CardiologyHD #33

LATEST PRODUCT NEWS

THE FACTSBehind the Headlines

CARDIOLOGIST INTERVIEWDr Stephen Furniss

CAREERSModernising Scienti fi c Careers for Cardiac Physiologists

MANAGEMENTSuccess through Responsibility

ECG CHALLENGE

JOURNAL REVIEWS

EVENTS CALENDAR

Interventional

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

CardiologyCardiologyCardiologyin Spain

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

Issue 33 • Nov/Dec 2011Subscribe FREE OnlineCardiologyHD.com

2 Nov/Dec 2011 www.cardiologyhd.com

CCO National ConferenceCardiovascular Update 2011

Strategies for Diagnosis & Treatment2 December 2011

Royal Pharmaceutical Society, Central London SE1

Provisional Programme:

KEYNOTE LECTURE: Cardiovascular Prevention & National priorities for Heart Disease

Professor Neil Poulter, Preventive Cardiovascular Disease, National Heart & Lung Institute, London.

HEART FAILURE: Evolving treatment goals in heart failure

Professor Martin Cowie, Professor of Cardiology & health services research, National Heart & Lung Institute, London

ACUTE CORONARY SYNDROME: Current challenges & emerging solutions

New strategies for ACS & Optimising the antithrombotic risk-benefit profile for percutaneous Coronary Intervention.Strategies for managing patients with Cardiorenal problems.

Dr Christopher Baker, Consultant Interventional Cardiologist, Imperial College London.

STROKE & AF: Improving cardiovascular outcomes

Early diagnosis of stroke, recognizing those at risk and evidence base for therapies in prevention & management & Innovative approach-es to anticoagulation management & insights from new trials.

Professor Gregory Lip, Professor of Cardiovascular Medicine, University of Birmingham.

HYPERTENSION: Evidence based guidelines

Review of NICE 2011 guidelines on treatment goals in hypertensionRevising concepts of blood pressure treatment: from target goals to target organ protection

Professor Mark Caulfield, Director of Institute Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine, London

CARDIOVASCULAR RISK: Obesity or Hypertension

Professor Nick Finer, Hon Professor, Consultant Endocrinologist and Bariatric PhysicianUniversity College London Hospitals, UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, London

INTERNATIONAL CONFERENCE REPORT

New evidence in cardiovascular medicine: Hot Topics from International Cardiology Conferences (ESC & ACC 2011)

Dr Tony Wierzbicki, Consultant in Chemical Pathology, Guy’s & St Thomas’ NHS Trust, Senior Lecturer King’s College London.

THERAPEUTIC MANAGEMENT OF LIPIDS IN CARDIAC PATIENTS

An update on the management of lipids in patients with cardiovascular disease. (Speaker to be confirmed)

Further information: [email protected] or [email protected]

www.cardiologyhd.com Nov/Dec 2011 3


Latest Product News

Round UpEP Labs Earn More by Recycling Whole CathetersCatheter recycling created a buzz at the Heart Rhythm Congress meeti ng in Birmingham last October. EPreward, a U.S. company created and managed by an EP nurse, purchas-es whole diagnosti c EP and ultrasound catheters thereby providing Cardiology Depart-ments with additi onal funds for conti nuing educati on and other department needs. In the past, EP staff would cut the ti ps of EP catheters as part of a plati num recovery program. Now these departments are earning over four ti mes more by selling their whole catheters to EPreward. “Brilliant” was used more than once to describe this new program. To verify this diff erence in earnings, The Royal Bournemouth Hospital in Dorsett con-ducted a side by side test using an identi cal batch of catheters. The payment from The London Refi nery, EP Recyclers/Eco-Wires Recycling and EPreward’s plati num ti p and whole catheter “Buy Back” program was determined for the same 345 catheters with the results shown below:

The London Refi neryPlati num Recovery

EP Recyclers/Eco-Wires Recycling

Plati num Recovery

EPrewardPlati num Recovery

EPrewardWhole Catheter Buy Back

£ 651.79 £ 818.06 £ 1,445.90 £ 3,191.00

Royal Bournemouth Hospital Earnings for an Identical Group of 345 EP Catheters

You can reach EPreward at [email protected] or visit their website at www.epreward.com. They will provide you with all of the data from the above test as well as a contact at the Royal Bournemouth Hospital. Their website also provides over 90 free online educati on classes.

ONLINE DISCUSSION FORUM

Have your say at www.cardiologyhd.com. Membership is free.

Radiographers (Imaging) Forum: Staff Pay Scales (Banding)Do you believe that all radiographers either permanently based or rotati ng through should be classifi ed as Band 6 - Senior Radiographer positi on?

Radiographers (Imaging) Forum: Radial Arm Boards Can anyone help with recommendati ons/suggesti ons with what they use for radial arm boards and how the arm is support-ed during the procedure. With parti cular a left radial approach.We use a wooden board/perspex boards but not ideal.


Cordis Radial Soluti ons – Integrated Soluti ons for Transradial Care Cordis is pleased to announce the launch of its Radial Soluti ons portf olio. Cordis has developed, in collaborati on with recognised specialists in radial approach in the UK and other countries, the Radial Soluti ons, a complete portf olio for transradial interventi ons.

Cordis Radial Soluti ons encompass a new transradial silicone coated sheath, RADIALSOURCE™, the Cordis EMERALD™ and Cordis AQUATRACK™ diagnosti c guidewires and the Cordis’ well known diagnosti c and guiding catheters portf olio, with a wide range of radial shapes. New to the shape portf olio is the Radial Bi-Lateral (RBL) catheter, available in both diagnosti c and guiding catheter.

Cordis, a Johnson & Johnson company, renowned for its technology know-how, has and will always be a strong partner in the Cardiology fi eld. The launch of this portf olio reaffi rms our commitment to this partnership. If you want to know more about this portf olio, contact your local Account Manager or our Customer Services team at 0800 3890932. (MAAF-11-042)

Specialist Cardiac Staff RequiredRegent’s Park Heart Clinics Ltd. are actively recruiting for specialist cardiac staff. Employment opportunities are available within both an invasive and non-invasive cardiac setting. We are inviting applications for the following positions:

Radiographer (Cath Lab) - Scarborough This position is within a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing.

Cardiac Physiologist (Non-Invasive) - CambridgeThis position is within a private patient facility operated by Regent’s Park called the Cambridge Heart Clinic, and requires the applicant to have the necessary skills to independently perform echocardiography, exercise testing and ambulatory monitoring. For more information visit: www.cambridgeheartclinic.co.uk

To find out more please contact Bryn Webber, Cardiac Services Director: [email protected]

Please visit our website for more details on our background and capabilities: www.rphc.co.uk

We look forward to hearing from you.

Next Edition

Coming up in the next editi on....

....Two Site Visits• Great Western Hospital (Swindon)

• Royal United Hospital (Bath)


Ultrasound upgrade at The Portland Hospital for Women and Children ACUSON S2000 from Siemens Healthcare enhances imaging faciliti es at private hospital

The Portland Hospital for Women and Children is benefi ti ng from increased image quality across multi ple disciplines following the installati on of an ACUSON S2000™ ultrasound system from Sie-mens Healthcare. The system will be used for general all purpose scanning in obstetric, gynaecological, paediatric, breast and cardiac examinati ons.

The private hospital has selected Siemens’ syngo® Auto OB soft ware applicati on to automate fetal measurements and has taken delivery of a 18L6 High Frequency, High Density Transducer. The hospital is also benefi ti ng from streamlined workfl ow, with Siemens’ highly cus-tomisable cardiac applicati on that gives sonographers easy access to imaging opti ons, measurements, calculati ons and reporti ng.

The S2000 off ers detailed 2D Doppler and 3D/4D imaging and is sup-porti ng clinical needs by increasing diagnosti c confi dence across a range of clinical applicati ons. The system, which has replaced an older machine, was chosen for its image quality, breadth of applica-ti ons and workfl ow effi ciency.

“When it came to replacing our ultrasound equipment, image qual-ity and ease of use were important factors in the decision making process,” said Dean Meredith, Sonography and Fetal Medicine Lead at Portland Hospital for Women and Children. “The versati lity of the S2000 is of huge benefi t as illustrated by its use across obstet-ric, gynaecological, breast, paediatric and cardiac examinati ons. The

system was installed smoothly, staff are fi nding the systems very user-friendly and radiologists have been very impressed with the image quality and panoramic scanning. We are also hoping to use the S2000 for more muscular skeletal work, something we have not had the ability to do in the past.”

“We are delighted that Portland Hospital for Women and Children has upgraded to the S2000,” said Zaheer Ali, Regional Business Man-ager for Ultrasound London and East Anglia at Siemens Healthcare. “The hospital is well recognised for providing specialist healthcare to women and their families in London. The system’s versati lity for dif-ferent clinical procedures will assist the hospital’s workfl ow and help ensure pati ents receive the highest quality of care.”

Echotech Invited to Present at this Year’s BSE Annual Meeti ng in Edinburgh This year, as a part of a ‘Changing Healthcare Delivery’ seminar at the Briti sh Society of Echocardiography Annual Meeti ng, Dominic Elton (Echotech Managing Director) was one of three speakers asked to give their perspecti ve on the future of delivering Echo services outside the hospital setti ng.

With the Briti sh Cardiovascular Society’s recently pub-lished guide to commissioning cardiac services - Elton’s presentati on resonated with some of the key recommen-dati ons relati ng to the delivery of transthoracic Echo in the community.

That is, Community Echo services should be delivered by organisati ons with BSE Departmental Accreditati on and Echo reports and images need to be made available for immediate access by local healthcare professionals.

Elton emphasised the importance of a quality fi rst approach with respect to service provision and that inno-vati on and effi ciency are the key tools to deliver high class services in these ti mes of fi nancial austerity.

For more informati on please contact www.echotech.co.uk or phone 023 9283 2016

Echocardiography


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.

Charles Bloe Training’s ECG

History• 65 year old man.• Diabeti c for 35 years. Signifi cant diabeti c compli-

cati ons: Bilateral below knee amputati ons and registered blind.

• Seen at routi ne diabeti c out pati ents clinic.• Had complained of feeling lethargic and out of sorts

for 4 or 5 days. Blood sugar had been running high and was 16.1 mmols/L at clinic.

• BP was 176/108 mmHg• Was short of breath at ti me of clinic att endance.

Chest auscultati on revealed widespread crepitati ons in both lungs.

• 12 lead ECG was requested.• Cardiac Troponin T was elevated.

What is your conclusion?

AVAILABLEONLINE

Answer Page 17

EXTRA ECG CHALLENGES ONLINE

Like our ECG Challenges?We have over 20 from previous editi ons already available online.

You can even rate and comment on each ECG.

Challenge


Healthy Eating Does chocolate protect the heart?“Eati ng high levels of chocolate could reduce the risk of cardiovas-cular disease and stroke,” reported BBC news. According to the broadcaster, a study has found that the highest levels of chocolate consumpti on “were associated with a 37% reducti on in cardiovascu-lar disease”.

The news is based on an analysis that combined the results of seven previous studies. These studies had looked at how chocolate con-sumpti on related to the risk of heart disease, stroke and metabolic diseases. Although this analysis did show that the risk of cardiovas-cular disease was lowered by about a third in the high chocolate consumers compared with the low chocolate consumers, it does not confi rm that chocolate is “good for you”. This is because the studies available for inclusion were limited by the designs and methods they employed. Also, each study categorised chocolate consumpti on dif-ferently, making their results hard to combine accurately.

Based on these studies it is not possible to say whether chocolate reduces the risk of cardiovascular disease and stroke. They also do not explain how chocolate might reduce risk, for example, whether chocolate contains chemicals that are protecti ve, or whether eat-ing chocolate causes people to be less stressed. Chocolate is high in calories, fat and sugar, and can lead to weight gain, which is a known risk factor for heart disease and diabetes. This study does not give enough evidence to suggest that chocolate is protecti ve of the heart.

The study was carried out by researchers from the University of Cam-bridge. It received no specifi c funding. The study was published in the peer-reviewed Briti sh Medical Journal.

The newspapers advised that it is not appropriate to eat large amounts of chocolate in an att empt to reduce the risk of heart dis-ease. This is appropriate advice.

Fruit and veg ‘counter heart risk genes’The Daily Express reports that a “wonder diet cures heart disease” and goes on to say that “a simple diet packed with fruit and raw vegetables is the key to beati ng heart disease.”

The news report is based on a large study that looked at how certain geneti c variati ons known to increase a person’s risk of heart att ack and cardiovascular disease (CVD) are infl u-enced by lifestyle factors, such as diet, physical acti vity levels and smoking.

The study found that some of the eff ects of these geneti c variati ons could be countered by a diet high in raw veg-etables, fruits and berries. Raw vegetables seemed to have parti cularly important eff ects. The researchers found similar eff ects when looking at the risk of CVD and diet in a diff er-ent group.

This well conducted study’s fi ndings indicate that people with specifi c geneti c risk factors for heart att ack can reduce their risk through a diet high in fresh fruit and vegetables. It does have some limitati ons in that it relied on people accurately recalling their food intake and assessed only one area of geneti c variati on. Despite these however, the fi nd-ings appear to be robust. As about 50% of the ethnic groups tested in this study carried one of the four risk variants, the applicati on of these fi ndings to the general populati on is likely to be high.

The research was led by researchers from McGill University in Canada in collaborati on with a number of researchers from other universiti es around the world. It was funded by a grant from the Heart and Stroke Foundati on of Ontario and other grants associated with the collaborati ng researchers.

The study was published in the peer-reviewed medical jour-nal Public Library of Science (PLoS) Medicine.

Generally, this study was reported accurately in the media although some headlines may have exaggerated the sig-nifi cance of these fi ndings. For instance, the Daily Express’ headline says, ‘Wonder diet cures heart disease’. However, although the study found this diet to be of benefi t for heart disease, the fi ndings do not signify a cure.

