Coronary Heart #29

LATEST PRODUCT NEWS

THE FACTSBehind the Headlines

CARDIOLOGIST HOT TOPICPFO Closure

MANAGEMENT ASSISTANCECare and Compassion

UK SITE VISITBarnet Hospital

ECG CHALLENGE

JOURNAL REVIEWS

CARDIOLOGY EVENTS

NepalLifestyles of Pati ents with CHD

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

Issue 29 • Mar/Apr 2011Subscribe FREE OnlineCardiologyHD.com

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

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


Latest Product News

Round UpNew hope for people with heart failure EXTERNAL ENHANCED COUNTER PULSATION (EECP)Dot Medical ltd. is delighted to announce that they are now supplying EECP therapy in the UK.

Although EECP is not currently a familiar therapy to many people, Dot Medical aims to change this percepti on. EECP has an established research pedigree that suggests it should be THE therapy of choice for the management of a wide range of medical conditi ons. It is non-invasive, cost eff ecti ve and off ers hospitals the opportunity to treat pati ents on an out-pati ent basis and can reduce hospitalizati on ti mes. This makes it extremely exciti ng given the cur-rent economic climate.

EECP is a non invasive therapy that helps treat heart failure by strengthening the heart muscle simply by pumping more blood back to the heart. The more blood pumped back to the heart, the stronger it gets. EECP increases blood fl ow to the heart by opening up collateral circulati on and creati ng new blood vessels, while at the same ti me strengthening the heart. It keeps blood vessels relaxed, open and prevents plaque buildup. EECP reduces arterial sti ff ness and releases nitric oxide which has an anti oxidant eff ect, making arteries resistant to spasm and clotti ng. It has a detoxifi cati on eff ect and increases lymphati c circulati on.

EECP has been FDA approved since 1995 to treat coronary artery angina, car-dioogenic shock and heart failure. It has had CE approval for over 10 years and is used for a wide variety of conditi ons including peripheral vascular disease, erecti le dysfuncti on (an early predictor of heart disease), sudden hearing loss and ti nnitus, stroke, restless leg syndrome, peripheral neuropathy and can facilitate sports rehabilitati on.

For further informati on contact: Dot Medical: [email protected]; 01625 668811

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lATE

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QuikClot®THE BLEEDING STOPS HERE!Dot Medical, is delighted to introduce QuikClot® an amazing non-invasive haemostati c bandage for safe and eff ecti ve control of bleeding.

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GATEWAY Registry Initi ated in U.K. to Investi gate OrbusNeich’s Genous™ Stent in Pati ents with Acute Coronary Syndrome (ACS) and High-Risk of Post-Procedural BleedingThe investi gator-led, multi center, non-randomized, observati onal prospecti ve GATEWAY registry will enroll 280 pati ents at eight sites in the U.K. The government-approved GATEWAY study proto-col recommends that these pati ents undergo three months of dual anti -platelet therapy (DAPT) or less following stent implantati on.

The primary endpoint of the registry is the occurrence of net adverse clinical events (NACE) at 30 days and at one year follow-up.

“High-risk pati ents who present with non-ST segment elevati on myocardial infarcti on (NSTEMI) remain a challenge,” said Dr. David Smith of the Regional Cardiac Centre at Morriston Hospital, Swansea, Wales, principal investi gator of the trial. “Identi fi cati on of pati ents with a higher propensity for bleeding may lead to improvements in NSTEMI care by prompti ng clinicians to make judicious treatment selecti ons, carefully dose anti thromboti c medicati ons and proceed with strategies to opti mize individual pati ent care.”

For more informati on, visit www.OrbusNeich.com. Follow all of OrbusNeich’s news on Twitt er at htt p://twitt er.com/OrbusNeich.

Dr David Smith

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THE

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Blood pressure device performs wellA watch-like device “could revoluti onise blood pressure mon-itoring”, BBC News has reported. According to the website, the monitor can be used to measure pressure in the wrist, which can then be used to esti mate pressure in the aorta, the largest artery in the body.

Although news coverage has focussed on the wrist-worn monitor, the research devised a technique to combine blood pressure readings from the wrist and upper-arm to esti mate central aorti c systolic pressure (CASP). This measure of pres-sure in the aorta is thought to be a bett er way of predicti ng heart problems than traditi onal measures of blood pressure, such as using an infl atable cuff around the bicep.

A device to measure blood pressure at the wrist is not new, and the method does not replace the traditi onal approach of using a cuff on the upper arm. However, the research-ers’ method for combining the two results to esti mate CASP appears to have some merit, and may fi lter into medical care.

The study was carried out by researchers from the University of Leicester, the Nati onal Insti tute for Health Research, Gle-neagles Medical Centre in Singapore and Healthstats Inter-nati onal in Singapore. The study was fi nancially supported by the Leicester Nati onal Insti tute for Health Research Bio-medical Research Unit in Cardiovascular Diseases. The study was published in the peer-reviewed Journal of the American College of Cardiology.

Television heart risk needs more study“Watching TV for four hours a day doubles the risk of a heart att ack,” The Sun has reported. “The reason is thought to be that simply sitti ng for so long causes coronary problems,” the arti cle added.

The story is based on a study that surveyed 4,512 people to esti mate their television viewing and physical acti vity, comparing their habits with their risk of death or cardiovascular disease over the next four years. Those viewing TV and video games for four hours or more per day were 48% more likely to die (due to any cause) and 125% more likely to have a cardiovascular-related event (such as a heart att ack or stroke) than those who watched less than two hours. The relati on-ship was independent of smoking, social class and how much physi-cal acti vity people did.

This well-conducted study suggests that lengthy periods of recrea-ti onal viewing may have harmful eff ects on the cardiovascular sys-tem, increasing the risk of heart att acks, strokes and early death.

However, the study had some limitati ons, such as not accounti ng for the infl uence of diet or ti me sitti ng in front of a computer at work. This initi al research is of interest, but there is now a need for larger, longer studies to verify the relati onship.

The study was carried out by researchers from University College London, the University of Queensland, Brisbane and Edith Cowan University and the Heart and Diabetes Insti tute, Melbourne. The researchers were fi nancially supported by the UK’s Nati onal Insti tute for Health Research, the Briti sh Heart Foundati on and the Victorian Health Promoti on Foundati on Public, Australia.

The study was published in the peer-reviewed Journal of the Ameri-can College of Cardiology. It was reported accurately, but uncriti cally, by newspapers.

New Technology


Sleep and heart risk link is uncertain“Lack of sleep is a ‘ti cking ti me bomb’,” The Independent reported. The newspaper said that people who regularly sleep less than six hours a night “have a 48 per cent greater chance of developing or dying from heart disease”.

The news is based on research that combined data on almost 475,000 adults, drawn from 15 studies on sleep durati on and the risk of strokes and heart att acks. The review found that, compared with a normal 7-8 hours’ sleep a night, shorter or longer sleep was associ-ated with increased risk of these heart problems.

The review has some important limitati ons. For example, many medical, psychological and lifestyle factors can aff ect both sleep and cardiovascular health but att empts to account for the infl uence of these factors varied widely between the studies. It is also unclear whether the parti cipants did not have any cardiovascular disease at the start of the studies, so it should not be assumed that poor sleep was the cause of the cardiovascular problems eventually observed. As the researchers say, the reasons behind any associati ons between sleep and cardiovascular disease are not fully understood.

The study was carried out by researchers from Warwick Medical School and the University of Naples in Italy. No sources of funding were reported. The study was published in the peer-reviewed Euro-pean Heart Journal.

The newspapers generally refl ected the fi ndings of the research accurately, but did not address the wider issues and limitati ons of the study.

Combined drugs ‘bett er’ for blood pressureA newly published study has suggested that “a combinati on of drugs is bett er than a single one in treati ng high blood pressure”, BBC News reported.

