoring inc event monitoring, exercise tolerance testing, echocardiography (TTE and TOE), pacing follow-up inc complex devices. Pacing and complex device implants. We also provide diagnostic angiograms, PCI and a Primary PCI service. Cardioversions, Radi pressure wire studies and IVUS.

Types of equipment used? GE echo machines, Quest exercise machine, Spacelabs, Toshiba lab with Siemens reporting system.

Above: Mohammed Malik

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How many studies are performed a year? Echo (TTE) 14,700 over 3 sites

What new procedures / techniques have you implemented into the department recently?Working towards implementi ng a paperless pacing clinic and providing dyssynchrony service for our pati ents at Wexham.

What are the benefi ts to pati ents att ending your facility? We off er a one-stop non invasive diagnosti cs for clinics held at Wexham, Heatherwood and St Marks. We are a friendly, professional and enthusiasti c team.

What measures has the department implemented to cut costs?To encourage multi skilling for the Cardiac Physiologists, and reducing agency spend by successfully recruiti ng overseas.

What kind of training can new employees expect to receive?Training / support from Senior physiologists, courses, conferences.

What kinds of competency checks do staff have to undergo once employed? All staff undergo mandatory training, all staff are required to be updated yearly for device training. Students are required to keep a log.

How do you deal with late fi nishing of cases? Physiologists take ti me back in lieu. This is formally recorded.

What is the best part of working at your facility? Friendly down to earth professional team who really do support each other to ensure that the service works.

SITE VISITS ONLINE

Cardiac Investigation Unit Staff

Mukbinder Jassal, Theo Rosales, Harmesh Lyal, Raquel Tango, Barbara Smith, Suzanne Jordan, Mohammed Malik, Michael Phillips, Fatama Khatun, Theresa Smith, Poonam Chaudhary, Mark Curson, Liezl Bernales

Extra Photos Available Online

We always have several great photos left over from every site visit we do. They are all now available on our website along with detailed Google Maps and Street View to enhance the user experience.

Coming Soon

• Royal Berkshire Hospital• Blackpool Victoria Hospital


Before we begin I’d like you to answer the following questi ons regarding the practi ce of acquiring a resti ng 12-lead ECG.

1. Are you a certi fi ed practi ti oner? 2. Have you had regular refresher training and assessment since

your initi al ECG training?3. How regularly do you perform resti ng 12-lead ECGs in line with

your duti es?

Now think about or enquire of the person(s) that have trained you, and ask the same questi ons of them.

Taking a resti ng 12-lead ECG is the most fundamental and rudimenta-ry part of the pati ents care pathway through Cardiology – and many other disciplines besides. Whether for an acute or a routi ne presen-tati on, this is the test that starts the whole diagnosti c ball rolling and to me this demonstrates one of the most remarkable contradicti ons about ECG training:

Because, for the majority:

1. You will not be a certi fi ed ECG practi ti oner, and nor will your trainer.

2. You will not have had regular refresher training, and nor would your trainer.

3. Yet, you will perform plenti ful numbers of ECGs in line with your duti es.

If you and your trainer are accredited, and if you undergo regular training and assessment and are able to show this then you must be commended, because it is so important for ensuring that there is standardised practi ce across all centres. The Society of Cardiologi-cal Science and Technology are the professional body that accredit cardiac physiologists and cardiographers in the acquisiti on and inter-pretati on of the resti ng 12-lead ECG, so despite any training course or ECG workshops you, or your trainer, may have done, it is the SCST accreditati on that is considered the gold standard.

Lesson 1.

Accreditati on, certi fi cati on and training.

The training that you receive, at any stage of your career, should be measurable. You should know who is teaching you, and what quali-fi es them to do so. You should know that the informati on you receive is evidence based and accurate. Realisti cally asking all those that teach you what their qualifi cati ons are will probably not warm peo-ple to you, and you should be able to gauge by the positi on they hold what skills they are likely to be able to pass down. However, anyone that is delivering training should not mind disclosing their creden-ti als. Those that do not, will not or can not you should perhaps be more cauti ous of.