The following articles are courtesy of NHS Choices

Behind The Headlines

The Facts


Interventi onal Cardiology Practi ce in Spain (2010)

INTRODUCTIONThe Working Group on Cardiac Catheterisati on and Interventi onal Cardiology of the Spanish Society of Cardiology presents on a yearly basis a report on the data collected from most centres in the country with catherisati on faciliti es for the nati onal registry. This informati on shows how procedures are distributed throughout Spain and allows comparisons with other countries. This data collecti on has been refi ned throughout the years (1-5) and is now 100% “on-line”, which renders the analysis more accurate. The data presented here represent the acti vity during 2010 and are a summary of the 20th report.

We would like to highlight three facts this year; fi rstly, the number of coronary inter-venti ons remains stable, with just a marginal growth. Secondly, procedures related to ST-elevati on myocardial infarcti on (STEMI) conti nue to increase in the same way as in previous years, and fi nally, percutaneous aorti c valve implantati on procedures (TAVI) show a geometric growth, both in the number of pati ents treated and in the number of centers performing the technique.

METHODSData submission is not mandatory or audited. Only those discordant with previous years are required to be reviewed by the investi gators. All calculati ons were made taking as a reference the offi cial Spanish populati on at 3 December 31, 2010 (46,152,926 inhab-itants). Centres were considered public when, irrespecti ve of the funding source, they serve a specifi c area of populati on belonging to the Nati onal Health System. All the rest are considered private.

RESULTSInfrastructure and resources

113 centres parti cipated in the registry, 71 of them public (out of 74) and 41 private (out of 114). There are a total of 175 cath-labs, 64% public. 42 hospitals have more than one. 68% of the hospitals have 24-hour coverage and 69% have cardiac surgery on-site. The total number of interventi onal cardiologists is 441, with 552 nurses and 98 technicians. We will refer only to adult-treati ng hospitals.

Diagnosti c acti vity

During 2010, 135,486 diagnosti c procedures were carried out, 1.2% more than in 2009 (fi gure 1). 119,918 were coronary angiograms; 24.9% of them were done on women and 23% on old pati ents (>75 years). The average of diagnosti c procedures in the country reaches 2945 per million, higher than in previous years but far from the 4030 procedures per million in Europe in 2005 (last data published) (6) or the 5500 procedures per mil-lion presented in the last euroPCR (7). 62 centres performed more than 1,000 diagnosti c

Introduction

I am delighted to introduce to our readership Dr José F. Diaz Fernández whom I have had the pleasure of meeti ng and getti ng to know well in a

Cairo conference last year.

Dr Diaz graduated from Universidad de Cádiz, Spain, in 1995, and has been practi sing interven-ti onal cardiology since 2000. He has directed the cath lab at the Juan Ramón Jiménez University Hospital, Huelva, since 2004. He is the current Sec-retary of the Spanish Working Group on Interven-ti onal Cardiology and is a Fellow of the European Society of Cardiology and a member of the Euro-pean Associati on of Percutaneous Cardiovascular Interventi ons. He undertakes a large number of complex interventi onal procedures, including rota-ti onal atherectomy, IVUS, ASD closure, percutane-ous mitral valvuloplasty and TAVI.

He has authored many publicati ons in peer-reviewed journals, and has acted as local PI for numerous pivotal, multi -centre, internati onal stud-ies, including TAO, ATLAS ACS TIMI 51, STREAM, TRACER, CLARITY TIMI 28, MULTI-STRATEGY, PRO-TECT and CURRENT-OASIS 7. He is an editorial consultant for several cardiology journals, includ-ing Catheterizati on and Cardiovascular Interven-ti ons, Interventi onal Journal of Cardiology and Cardiocore.

In the following arti cle, Dr Diaz provides us with an insightf ul overview of contemporary interven-ti onal practi ces in one of our dearest European neighbours, Spain. I am confi dent that you will fi nd his arti cle not only very interesti ng, but also highly informati ve and educati ng.

SpainInternational Practice

José F Díaz, MD, FESC

On behalf of the Working Group on Interventi onal Cardiology of the Spanish Society of CardiologyDr Magdi El-Omar

Lead Consulti ng EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundati on Trust


InterviewCardiologist

Consultant CardiologistEast Sussex Healthcare TrustEastbourneUnited Kingdom

Dr Steve Furniss

Tell us about your role as President of HRUK and the mission?I think you may have to ask me that next year as I am sti ll fi nding my feet! I want to represent all the professionals involved in arrhythmia care and help grow services and deliver bett er care for our pati ents. What are some of the projects you are working on to improve HRUK for members?There are 3 current priority areas that I’m working on that I hope will improve HRUK for its members.

1. the Cardiac Rhythm management (CRM) databaseAs your readers will know the government decided not to conti nue funding the CRM database (unlike all the other car-diac databases). This has caused us to not only review funding streams but also to review the database itself and its functi on-ality. Changes are planned to the structure use of the database but also it is hoped that feedback to the members who enter data will be improved.

2. the HRUK websiteI am keen that we try and connect bett er with the HRUK membership as I feel that there is a percepti on that HRUK is irrelevant for most members. I am exploring a change to the representati on of council so that there is more geographical representati on parti cularly as some of the current issues such as commissioning are very diff erent in diff erent parts of the country. Contact and communicati on with the membership will parti cularly be dependent on the website. We are exploring a new website that will allow much more membership input, with for example membership only pages etc. However good the actual website may be it is sti ll dependent on the content. I announced at HRC a new category of Sub-Editor HRUK Mem-bership. Free HRUK membership will be available for individu-als (doctors, physiologists and nurses) in return for regular input into the website for the membership. This could be case reports, meeti ng reviews, book reviews, service developments etc. Further informati on about this will be available shortly on the HRUK website. Departmental accreditati on is also raising it’s head for HRUK and arrhythmia centres across the UK and the website is also going to be the contact route for the mem-bership for this important new area. Our sister affi liated group the Briti sh Society of Echocardiography has been working for 10 years on this and I hope we can learn from their experi-ences to develop a robust system for the future.

3. Professional identi tyArrhythmia care in the UK is unusual in that we have a stronger associati on and interdependence between industry, the pati ents and the professionals than for many other branches of cardiology. I am leading a review of HRUK’s role so that we can focus on the things that we are primarily about. I believe we will all be strengthened if we are clearer about what it is we are mean to be doing!

What will be the major developments within Heart Rhythm technologies over the next fi ve years?I believe there are several major technological changes that will very signifi cantly change arrhythmia care over the next 5 years. I have to admit that these personal views of what lies ahead are rather extreme and may not be accepted by most of my colleagues!

I believe the biggest change will be in the fi eld of AF. This is clearly the huge numerical challenge for us and for me it is the reason I moved from Newcastle to Eastbourne – I wanted to explore a dif-ferent model of service delivery for arrhythmias. Although there will be developments in mapping and technologies such as contact force sensing and direct ti ssue temperature sensing during ablati on etc I feel there will be a move to “anatomical ablati on”. Pulmonary vein isolati on works far bett er than drugs and although we can debate risks and benefi ts of diff erent catheter techniques the big problem is how on earth can we in the UK deliver an ablati on service?

Dr Steve Furniss


Journals

Old Wives Tails

Colchicine oft en gets wheeled out for problemati c pericarditi s, but does it actually work? Amazingly, not only yes, but it actually works fairly well. In the CORP trial, in 120 Italian pati ents with a fi rst recur-rence of pericarditi s randomly assigned to colchicine or placebo, symptoms resolved more quickly (23 vs. 53% resoluti on within 72 hours) and pati ents experienced less recurrence at 6 months (24 vs. 55%).Massimo Imazio and others. Ann Intern Med. 2011;155:409-414.

In Brugada syndrome, is a family history of sudden cardiac death prognosti cally signifi cant? No (didn’t we know this already?).Andrea Sarkozy and others European Heart Journal. 2011; 32 2153–2160.

Anti coagulants

The blood thinners are pouring out. Aft er endpoint data on Dabi-gatran and Rivaroxiban, Apixaban has now produced quality data. In the ARISTOTLE trial, over 18,000 pati ents with AF and an addi-ti onal risk factor for stroke the factor Xa inhibitor was compared to warfarin aiming for an INR of 2-3. There was a stati sti cal, but not parti cularly clinically important reducti on in ischaemic stroke (from 1.05 to 0.97% per year), but more signifi cantly a near halving of haemorrhagic stroke risk (from 0.47% to 0.24% per year) and major haemorrhage (from 2.46 to 1.55% per year). As with Rivaroxiban the improvements cover all major subgroups, but are not compared between those with good and labile INR control.Christopher B Granger and others N Engl J Med 2011;365:981-92.

Factor Xa inhibitors are substanti ally eliminated by the liver, but do have a renal component of excreti on. Use of the agents has not been studied in severe renal impairment, but pati ents with creati -nine clearances down to 30 ml/min have been included. Reassur-ingly although haemorrhage and stroke were more prevalent in the renal impairment pati ents the benefi ts of Rivaroxaban in reducing fatal bleeding held up in these pati ents and there were no parti cular safety concerns.Keith A Fox and others European Heart Journal. 2011;32:2387–2394.

Stents, again

I suspect that we have all got the message, but just in case you hadn’t this pooled analysis of the randomised SPIRIT II, III and IV and COM-PARE trials confi rms that the second generati on everolimus-eluti ng stents (EES, Xience V or Promus) have bett er outcomes than the fi rst generati on paclitaxel-eluti ng stents (PES, Taxus Express2 or Lib-erté). Aft er 2 years follow-up of pati ents with an acute coronary syn-drome (ACS) treated with stents, EES reduced the combined rate of death and MI (6.6 vs. 9.3%, p=0.02), stent thrombosis (0.7 vs. 2.9%, p=0.0002) and ischaemia-driven target lesion revascularisati on (4.7 vs. 6.2%, p=0.04). The benefi ts were also seen, but were stati sti cally more signifi cant, in pati ents with stable coronary artery disease.

The low mortality rates seen in the analysis at 2 years follow-up (3.2% for those with ACS and 2.4% with stable coronary artery dis-ease) are parti cularly striking, refl ecti ng the nature of pati ents that make it into randomised controlled studies.D Planer and others. J Am Coll Cardiol Intv. 2011;4:1104-1111.

……also EES were shown to be non-inferior to the fi rst-generati on sirolimus eluti ng stents (SES, Cordis/J&J) in a randomised open label study looking at 9-month angiographic and 12-month clinical outcomes.K-W Park and others. J Am Coll Cardiol. 2011;58;18:1844-1854.

……but another study in pati ents undergoing stenti ng of long (mean 34mm) segments of diseased coronary artery, EES had more angio-graphic in-segment restenosis (i.e. narrowing within the stent and 5mm either side) and in-segment late lumen loss (i.e. how much neointi ma forms) than SES at 9-month angiographic follow-up. Important things to note are that there were no clinically signifi cant diff erences, angiographic follow-up studies should be interpreted cauti ously and Cordis/J&J have withdrawn the Cypher stent from the market!D-W Park and others. J Am Coll Cardiol Intv. 2011;4:1096-1103.

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

Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews


C

M

Y

CM

MY

CY

CMY

K

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


Environmental

Polluti on ‘linked to heart att ack risk’“Traffi c fumes can trigger heart att acks, say researchers,” The Guardian reported today. It said that “breathing in large amounts of traffi c fumes can trigger a heart att ack up to six hours aft er exposure”.

This large study investi gated the relati onship between the risk of having a heart att ack and exposure to diff erent traffi c pollutants. Researchers analysed nearly 80,000 heart att acks and the person’s exposure to air polluti on in the ti me leading up to the att ack. Certain pollutants were found to be associ-ated with an increased risk of a heart att ack within six hours of exposure. Aft er that ti me there was no increase in risk.

Importantly, as the increase in risk was only short term, the authors suggest that these heart att acks would have hap-pened anyway and that polluti on only made them happen earlier. In other words, the study does not appear to show that polluti on triggers heart att acks in previously healthy people. It suggests that these att acks were in people already at risk.

This large, complex study is a valuable contributi on to this area of research. Previous studies have found a link between polluti on and risk of death, especially death from cardiovas-cular disease, but few have looked at the eff ects of exposure in the hours leading up to a heart att ack.

People who have been diagnosed with heart disease and other conditi ons are currently advised to avoid spending long periods in areas with high traffi c polluti on levels.

The study was carried out by researchers from the London School of Hygiene and Tropical Medicine. It was funded by the Briti sh Heart Foundati on and the Garfi eld Weston Foun-dati on. The study was published in the peer-reviewed Brit-ish Medical Journal, along with an editorial discussing the study’s fi ndings.

The study was widely reported in the press, which correctly reported that the increased risk was limited to the fi rst six hours following exposure to polluti on. Most reports also menti oned that the increase in risk was relati vely small, and that polluti on probably hastens rather than causes heart att acks.

Eyelid marks are ‘sign of heart risk’“Yellow markings on the eyelids are a sign of increased risk of heart att ack and other illnesses,” reported BBC News. These markings, called xanthelasmata, are mostly made up of cholesterol and can be treated cosmeti cally, but are also a warning sign of raised cholesterol.

This study examined the associati on between these deposits and heart disease, by recruiti ng 12,745 Danish people in the 1970s, 4.4% of whom had these eye signs. Thirty years later those with xanthe-lasmata were 48% more likely to have had a heart att ack, 39% more likely to have heart disease and 14% more likely to have died.

This was a large, well-conducted study carried out over a long period. The fi ndings will come as no surprise to the medical profession, as xanthelasmata are known to be cholesterol deposits. They suggest raised cholesterol levels, which is a well-known risk factor for cardio-vascular disease. What these fi ndings add is an idea of the strength of their associati on with cardiovascular disease outcomes.

The research highlights that people with these marks should have their cardiovascular risk assessed, taking into account other risk fac-tors, such as age, BMI, smoking, diabetes, family history of heart att ack or stroke and raised blood pressure. Together, this knowledge will allow doctors to assess a person’s risk of cardiovascular disease, and allow them to make lifestyle changes to help reduce their risk.

The study was carried out by researchers from the Departments of Clinical Biochemistry and Cardiology from three hospitals in Den-mark. Funding was provided by the Research Fund at Rigshospitalet, the Lundbeck Foundati on, the Danish Medical Research Council and the Danish Heart Foundati on.

The study was published in the peer-reviewed Briti sh Medical Journal.

The BBC provides good coverage of this research.