This randomised controlled trial found that starti ng pati ents on a combinati on of hypertension drugs gives a faster and greater reducti on in blood pressure than either of the drugs on their own, without any more side eff ects. The drugs, amlodipine and aliskiren, work to lower blood pressure in diff erent ways.

Doctors currently start pati ents with high blood pressure on one drug and may add others later if needed. The authors of this well-designed trial suggest that clinical practi ce should now be changed and that pati ents with high blood pressure be started on two drugs rather than one. However, although the results of this study are signifi cant, it looked only at two specifi c types of drug, so cannot make comparisons of the eff ecti veness of treatment with other classes of blood pres-sure drug, whether used alone or in combinati on. Longer-term eff ects and adverse outcomes beyond 32 weeks (such as stroke, heart att ack or early death) have not yet been examined.

People who are concerned about their blood pressure or its treatment should visit their GP.

The study was carried out by researchers from the Univer-sity of Cambridge, the Briti sh Hypertension Society, the Uni-versity of Glasgow, Novarti s Pharma AG, Switzerland, and Ninewells Hospital and Medical School, Dundee. It was fund-ed by Novarti s Pharma AG and two of the study’s authors are employees of this company. The study was published in peer-reviewed medical journal The Lancet.

The study was mostly reported accurately by the BBC, how-ever, the statement that the combined treatment had fewer side eff ects is incorrect. The proporti on of people who with-drew due to side eff ects was actually the same for combined treatment and the group taking aliskiren plus placebo, but higher (18%) for those taking amlodipine. The claim by the Daily Express that the pill could “prevent 5,000 strokes a year” is not supported by the study, which looked at the eff ect of diff erent treatments on blood pressure measure-ments, not on strokes or other cardiovascular outcomes.

Behind The Headlines

The Facts

The following articles are courtesy of NHS Choices

Blood Pressure

the study.


PFO closure: is there sti ll a future post CLOSURE 1?

Strokes are a greatly feared and debilitati ng event in anyone and perhaps even more so in young people in whom they are thankfully rare. Strokes are ischemic in 80% of cases and, using

our current understanding of their causes, the reason can be found in about 60% of these individuals. Recognised precipitants include caroti d atheroma, dissecti ons, vasculiti s, pro-thomboti c states and cardiac sources of emboli such as atrial fi brillati on, left ventricular thrombus and endocarditi s.

In the absence of any of these factors numerous alternati ve mech-anisms for “cryptogenic” strokes have been proposed and most popular amongst these are intra-cardiac communicati ons that allow unfi ltered venous blood to bypass the pulmonary circuit and enter the arterial tree. Of these communicati ons the most common is the patent foramen ovale (PFO) which is a foetal structure that allows oxygenated blood to pass from the right to left atrium and from pathology studies remains patent in 20-25% of adults in the general populati on.

The theory runs that small clots return from the peripheral veins to the heart and instead of passing on to the lungs, and being destroyed by the natural thromboti c pathways there, are able to pass across the PFO into the systemic arterial circulati on and cause embolic phenom-enon such as a stroke. What is the evidence for this? Support exists in two forms – fi rstly there are numerous case reports where long clots are found caught in the process of passing through a PFO. Sec-ondly cross-secti onal studies have shown that the presence of a PFO (parti cularly in associati on with an atrial septal aneurysm) is much more likely in pati ents with cryptogenic strokes than the general populati on – increasing in Lechat’s series (NEJM 1988) to over 50%.

These fi ndings may implicate the PFO in cryptogenic strokes; how-ever they do not give insight into the best treatment opti ons. In non-randomised studies pati ents have either been treated with anti -platelets, formal anti -coagulati on or closure of the defect with a prosthesis. Att empts to compare these disparate groups indicated that device closure, parti cularly in the presence of a septal aneu-rysm, was superior (annual recurrence rates for medically treated

ranging from 3.8-12% and device treated from 0-4.9%). As these are non-randomised studies there was a drive to obtain properly con-trolled data and to that end fi ve studies were started using diff erent commercially available devices pitched against medical therapy in a fully randomised fashion.

The fi rst to report, at the American Heart Associati on meeti ng in November 2010 (although not yet in print), was the CLOSURE 1 study. This compared medical therapy, a mixture of anti -coagulati on and anti -platelets, to device closure with the NMT Biostar device. The primary end-point in this superiority study was a composite of stroke/TIA and mortality (all cause to 30 days and then neurologi-cal out to two years) and as has been reported was negati ve with an event rate of 5.9% in the device arm against 7.7% (P=0.3) in the medical group.

Do we read from this that device closure is unnecessary?

Well this is not straightf orward to answer - at least in part because we do not as yet have the full published dataset and therefore can only comment on the informati on presented at the AHA meeti ng. There are a number of points that should be raised in considering this result. The fi rst is that of its power to detect a real eff ect (as an under-powered study may miss a small but clinically important eff ect) – this study originally intended to recruit 1600 pati ents and due to very slow uptake was terminated early with fewer than 1000 subjects. Concern that this change under-powers the fi ndings is sup-ported by the absence of the usual negati ve eff ect of having a septal aneurysm upon risk and is a parti cular danger in superiority studies. As a result of the reduced size the expected event rate in the treated arm was 2% or less by intenti on to treat analysis. Unfortunately in this study there was a high procedural complicati on rate with only a 90% procedural success rate – the reason for this is not clear although the large number of centres performing small numbers of procedures has been put forward as a potenti al factor. As a result the event rate in the device therapy arm was increased by these early complicati ons and may have biased the outcome.

Hot TopicCardiologist

Dr Brian ClappMA PhD MRCPConsultant CardiologistGuy’s & St Thomas’ HospitalLondon, UK


Journals

Atrial Fibrillati on

Predicti ng thromboembolic risk in atrial fi brillati on is a growth indus-try. The simplicity of the CHADS2 scoring system, which seemed too good to be true probably is: the lack of recogniti on of vascular dis-ease and under esti mati on of the risk associated with age in par-ti cular producing falsely reassuring results. A Danish group have examined the predicti ve value of both CHADS2 and the more aggres-sive CHA2DS2vasc in a cohort of over 70 000 pati ents.

Headline fi ndings are: the added risk factors in CHA2DS2vasc hold up well; those with a CHA2DS2vasc of 1 are at genuinely intermediate risk (2%pa) whereas CHADS2 of 1 have an uncomfortably high risk (4.75% pa). Risks are maintained year on year.JB Oleson and others BMJ 2011;342:d124

We know that Dabigatran is more eff ecti ve than warfarin (at high dose) and safer than warfarin (at reduced dose), but is it cost eff ec-ti ve (stop yawning)? A group wanted to fi nd if Dabi was cost eff ecti ve, so, as is the way with these things, they did. The cost per QALY of high dose Dabigatran when compared with warfarin at current US prices was $50K.

The study has many limitati ons including a noti onal cost of warfarin, which seems very high and an assumpti on that observati ons in RE-LY over 2 years can be extrapolated in the long term.JV Freeman and others Ann Intern Med. 2011;154:1-11

Heart Failure and Devices

Heart failure is an ever growing problem due to our ageing popula-ti on, improved revascularisati on techniques, and evidenced based secondary preventi on. Cell therapy is hoping to be the next big thing in treati ng heart failure pati ents. Sadly, the results of the SEISMIC trial of intramyocardial implantati on of autologous skeletal myo-blasts, in a small cohort pati ents, were not earth moving. Whilst the technique appears safe and feasible, there was no benefi t in LVEF, with ‘suggesti ons’ of improvement in symptoms. Further larger stud-ies are awaited.H Duckers and Others EuroInterventi on. 2011;6:794-797

Bett er news for heart failure pati ents comes from the CHAMPION study, in which a wireless implant (CardioMEMS) that monitors haemodynamics has been shown to reduce hospitalisati ons com-pared to standard management. The pulmonary artery pressure sen-sor was implanted in NYHA class III pati ents, improving management and outcome over a 15 month follow up. I suspect this will appeal to device companies, implanters and pati ents, but feel that basic man-agement and heart failure support in the community is needed fi rst.WT Abraham and Others. The Lancet;377:658-666.