Therefore, or the purpose of this training I disclose to you my level of training, practi ce and accreditati on relevant to ECGs below:

I am an RCCP registered Clinical Cardiac Physiologist with 12 years experience working as a clinical cardiac physiologist. I am a mem-ber of the Society of Cardiological Science and Technology accred-ited with both my part 1 and part 2 SCST exams. I am a practi cing work based assessor – which means I regularly assess trainee clinical cardiac physiologists in all aspects of their cardiology training, and I am also an SCST examiner providing assessment at the part 1 and 2 SCST exams for cardiac physiologists and cardiographers nati onally. I am on the SCST educati on committ ee and SCST council and I work at West Hertf ordshire Hospitals NHS Trust as the Principal Clinical Cardiac Physiologist.

To fulfi l all these duti es I am an accredited and certi fi ed practi ti oner for recording resti ng 12-lead ECGs, as well as certi fi ed to assess those doing ECGs in the workplace, and at the professional body exam. To do this I am regularly assessed and regularly practi cing.

EducationSophie Blackman’s ECG

ECG Educati on: Lessons 1 and 2Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust


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Here are just some of our great writers

Lesson 2.

Preparing the room and preparing the equipment.

Before I even get onto the bit about where the electrodes should be stuck, and more importantly why, I need to concentrate on the bits you need to know before you even have a pati ent to do an ECG on.

In order to accurately record a resti ng 12-lead ECG you will need to ensure you have the correct equipment available:

1. A clean and fully functi onal electrocardiograph (ECG machine) should be plugged into the mains (where applicable) with its date and ti me set accurately.

2. The electrograph cables and module – clean and in good conditi on.

3. There should be an electrical safety test sti cker on the ECG machine to demonstrate that it has been electrically tested and is safe for use.

4. A manual for the electrocardiograph should be available. 5. An investi gati on couch that is in a recumbent positi on, that is

wide enough and long enough to support the pati ent’s limbs.6. Suffi cient paper, electrodes and spare leads for the ECG machine. 7. Skin preparati on equipment, including razors, skin-friendly alco-

hol wipes, abrasive tape designed for skin exfoliati on, gauze, ti s-sues etc.

8. A sharps bin.9. A clinical waste bin, a refuse bin, and a confi denti al waste bin. 10. Disposable towelling for the bed. 11. Clean gowns and clean sheets and a laundry bin.

You must remember that you will be asking the pati ent to remove all garments from their upper body and in line with this the room should be of an appropriate temperature.

The clinical area must be clean, and ti dy. The investi gati on couch should be clean with a clean strip of disposable towelling upon it, and the ECG machine and its components should be clean and ready for use.

ECG Challenge AnswerQuesti on Page 12

12 Lead ECG discussion.• The rhythm is sinus rhythm rate approx. 60 per minute. • Normal cardiac axis• There is signifi cant ST elevati on in V1-V4 and aVL

(anterior septal leads) of up to 12 mm. There is also ST depression in the inferior leads II,

• III and aVF.

In the context of his clinical presentati on this ECG would sug-gest an Anterior Septal ST elevati on myocardial infarcti on (STEMI).

There is no evidence of T-wave inversion or pathological Q wave development on the leads aff ected by ST elevati on. This would suggest a recent, hyperacute presentati on. This wouldfi t with the very recent onset of symptoms.

Ian Sophie Stuart


October 2-5HRC 2011Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October 7-8Briti sh Society of Echocardiography Annual Meeti ngEdinburgh Internati onal Conference CentreEdinburgh, Scotlandwww.bsecho.org

October 14-15Cardiac Risk in the Young (CRY) Internati onal Conference The Cavendish Conference CentreLondon, Englandwww.c-r-y.org.uk

October 16-18PCR London Valves 2011London Englandwww.pcrlondonvalves.com

October 23SADS UK - Heart to Heart Conference 2011Royal College of Pathologists London, Englandwww.sadsuk.org

November 24-25Briti sh Society for Heart Failure 14th Annual Autumn Meeti ngQueen Elizabeth II Conference CentreLondon, Englandwww.bsh.org.uk

November 29The Sixth UK Stroke Forum ConferenceSECCGlasgow, Scotlandwww.ukstrokeforum.org

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