THE

FAC

TS


procedures, and 21 more than 2,000. The average number was 1198 procedures per centre and 774 per cath-lab.

Intravascular Ultrasound (IVUS), followed by Frac-ti onal Flow Reserve (FFR) were the most used invasive diagnosti c techniques (fi gure 2). Opti cal Coherence Tomography (OCT) reached 557 cases.

Radial access conti nues to increase and for the fi rst ti me overpasses the femoral approach (56% of cases).

Coronary interventi ons

Similar to diagnosti c procedures, percutaneous coro-nary interventi ons (PCI) show just a slight increase. With a total number of 64,331, their growth is only 1.9% compared to 2009 (fi gure 3). PCIs per million were 1398, very far from the 1601 in Europe in 2005 (6) or the almost 2000 in 2009 (7). The PCI/angiogram rati o grows to 0.54 (0.51 in 2009). Multi vessel coro-nary interventi ons account for 25.4% and PCI carried out in the same session as the diagnosti c angiogram for 77%. 20.9% of PCI were done on women and 23,3% on the elderly. 5.3% were restenoti c lesions, a low percentage that may be a consequence of the high proporti on of drug-eluti ng stents (DES) implanted.

Percutaneous treatment of left main lesions remain high (3.5% of the total number of PCI), with only 994 interventi ons on saphenous vein graft s and 184 on mammary artery graft s. GP IIbIIIa inhibitors were used in 21.5% of the procedures.

47% of the centres performed less than 500 PCI (most of them private) and 17 centres carried out more than 1000 interventi ons.

The use of IVUS reached 9.2% and FFR 3.7%, mostly for intermediate lesion assessment.

Radial interventi ons accounted for a 48.4%. Consid-ering the femoral approach, more than 37,000 clo-sure devices were used, 68% of them collagen plugs.

0

20000

40000

60000

80000

100000

120000

140000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Coronary Valvular Congenital Biopsies Others

Radial approach 56,46%

ICP/Angiograms = 0,54

Figure 1: Diagnostic procedures between 2000 and 2010

Figure 2: Evolution of invasive diagnostic techniques

Figure 3: PCI between 1999 and 2010

∆ [2009-2010] = 1.9 %


There are only 3 soluti ons as I see it:

1. rati oning – this is what we currently have whether by price or postcode – UNACCEPTABLE!

2. mega terti ary centres. Current terti ary EP centres however would need to build 20-30 cath labs and employ hundreds of ablaters ! – UNLIKLELY!

3. PV ablati on is done in all centres with cath labs. This is the model that I want to pursue and I think we will see “plumbers” dong anatomical PV ablati on whether it be by balloon or what-ever (there is no perfect device yet!). This model will be quick and cost eff ecti ve but will depend on correct pati ent selecti on - under 65, with normal hearts and less than a year of PAF! I don’t believe this will disempower the terti ary centres at all. It’s just that I think they will be doing all the redo’s and com-plex stuff that their specialist skills and kit are required for! Whether this seismic shift in the percepti on of EP will happen only ti me will tell! The current percepti on of EP is that it’s eso-teric and small-print and should be restricted to a few terti ary centres. I believe that EP is simple, sexy and straightf orward and the numbers dictate should be done anywhere!

Next year the HRC will be held at the ICC in Birmingham. Why the change?The Hilton has been great for HRC but it’s ti me for a change! The meeti ng is conti nuing to expand and we are delighted to have more companies wanti ng exhibiti on space and a larger venue is now needed. The ICC is a fantasti c new venue in the heart of Birmingham that I will allow us to grow the meeti ng but also allow the unique atmosphere of the current HRC to conti nue. Remem-ber book it in your diary 23-26 th September!

NHS SPeC IAl PR ICe

ONLY £299 eachWhen 2 places bookedTel: 01732 89 77 88 Fax: 01732 44 80 47

[email protected] | www.sbk-healthcare.com

Hear about the latest changes, exchange best practice,listen to innovative case studies and network with your peers:

• Eradicate bottlenecks: implement cardiac physiologist ledrapid access clinics and improve access, and savings throughone-stop

• Invest to save: share QIPP strategies and build a business case to invest in remote monitoring

• Transform your workforce: make Modernising Scientific Careers work, improve productivity through AssistantPractitioners and implementing a 24/7 primary angioplasty service

• Deliver services in the community: share commissioningplans and reconfigure to achieve satellite services

Reinvigorate yourpractices and relieve

your pressuresWednesday 18th January 2012 Maple House, Birmingham

Optimising Cardiac Physiology ServicesImprove efficiency, share workforce solutions and deliver community services

BOOK YOUR PLACE NOW

• City Hospitals Sunderland NHS Foundation Trust

• The Newcastle upon Tyne Hospitals NHSFoundation Trust

• South Tees Hospitals NHS Foundation Trust

• The Royal Berkshire NHS Foundation Trust

• NHS Improvement

Take away ideas from the trailblazers and adaptthem to your own trust:

Benefit from this practical case studydriven day

Cardiology Ad-Final_Template 07/10/2011 14:31 Page 1

ECG Challenge AnswerQuesti on Page 9

• The rhythm is sinus rhythm, rate approximately 75 per minute.

• The cardiac axis is normal.• The most striking feature is ST elevati on in the chest leads

V1-V4.• There is T wave inversion and pathological Q waves in

V1-V3.• The changes are suggesti ve of Anterior Septal ST eleva-

ti on myocardial infarcti on (STEMI)• However this pati ent has not presented with classical

symptoms of STEMI. Most notably there is an absence of chest pain, generally the cardinal feature in these pati ents.

• This is likely a “silent MI” presentati on, not uncommon in diabeti c pati ents.


Acute coronary syndromes

Non-steroidal anti infl ammatory drugs (NSAIDs) are probably bad for the heart. Rofecoxib, a cyclo-oxygenase 2 inhibitor was withdrawn in 2004 because of cardiovascular safety concerns. It is hypothesised that NSAIDs with some cyclooxygenase 2 selecti vity may facilitate the development of small platelet thrombi on the vascular surface and that these are more likely to result in NSTEMI rather than the complete vascular occlusion seen in STEMI. This matched case-con-trol study of 1548 pati ents confi rms that suspicion, showing that diclofenac is associated with an increased risk of NSTEMI, whilst nap-roxen reduced the risk.L Grimaldi-Bensouda and others. Heart 2011;97:1828-1833.

European and US guidelines recommend 12 months of dual anti -platelet therapy following implantati on of a drug eluti ng stent due to the concerns regarding late stent thrombosis. Would it be pos-sible to give dual anti platelet therapy (DAP) for a shorter period? Yes, according to this study in stable pati ents receiving zotarolimus-eluti ng stents (ZES, Endeavor). In 2,032 pati ents there were no clini-cally signifi cant diff erences (death, MI, stroke, stent thrombosis or bleeding) in those receiving DAP for 6 months vs. 12 months, or for 6 months vs. 24 months, at 3 years follow-up. The questi on is whether this applies to other stents and clinical indicati ons and we doubt that current guidelines will change for some ti me.D Kandarzi and others. J Am Coll Cardiol Intv. 2011;4:1119-1128.

TAVI

Transcatheter aorti c valve implantati on (TAVI) is now relati vely well established in the treatment of severe symptomati c aorti c stenosis in pati ents deemed too high risk for conventi onal aorti c valve replace-ment surgery (AVR), as well as in selected high risk surgical pati ents. The fi rst percutaneous implant was performed in 2002 by Alain Cribi-er in France, whilst the techniques were introduced into UK practi ce in 2007. All of the UK TAVI procedures are recorded on the central cardiac audit database (CCAD) and the UK practi ti oners have now published data on 877 procedures, demonstrati ng an overall survival of 92.9% at 30 days, 78.6% at 1 year and 73.7% at 2 years. This com-pares favourably with the previously reported outcomes for severe aorti c stenosis managed medically (~50% mortality at 1 year, 75% at 3 years). Predictably; renal failure, chronic obstructi ve pulmonary disease, poor left ventricular functi on, concomitant coronary artery disease, implantati on via a non-femoral route (trans-apical or subcla-vian) and moderate/severe aorti c regurgitati on were associated with worse outcome. The att riti on rate between 30-days and 1 year is of some concern, but compares to that seen in octogenarians undergo-ing surgical AVR.N Moat and others. J Am Coll Cardiol. 2011;58;20:1844-1854.

Implantable Devices

The PACE trial looked at the benefi t of biventricular vs. right ventricu-lar (RV) pacing in bradycardic pati ents with LVEF>0.45. This report of extended follow up out to 2 years demonstrates progressive left ventricular (LV) dysfuncti on in the RV group with a 9.9% diff erence in EF between groups at 2 years. Although there were no clinical heart failure diff erences detected, the progressive decline in LV functi on certainly raises the possibility that BiV pacing will become the stand-ard for all pati ents with a predictably high ventricular pacing burden in the future.Joseph Yat-Sun Chan and others European Heart Journal. 2011; 32:2533–2540.

Thoracic impedance as a marker of heart failure has a clear logic and is easily measurable through implantable devices. Unfortunately, we really haven’t worked out how to use it yet.Viviane M Canraads and others European Heart Journal. 2011;32: 2266–2273.

Dedicated MRI safe implantable devices are being developed, we already have bradycardia systems with CRT and ICD well on the way. Some think that existi ng systems are already compati ble if a few simple rules are followed. In a study of 438 pati ents with ICDs and PPMs undergoing at MRIs no lasti ng adverse eff ects were observed. Transient electrical eff ects were observed and close monitoring is recommended.Sam Nazarlan and others Ann Intern Med. 2011;155:415-424.

The MADIT CRT trial has been a rich source of analyses regarding factors associated with CRT response. The authors have devised a scoring system for predictors of response including LV size, QRS dura-ti on, aeti ology, gender and left atrial (LA) size. A signifi cant cauti on in applying this data to a wider populati on is the parti cular inclusion criteria of only minimally symptomati c individuals.Ilan Goldenburg and others Circulati on. 2011;124:1527-1536.

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) has a well recognised associati on with sudden cardiac death but the risk factors associated with arrhythmias are ill defi ned. In this registry of ARVC pati ents with ICDs, appropriate therapy was found to be correlated with NSVT and inducibility. Burden of ectopy was also correlated with probability of arrhythmia.Aditya Bhonsale and others J Am Coll Cardiol 2011;58: 1485–96 .

You want to read more?

If your ti me is precious, but you want to learn more than the Trawl can provide, the Almanac 2011 series in Heart is well worth a read. The most recent topics include arrhythmias, pacing and acute coro-nary syndromes.R Liew Heart 2011;97:1734-1743.

C Knight and A Timmis. Heart 2011;97:1820-27.

AVAILABLEONLINE

You can read this Journal Trawl as well as all previous versions on our website at www.cardiologyhd.com.

ContentsNov / Dec 2011


I know the Modernising Scienti fi c Careers (MSC) program has trou-bled the minds of many Cardiac Physiologists recently. When I fi rst read about MSC, I was also concerned about its implicati ons.However, the more I delved into it and understood what it could help us to achieve, the less I feared it.

Before MSC there were over fi ft y healthcare science career paths with multi ple exit routes, funding arrangements and no clear struc-ture. MSC creates a structured educati onal framework for all health-care scienti sts and more importantly, for the fi rst ti me ever, Cardiac Physiologists have a defi ned career path from band one to band nine.

MSC has ordered the career paths into three streams:-Life Sciences, Physical Sciences and Physiological Sciences, which currently has two pathways Cardiovascular, Respiratory and Sleep (CVRS) and Neurosensory science.

MSC has two main methods for change, educati on and service transformati on.The educati onal component has already started with the withdrawal of the strategic health authoriti es (SHA) funding for the old style car-diac physiology degree programs.In its place the Practi ti oner Training Program (PTP) and Scienti st Train-ing Program (STP) have been created along with the future planned development of Higher Specialist Scienti st Training programs (HSST), Consultant Healthcare Scienti sts and the expansion of foundati on degrees for the Assistant and Associate Practi ti oners.The PTP BSc level students are self funded and are farmed out to hospital placements. Also, they will not have expected to have the competencies as the old BSc. when they graduate.The STP MSc level students are currently funded by the SHA and placements are awarded to trusts from the SHA Science Educati on Commissioning Leads. These students are recruited to trusts via a

John HutchinsonLead Cardiac Physiologist (Invasive Cardiology)Papworth Hospital NHS Foundati on TrustPapworth EverardCambridge

MSC: Career and Training Pathways

Cardiac Physiologists

Careers

What does the future hold for Cardiac Physiologists?Modernising Scienti fi c Careers:


All the stories in the news are fi lled with sadness. Whether about the current economic climate, the gross failing of the NHS for elderly pati ents, or of the changes the Nati onal Health

Service faces, changes which seem so unpredictable and unsafe. Morale is low and as a manager your team look to you for guidance, and yet as managers we oft en feel the most pressure in these ti mes of uncertainty due to the responsibility we hold for our teams and departments.

With the pressure of one budget cut to the next whilst simultane-ously trying, against the odds, to maintain a service of high quality, I can oft en fi nd myself trapped in my offi ce for days fi ghti ng the batt les I am protecti ng my staff from. Yet this acti on, of someti mes becom-ing invisible, can dangerously loosen your teams faith in your control and management.

In the face of these diffi cult ti mes there are two things you must remember.

Firstly, is that a gesture of kindness and thanks to your team can bring powerful reward. It may not be possible to have a visible pres-ence every day and this is alright so long as the presence you have is sincere and inclusive. When I walk around my department and talk to my staff I fi nd that they bring me soluti ons to problems that I would otherwise fail to fi nd alone. I ask staff for ideas to improve pati ent experience and to improve effi ciency and they are always eager to provide them. They thrive on being involved in the decisions I make and being listened to. As to be genuinely heard gives a sense of true importance and responsibility.

By involving your team in this way they are more forgiving of the ti mes you have to distance yourself to manage the more complex and pressing issues alone. They trust that you are not abandoning them, and have trust in themselves that they can manage the service to allow you this ti me.