Apparent primary preventi on ICD candidates have been shown to lack benefi t and even derive harm when implanted soon aft er an acute event (most studied in MI or CABG). It has become accept-ed, though not parti cularly illuminati ng, to describe this as ICDs changing the mode of death in these populati ons.

Should we be opti mising AV delay in all CRT implants?

No, because it doesn’t make any

diff erence.K Ellenbogen and others Circulati on.

2010;122:2660-2668

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


NepalLifestyles of Pati ents with Coronary Heart Disease (CHD) Att ending Cardiac OPD of BPKIHS, Dharan, Nepal

Developing Countries

INTRODUCTION

Background: Heart disease as a leading cause of morbidity and mor-tality is of global concern, especially in North American and Euro-pean societi es. In the US, nearly one-quarter of the enti re adult US populati on (about 61 million) lives with some form of heart disease, and approximately one million Americans die of heart disease every year, which accounts for more than 40% of all deaths1. According to a recent report by the World Health Organizati on (WHO) on reducing risks and promoti ng healthy life, inacti ve lifestyles, tobacco use, and low fruit and vegetable intake each account for 20% of deaths and disabiliti es from cardiovascular disease risk worldwide2.

Rati onales for the Study: Coronary Heart Disease (CHD) is one of the leading causes of illness and death among the top three disease classifi cati ons all over the world. Although CHD is an interesti ng area of research, in context to Nepal, studies regarding the knowledge of cardiovascular risk factors are limited. This study will help to pro-vide the baseline data on knowledge and preventi on of risk factors of CHD.

Signifi cance of the Study: This study might be helpful to provide the baseline data about lifestyle factors in relati on to CHD. The fi ndings of the study can be used by healthcare personnel to carry out fur-ther interventi onal studies on non-pharmacological management for cardiac pati ents. It also could be used within health educati on for cardiac pati ents to encourage them for regular follow-ups and com-pliance of treatment modaliti es.

General Objecti ve: To assess the lifestyle of pati ents with Coronary Heart Disease att ending the Cardiac Outpati ent Department of B.P. Koirala Insti tute of Health Sciences (BPKIHS), Dharan, Nepal.

Specifi c Objecti ves:

• To assess the lifestyle of pati ents with coronary heart disease.• To fi nd out the associati on between lifestyle and selected

variables.• To fi nd out the associati on between lifestyle and clinical

characteristi cs.

Mrs. Rosy ShresthaAssistant Professor, Dept. of Medical Surgical NursingCollege of NursingB.P. Koirala Insti tute of Health Sciences (BPKIHS) DharanNepal

Nepal Overview

Kathmandu

Dharan

Mt EverestNepal

Country: NepalPopulation: 29,331,000 (2009 est)Official Language: Nepali

Nepal is a landlocked country in South-East Asia bordered on the north by the People’s Republic of China, and to the south, east, and west by the Republic of India. Located in the Him-alayas, Nepal has eight of the world’s ten tallest mountains, including the highest point on Earth, Mount Everest. The capital city is Kathmandu.

Source: Wikipedia


CONCLUSION

From this study it is concluded that most of the pati ents were not aware of their disease conditi on and need for modifi cati on of life-style for managing cardiac problems.

Nurses can play a vital role in the identi fi cati on and management of cardiac pati ents by identi fying the risk factors associated with their lifestyle, and by providing referral services in taking care of pati ents with cardiac related problems. Health educati on, especially encouragement of healthy lifestyles at the nati onal level should be launched, and an overall policy of health promoti on to reduce car-diac problems implemented.

REFERENCES:1. Cardiovascular Disease. [serial online] 2003 [cited 2010 January 27].

Available fro: URL:htt p://www.labtestonlie.org. 2. WHO Cardiovascular Disease. [serial online] 2009 [cited 2010 January

26]. Available from: URL: htt p: // www. Who.int.com.3. Black H. Cardiovascular Risk Factors. [serial online] 1997 [ cited 2010

January 26]. Available from : URL: htt p:// www.yahoo.com4. Cardiovascular Risk Factors for Cardiovascular Diseases. [Serial online]

2005 [cited 2010 January 27]. Available from: URL: htt p://www.asu.edu.

5. Barett S. Risk Factors For Cardiovascular Diseases. [serial online] 2000 [ cited 2010 January 28]. Available from: URL: htt p: // www.quackwatch.org

6. Prevalence and incidence of Cardiovascular Disease[ serial online] 2010 [ cited 2010 January 28]. Available from: URL: htt p: // www. silverbook.org

7. Prevalence of Cardiovascular Disease. [serial online] 2006 [ cited 2010 January 28]. Available from: URL: htt p: // www. wrongdiagnosis.com

8. Goyal A. Yusuf S. Burden of Cardiovascular Disease in the Indian Sub-conti nent [serial online] 2006 [cited 2010 January 15]. Available from: URL: htt p: // www.icmr.nic.in

9. Smith D. University Students Knowledge of Cardiovascular Disease Risk Factors. [serial online] 2006 [cited 2010 February 16]. Available from: URL: htt p: // www. cababstractplus.org

10. Adili F. Knowledge and Practi ce Status and Trend in Risk Factors. [serial online] 2005 [ cited 2010 February 16]. Available from: URL: htt p: //journals.turns.ac.ir

11. Vanhecke T. Awareness, Knowledge and Percepti on of Heart Disease. [serial online] 2006 [ cited 2010 February 16]. Available from: URL: htt p: // journals.lww.com

12. Jafary et al CARDIOVASCULAR HEALTH Knowledge behavior in pati ent att endants at four care terti ary hospitals in Pakistan-a cause for concern. [serial online] 2005 [ cited 2010 February 17]. Available from: URL: htt p: //www.biomedcentral.com.

13. Khan MS. Knowledge of Modifi able Risk Factors of heart disease among pati ents with acute MI in Karanchi, Pakistan. [serial online] 2006 [cited 2010 February 17]. Available from: URL: htt p: //www.biomedcentral.com.

14. Frost R. Cardiovascular Risk Modifi cati on in College Student. [serial online] 2007 [ cited 2010 February 16]. Available from: URL: htt p: //www.springerlink.com

15. FHA-Health Belief Model Percepti ons, Knowledge of Heart Disease. [serial online] 2006 November 29 [cited 2010 February 1]. Available from: URL: htt p: ///www.fi nal.health-arti cles.com.

16. Knowledge and Awareness of Risk Factors for Cardiovascular Risk Fac-tors for Cardiovascular Disease. [serial online] 2008 September 1 [cited 2010 February 1]. Available from: URL: htt p: ///www.thefreelibrary.com.

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Cultural Understanding

The Nepalese caste system is highly complex and continues the traditional system of social stratification defining the social classes by a number of hierarchical groups. In basic terms it refers to socio-economic classes, however once you are born into that class that is where you remain. Low-caste people are often deprived of utilizing most of the temples, funeral places, drinking water taps and wells, restaurants, shops and other public places.

High to Low Caste: Brahman, Chhetri, Vaisya, & Kirat

Source: Wikipedia


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

There has recently been great publicity surrounding ‘Care and Compassion? Report of the Health Service Ombudsman on ten investi gati ons into NHS care of older people’.

This document fi rst came to my att enti on aft er I saw such damning headlines in the nati onal newspapers as: ‘The NHS has failed the elderly’ The Times.