Thanking staff for the jobs they do and for the contributi ons they bring to the team takes no eff ort. Showing acts of kindness are sim-ple, usually free and always powerful. I fi nd bringing in donuts and getti ng staff together for a quick catch up on a quiet Friday aft ernoon works well, and always remembering to thank individuals for ti mes they have been markedly hardworking shows you noti ce and are grateful for their eff orts and this only encourages more hard work.

Secondly, is to remember that for every negati ve news story about the NHS, and every serious failing, there are hundreds and thousands of pati ents lives that have been improved, or saved, by the work we do. This is so commonly forgott en but it is our failure to keep this in mind that these failings occur at all.

My latest project is for my staff to submit a case report each month. This case report is a descripti on of a pati ent interacti on where they feel they have signifi cantly contributed to a pati ents experience and well being. This may be a diagnosis made on a Holter monitor or on echo, opti misati on of a CRT-P, making a cup of tea for a pati ent awaiti ng transport or volunteering half a lunch break once a week to sit on a ward and help a pati ent to eat their lunch when they might otherwise go hungry if left unassisted.

By submitti ng this case report my staff are able to highlight the good work they have done, but also by merit of this refl ecti ve practi ce they are incenti vised to look at making each pati ents experience positi ve, not only for the benefi t of the pati ent but for them as NHS workers. Complacency in our work is dangerous so someti mes we have to fi nd incenti ves that appeal to the audience we have. All my staff strive to deliver good pati ent care, but giving them personal reward for the job they do can help prevent that complacency from creeping in.

Keeping this NHS from failing and positi vely encouraging it’s improve-ment starts from the bott om up. As a manager you must take respon-sibility for this and helping your staff to believe in the work we do is fundamental. We must all believe that we can improve and be the best we can be. For our staff to truly believe this they must see this convicti on in you too. You must display this ethos proudly and reward them for each eff ort they make to bring your department up to the highest standard. Most importantly knowing that, as the manager, you hold responsibility for the success of your team and equally for its failings.

I think the moral here is to remember, despite the news and the negati vity surrounding the NHS, that there really are people whose lives we change for the bett er, and we must equally not become complacent of that.

Management: Success through ResponsibilityMs Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

AssistanceManagement


United Kingdom

November 24SHARP Annual Scienti fi c Meeti ng “Cardiovascular Disease, Every Day Management”Dunkeld, ScotlandContact: Miss Victoria Kirkwood, Email: [email protected] or Tel 01382 60111 ext 33124

November 28 - 29Briti sh Society for Heart Failure - 14th Annual Autumn Meeti ng Queen Elizabeth II Conference CentreLondon, Englandwww.bsh.org.uk

December 2CCO Nati onal ConferenceCardiovascular Update 2011 - Strategies for Diagnosis & TreatmentLondon, EnglandEmail: [email protected] or [email protected]

December 14BCS - A Year in CardiologyRoyal College of Physicians London, Englandwww.bcs.com/educati on

January 18, 2012Opti mising Cardiac Physiology ServicesMaple HouseBirmingham, Englandwww.sbk-healthcare.com

May 28 - 30, 2012BCS Annual ConferenceManchester CentralManchester, Englandwww.bcs.com

September 23 - 26, 2012HRC 2012The ICCBirmingham, Englandwww.heartrhythmcongress.com

MOREONLINE

To have your event listed see page 3 for contact details.

Events

1

2

3

4

5

6

7

1

23

4

7

6

5


Stents

In 94.5% of PCI stents were implanted (62,045 units in total), with a stent/pati ent rati o of 1.56. This is, lower than in previous years most likely due to the increase in primary PCI. DES use was 61.3%, but only 37% of the cases were treated with DES only.

Other devices

Rotati onal atherectomy grew again (1213 procedures). 2092 cases with cut-ti ng-balloon were carried out, an increase of 17% when compared to 2009. These two facts can be explained on the basis of an increase in case com-plexity. Thrombectomy catheters were used in 7032 cases, 23% more than in 2009.

PCI for STEMI

In the acute phase of myocardial infarcti on (MI), 14,248 PCI were performed, 22% of the total number of PCI and 9% higher than in 2009. 22% of them involved women and 23% old pati ents. The most frequent modality was pri-mary PCI (10,339 cases), 10% more than in 2009 and 29% more than in 2008. Although no data are published on the total number of MI in the country, and taking the esti mate of 45,000 per year as a reference (8, 9), primary PCI is applied only to 20% of the MI cases, far from the target (70%) of the stent for life initi ati ve (10).

27 centres perform more than 200 STEMI-related PCI per year, and 40 less than 50 (fi gure 4).

Structural heart disease

Percutaneous mitral valvuloplasty (PMV), with 324 cases, is one the most frequent interventi ons, but its number decreases every year. Undoubtedly, transaorti c percutaneous aorti c valve implantati on (TAVI) is the fastest-growing procedure, and accounted for 655 cases in 2010 (426 in 2009). In 51% of cases self-expandable valves were used and in 49% of them they were balloon-expandable, with in-hospital mortality rates of 5.6% and 7.9%, respecti vely.

Atrial septal defect (ASD) closure was carried out in 295 cases, and patent foramen ovale (PFO) closure in 265. 47 aorti c coarctati ons were treated and 114 para-valvular leaks, 27 mitral and 87 aorti c.

CONCLUSIONS2010 shows a phase of marginal growth both in diagnosti c and interventi on procedures. The increase in procedures related to STEMI, especially primary PCI, is remarkable. The initi ati ve stent for life selected Spain as one of the target countries and this is, probably, one of the most important reasons for this increase. The use of DES remains high and stable compared to oth-er countries. Cutti ng-balloon and rotablator also grew as a consequence of more complex cases treated. The increase in thrombectomy catheters can be explained by an increase in the rate of primary PCI.

REFERENCES

1. López-Palop R, Moreu J, Fernández-Vázquez F, Hernández R. Registro Español de Hemodinámica y Cardiología Intervencionista. XV Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2005). Rev Esp Cardiol. 2006;59:1146-64.

2. Baz J.A, Mauri J., Albarrán A, Pinar E. Registro Español de Hemod-inámica y Cardiología Intervencionista. XVI Informe Ofi cial de la Sec-ción de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2006). Rev Esp Cardiol. 2007 Dec;60(12):1273-89.

3. Baz J.A, Pinar E, Albarrán A, Mauri J. Registro Español de Hemod-inámica y Cardiología Intervencionista. XVII Informe Ofi cial de la Sec-ción de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2007). Rev Esp Cardiol. 2008 Dec;61(12):1298-314.

4. Baz J.A, Albarrán A, Pinar E, Mauri J. Registro Español de Hemodinámi-ca y Cardiología Intervencionista. XVIII Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2008). Rev Esp Cardiol. 2009; 62(12):1418-34

5. Díaz JF, De la Torre JM, Sabaté M y Goicolea J. Registro Español de Hemodinámica y Cardiología Intervencionista. XIX Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Socie-dad Española de Cardiología (años 1990-2009). Rev Esp Cardiol. 2010; 63(11): 1304-16.

6. Praz L, Cook S, Meier B on behalf of the Working group on Interven-ti onal Cardiology of the European Society of Cardiology. Percutaneous coronary interventi ons in Europe in 2005. Eurointerventi on 2008; 3: 442-446.

7. Cook S. Cardiovascular Interventi ons in Europe 2009/2010. Presented at euroPCR 2011 (www.europcronline.com)

8. Marrugat J, Elosua R, Marti H. Epidemiología de la cardiopatí a isquémi-ca en España: esti mación del número de casos y tendencias desde 1997 a 2005. Rev Esp Cardiol. 2002;55:337-46

9. Ivarez-León EE, Elosua R, Zamora A, Aldasoro E, Galcera J, Vanaclocha H, et al. Recursos hospitalarios y letalidad por infarto de miocardio. Estu-dio IBERICA. Rev Esp Cardiol 2004;57:514-23

10. Widimsky P, Fajadet J, Danchin N, Wijns W. “Stent 4 Life”. Targeti ng PCI at all who will Benefi t the most. EuroInterv. 2009; 4: 555-557

Figure 4: Distribution of centres according to the number of STEMI-related PCI


national recruitment program and they are funded by the SHA. The funding includes educational fees and they are paid a flat rate for three years at the bottom of AFC band six. SHA’s may or may not pay for travel expenses. This may be an important factor to look at as currently only Newcastle University has been accredited to run the CVRS STP. Cardiac STP students will spend three months in their first year rotat-ing around Cardiovascular, Respiratory and Sleep and then they will have blocks in clinical assessments and investigations.The Cardiac STP student will graduate from the program with either specialising in cardiac rhythm management or cardiac imaging.

The second method MSC has for change is ‘work force planning’. The MSC team is in the process of rolling out the Physiological Sci-ences work force profiling tool, which is designed to allow manag-ers to critically review all levels of Cardiac Physiology, with a view to matching department skills mix to meet the needs of the patients. In other words, to stop Senior Physiologists performing tasks that an Associate Practitioner could perform. This is not a “dumbing down” exercise set against us. It is an enabler designed to help departments increase efficiency and allows highly skilled physiologists to do what they do best.

The reality is MSC has happened and it is here to stay. We can try and fight it but it will eventually win out because it has changed the way we train our students and they are our future work force.Once we have accepted this we can move forward and capitalise on this massive opportunity. We have to stop the internal wrangling and stop blaming our profes-sional bodies as we have more pressing areas to direct our attention. We are newcomers to the SHA funded MSc level training and older more established scientific groups, who have SHA appointed lead sci-entists, who need convincing that we are eligible and scientists in our own right. Even if you don’t call yourself a scientist, if you are compe-tent in Echo or Pacing follow-up in MSC terms you are a Scientist and that’s what we need to train. We need to make sure the SHA Lead Scientists and the SHA Science Education Commissioning Leads know who we are and that we need these STP funded places. This year Cardiac Physiology was awarded 3 of the 157 SHA funded STP places in England. This represents a 1.9% share of the awards. Cardiac Physiology represents 8% of the total healthcare science work force, so we have a way to go considering we are already play-ing catch-up with the more established healthcare scientists.

If you care what the future holds for Cardiac Physiology contact your trusts education department, work force planning and your SHA Education Commissioning Leads and tell them you must have an STP trainee for 2012/13.

Part of the hca group

THIS IS

THIS IS your chance to change the pace of your career.

The Cardiology Department consists of three Cardiac Cath Labs and full non invasive facilities. We have been steadily expanding over recent years achieving a high profi le within the organisation due to our provision of excellent standards of patient care and delivery of a fi rst class service to consultant cardiologists. We provide a wide range of invasive and non-invasive procedures including adult cardiac catheterisation, PTCA and Stent procedures, Rotablator and Electrophysiology studies including 3D Mapping systems, RF and Cryo ablations, PFO/ASD closure, TAVI, Pacemaker/Bivent/Defi brillator/Reveal implants, Transoesophageal and Stress Echos, pacemaker clinics for brady, tachy and bivent.

Highly SpecialisedCardiac PhysiologistEP (equivalent to Band 7)Quote Ref: 001/5410/SCTWe are seeking a highly motivated, experienced and enthusiastic Cardiac Physiologist to oversee the running and further development of the Electrophysiology service. You will have experience in all aspects of electrophysiology including 3D mapping, and will be looking to further develop your management and teaching skills; this is a rare opportunity to move up the ladder. You must be self-motivated, well organised, have excellent interpersonal skills, and have the ability to prioritise and use your own initiative. A willingness to participate in the on-call rota is important.You will have a BSc (Hons) Degree qualifi cation in Cardiac Physiology or equivalent and proven post-registration experience including experience as a Senior Cardiac Physiologist. You should have or be entitled to RCCP registration. Support will be provided to maintain and enhance your skills through attendance of courses and conferences.

For further information or to arrange an informal visit please contact Ruth Altmiks, Cardiology Manager or Peter Eades, Lead Cardiac Physiologist on 020 7483 5361 or email [email protected]/[email protected]

To apply please visit www.hcarecruitment.com or call the Human Resources Department on 020 7483 5305 quoting the appropriate reference number (001/5410/SCT).

In this post you will have the opportunity to develop additional skills and extend your clinical role within the team. In addition, we offer very fl exible working arrangements, competitive salary, private health insurance, critical illness cover, pension scheme and accommodation.

Closing date: 30 November 2011.

This post is exempt from the Rehabilitation of Offenders Act 1974 and the successful candidates will therefore be required to apply for a standard or enhanced disclosure.HCA is committed to equal opportunities in employment.

www.hcarecruitment.com

Break Down of Health

Care Science Workforce

© 2011 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Horizon Cardiology is a trademark of McKesson Corporation and/or one of its subsidiaries.

Horizon Cardiology™

Delivers the Fully Integrated Cath Lab

Scan here with your codereader on your smartphone.

Imagine all the modules that make up the cath lab working together — resulting in a fast, accurate and efficient flow of information. That is the power of the single-system, integrated cath lab (ICL) from McKesson.

• Increase the accuracy and efficiency of data collection through parallel workflows that allow data to be entered simultaneously in the haemodynamic system, the in-room nurse charting station and the physician’s reporting tool

• Eliminate manual data entry with fully integrated FFR technology that ensures critical data is instantaneously available to cardiologists

• Streamline data submission to the BCIS registry, by submitting data already collected during point-of-care documentation process

The ICL is all about periprocedural workflow and dataflow, and it’s all about improving your efficiency.

Visit McKesson during ACI, Jan 25-27, 2012.

To learn more, visit AllAboutCVIS.com/CardioHD.

McKesson Provider TechnologiesBlock 3The ExchangeBrent Cross GardensLondon NW4 3RJUnited KingdomPhone: 01926 478728

cardiology hd pub 210mm x 297mm plus 3mm bleed3066_Coronary Heart Print Nov v2eeF.indd 1 10/17/11 1:11 PM

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

20%Balloon-expandaBle

TranscaTheTer aorTic ValVeimplanTaTion (TaVi)

ABSOLUTE REDUCTION IN ALL-CAUSEmORTALITy AT ONE yEAR1

sTandard medical TherapY*

a new option for your aortic stenosis patients who cannot undergo surgery In Cohort B of the landmark clinical study - The PARTNER Trial - patients receiving an Edwards SAPIEN balloon-expandable transcatheter aortic valve demonstrated a 20% absolute reduction in all-cause mortality compared to the standard medical therapy control group at one year.1 For more information and to find a TAVI center near you, please visit edwards.com/eu/products/transcathetervalves.