I downloaded a copy of the report, and it certainly makes for uncom-fortable reading. Of the 10 cases discussed, 9 of the pati ents died during or as a direct result of the treatment that they received. The stories within the document are truly harrowing, but I would urge you to read them as there is much we can learn.

htt p://www.ombudsman.org.uk/care-and-compassion/home

There has been signifi cant discussion in the press since this report was published and there are a few points that I think are important regarding this document which I have impressed upon my staff .

Firstly, ‘the NHS sees over a million people every 36 hours’, Nigel Edwards Chief Executi ve of the NHS Federati on is reported to have said on www.nhs.uk, and so ‘the ten cases included in the report need to be kept in perspecti ve’. While the Ombudsman’s document is ‘powerful and informati ve regarding the individual cases, it cannot be thought of as reliable evidence that can be applied generally to the care of the elderly across the NHS’.

Nevertheless, whilst I think it is important is that we keep the report in perspecti ve, for these individuals and families there were crucial errors made in the care received. When you read the report what is so upsetti ng is how very easily the errors could have been avoided through bett er communicati on, bett er understanding of the pati ent and families perspecti ves, and by someti mes pushing the boundaries of our roles. It is evident of a service stretching to its limits, oft en with insuffi cient fi nance and resources and never ending cut backs that someti mes staff are so pushed to get things done to fi t a ti me-frame that is comes at the compromise of the expected standards.

I have asked all my staff to read this document because I think it serves as a good reminder for us as we go about our daily work, that despite the endless increases in service demand and external pres-sures we have, we all came into this profession to care.Irrespecti ve of anything else that is going on, every single pati ent that we see - young or old - deserves our undivided att enti on. It reminds us that things we do day in, day out, are unfamiliar and invoke fear in our pati ents, and we must not take for granted the value and importance of taking an extra few moments to ensure the pati ent is informed and comfortable, that you are respecti ng their dignity, and providing them with the best service of care.

For surely without providing this level of care, commitment and courtesy for every pati ent you see you would not be fulfi lling your duty of care? Someti mes our duty of care has much wider scope than the exact job descripti on we have on paper, and just a small eff ort beyond our normal role can help prevent the communicati on break-downs, and leave our pati ents and their relati ves with a much more positi ve experience of our NHS.

AssistanceManagement


Sophie Blackman’s ECG

Challenge

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust United Kingdom

We have 20 ECG Challenges on our website just waiti ng for you to solve, all of which have been featured in this publicati on over the years.

In our May/June editi on, Sophie will also be starti ng a series on ECG Educati on. This series will be perfect not only for other cardiol-ogy professionals but also students and newly qualifi ed staff .

Our ECG Challenge for this editi on is only avail-able on our website. This is because the ECG image obtained didn’t quite have the resoluti on required to look great in this magazine.

However here is a quick overview:This ECG was the taken from the fi rst pati ent diagnosed with short QT syndrome (SQTS). This phenomenon, fi rst described in 1999 by Dr. Preben Bjerregaard MD, DMSc, is sti ll a rela-ti vely unknown disease, and due to this may oft en go undiagnosed.

Check out this ECG, the questi ons, and the answers on our website: www.cardiologyhd.com

Online Only.......Sorry!

Love our ECG Challenges?


Syntheti c veins for heart bypassScienti sts have grown human veins in a laboratory, in a break-through that could revoluti onise heart bypass surgery, reported the Daily Mail.

The news comes from research in which scienti sts developed a method for using human muscle ti ssue to create human blood ves-sels in the laboratory. These were then tested in animals, where they showed “excellent” blood fl ow and resistance to blockages and other complicati ons. The vessels could also be safely refrigerated for up to a year.

This initi al animal research has suggested that it may be possible in the future to use these synthesized vessels in humans, for example in coronary artery bypass operati ons, which currently rely on pati ents providing a healthy blood vessel to form their bypass graft . However, this short, preliminary research was in its early stages and therefore scienti sts will need to undertake many further stages of research before these lab-grown veins are proven to be safe and eff ecti ve in humans.

The study was carried out by researchers from East Carolina Univer-sity, Duke University, Yale University and Humacyte Inc, a company involved in commercially developing products for vascular disease. The research was also funded by Humacyte and the study was published in the peer-reviewed journal, Science Translati onal Medicine.

The newspapers reported the research accurately, although they tended to refl ect the opti mism of the scienti sts rather than the limi-tati ons of the research. The Daily Telegraph’s report that the new veins can be “safely transplanted into any pati ent” is not supported by the research conducted so far. The BBC’s report quoted independ-ent experts who correctly pointed out that this is early research, and the Daily Mail also highlighted that the veins were unlikely to be available to pati ents for several years.

Stati n benefi t for low risk people ‘questi onable’“Up to three million people are taking stati ns needlessly,” says The Daily Telegraph. It reports that a comprehensive study suggests stati ns are “ineff ecti ve in many cases and could be doing more harm than good”.

The news story is based on a review of trials of stati ns in peo-ple who had not (yet) suff ered a cardiovascular event such as a heart att ack or stroke. There was some evidence that stati ns reduced the risk of dying from any cause, and the risk of any cardiovascular outcome. However, the trials and review have several limitati ons, including some indicati ons that adverse events within the trials were not recorded.

It is important to point out that the benefi t of stati ns in peo-ple with cardiovascular disease, who have already suff ered a heart att ack or stroke, or who are considered to be at high risk of an event, is not in questi on here.

This review supports the need for careful considerati on of the overall cardiovascular risk of the individual when deciding whether to prescribe a stati n. In higher-risk populati ons, the benefi ts of a drug oft en clearly outweigh the risks. However, when lower-risk populati ons are considered, this balance can oft en ti p the other way. The results here do not support the widespread use of stati ns in people at low risk of cardiovas-cular events.

The news reports follow a Cochrane systemati c review con-ducted by researchers from the London School of Hygiene and Tropical Medicine and the University of Bristol.

The main conclusion of this review is that there is a lack of quality evidence to support the use of stati ns in people with low cardiovascular risk. This has been generally refl ected in the arti cles by The Daily Telegraph, the Daily Mirror and the Daily Express. However, the Daily Mail’s headline (“Stati ns ‘may cause loss of memory and depression’”) is incorrect. The researchers’ main concern is that there is not enough reporti ng of adverse events, not that there is evidence for any parti cular harm.

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Cardiac Statins


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PIC

The answer is yes, although the Closure I study is certainly food for thought. I think it has probably come at a good ti me, as we have seen a proliferati on of new devices and what feels like a renewed drive

from industry to market these devices. The eff ect of Closure I has been for everyone concerned with PFO device closure to pause and think hard about what are trying to achieve when we close a PFO.

My personal view is that the Closure I results are not that surprising. This is for a number of reasons:

1. The study included TIAs without any evidence of cerebral infarcti on/embolism. We all know that the ‘TIA populati on’ is very heterogenous and oft en there is litt le objecti ve evidence of cerebral embolism in this group. The grey area between migraine and cerebral ischaemia is also diffi cult, but there is oft en pressure from referring doctors to close the PFO in this group.

2. The medical therapy in the ‘best medical/anti coagulati on’ group was heterogenous. Whilst under-treatment should emphasize the benefi ts of device closure, it will not cause any ill-eff ect either. Many pati ents fear being on warfarin in the long-term and there will be an excess of bleeding in anti coagulated pati ents over a more prolonged period

3. The follow-up period was too short.

4. We do not yet know the details of the histories of these pati ents. Many pati ents I see with PFO-related events give a history very suggesti ve of a valsalva just before their neurological symptoms or have evidence of thrombophilia/DVT.

I sti ll feel that if a study was done using a device with a good closure rate in pati ents with defi nite scars on their brains on CT or MRI and a history suggesti ve of paradoxical embolus - it would be positi ve, parti cularly if the medical therapy group was homogenous (warfarin) and included adverse eff ects of anti coagulati on as a composite end-point. I think most PFO opera-tors would agree but we all know the diffi culti es associated with completi ng a trial like this.

The eff ect of Closure I on my own practi ce has been to make me even more reluctant to close PFOs in pati ents with no imaging evidence of cerebral infarcti on and shift me away from the ‘grey area’ towards the more defi nite (good history/cerebral scar) populati on and maybe this is a good thing.

In order to be eff ecti ve device closure needs to have been both necessary and also successful in preventi ng conti nued passage of material across the tunnel. It is possible to questi on both of these points. Firstly only a litt le over half the subjects had a moderate or large shunt at baseline and only one third had a septal aneu-rysm. Therefore a signifi cant proporti on of the recruited populati on had a “low risk” PFO as defi ned by previous cross-secti onal studies. Secondly success, assessed by TOE, was constant at 86% at all ti me points – this means nearly 15% had signifi cant residual shunts despite using an ultrasound technique which tends to under-report shunts due to the diffi culty in performing an adequate Valsalva manoeuvre with a probe in the oesophagus. Both of these factors would work against seeing superi-ority in the device arm.

Finally in the data presented it became clear that exhausti ve searches for alternati ve embolic sources may not have occurred, as they were then retrospecti vely found in the majority of pati ents with recurrent events. Of concern for the use of devices in the heart there did appear to be an increased risk of atrial fi brillati on in the acti ve arm, although as the full data has not been pub-lished it is unclear when this occurred and whether it was sustained or related to hazardous end-points.

Where does this study leave the fi eld of PFO device closure?

Clearly in discussing with pati ents one cannot ignore these results and they are the only randomised data available. That being said CLOSURE 1 does not indicate that device closure is never benefi cial, but rather tells us more about the importance of very careful assess-ment of pati ents for alternati ve causes before contem-plati ng closure and the need to concentrate this work within high volume centres who can achieve low pro-cedural complicati on and high closure rates. More clar-ity should come from the publicati on of further studies, parti cularly the RESPECT trial as this is event driven, and help us to defi ne exactly which pati ents should be off ered device therapy and which are bett er served by medical treatment.

Dr Philip MacCarthy BSc PhD FRCPConsultant Cardiologist and Clinical LeadDepartment of CardiologyKing’s College HospitalLondon, UK.


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A thorough examinati on of the DINAMIT data sheds some light. Essenti ally pati ents at high risk of early arrhythmias are also those at the highest risk of other modes of death (progressive heart failure, recurrent ischaemia, non cardiac morbidity).P Dorian and others Circulati on. 2010;122:2645-2652

Risk strati fi cati on for sudden death in Brugada syndrome has been controversial since the conditi on was described. An Italian registry of 320 pati ents provides a further contributi on. Observati ons arising reinforce the role of a spontaneous type 1 ECG, syncope and male gender, but also resurrect family history and electrophysiological studies as relevant factors. In parti cular the negati ve predicti ve value of EPS when a rigorous and aggressive protocol is followed warrants further evaluati on.P Delise and others European Heart Journal (2011) 32, 169–176

It is well recognised that ischaemic pati ents derive less benefi t than non ischaemics from CRT. It has always been assumed this is due to a higher burden of full thickness scar. This radionucleide study provides support for this with low scar burden ischaemics doing bett er post CRT than higher scar burden (regardless of dysynchrony measures).Evan C. Adelstein and others, European Heart Journal (2011) 32, 93–103

Aft er more than ten years one would have hoped we would have got past “two centre non randomised comparison” studies to tell us how to assess dysynchrony in narrow QRS heart failure pati ents. Sadly we have not, but the latest contributi on (for what it is worth) suggest two echo measures: opposite wall delay (OWD) >75ms and anter-oseptal posterior wall delay assessed by speckle tracking (ASPD) >107ms.The ROC curve for OWD is parti cularly unimpressive, but the ASPD cut off suggested gives sensiti vity and specifi city of 71 and 75% respecti vely for echocardiographic response to CRT. We look forward to validati on of these results by other operators.RJ Van Bommel and others European Heart Journal (2010) 31, 3054–3062 Should a ti ered therapy zone be programmed in for primary pre-venti on ICDs? Obviously, according to virtually every experienced implanter or physiologist I’ve met, and yes according to this piece from the PROVE trial. Basically, pati ents implanted with a device because they’re at risk of ventricular arrhythmias, get ventricular arrhythmias and would rather have them treated by ATP if possible than by shocks.M Saeed and others J Cardiovasc Electrophysiol, Vol. 21, pp. 1349-135

Should we be opti mising AV delay in all CRT implants? No because it doesn’t make any diff erence.K Ellenbogen and others Circulati on. 2010;122:2660-2668

Coronary Heart Disease

Another novel treatment with recent disappointi ng results is gene therapy for severe coronary artery disease. The NOVA trial, a small muliti centre randomised, double-blind, placebo (sham)-controlled study of direct intramyocardial injecti on of genes encoding vascular endothelial growth factor (VGEF), was again safe and feasible, but made no diff erence to exer-cise capacity or ti me to ischaemic threshold. Symptoms improved in both groups, similar to previous fi ndings with transmyocardial revascularisati on. Kastrup and Others EuroInterventi on. 2011;813-818

Another month, another risk score for cardiovascular pati ents. The ASSIGN CV risk score has been evaluated against the Framingham and QRISK scores in primary care pati ents in England and Wales and is as good/bad. All models overesti mated risk, parti cularly for men with low specifi city and sensiti vity. Family history and ethnicity are important and QRISK2 may be bett er. B De la Iglesia and Others. Heart 2011;97:491-499.

Does Epti bati de (the Glycoprotein IIbIIa inhibitor) given upstream improve outcomes in ACS pati ents. No, unless the pati ents are also pre-treated with early clopidogrel loading, but it does lead to more bleeding according to the EARLY-ACS study.T Wang and Others Circulati on 2011;123:722-730.


MATERIALS & METHODS

Design of the Study: Cross secti onal descripti ve study

Populati on: All clients having CHD att ending cardiac OPD, BPKIHS

Sample size: sixty cardiac pati ents.

Sampling technique: Purposive sampling technique

Research Instruments: Self-prepared semi-structured questi onnaire.

Research Validity and Reliability: content validity of the instrument was established by seeking opinion from the concerned authority.

Data collecti on Procedure: Verbal consent was taken from all sub-jects before data collecti on.

Data analysis Procedure: Data was entered at fi rst in Microsoft Excel & converted in SPSS. It was then analyzed by using descripti ve and inferenti al techniques to assess the associati on between selected variable and clinical characteristi cs of cardiac pati ents.

FINDINGS OF THE STUDY

Please visit our website www.cardiologyhd.com for a detailed breakdown of the study data.

DISCUSSION

Cardiovascular disease is becoming a major cause of illness and death in the eastern Mediterranean region, currently accounti ng for 31% of deaths. This rate is att ributable to an ageing populati on, high rates of smoking, and changes in nutriti onal behavior habits, along

with sedentary lifestyles. From our study it is depicted that out of the total 60 pati ents interviewed, the majority of respondents (52%) were females, 31.7% of pati ents were in the age group >60 years, 17 (28.3%) where in the age group 51-60, 9 (15%) where in the age group 41-50, 7 (11.7%) where in the age group 31-40, and 8 (13.3%) where in the age group 20-30. Pati ents who were Kirat comprised 17 (28.3%), followed by Chhetri 25%, whilst Vaisya and Brahman were 16.7% respecti vely. The majority of respondents found 86.7% are Hindus by religion. Most (51.7%) of the respondents were from the rural community.