*Patients in control arm received best medical management which frequently (78.2%) included balloon aortic valvuloplasty.

Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis inpatients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.

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, PARTNER, and SAPIEN are trademarks of Edwards Lifesciences Corporation. © 2011 Edwards Lifesciences Corporation. All rights reserved. E2385/10-11/THV.

Latest ProductNews

5

ECG Challenge

The Facts

9

12

16

18Management Hot Topic- Changing work patt erns with PPCI

20

22

23Events Calendar

- Behind the Headlines

- Dr Steve Furniss

- Interventi onal Cardiology Practi ce in Spain (2010)

- Modernising Scienti fi c Careers for Cardiac Physiologists

- Success through Responsibility

Internati onal

Careers

Management Assistance

10

Cardiologist Interview

Modernising Scienti fi c Careers20

Interventi onal Cardiology Practi ce in Spain12

How to get in touch

@ Email

Phone

Post

Circulati on

Editorial, Subscripti on, & General [email protected] sing enquiriesadverti [email protected]

Coronary Heart Publishing Ltd, Peter House, Oxford Street, Manchester, M1 5AN, UK

Editorial, Subscripti on, & General enquires+44 (0) 845 299 6220Adverti sing enquiries+44 (0) 845 299 6220

Free Distributi on of 2800 copies to named individuals within cardiology in UK/Ireland.Distributed to all cardiology departments (invasive and non-invasive) and cardiologists.

For your free copy subscribe on our website at www.cardiologyhd.com.


ExpertsOur Cardiology

Dr Mojgan Sani

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

Stuart AllenConsulti ng EditorPrincipal Cardiac Physiologist, Manchester Heart Centre, Manchester Royal Infi rmary

Disclaimer:This publicati on should never be regarded as an authoritati ve peer reviewed medical journal. This publicati on 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 speaking 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 Ltd. The publicati on of an adverti sement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

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

Prof Ahmed MagdyConsulti ng Editor (Middle East)Head Unit Cardiology, Head CMENati onal Heart Insti tute, CairoChairman, COMBATMI Program and Annual Meeti ngSCAI Member Board of Trustees


Latest Product News

Round UpEP Labs Earn More by Recycling Whole CathetersCatheter recycling created a buzz at the Heart Rhythm Congress meeti ng in Birmingham last October. EPreward, a U.S. company created and managed by an EP nurse, purchas-es whole diagnosti c EP and ultrasound catheters thereby providing Cardiology Depart-ments with additi onal funds for conti nuing educati on and other department needs. In the past, EP staff would cut the ti ps of EP catheters as part of a plati num recovery program. Now these departments are earning over four ti mes more by selling their whole catheters to EPreward. “Brilliant” was used more than once to describe this new program. To verify this diff erence in earnings, The Royal Bournemouth Hospital in Dorsett con-ducted a side by side test using an identi cal batch of catheters. The payment from The London Refi nery, EP Recyclers/Eco-Wires Recycling and EPreward’s plati num ti p and whole catheter “Buy Back” program was determined for the same 345 catheters with the results shown below:

The London Refi neryPlati num Recovery

EP Recyclers/Eco-Wires Recycling

Plati num Recovery

EPrewardPlati num Recovery

EPrewardWhole Catheter Buy Back

£ 651.79 £ 818.06 £ 1,445.90 £ 3,191.00

Royal Bournemouth Hospital Earnings for an Identical Group of 345 EP Catheters

You can reach EPreward at [email protected] or visit their website at www.epreward.com. They will provide you with all of the data from the above test as well as a contact at the Royal Bournemouth Hospital. Their website also provides over 90 free online educati on classes.

ONLINE DISCUSSION FORUM

Have your say at www.cardiologyhd.com. Membership is free.

Radiographers (Imaging) Forum: Staff Pay Scales (Banding)Do you believe that all radiographers either permanently based or rotati ng through should be classifi ed as Band 6 - Senior Radiographer positi on?

Radiographers (Imaging) Forum: Radial Arm Boards Can anyone help with recommendati ons/suggesti ons with what they use for radial arm boards and how the arm is supported during the procedure. With parti cular a left radial approach.We use a wooden board/perspex boards but not ideal.


Cordis Radial Soluti ons – Integrated Soluti ons for Transradial Care Cordis is pleased to announce the launch of its Radial Soluti ons portf olio. Cordis has developed, in collaborati on with recognised specialists in radial approach in the UK and other countries, the Radial Soluti ons, a complete portf olio for transradial interventi ons.

Cordis Radial Soluti ons encompass a new transradial silicone coated sheath, RADIALSOURCE™, the Cordis EMERALD™ and Cordis AQUATRACK™ diagnosti c guidewires and the Cordis’ well known diagnosti c and guiding catheters portf olio, with a wide range of radial shapes. New to the shape portf olio is the Radial Bi-Lateral (RBL) catheter, available in both diagnosti c and guiding catheter.

Cordis, a Johnson & Johnson company, renowned for its technology know-how, has and will always be a strong partner in the Cardiology fi eld. The launch of this portf olio reaffi rms our commitment to this partnership. If you want to know more about this portf olio, contact your local Account Manager or our Customer Services team at 0800 3890932. (MAAF-11-042)

Specialist Cardiac Staff RequiredRegent’s Park Heart Clinics Ltd. are actively recruiting for specialist cardiac staff. Employment opportunities are available within both an invasive and non-invasive cardiac setting. We are inviting applications for the following positions:

Radiographer (Cath Lab) - Scarborough This position is within a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing.

Cardiac Physiologist (Non-Invasive) - CambridgeThis position is within a private patient facility operated by Regent’s Park called the Cambridge Heart Clinic, and requires the applicant to have the necessary skills to independently perform echocardiography, exercise testing and ambulatory monitoring. For more information visit: www.cambridgeheartclinic.co.uk

To find out more please contact Bryn Webber, Cardiac Services Director: [email protected]

Please visit our website for more details on our background and capabilities: www.rphc.co.uk

We look forward to hearing from you.

Next Edition

Coming up in the next editi on....

....Two Site Visits• Great Western Hospital (Swindon)

• Royal United Hospital (Bath)


C

M

Y

CM

MY

CY

CMY

K

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


Ultrasound upgrade at The Portland Hospital for Women and Children ACUSON S2000 from Siemens Healthcare enhances imaging faciliti es at private hospital

The Portland Hospital for Women and Children is benefi ti ng from increased image quality across multi ple disciplines following the installati on of an ACUSON S2000™ ultrasound system from Sie-mens Healthcare. The system will be used for general all purpose scanning in obstetric, gynaecological, paediatric, breast and cardiac examinati ons.

The private hospital has selected Siemens’ syngo® Auto OB soft ware applicati on to automate fetal measurements and has taken delivery of a 18L6 High Frequency, High Density Transducer. The hospital is also benefi ti ng from streamlined workfl ow, with Siemens’ highly cus-tomisable cardiac applicati on that gives sonographers easy access to imaging opti ons, measurements, calculati ons and reporti ng.

The S2000 off ers detailed 2D Doppler and 3D/4D imaging and is sup-porti ng clinical needs by increasing diagnosti c confi dence across a range of clinical applicati ons. The system, which has replaced an older machine, was chosen for its image quality, breadth of applica-ti ons and workfl ow effi ciency.

“When it came to replacing our ultrasound equipment, image qual-ity and ease of use were important factors in the decision making process,” said Dean Meredith, Sonography and Fetal Medicine Lead at Portland Hospital for Women and Children. “The versati lity of the S2000 is of huge benefi t as illustrated by its use across obstet-ric, gynaecological, breast, paediatric and cardiac examinati ons. The

system was installed smoothly, staff are fi nding the systems very user-friendly and radiologists have been very impressed with the image quality and panoramic scanning. We are also hoping to use the S2000 for more muscular skeletal work, something we have not had the ability to do in the past.”

“We are delighted that Portland Hospital for Women and Children has upgraded to the S2000,” said Zaheer Ali, Regional Business Man-ager for Ultrasound London and East Anglia at Siemens Healthcare. “The hospital is well recognised for providing specialist healthcare to women and their families in London. The system’s versati lity for dif-ferent clinical procedures will assist the hospital’s workfl ow and help ensure pati ents receive the highest quality of care.”

Echotech Invited to Present at this Year’s BSE Annual Meeti ng in Edinburgh This year, as a part of a ‘Changing Healthcare Delivery’ seminar at the Briti sh Society of Echocardiography Annual Meeti ng, Dominic Elton (Echotech Managing Director) was one of three speakers asked to give their perspecti ve on the future of delivering Echo services outside the hospital setti ng.

With the Briti sh Cardiovascular Society’s recently pub-lished guide to commissioning cardiac services - Elton’s presentati on resonated with some of the key recommen-dati ons relati ng to the delivery of transthoracic Echo in the community.

That is, Community Echo services should be delivered by organisati ons with BSE Departmental Accreditati on and Echo reports and images need to be made available for immediate access by local healthcare professionals.

Elton emphasised the importance of a quality fi rst approach with respect to service provision and that inno-vati on and effi ciency are the key tools to deliver high class services in these ti mes of fi nancial austerity.

For more informati on please contact www.echotech.co.uk or phone 023 9283 2016

Echocardiography


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.

Charles Bloe Training’s ECG

History• 65 year old man.• Diabeti c for 35 years. Signifi cant diabeti c compli-

cati ons: Bilateral below knee amputati ons and registered blind.

• Seen at routi ne diabeti c out pati ents clinic.• Had complained of feeling lethargic and out of sorts

for 4 or 5 days. Blood sugar had been running high and was 16.1 mmols/L at clinic.

• BP was 176/108 mmHg• Was short of breath at ti me of clinic att endance.

Chest auscultati on revealed widespread crepitati ons in both lungs.

• 12 lead ECG was requested.• Cardiac Troponin T was elevated.

What is your conclusion?

AVAILABLEONLINE

Answer Page 17

EXTRA ECG CHALLENGES ONLINE

Like our ECG Challenges?We have over 20 from previous editi ons already available online.

You can even rate and comment on each ECG.

Challenge


Healthy Eating Does chocolate protect the heart?“Eati ng high levels of chocolate could reduce the risk of cardiovas-cular disease and stroke,” reported BBC news. According to the broadcaster, a study has found that the highest levels of chocolate consumpti on “were associated with a 37% reducti on in cardiovascu-lar disease”.

The news is based on an analysis that combined the results of seven previous studies. These studies had looked at how chocolate con-sumpti on related to the risk of heart disease, stroke and metabolic diseases. Although this analysis did show that the risk of cardiovas-cular disease was lowered by about a third in the high chocolate consumers compared with the low chocolate consumers, it does not confi rm that chocolate is “good for you”. This is because the studies available for inclusion were limited by the designs and methods they employed. Also, each study categorised chocolate consumpti on dif-ferently, making their results hard to combine accurately.

Based on these studies it is not possible to say whether chocolate reduces the risk of cardiovascular disease and stroke. They also do not explain how chocolate might reduce risk, for example, whether chocolate contains chemicals that are protecti ve, or whether eat-ing chocolate causes people to be less stressed. Chocolate is high in calories, fat and sugar, and can lead to weight gain, which is a known risk factor for heart disease and diabetes. This study does not give enough evidence to suggest that chocolate is protecti ve of the heart.

The study was carried out by researchers from the University of Cam-bridge. It received no specifi c funding. The study was published in the peer-reviewed Briti sh Medical Journal.

The newspapers advised that it is not appropriate to eat large amounts of chocolate in an att empt to reduce the risk of heart dis-ease. This is appropriate advice.

Fruit and veg ‘counter heart risk genes’The Daily Express reports that a “wonder diet cures heart disease” and goes on to say that “a simple diet packed with fruit and raw vegetables is the key to beati ng heart disease.”

The news report is based on a large study that looked at how certain geneti c variati ons known to increase a person’s risk of heart att ack and cardiovascular disease (CVD) are infl u-enced by lifestyle factors, such as diet, physical acti vity levels and smoking.

The study found that some of the eff ects of these geneti c variati ons could be countered by a diet high in raw veg-etables, fruits and berries. Raw vegetables seemed to have parti cularly important eff ects. The researchers found similar eff ects when looking at the risk of CVD and diet in a diff er-ent group.

This well conducted study’s fi ndings indicate that people with specifi c geneti c risk factors for heart att ack can reduce their risk through a diet high in fresh fruit and vegetables. It does have some limitati ons in that it relied on people accurately recalling their food intake and assessed only one area of geneti c variati on. Despite these however, the fi nd-ings appear to be robust. As about 50% of the ethnic groups tested in this study carried one of the four risk variants, the applicati on of these fi ndings to the general populati on is likely to be high.

The research was led by researchers from McGill University in Canada in collaborati on with a number of researchers from other universiti es around the world. It was funded by a grant from the Heart and Stroke Foundati on of Ontario and other grants associated with the collaborati ng researchers.

The study was published in the peer-reviewed medical jour-nal Public Library of Science (PLoS) Medicine.

Generally, this study was reported accurately in the media although some headlines may have exaggerated the sig-nifi cance of these fi ndings. For instance, the Daily Express’ headline says, ‘Wonder diet cures heart disease’. However, although the study found this diet to be of benefi t for heart disease, the fi ndings do not signify a cure.

The following articles are courtesy of NHS Choices

Behind The Headlines

The Facts


Environmental

Polluti on ‘linked to heart att ack risk’“Traffi c fumes can trigger heart att acks, say researchers,” The Guardian reported today. It said that “breathing in large amounts of traffi c fumes can trigger a heart att ack up to six hours aft er exposure”.

This large study investi gated the relati onship between the risk of having a heart att ack and exposure to diff erent traffi c pollutants. Researchers analysed nearly 80,000 heart att acks and the person’s exposure to air polluti on in the ti me leading up to the att ack. Certain pollutants were found to be associ-ated with an increased risk of a heart att ack within six hours of exposure. Aft er that ti me there was no increase in risk.