Most of the pati ents (83.3%) were non- vegetarian, 33.3% were past smokers, and 60% of the pati ents had history of doing exer-cise. Among females, 58.3% had menopause. Most of the pati ents (53.3%) had systolic blood pressure above normal. Also 71.7% of the pati ents had diastolic blood pressure as normal and below normal.

Frequency of overall favorable lifestyle was only 25%, among which those with a good dietary patt ern was 28.3%, and non-smoker per-centage was 66.7 %. About 68.3% of pati ents were non-alcoholic, and among all pati ents 83.3% had a good follow up patt ern. On the other hand, pati ents carrying their prescripti on papers regularly with them and with a good meditati on habit were found to be very rare (26.7%).

So there is need for improvement for bett er lifestyle (75 %), and there was associati on between the lifestyle and selected variables ie. the residence (p=0.037). There was also associati on between the lifestyle and clinical characteristi cs i.e. the physical acti vity (p=0.000). Findings show that only 25% of the respondents had a good lifestyle. In this study, respondents with a lifestyle score greater than 14.4 out of 24 (>60%) were considered to have a good lifestyle.

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Right: B.P. Koirala Insti tute of Health Sciences (BPKIHS) in Dharan, Nepal

ContentsMar / Apr 2011


Barnet Hospital

Site VisitUnited Kingdom

What are the sizes of your Cardiology Department and Hospital?

Barnet and Chase Farm Cardiac Services

Cardiology Service

The specialty of cardiology lies within the directorate of General Medicine and Pharmacy. The specialty provides a combinati on of inpati ent work, a large outpati ent service, and a full range of cardiac investi gati ons. In additi on there are electi ve and emergency proce-dures undertaken mainly as day cases.

The ward base consists of 8 bedded CCUs on both sites, a 24 bed-ded cardiology ward, Rowan, at Barnet, and 11 beds on Melbourne ward at Chase Farm, with access to further beds on Toronto ward at Chase Farm. There are cardiac departments providing a full range of non-invasive cardiac investi gati ons at both Barnet and Chase Farm, with a more limited service at Edgware hospital. Outpati ent clinics are run from these sites as well as Cheshunt Community Hospital and Pott ers Bar, and include 7 Rapid access chest pain clinics weekly. Cardiac Rehabilitati on is off ered as an inpati ent and outpati ent ser-vice at both sites and extended into the community. Outreach heart failure clinics are run for Enfi eld pati ents at Forest Road. Myocardial perfusion scanning is also undertaken at Barnet in the Radiology department.

The cardiac catheterisati on lab and a six bedded day case unit is sited at Barnet, opening in April 2008. This is a trust-wide service providing faciliti es for diagnosti c cardiac catheterisati on, CRT, ICD and perma-nent pacemaker implantati on for electi ve and emergency admis-sions. We are expecti ng to increase our service to include electi ve PCI in 2011.

Barnet Hospital forms part of the Barnet and Chase Farm Hospitals NHS Trust and is located in north London. The hospital was modernized between 1999 and 2002 through a private fi nance initi ati ve and was re-opened in 2003 by HRH The Princess Royal. The Care Quality Commission recently publicly congratulated the Trust as one of the 13 most improved NHS trusts in the country.

Barnet HospitalWellhouse LaneBarnet, HertsEN5 3DJUnited Kingdom

BarnetHospital

courtesy Google


SITE

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The purpose built cardiology department at Barnet carries out:• 12 lead interpretati ve ECG• Treadmill exercise testi ng• Nuclear scanning• M-Mode, 2D, 3D, Doppler, Stress and trans-oesophageal

echocardiography• Trans-telephonic monitoring• 24 hour ambulatory rhythm monitoring• Event recording• 24 hour ambulatory blood pressure monitoring What is the geographical intake area and populati on served by your hospital?Barnet and Chase Farm hospitals are part of the North Central Sec-tor which has a catchment of 1 million, 50% of which being served by Barnet and Chase Farm Hospital

How many staff ? Roles?Staffi ng

• 7 Consultants, all with commitments at other hospitals/com-munity services.

• 1 Associate specialists• 2 Specialty doctors• 4 SpRs• 4 ST grade juniors• 2 FY grade juniors• 1 Physician Assistant• 2 Consultant Cardiac Surgeons – 1 PA acti vity weekly each• 2 Consultant Electrophysiologists – 2 PA total acti vity weekly.

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The Cath Lab Team (from left): Naveena Patel, Sara Fershi, Dr Ameet Bakhai, Beryl Broadhurst, Carolyn Forte, Claire Roaf, Louise Harney


Nursing

Cardiology matron.Cardiology Nurse Specialists5 WTE – RACPC, Heart Failure, Pre assessment and Revascularisa-ti on and Research

CCU (Barnet)19.5 WTE

Cath Lab, Day Unit, Pre assessment 15.29 WTE

Barnet cardiology ward27.95 WTE

Chase Farm Melbourne (CCU & step down) ward26.24 WTE

Cardiac Rehab team4.5 WTE

Cardiac Physiologists22 WTE (all sites, and including respiratory service)

Admin Staff 8 WTE (all sites, and including waiti ng list management)

Secretarial support8.5 WTE

Types of procedures?Currently performing diagnosti c Angiography.

Device implantati on including, temporary and Permanent Pacemak-er inserti on, ICD, and CRT-P. We have completed our training and BCIS evaluati on and hope to commence PCI in the early part of 2011

Types of equipment used?• Siemens Axiom Arti s (X-Ray)• McKesson – Medcon: Horizon Cardiology (CVIS and

Haemodynamic)• Philips iE33 (Echo)• Siemens Cyprus (Echo)

How many procedures are performed a year?Acti vity

Y2008/9 Y2009/10

Electi ve angio 932 1089

Emergency angio 645 446

Electi ve Device implantati on 185 204

Emergency device implantati on

155 179

Total 1917 1918

What is the approximate percentage of cath lab cases performed radially compared with femoral?Approximately 36%

Does your department off er a Primary Angioplasty Service?Barnet Hospital hope to start a PCI service in 2011, Primary Angio-plasty will remain in the established centres.

What new procedures / techniques have you implemented into the department recently? Future?CRT, ICD, future PCI, FFR

What are the benefi ts to pati ents att ending your facility?No longer need to commute into London for service

SITE

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Horizon Cardiology

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McKesson (Medcon), UKPremier House 112 Station RoadEdgware, MiddlesexHA8 7BJ United KingdomPhone: 0208 [email protected]/cardiology

Copyright © 2010 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.

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How is your inventory managed?Electronic Stock ordering through EROS, will use McKesson - Medcon inventory module for consignment and PCI when we start.

How does the lab handle haemostasis?TR Band for Radial approach, Angioseal for approximately 80 percent of femoral access, remainder of femoral Manual compression.

What measures has the department implemented to cut costs?Careful stock management, stock rotati on, consignment stock, early diagnosti c procedures to reduce length of stay.

What kind of training can new employees expect to receive?Off site training under honorary contract with the London Chest for PCI procedures, we hope to access the same support through Bart’s for Complex device therapies.

We also schedule training days on site during Lab down ti me, invit-ing external trainers and industry to ensure ongoing educati on and training.

What kinds of competency checks do staff have to undergo once employed?General competencies relati ve to all trained nurses.

Department specifi c competencies such as IABP set up and transpor-tati on, ECG interpretati on, IV Cannulisati on, BLS, ILS. Assisti ng with Cardiac interventi onal procedures. Scrub Technique.

How do you deal with late fi nishing of cases? For example stag-gered working hours or just staff overti me? Nursing Staff work Long days 07.30-19.00 so as to overlap the lab operati ng ti me of 09.00-17.00. Physiologists and radiographers claim overti me for overruns or take ti me back.

What is the best part of working at your facility?We are well supported by our Managers to provide an excellent ser-vice for our pati ents, waiti ng ti me for electi ve Angiography is usually less than three weeks. Great People, hard working, a busy lab that gets through a large volume of work for a single Lab with no aft er hours work. It is a great environment for learning, and our young staff are proving to be excellent Cath lab professionals who will no doubt remain in this speciality for many years to come.

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VIS

ITWould you like your department featured here?Write to us at [email protected] for more details.

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ECG Challenge- with Sophie Blackman

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Events Calendar

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Developing Countries: Dharan, Nepal16

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Nepal- Lifestyles of Pati ents with Coronary Heart Disease

- Barnet Hospital

- PFO Closure

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How to get in touch@ Email

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

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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.

Dr Mojgan Sani

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

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

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

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

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



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

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

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

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

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


Latest Product News

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EECP is a non invasive therapy that helps treat heart failure by strengthening the heart muscle simply by pumping more blood back to the heart. The more blood pumped back to the heart, the stronger it gets. EECP increases blood fl ow to the heart by opening up collateral circulati on and creati ng new blood vessels, while at the same ti me strengthening the heart. It keeps blood vessels relaxed, open and prevents plaque buildup. EECP reduces arterial sti ff ness and releases nitric oxide which has an anti oxidant eff ect, making arteries resistant to spasm and clotti ng. It has a detoxifi cati on eff ect and increases lymphati c circulati on.

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Kings College Hospital, London

One of the most popular secti ons in our publica-ti on is the Site Visits. Over the last fi ve years we have featured 35 diff erent departments from all over the world, and now we would like to feature yours.

In the coming editi ons we will be enhancing the Site Visits secti on, featuring multi ple hospitals from not just the UK, but further afi eld through-out the world. Recently we sent word out on our CardiologyHD Facebook page, so you can now expect Romania and New Zealand to be amongst the fi rst countries featured.

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QuikClot® provides safe, rapid and eff ecti ve control of bleeding – when you need it and where you need it. It is also eff ecti ve for use on pati ents who are taking Warfarin, Aspirin + Warfarin or Aspirin + Clopidogrel.

But don’t just take our word for it – QuikClot® is the US Military’s exclusive choice for extreme bleeding in warti me injuries in the combat fi eld – so it has to be good!

The acti ve haemostati c ingredient (kaolin) is non-invasive and woven into the hydrophilic bandage, allowing swift control of bleeding. Kaolin has been recognised for more than 50 years as an aff ecti ve clotti ng product. It does not use thrombin, fi brinogen or shellfi sh by-products and so has no known contraindicati ons.

It literally does what it says on the ti n - QuikClot®!

QuikClot® NOW AVAILABLE IN THE UK

Contact Dot Medical: [email protected] or call 01625 668811. www.dot-medical.com

GATEWAY Registry Initi ated in U.K. to Investi gate OrbusNeich’s Genous™ Stent in Pati ents with Acute Coronary Syndrome (ACS) and High-Risk of Post-Procedural BleedingThe investi gator-led, multi center, non-randomized, observati onal prospecti ve GATEWAY registry will enroll 280 pati ents at eight sites in the U.K. The government-approved GATEWAY study proto-col recommends that these pati ents undergo three months of dual anti -platelet therapy (DAPT) or less following stent implantati on.

The primary endpoint of the registry is the occurrence of net adverse clinical events (NACE) at 30 days and at one year follow-up.

“High-risk pati ents who present with non-ST segment elevati on myocardial infarcti on (NSTEMI) remain a challenge,” said Dr. David Smith of the Regional Cardiac Centre at Morriston Hospital, Swansea, Wales, principal investi gator of the trial. “Identi fi cati on of pati ents with a higher propensity for bleeding may lead to improvements in NSTEMI care by prompti ng clinicians to make judicious treatment selecti ons, carefully dose anti thromboti c medicati ons and proceed with strategies to opti mize individual pati ent care.”

For more informati on, visit www.OrbusNeich.com. Follow all of OrbusNeich’s news on Twitt er at htt p://twitt er.com/OrbusNeich.

Dr David Smith

32


Sleep and heart risk link is uncertain“Lack of sleep is a ‘ti cking ti me bomb’,” The Independent reported. The newspaper said that people who regularly sleep less than six hours a night “have a 48 per cent greater chance of developing or dying from heart disease”.

The news is based on research that combined data on almost 475,000 adults, drawn from 15 studies on sleep durati on and the risk of strokes and heart att acks. The review found that, compared with a normal 7-8 hours’ sleep a night, shorter or longer sleep was associ-ated with increased risk of these heart problems.

The review has some important limitati ons. For example, many medical, psychological and lifestyle factors can aff ect both sleep and cardiovascular health but att empts to account for the infl uence of these factors varied widely between the studies. It is also unclear whether the parti cipants did not have any cardiovascular disease at the start of the studies, so it should not be assumed that poor sleep was the cause of the cardiovascular problems eventually observed. As the researchers say, the reasons behind any associati ons between sleep and cardiovascular disease are not fully understood.

The study was carried out by researchers from Warwick Medical School and the University of Naples in Italy. No sources of funding were reported. The study was published in the peer-reviewed Euro-pean Heart Journal.

The newspapers generally refl ected the fi ndings of the research accurately, but did not address the wider issues and limitati ons of the study.

Combined drugs ‘bett er’ for blood pressureA newly published study has suggested that “a combinati on of drugs is bett er than a single one in treati ng high blood pressure”, BBC News reported.

This randomised controlled trial found that starti ng pati ents on a combinati on of hypertension drugs gives a faster and greater reducti on in blood pressure than either of the drugs on their own, without any more side eff ects. The drugs, amlodipine and aliskiren, work to lower blood pressure in diff erent ways.

Doctors currently start pati ents with high blood pressure on one drug and may add others later if needed. The authors of this well-designed trial suggest that clinical practi ce should now be changed and that pati ents with high blood pressure be started on two drugs rather than one. However, although the results of this study are signifi cant, it looked only at two specifi c types of drug, so cannot make comparisons of the eff ecti veness of treatment with other classes of blood pres-sure drug, whether used alone or in combinati on. Longer-term eff ects and adverse outcomes beyond 32 weeks (such as stroke, heart att ack or early death) have not yet been examined.

People who are concerned about their blood pressure or its treatment should visit their GP.

The study was carried out by researchers from the Univer-sity of Cambridge, the Briti sh Hypertension Society, the Uni-versity of Glasgow, Novarti s Pharma AG, Switzerland, and Ninewells Hospital and Medical School, Dundee. It was fund-ed by Novarti s Pharma AG and two of the study’s authors are employees of this company. The study was published in peer-reviewed medical journal The Lancet.

The study was mostly reported accurately by the BBC, how-ever, the statement that the combined treatment had fewer side eff ects is incorrect. The proporti on of people who with-drew due to side eff ects was actually the same for combined treatment and the group taking aliskiren plus placebo, but higher (18%) for those taking amlodipine. The claim by the Daily Express that the pill could “prevent 5,000 strokes a year” is not supported by the study, which looked at the eff ect of diff erent treatments on blood pressure measure-ments, not on strokes or other cardiovascular outcomes.

Behind The Headlines

The Facts

The following articles are courtesy of NHS Choices

Blood Pressure

the study.


Syntheti c veins for heart bypassScienti sts have grown human veins in a laboratory, in a break-through that could revoluti onise heart bypass surgery, reported the Daily Mail.

The news comes from research in which scienti sts developed a method for using human muscle ti ssue to create human blood ves-sels in the laboratory. These were then tested in animals, where they showed “excellent” blood fl ow and resistance to blockages and other complicati ons. The vessels could also be safely refrigerated for up to a year.