Importantly, as the increase in risk was only short term, the authors suggest that these heart att acks would have hap-pened anyway and that polluti on only made them happen earlier. In other words, the study does not appear to show that polluti on triggers heart att acks in previously healthy people. It suggests that these att acks were in people already at risk.

This large, complex study is a valuable contributi on to this area of research. Previous studies have found a link between polluti on and risk of death, especially death from cardiovas-cular disease, but few have looked at the eff ects of exposure in the hours leading up to a heart att ack.

People who have been diagnosed with heart disease and other conditi ons are currently advised to avoid spending long periods in areas with high traffi c polluti on levels.

The study was carried out by researchers from the London School of Hygiene and Tropical Medicine. It was funded by the Briti sh Heart Foundati on and the Garfi eld Weston Foun-dati on. The study was published in the peer-reviewed Brit-ish Medical Journal, along with an editorial discussing the study’s fi ndings.

The study was widely reported in the press, which correctly reported that the increased risk was limited to the fi rst six hours following exposure to polluti on. Most reports also menti oned that the increase in risk was relati vely small, and that polluti on probably hastens rather than causes heart att acks.

Eyelid marks are ‘sign of heart risk’“Yellow markings on the eyelids are a sign of increased risk of heart att ack and other illnesses,” reported BBC News. These markings, called xanthelasmata, are mostly made up of cholesterol and can be treated cosmeti cally, but are also a warning sign of raised cholesterol.

This study examined the associati on between these deposits and heart disease, by recruiti ng 12,745 Danish people in the 1970s, 4.4% of whom had these eye signs. Thirty years later those with xanthe-lasmata were 48% more likely to have had a heart att ack, 39% more likely to have heart disease and 14% more likely to have died.

This was a large, well-conducted study carried out over a long period. The fi ndings will come as no surprise to the medical profession, as xanthelasmata are known to be cholesterol deposits. They suggest raised cholesterol levels, which is a well-known risk factor for cardio-vascular disease. What these fi ndings add is an idea of the strength of their associati on with cardiovascular disease outcomes.

The research highlights that people with these marks should have their cardiovascular risk assessed, taking into account other risk fac-tors, such as age, BMI, smoking, diabetes, family history of heart att ack or stroke and raised blood pressure. Together, this knowledge will allow doctors to assess a person’s risk of cardiovascular disease, and allow them to make lifestyle changes to help reduce their risk.

The study was carried out by researchers from the Departments of Clinical Biochemistry and Cardiology from three hospitals in Den-mark. Funding was provided by the Research Fund at Rigshospitalet, the Lundbeck Foundati on, the Danish Medical Research Council and the Danish Heart Foundati on.

The study was published in the peer-reviewed Briti sh Medical Journal. The BBC provides good coverage of this research.

THE

FAC

TS


Interventi onal Cardiology Practi ce in Spain (2010)

INTRODUCTIONThe Working Group on Cardiac Catheterisati on and Interventi onal Cardiology of the Spanish Society of Cardiology presents on a yearly basis a report on the data collected from most centres in the country with catheterisati on faciliti es for the nati onal registry. This informati on shows how procedures are distrib-uted throughout Spain and allows comparisons with other countries. This data collecti on has been refi ned throughout the years 1-5 and is now 100% “on-line”, which renders the analysis more accurate. The data presented here represent the acti vity during 2010 and are a summary of the 20th report.

We would like to highlight three facts this year; fi rstly, the number of coronary interventi ons remains stable, with just a marginal growth. Secondly, proce-dures related to ST-elevati on myocardial infarcti on (STEMI) conti nue to increase in the same way as in previous years, and fi nally, percutaneous aorti c valve implantati on procedures (TAVI) show a geometric growth, both in the number of pati ents treated and in the number of centers performing the technique.

METHODSData submission is not mandatory or audited. Only those discordant with previ-ous years are required to be reviewed by the investi gators. All calculati ons were made taking as a reference the offi cial Spanish populati on at 3 December 31, 2010 (46,152,926 inhabitants). Centres were considered public when, irrespec-ti ve of the funding source, they serve a specifi c area of populati on belonging to the Nati onal Health System. All the rest are considered private.

RESULTSInfrastructure and resources

113 centres parti cipated in the registry, 71 of them public (out of 74) and 41 private (out of 114). There are a total of 175 cath-labs, 64% public. 42 hospitals have more than one. 68% of the hospitals have 24-hour coverage and 69% have cardiac surgery on-site. The total number of interventi onal cardiologists is 441, with 552 nurses and 98 technicians. We will refer only to adult-treati ng hospitals.

Diagnosti c acti vity

During 2010, 135,486 diagnosti c procedures were carried out, 1.2% more than in 2009 (fi gure 1). 119,918 were coronary angiograms; 24.9% of them were

Introduction

I am delighted to introduce to our readership Dr José F. Diaz Fernández whom I have had the pleasure of meeti ng and getti ng to know well in a

Cairo conference last year.

Dr Diaz graduated from Universidad de Cádiz, Spain, in 1995, and has been practi sing interven-ti onal cardiology since 2000. He has directed the cath lab at the Juan Ramón Jiménez University Hospital, Huelva, since 2004. He is the current Sec-retary of the Spanish Working Group on Interven-ti onal Cardiology and is a Fellow of the European Society of Cardiology and a member of the Euro-pean Associati on of Percutaneous Cardiovascular Interventi ons. He undertakes a large number of complex interventi onal procedures, including rota-ti onal atherectomy, IVUS, ASD closure, percutane-ous mitral valvuloplasty and TAVI.

He has authored many publicati ons in peer-reviewed journals, and has acted as local PI for numerous pivotal, multi -centre, internati onal stud-ies, including TAO, ATLAS ACS TIMI 51, STREAM, TRACER, CLARITY TIMI 28, MULTI-STRATEGY, PRO-TECT and CURRENT-OASIS 7. He is an editorial consultant for several cardiology journals, includ-ing Catheterizati on and Cardiovascular Interven-ti ons, Interventi onal Journal of Cardiology and Cardiocore.

In the following arti cle, Dr Diaz provides us with an insightf ul overview of contemporary interven-ti onal practi ces in one of our dearest European neighbours, Spain. I am confi dent that you will fi nd his arti cle not only very interesti ng, but also highly informati ve and educati ng.

SpainInternational Practice

José F Díaz, MD, FESC

On behalf of the Working Group on Interventi onal Cardiology of the Spanish Society of CardiologyDr Magdi El-Omar

Lead Consulti ng EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundati on Trust


done on women and 23% on old pati ents (>75 years). The average of diagnosti c procedures in the country reaches 2945 per million, higher than in previous years but far from the 4030 pro-cedures per million in Europe in 2005 (last data published) 6 or the 5500 procedures per million presented in the last euroPCR 7. 62 centres per-formed more than 1,000 diagnosti c procedures, and 21 more than 2,000. The average number was 1198 procedures per centre and 774 per cath-lab.

Intravascular Ultrasound (IVUS), followed by Fracti onal Flow Reserve (FFR) were the most used invasive diagnosti c techniques (fi gure 2). Opti cal Coherence Tomography (OCT) reached 557 cases.

Radial access conti nues to increase and for the fi rst ti me overpasses the femoral approach (56% of cases).

Coronary interventi ons

Similar to diagnosti c procedures, percutaneous coronary interventi ons (PCI) show just a slight increase. With a total number of 64,331, their growth is only 1.9% compared to 2009 (fi gure 3). PCIs per million were 1398, very far from the 1601 in Europe in 2005 6 or the almost 2000 in 2009 7. The PCI/angiogram rati o grows to 0.54 (0.51 in 2009). Multi vessel coronary interven-ti ons account for 25.4% and PCI carried out in the same session as the diagnosti c angiogram for 77%. 20.9% of PCI were done on women and 23,3% on the elderly. 5.3% were restenoti c lesions, a low percentage that may be a conse-quence of the high proporti on of drug-eluti ng stents (DES) implanted.

Percutaneous treatment of left main lesions remain high (3.5% of the total number of PCI), with only 994 interventi ons on saphenous vein graft s and 184 on mammary artery graft s. GP IIbIIIa inhibitors were used in 21.5% of the procedures.

>>

0

20000

40000

60000

80000

100000

120000

140000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Coronary Valvular Congenital Biopsies Others

Radial approach 56.46%

ICP/Angiograms = 0.54

Figure 1: Diagnostic procedures between 2000 and 2010

Figure 2: Evolution of invasive diagnostic techniques

Figure 3: PCI between 1999 and 2010

∆ [2009-2010] = 1.9 %


47% of the centres performed less than 500 PCI (most of them private) and 17 centres carried out more than 1000 interventi ons.

The use of IVUS reached 9.2% and FFR 3.7%, mostly for intermediate lesion assessment.

Radial interventi ons accounted for a 48.4%. Considering the femoral approach, more than 37,000 closure devices were used, 68% of them collagen plugs.

Stents

In 94.5% of PCI stents were implanted (62,045 units in total), with a stent/pati ent rati o of 1.56. This is, lower than in previous years most likely due to the increase in primary PCI. DES use was 61.3%, but only 37% of the cases were treated with DES only.

Other devices

Rotati onal atherectomy grew again (1213 procedures). 2092 cases with cutti ng-balloon were carried out, an increase of 17% when com-pared to 2009. These two facts can be explained on the basis of an increase in case complexity. Thrombectomy catheters were used in 7032 cases, 23% more than in 2009.

PCI for STEMI

In the acute phase of myocardial infarcti on (MI), 14,248 PCI were performed, 22% of the total number of PCI and 9% higher than in 2009. 22% of them involved women and 23% old pati ents. The most frequent modality was primary PCI (10,339 cases), 10% more than in 2009 and 29% more than in 2008. Although no data are published on the total number of MI in the country, and taking the esti mate of 45,000 per year as a reference 8, 9, primary PCI is applied only to 20% of the MI cases, far from the target (70%) of the stent for life initi ati ve 10.

27 centres perform more than 200 STEMI-related PCI per year, and 40 less than 50 (fi gure 4).

Structural heart disease

Percutaneous mitral valvuloplasty (PMV), with 324 cases, is one the most frequent interventi ons, but its number decreases every year. Undoubtedly, transaorti c percutaneous aorti c valve implantati on (TAVI) is the fastest-growing procedure, and accounted for 655 cases in 2010 (426 in 2009). In 51% of cases self-expandable valves were used and in 49% of them they were balloon-expandable, with in-hos-pital mortality rates of 5.6% and 7.9%, respecti vely.

Atrial septal defect (ASD) closure was carried out in 295 cases, and patent foramen ovale (PFO) closure in 265. 47 aorti c coarctati ons were treated and 114 para-valvular leaks, 27 mitral and 87 aorti c.

CONCLUSIONS2010 shows a phase of marginal growth both in diagnosti c and inter-venti on procedures. The increase in procedures related to STEMI, especially primary PCI, is remarkable. The initi ati ve ‘stent for life’ selected Spain as one of the target countries and this is, probably, one of the most important reasons for this increase. The use of DES remains high and stable compared to other countries. Cutti ng-balloon and rotablator also grew as a consequence of more com-plex cases treated. The increase in thrombectomy catheters can be explained by an increase in the rate of primary PCI.

REFERENCES

1. López-Palop R, Moreu J, Fernández-Vázquez F, Hernández R. Registro Español de Hemodinámica y Cardiología Intervencionista. XV Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2005). Rev Esp Cardiol. 2006;59:1146-64.

2. Baz J.A, Mauri J., Albarrán A, Pinar E. Registro Español de Hemod-inámica y Cardiología Intervencionista. XVI Informe Ofi cial de la Sec-ción de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2006). Rev Esp Cardiol. 2007 Dec;60(12):1273-89.

3. Baz J.A, Pinar E, Albarrán A, Mauri J. Registro Español de Hemod-inámica y Cardiología Intervencionista. XVII Informe Ofi cial de la Sec-ción de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2007). Rev Esp Cardiol. 2008 Dec;61(12):1298-314.

4. Baz J.A, Albarrán A, Pinar E, Mauri J. Registro Español de Hemodinámi-ca y Cardiología Intervencionista. XVIII Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (años 1990-2008). Rev Esp Cardiol. 2009; 62(12):1418-34

5. Díaz JF, De la Torre JM, Sabaté M y Goicolea J. Registro Español de Hemodinámica y Cardiología Intervencionista. XIX Informe Ofi cial de la Sección de Hemodinámica y Cardiología Intervencionista de la Socie-dad Española de Cardiología (años 1990-2009). Rev Esp Cardiol. 2010; 63(11): 1304-16.

6. Praz L, Cook S, Meier B on behalf of the Working group on Interven-ti onal Cardiology of the European Society of Cardiology. Percutaneous coronary interventi ons in Europe in 2005. Eurointerventi on 2008; 3: 442-446.

7. Cook S. Cardiovascular Interventi ons in Europe 2009/2010. Presented at euroPCR 2011 (www.europcronline.com)

8. Marrugat J, Elosua R, Marti H. Epidemiología de la cardiopatí a isquémi-ca en España: esti mación del número de casos y tendencias desde 1997 a 2005. Rev Esp Cardiol. 2002;55:337-46

9. Ivarez-León EE, Elosua R, Zamora A, Aldasoro E, Galcera J, Vanaclocha H, et al. Recursos hospitalarios y letalidad por infarto de miocardio. Estu-dio IBERICA. Rev Esp Cardiol 2004;57:514-23

10. Widimsky P, Fajadet J, Danchin N, Wijns W. “Stent 4 Life”. Targeti ng PCI at all who will Benefi t the most. EuroInterv. 2009; 4: 555-557

Figure 4: Distribution of centres according to the number of STEMI-related PCI

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

20%Balloon-expandaBle

TranscaTheTer aorTic ValVeimplanTaTion (TaVi)

ABSOLUTE REDUCTION IN ALL-CAUSEmORTALITy AT ONE yEAR1

sTandard medical TherapY*

a new option for your aortic stenosis patients who cannot undergo surgery In Cohort B of the landmark clinical study - The PARTNER Trial - patients receiving an Edwards SAPIEN balloon-expandable transcatheter aortic valve demonstrated a 20% absolute reduction in all-cause mortality compared to the standard medical therapy control group at one year.1 For more information and to find a TAVI center near you, please visit edwards.com/eu/products/transcathetervalves.

*Patients in control arm received best medical management which frequently (78.2%) included balloon aortic valvuloplasty.

Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis inpatients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.

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, PARTNER, and SAPIEN are trademarks of Edwards Lifesciences Corporation. © 2011 Edwards Lifesciences Corporation. All rights reserved. E2385/10-11/THV.


InterviewCardiologist

Consultant CardiologistEast Sussex Healthcare TrustEastbourneUnited Kingdom

Dr Stephen Furniss

Tell us about your role as President of HRUK and the mission?I think you may have to ask me that next year as I am sti ll fi nding my feet! I want to represent all the professionals involved in arrhythmia care and help grow services and deliver bett er care for our pati ents. What are some of the projects you are working on to improve HRUK for members?There are 3 current priority areas that I’m working on that I hope will improve HRUK for its members.

1. The Cardiac Rhythm management (CRM) databaseAs your readers will know the government decided not to conti nue funding the CRM database (unlike all the other car-diac databases). This has caused us to not only review funding streams but also to review the database itself and its functi on-ality. Changes are planned to the structural use of the database but also it is hoped that feedback to the members who enter data will be improved.

2. The HRUK websiteI am keen that we try and connect bett er with the HRUK membership as I feel that there is a percepti on that HRUK is irrelevant for most members. I am exploring a change to the representati on of the council so that there is more geographi-cal representati on, parti cularly as some of the current issues such as commissioning are very diff erent in diff erent parts of the country. Contact and communicati on with the membership will parti cularly be dependent on the website. We are explor-ing a new website that will allow much more membership input, with for example membership only pages etc. However good the actual website may be it is sti ll dependent on the content. I announced at HRC a new category of Sub-Editor HRUK Membership. Free HRUK membership will be available for individuals (doctors, physiologists and nurses) in return for regular input into the website for the membership. This could be case reports, meeti ng reviews, book reviews, service developments etc. Further informati on about this will be avail-able shortly on the HRUK website. Departmental accreditati on is also raising it’s head for HRUK and arrhythmia centres across the UK and the website is also going to be the contact route for the membership for this important new area. Our sister affi li-ated group, the Briti sh Society of Echocardiography has been working for 10 years on this and I hope we can learn from their experiences to develop a robust system for the future.

3. Professional identi tyArrhythmia care in the UK is unusual in that we have a stronger associati on and interdependence between industry, the pati ents and the professionals than for many other branches of cardiology. I am leading a review of HRUK’s role so that we can focus on the things that we are primarily about. I believe we will all be strengthened if we are clearer about what it is we are meant to be doing!

What will be the major developments within Heart Rhythm technologies over the next fi ve years?I believe there are several major technological changes that will very signifi cantly change arrhythmia care over the next 5 years. I have to admit that these personal views of what lies ahead are rather extreme and may not be accepted by most of my colleagues!

I believe the biggest change will be in the fi eld of AF. This is clearly the huge numerical challenge for us and for me it is the reason I moved from Newcastle to Eastbourne – I wanted to explore a dif-ferent model of service delivery for arrhythmias. Although there will be developments in mapping and technologies such as contact force sensing and direct ti ssue temperature sensing during ablati on etc I feel there will be a move to “anatomical ablati on”. Pulmonary vein isolati on works far bett er than drugs and although we can debate risks and benefi ts of diff erent catheter techniques, the big problem is how on earth can we in the UK deliver an ablati on service?

Dr Stephen Furniss


There are only 3 soluti ons as I see it:

1. rati oning – this is what we currently have whether by price or postcode – UNACCEPTABLE!

2. mega terti ary centres. Current terti ary EP centres however would need to build 20-30 cath labs and employ hundreds of ablaters ! – UNLIKELY!

3. PV ablati on is done in all centres with cath labs. This is the model that I want to pursue and I think we will see “plumbers” doing anatomical PV ablati on whether it be by balloon or what-ever (there is no perfect device yet!). This model will be quick and cost eff ecti ve but will depend on correct pati ent selecti on - under 65, with normal hearts and less than a year of PAF! I don’t believe this will disempower the terti ary centres at all. It’s just that I think they will be doing all the redo’s and com-plex stuff that their specialist skills and kit are required for!

Whether this seismic shift in the percepti on of EP will happen only ti me will tell! The current percepti on of EP is that it’s esoteric and small-print and should be restricted to a few terti ary centres. I believe that EP is simple, sexy and straightf orward and the numbers dictate should be done anywhere!

Next year the HRC will be held at the ICC in Birmingham. Why the change?The Hilton has been great for HRC but it’s ti me for a change! The meeti ng is conti nuing to expand and we are delighted to have more companies wanti ng exhibiti on space and a larger venue is now needed. The ICC is a fantasti c new venue in the heart of Birmingham that I will allow us to grow the meeti ng but also allow the unique atmosphere of the current HRC to conti nue. Remember book it in your diary 23-26th September, 2012!

NHS SPeC IAl PR ICe

ONLY £299 eachWhen 2 places bookedTel: 01732 89 77 88 Fax: 01732 44 80 47

[email protected] | www.sbk-healthcare.com

Hear about the latest changes, exchange best practice,listen to innovative case studies and network with your peers:

• Eradicate bottlenecks: implement cardiac physiologist ledrapid access clinics and improve access, and savings throughone-stop

• Invest to save: share QIPP strategies and build a business case to invest in remote monitoring

• Transform your workforce: make Modernising Scientific Careers work, improve productivity through AssistantPractitioners and implementing a 24/7 primary angioplasty service

• Deliver services in the community: share commissioningplans and reconfigure to achieve satellite services

Reinvigorate yourpractices and relieve

your pressuresWednesday 18th January 2012 Maple House, Birmingham

Optimising Cardiac Physiology ServicesImprove efficiency, share workforce solutions and deliver community services

BOOK YOUR PLACE NOW

• City Hospitals Sunderland NHS Foundation Trust

• The Newcastle upon Tyne Hospitals NHSFoundation Trust

• South Tees Hospitals NHS Foundation Trust

• The Royal Berkshire NHS Foundation Trust

• NHS Improvement

Take away ideas from the trailblazers and adaptthem to your own trust:

Benefit from this practical case studydriven day

Cardiology Ad-Final_Template 07/10/2011 14:31 Page 1

ECG Challenge AnswerQuesti on Page 9

• The rhythm is sinus rhythm, rate approximately 75 per minute.

• The cardiac axis is normal.• The most striking feature is ST elevati on in the chest leads

V1-V4.• There is T wave inversion and pathological Q waves in

V1-V3.• The changes are suggesti ve of Anterior Septal ST eleva-

ti on myocardial infarcti on (STEMI)• However this pati ent has not presented with classical

symptoms of STEMI. Most notably there is an absence of chest pain, generally the cardinal feature in these pati ents.

• This is likely a “silent MI” presentati on, not uncommon in diabeti c pati ents.


Journals

Old Wives Tails

Colchicine oft en gets wheeled out for problemati c pericarditi s, but does it actually work? Amazingly, not only yes, but it actually works fairly well. In the CORP trial, in 120 Italian pati ents with a fi rst recur-rence of pericarditi s randomly assigned to colchicine or placebo, symptoms resolved more quickly (23 vs. 53% resoluti on within 72 hours) and pati ents experienced less recurrence at 6 months (24 vs. 55%).Massimo Imazio and others. Ann Intern Med. 2011;155:409-414.

In Brugada syndrome, is a family history of sudden cardiac death prognosti cally signifi cant? No (didn’t we know this already?).Andrea Sarkozy and others European Heart Journal. 2011; 32 2153–2160.

Anti coagulants

The blood thinners are pouring out. Aft er endpoint data on Dabi-gatran and Rivaroxiban, Apixaban has now produced quality data. In the ARISTOTLE trial, over 18,000 pati ents with AF and an addi-ti onal risk factor for stroke the factor Xa inhibitor was compared to warfarin aiming for an INR of 2-3. There was a stati sti cal, but not parti cularly clinically important reducti on in ischaemic stroke (from 1.05 to 0.97% per year), but more signifi cantly a near halving of haemorrhagic stroke risk (from 0.47% to 0.24% per year) and major haemorrhage (from 2.46 to 1.55% per year). As with Rivaroxiban the improvements cover all major subgroups, but are not compared between those with good and labile INR control.Christopher B Granger and others N Engl J Med 2011;365:981-92.

Factor Xa inhibitors are substanti ally eliminated by the liver, but do have a renal component of excreti on. Use of the agents has not been studied in severe renal impairment, but pati ents with creati -nine clearances down to 30 ml/min have been included. Reassur-ingly although haemorrhage and stroke were more prevalent in the renal impairment pati ents the benefi ts of Rivaroxaban in reducing fatal bleeding held up in these pati ents and there were no parti cular safety concerns.Keith A Fox and others European Heart Journal. 2011;32:2387–2394.

Stents, again

I suspect that we have all got the message, but just in case you hadn’t this pooled analysis of the randomised SPIRIT II, III and IV and COM-PARE trials confi rms that the second generati on everolimus-eluti ng stents (EES, Xience V or Promus) have bett er outcomes than the fi rst generati on paclitaxel-eluti ng stents (PES, Taxus Express2 or Lib-erté). Aft er 2 years follow-up of pati ents with an acute coronary syn-drome (ACS) treated with stents, EES reduced the combined rate of death and MI (6.6 vs. 9.3%, p=0.02), stent thrombosis (0.7 vs. 2.9%, p=0.0002) and ischaemia-driven target lesion revascularisati on (4.7 vs. 6.2%, p=0.04). The benefi ts were also seen, but were stati sti cally more signifi cant, in pati ents with stable coronary artery disease.

The low mortality rates seen in the analysis at 2 years follow-up (3.2% for those with ACS and 2.4% with stable coronary artery dis-ease) are parti cularly striking, refl ecti ng the nature of pati ents that make it into randomised controlled studies.D Planer and others. J Am Coll Cardiol Intv. 2011;4:1104-1111.

……also EES were shown to be non-inferior to the fi rst-generati on sirolimus eluti ng stents (SES, Cordis/J&J) in a randomised open label study looking at 9-month angiographic and 12-month clinical outcomes.K-W Park and others. J Am Coll Cardiol. 2011;58;18:1844-1854.

……but another study in pati ents undergoing stenti ng of long (mean 34mm) segments of diseased coronary artery, EES had more angio-graphic in-segment restenosis (i.e. narrowing within the stent and 5mm either side) and in-segment late lumen loss (i.e. how much neointi ma forms) than SES at 9-month angiographic follow-up. Important things to note are that there were no clinically signifi cant diff erences, angiographic follow-up studies should be interpreted cauti ously and Cordis/J&J have withdrawn the Cypher stent from the market!D-W Park and others. J Am Coll Cardiol Intv. 2011;4:1096-1103.



Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews


Acute coronary syndromes

Non-steroidal anti infl ammatory drugs (NSAIDs) are probably bad for the heart. Rofecoxib, a cyclo-oxygenase 2 inhibitor was withdrawn in 2004 because of cardiovascular safety concerns. It is hypothesised that NSAIDs with some cyclooxygenase 2 selecti vity may facilitate the development of small platelet thrombi on the vascular surface and that these are more likely to result in NSTEMI rather than the complete vascular occlusion seen in STEMI. This matched case-con-trol study of 1548 pati ents confi rms that suspicion, showing that diclofenac is associated with an increased risk of NSTEMI, whilst nap-roxen reduced the risk.L Grimaldi-Bensouda and others. Heart 2011;97:1828-1833.

European and US guidelines recommend 12 months of dual anti -platelet therapy following implantati on of a drug eluti ng stent due to the concerns regarding late stent thrombosis. Would it be pos-sible to give dual anti platelet therapy (DAP) for a shorter period? Yes, according to this study in stable pati ents receiving zotarolimus-eluti ng stents (ZES, Endeavor). In 2,032 pati ents there were no clini-cally signifi cant diff erences (death, MI, stroke, stent thrombosis or bleeding) in those receiving DAP for 6 months vs. 12 months, or for 6 months vs. 24 months, at 3 years follow-up. The questi on is whether this applies to other stents and clinical indicati ons and we doubt that current guidelines will change for some ti me.D Kandarzi and others. J Am Coll Cardiol Intv. 2011;4:1119-1128.

TAVI

Transcatheter aorti c valve implantati on (TAVI) is now relati vely well established in the treatment of severe symptomati c aorti c stenosis in pati ents deemed too high risk for conventi onal aorti c valve replace-ment surgery (AVR), as well as in selected high risk surgical pati ents. The fi rst percutaneous implant was performed in 2002 by Alain Cribi-er in France, whilst the techniques were introduced into UK practi ce in 2007. All of the UK TAVI procedures are recorded on the central cardiac audit database (CCAD) and the UK practi ti oners have now published data on 877 procedures, demonstrati ng an overall survival of 92.9% at 30 days, 78.6% at 1 year and 73.7% at 2 years. This com-pares favourably with the previously reported outcomes for severe aorti c stenosis managed medically (~50% mortality at 1 year, 75% at 3 years). Predictably; renal failure, chronic obstructi ve pulmonary disease, poor left ventricular functi on, concomitant coronary artery disease, implantati on via a non-femoral route (trans-apical or subcla-vian) and moderate/severe aorti c regurgitati on were associated with worse outcome. The att riti on rate between 30-days and 1 year is of some concern, but compares to that seen in octogenarians undergo-ing surgical AVR.N Moat and others. J Am Coll Cardiol. 2011;58;20:1844-1854.

Implantable Devices

The PACE trial looked at the benefi t of biventricular vs. right ventricu-lar (RV) pacing in bradycardic pati ents with LVEF>0.45. This report of extended follow up out to 2 years demonstrates progressive left ventricular (LV) dysfuncti on in the RV group with a 9.9% diff erence in EF between groups at 2 years. Although there were no clinical heart failure diff erences detected, the progressive decline in LV functi on certainly raises the possibility that BiV pacing will become the stand-ard for all pati ents with a predictably high ventricular pacing burden in the future.Joseph Yat-Sun Chan and others European Heart Journal. 2011; 32:2533–2540.

Thoracic impedance as a marker of heart failure has a clear logic and is easily measurable through implantable devices. Unfortunately, we really haven’t worked out how to use it yet.Viviane M Canraads and others European Heart Journal. 2011;32: 2266–2273.

Dedicated MRI safe implantable devices are being developed, we already have bradycardia systems with CRT and ICD well on the way. Some think that existi ng systems are already compati ble if a few simple rules are followed. In a study of 438 pati ents with ICDs and PPMs undergoing at MRIs no lasti ng adverse eff ects were observed. Transient electrical eff ects were observed and close monitoring is recommended.Sam Nazarlan and others Ann Intern Med. 2011;155:415-424.

The MADIT CRT trial has been a rich source of analyses regarding factors associated with CRT response. The authors have devised a scoring system for predictors of response including LV size, QRS dura-ti on, aeti ology, gender and left atrial (LA) size. A signifi cant cauti on in applying this data to a wider populati on is the parti cular inclusion criteria of only minimally symptomati c individuals.Ilan Goldenburg and others Circulati on. 2011;124:1527-1536.

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) has a well recognised associati on with sudden cardiac death but the risk factors associated with arrhythmias are ill defi ned. In this registry of ARVC pati ents with ICDs, appropriate therapy was found to be correlated with NSVT and inducibility. Burden of ectopy was also correlated with probability of arrhythmia.Aditya Bhonsale and others J Am Coll Cardiol 2011;58: 1485–96 .

You want to read more?

If your ti me is precious, but you want to learn more than the Trawl can provide, the Almanac 2011 series in Heart is well worth a read. The most recent topics include arrhythmias, pacing and acute coro-nary syndromes.R Liew Heart 2011;97:1734-1743.

C Knight and A Timmis. Heart 2011;97:1820-27.

AVAILABLEONLINE

You can read this Journal Trawl as well as all previous versions on our website at www.cardiologyhd.com.


I know the Modernising Scienti fi c Careers (MSC) program has trou-bled the minds of many Cardiac Physiologists recently. When I fi rst read about MSC, I was also concerned about its implicati ons.

However, the more I delved into it and understood what it could help us to achieve, the less I feared it.

Before MSC there were over fi ft y healthcare science career paths with multi ple exit routes, funding arrangements and no clear struc-ture. MSC creates a structured educati onal framework for all health-care scienti sts and more importantly, for the fi rst ti me ever, Cardiac Physiologists have a defi ned career path from band one to band nine.

MSC has ordered the career paths into three streams:-Life Sciences, Physical Sciences and Physiological Sciences, which currently has two pathways Cardiovascular, Respiratory and Sleep (CVRS) and Neurosensory science.

MSC has two main methods for change, educati on and service transformati on.The educati onal component has already started with the withdrawal of the strategic health authoriti es (SHA) funding for the old style car-diac physiology degree programs.In its place the Practi ti oner Training Program (PTP) and Scienti st Train-ing Program (STP) have been created along with the future planned development of Higher Specialist Scienti st Training programs (HSST), Consultant Healthcare Scienti sts and the expansion of foundati on degrees for the Assistant and Associate Practi ti oners.The PTP BSc level students are self funded and are farmed out to hospital placements. Also, they will not have expected to have the competencies as the old BSc. when they graduate.The STP MSc level students are currently funded by the SHA and placements are awarded to trusts from the SHA Science Educati on Commissioning Leads. These students are recruited to trusts via a

John HutchinsonLead Cardiac Physiologist (Invasive Cardiology)Papworth Hospital NHS Foundati on TrustPapworth EverardCambridge

MSC: Career and Training Pathways

Cardiac Physiologists

Careers

What does the future hold for Cardiac Physiologists?Modernising Scienti fi c Careers:


national recruitment program and they are funded by the SHA. The funding includes educational fees and they are paid a flat rate for three years at the bottom of AFC band six. SHA’s may or may not pay for travel expenses. This may be an important factor to look at as currently only Newcastle University has been accredited to run the CVRS STP. Cardiac STP students will spend three months in their first year rotat-ing around Cardiovascular, Respiratory and Sleep and then they will have blocks in clinical assessments and investigations.The Cardiac STP student will graduate from the program with either specialising in cardiac rhythm management or cardiac imaging.

The second method MSC has for change is ‘work force planning’. The MSC team is in the process of rolling out the Physiological Sci-ences work force profiling tool, which is designed to allow manag-ers to critically review all levels of Cardiac Physiology, with a view to matching department skills mix to meet the needs of the patients. In other words, to stop Senior Physiologists performing tasks that an Associate Practitioner could perform. This is not a “dumbing down” exercise set against us. It is an enabler designed to help departments increase efficiency and allows highly skilled physiologists to do what they do best.

The reality is MSC has happened and it is here to stay. We can try and fight it but it will eventually win out because it has changed the way we train our students and they are our future work force.Once we have accepted this we can move forward and capitalise on this massive opportunity. We have to stop the internal wrangling and stop blaming our profes-sional bodies as we have more pressing areas to direct our attention. We are newcomers to the SHA funded MSc level training and older more established scientific groups, who have SHA appointed lead sci-entists, who need convincing that we are eligible and scientists in our own right. Even if you don’t call yourself a scientist, if you are compe-tent in Echo or Pacing follow-up in MSC terms you are a Scientist and that’s what we need to train. We need to make sure the SHA Lead Scientists and the SHA Science Education Commissioning Leads know who we are and that we need these STP funded places. This year Cardiac Physiology was awarded 3 of the 157 SHA funded STP places in England. This represents a 1.9% share of the awards. Cardiac Physiology represents 8% of the total healthcare science work force, so we have a way to go considering we are already play-ing catch-up with the more established healthcare scientists.

If you care what the future holds for Cardiac Physiology contact your trusts education department, work force planning and your SHA Education Commissioning Leads and tell them you must have an STP trainee for 2012/13.

Part of the hca group

THIS IS

THIS IS your chance to change the pace of your career.

The Cardiology Department consists of three Cardiac Cath Labs and full non invasive facilities. We have been steadily expanding over recent years achieving a high profi le within the organisation due to our provision of excellent standards of patient care and delivery of a fi rst class service to consultant cardiologists. We provide a wide range of invasive and non-invasive procedures including adult cardiac catheterisation, PTCA and Stent procedures, Rotablator and Electrophysiology studies including 3D Mapping systems, RF and Cryo ablations, PFO/ASD closure, TAVI, Pacemaker/Bivent/Defi brillator/Reveal implants, Transoesophageal and Stress Echos, pacemaker clinics for brady, tachy and bivent.

Highly SpecialisedCardiac PhysiologistEP (equivalent to Band 7)Quote Ref: 001/5410/SCTWe are seeking a highly motivated, experienced and enthusiastic Cardiac Physiologist to oversee the running and further development of the Electrophysiology service. You will have experience in all aspects of electrophysiology including 3D mapping, and will be looking to further develop your management and teaching skills; this is a rare opportunity to move up the ladder. You must be self-motivated, well organised, have excellent interpersonal skills, and have the ability to prioritise and use your own initiative. A willingness to participate in the on-call rota is important.You will have a BSc (Hons) Degree qualifi cation in Cardiac Physiology or equivalent and proven post-registration experience including experience as a Senior Cardiac Physiologist. You should have or be entitled to RCCP registration. Support will be provided to maintain and enhance your skills through attendance of courses and conferences.

For further information or to arrange an informal visit please contact Ruth Altmiks, Cardiology Manager or Peter Eades, Lead Cardiac Physiologist on 020 7483 5361 or email [email protected]/[email protected]

To apply please visit www.hcarecruitment.com or call the Human Resources Department on 020 7483 5305 quoting the appropriate reference number (001/5410/SCT).

In this post you will have the opportunity to develop additional skills and extend your clinical role within the team. In addition, we offer very fl exible working arrangements, competitive salary, private health insurance, critical illness cover, pension scheme and accommodation.

Closing date: 30 November 2011.

This post is exempt from the Rehabilitation of Offenders Act 1974 and the successful candidates will therefore be required to apply for a standard or enhanced disclosure.HCA is committed to equal opportunities in employment.

www.hcarecruitment.com

Break Down of Health

Care Science Workforce


All the stories in the news are fi lled with sadness. Whether about the current economic climate, the gross failing of the NHS for elderly pati ents, or of the changes the Nati onal Health

Service faces, changes which seem so unpredictable and unsafe. Morale is low and as a manager your team look to you for guidance, and yet as managers we oft en feel the most pressure in these ti mes of uncertainty due to the responsibility we hold for our teams and departments.

With the pressure of one budget cut to the next whilst simultane-ously trying, against the odds, to maintain a service of high quality, I can oft en fi nd myself trapped in my offi ce for days fi ghti ng the batt les I am protecti ng my staff from. Yet this acti on, of someti mes becom-ing invisible, can dangerously loosen your teams faith in your control and management.

In the face of these diffi cult ti mes there are two things you must remember.

Firstly, is that a gesture of kindness and thanks to your team can bring powerful reward. It may not be possible to have a visible pres-ence every day and this is alright so long as the presence you have is sincere and inclusive. When I walk around my department and talk to my staff I fi nd that they bring me soluti ons to problems that I would otherwise fail to fi nd alone. I ask staff for ideas to improve pati ent experience and to improve effi ciency and they are always eager to provide them. They thrive on being involved in the decisions I make and being listened to. As to be genuinely heard gives a sense of true importance and responsibility.

By involving your team in this way they are more forgiving of the ti mes you have to distance yourself to manage the more complex and pressing issues alone. They trust that you are not abandoning them, and have trust in themselves that they can manage the service to allow you this ti me.

Thanking staff for the jobs they do and for the contributi ons they bring to the team takes no eff ort. Showing acts of kindness are sim-ple, usually free and always powerful. I fi nd bringing in donuts and getti ng staff together for a quick catch up on a quiet Friday aft ernoon works well, and always remembering to thank individuals for ti mes they have been markedly hardworking shows you noti ce and are grateful for their eff orts and this only encourages more hard work.

Secondly, is to remember that for every negati ve news story about the NHS, and every serious failing, there are hundreds and thousands of pati ents lives that have been improved, or saved, by the work we do. This is so commonly forgott en but it is our failure to keep this in mind that these failings occur at all.

My latest project is for my staff to submit a case report each month. This case report is a descripti on of a pati ent interacti on where they feel they have signifi cantly contributed to a pati ents experience and well being. This may be a diagnosis made on a Holter monitor or on echo, opti misati on of a CRT-P, making a cup of tea for a pati ent awaiti ng transport or volunteering half a lunch break once a week to sit on a ward and help a pati ent to eat their lunch when they might otherwise go hungry if left unassisted.

By submitti ng this case report my staff are able to highlight the good work they have done, but also by merit of this refl ecti ve practi ce they are incenti vised to look at making each pati ents experience positi ve, not only for the benefi t of the pati ent but for them as NHS workers. Complacency in our work is dangerous so someti mes we have to fi nd incenti ves that appeal to the audience we have. All my staff strive to deliver good pati ent care, but giving them personal reward for the job they do can help prevent that complacency from creeping in.

Keeping this NHS from failing and positi vely encouraging it’s improve-ment starts from the bott om up. As a manager you must take respon-sibility for this and helping your staff to believe in the work we do is fundamental. We must all believe that we can improve and be the best we can be. For our staff to truly believe this they must see this convicti on in you too. You must display this ethos proudly and reward them for each eff ort they make to bring your department up to the highest standard. Most importantly knowing that, as the manager, you hold responsibility for the success of your team and equally for its failings.

I think the moral here is to remember, despite the news and the negati vity surrounding the NHS, that there really are people whose lives we change for the bett er, and we must equally not become complacent of that.

Management: Success through ResponsibilityMs Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

AssistanceManagement


United Kingdom

November 24SHARP Annual Scienti fi c Meeti ng “Cardiovascular Disease, Every Day Management”Dunkeld, ScotlandContact: Miss Victoria Kirkwood, Email: [email protected] or Tel 01382 60111 ext 33124

November 28 - 29Briti sh Society for Heart Failure - 14th Annual Autumn Meeti ng Queen Elizabeth II Conference CentreLondon, Englandwww.bsh.org.uk

December 2CCO Nati onal ConferenceCardiovascular Update 2011 - Strategies for Diagnosis & TreatmentLondon, EnglandEmail: [email protected] or [email protected]

December 14BCS - A Year in CardiologyRoyal College of Physicians London, Englandwww.bcs.com/educati on

January 18, 2012Opti mising Cardiac Physiology ServicesMaple HouseBirmingham, Englandwww.sbk-healthcare.com

May 28 - 30, 2012BCS Annual ConferenceManchester CentralManchester, Englandwww.bcs.com

September 23 - 26, 2012HRC 2012The ICCBirmingham, Englandwww.heartrhythmcongress.com

MOREONLINE

To have your event listed see page 3 for contact details.

Events

1

2

3

4

5

6

7

1

23

4

7

6

5

© 2011 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Horizon Cardiology is a trademark of McKesson Corporation and/or one of its subsidiaries.

Horizon Cardiology™

Delivers the Fully Integrated Cath Lab

Scan here with your codereader on your smartphone.

Imagine all the modules that make up the cath lab working together — resulting in a fast, accurate and efficient flow of information. That is the power of the single-system, integrated cath lab (ICL) from McKesson.

• Increase the accuracy and efficiency of data collection through parallel workflows that allow data to be entered simultaneously in the haemodynamic system, the in-room nurse charting station and the physician’s reporting tool

• Eliminate manual data entry with fully integrated FFR technology that ensures critical data is instantaneously available to cardiologists

• Streamline data submission to the BCIS registry, by submitting data already collected during point-of-care documentation process

The ICL is all about periprocedural workflow and dataflow, and it’s all about improving your efficiency.

Visit McKesson during ACI, Jan 25-27, 2012.

To learn more, visit AllAboutCVIS.com/CardioHD.

McKesson Provider TechnologiesBlock 3The ExchangeBrent Cross GardensLondon NW4 3RJUnited KingdomPhone: 01926 478728

cardiology hd pub 210mm x 297mm plus 3mm bleed3066_Coronary Heart Print Nov v2eeF.indd 1 10/17/11 1:11 PM

Documents

CardiologyHD #33