This initi al animal research has suggested that it may be possible in the future to use these synthesized vessels in humans, for example in coronary artery bypass operati ons, which currently rely on pati ents providing a healthy blood vessel to form their bypass graft . However, this short, preliminary research was in its early stages and therefore scienti sts will need to undertake many further stages of research before these lab-grown veins are proven to be safe and eff ecti ve in humans.

The study was carried out by researchers from East Carolina Univer-sity, Duke University, Yale University and Humacyte Inc, a company involved in commercially developing products for vascular disease. The research was also funded by Humacyte and the study was published in the peer-reviewed journal, Science Translati onal Medicine.

The newspapers reported the research accurately, although they tended to refl ect the opti mism of the scienti sts rather than the limi-tati ons of the research. The Daily Telegraph’s report that the new veins can be “safely transplanted into any pati ent” is not supported by the research conducted so far. The BBC’s report quoted independ-ent experts who correctly pointed out that this is early research, and the Daily Mail also highlighted that the veins were unlikely to be available to pati ents for several years.

Stati n benefi t for low risk people ‘questi onable’“Up to three million people are taking stati ns needlessly,” says The Daily Telegraph. It reports that a comprehensive study suggests stati ns are “ineff ecti ve in many cases and could be doing more harm than good”.

The news story is based on a review of trials of stati ns in peo-ple who had not (yet) suff ered a cardiovascular event such as a heart att ack or stroke. There was some evidence that stati ns reduced the risk of dying from any cause, and the risk of any cardiovascular outcome. However, the trials and review have several limitati ons, including some indicati ons that adverse events within the trials were not recorded.

It is important to point out that the benefi t of stati ns in peo-ple with cardiovascular disease, who have already suff ered a heart att ack or stroke, or who are considered to be at high risk of an event, is not in questi on here.

This review supports the need for careful considerati on of the overall cardiovascular risk of the individual when deciding whether to prescribe a stati n. In higher-risk populati ons, the benefi ts of a drug oft en clearly outweigh the risks. However, when lower-risk populati ons are considered, this balance can oft en ti p the other way. The results here do not support the widespread use of stati ns in people at low risk of cardiovas-cular events.

The news reports follow a Cochrane systemati c review con-ducted by researchers from the London School of Hygiene and Tropical Medicine and the University of Bristol.

The main conclusion of this review is that there is a lack of quality evidence to support the use of stati ns in people with low cardiovascular risk. This has been generally refl ected in the arti cles by The Daily Telegraph, the Daily Mirror and the Daily Express. However, the Daily Mail’s headline (“Stati ns ‘may cause loss of memory and depression’”) is incorrect. The researchers’ main concern is that there is not enough reporti ng of adverse events, not that there is evidence for any parti cular harm.

THE

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Cardiac Statins


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Blood pressure device performs wellA watch-like device “could revoluti onise blood pressure mon-itoring”, BBC News has reported. According to the website, the monitor can be used to measure pressure in the wrist, which can then be used to esti mate pressure in the aorta, the largest artery in the body.

Although news coverage has focussed on the wrist-worn monitor, the research devised a technique to combine blood pressure readings from the wrist and upper-arm to esti mate central aorti c systolic pressure (CASP). This measure of pres-sure in the aorta is thought to be a bett er way of predicti ng heart problems than traditi onal measures of blood pressure, such as using an infl atable cuff around the bicep.

A device to measure blood pressure at the wrist is not new, and the method does not replace the traditi onal approach of using a cuff on the upper arm. However, the research-ers’ method for combining the two results to esti mate CASP appears to have some merit, and may fi lter into medical care.

The study was carried out by researchers from the University of Leicester, the Nati onal Insti tute for Health Research, Gle-neagles Medical Centre in Singapore and Healthstats Inter-nati onal in Singapore. The study was fi nancially supported by the Leicester Nati onal Insti tute for Health Research Bio-medical Research Unit in Cardiovascular Diseases. The study was published in the peer-reviewed Journal of the American College of Cardiology.

Television heart risk needs more study“Watching TV for four hours a day doubles the risk of a heart att ack,” The Sun has reported. “The reason is thought to be that simply sitti ng for so long causes coronary problems,” the arti cle added.

The story is based on a study that surveyed 4,512 people to esti mate their television viewing and physical acti vity, comparing their habits with their risk of death or cardiovascular disease over the next four years. Those viewing TV and video games for four hours or more per day were 48% more likely to die (due to any cause) and 125% more likely to have a cardiovascular-related event (such as a heart att ack or stroke) than those who watched less than two hours. The relati on-ship was independent of smoking, social class and how much physi-cal acti vity people did.

This well-conducted study suggests that lengthy periods of recrea-ti onal viewing may have harmful eff ects on the cardiovascular sys-tem, increasing the risk of heart att acks, strokes and early death.

However, the study had some limitati ons, such as not accounti ng for the infl uence of diet or ti me sitti ng in front of a computer at work. This initi al research is of interest, but there is now a need for larger, longer studies to verify the relati onship.

The study was carried out by researchers from University College London, the University of Queensland, Brisbane and Edith Cowan University and the Heart and Diabetes Insti tute, Melbourne. The researchers were fi nancially supported by the UK’s Nati onal Insti tute for Health Research, the Briti sh Heart Foundati on and the Victorian Health Promoti on Foundati on Public, Australia.

The study was published in the peer-reviewed Journal of the Ameri-can College of Cardiology. It was reported accurately, but uncriti cally, by newspapers.

New Technology


PFO closure: is there sti ll a future post CLOSURE 1?

Strokes are a greatly feared and debilitati ng event in anyone and perhaps even more so in young people in whom they are thankfully rare. Strokes are ischemic in 80% of cases and, using

our current understanding of their causes, the reason can be found in about 60% of these individuals. Recognised precipitants include caroti d atheroma, dissecti ons, vasculiti s, pro-thomboti c states and cardiac sources of emboli such as atrial fi brillati on, left ventricular thrombus and endocarditi s.

In the absence of any of these factors numerous alternati ve mech-anisms for “cryptogenic” strokes have been proposed and most popular amongst these are intra-cardiac communicati ons that allow unfi ltered venous blood to bypass the pulmonary circuit and enter the arterial tree. Of these communicati ons the most common is the patent foramen ovale (PFO) which is a foetal structure that allows oxygenated blood to pass from the right to left atrium and from pathology studies remains patent in 20-25% of adults in the general populati on.

The theory runs that small clots return from the peripheral veins to the heart and instead of passing on to the lungs, and being destroyed by the natural thromboti c pathways there, are able to pass across the PFO into the systemic arterial circulati on and cause embolic phenom-enon such as a stroke. What is the evidence for this? Support exists in two forms – fi rstly there are numerous case reports where long clots are found caught in the process of passing through a PFO. Sec-ondly cross-secti onal studies have shown that the presence of a PFO (parti cularly in associati on with an atrial septal aneurysm) is much more likely in pati ents with cryptogenic strokes than the general populati on – increasing in Lechat’s series (NEJM 1988) to over 50%.

These fi ndings may implicate the PFO in cryptogenic strokes; how-ever they do not give insight into the best treatment opti ons. In non-randomised studies pati ents have either been treated with anti -platelets, formal anti -coagulati on or closure of the defect with a prosthesis. Att empts to compare these disparate groups indicated that device closure, parti cularly in the presence of a septal aneu-rysm, was superior (annual recurrence rates for medically treated

ranging from 3.8-12% and device treated from 0-4.9%). As these are non-randomised studies there was a drive to obtain properly con-trolled data and to that end fi ve studies were started using diff erent commercially available devices pitched against medical therapy in a fully randomised fashion.

The fi rst to report, at the American Heart Associati on meeti ng in November 2010 (although not yet in print), was the CLOSURE 1 study. This compared medical therapy, a mixture of anti -coagulati on and anti -platelets, to device closure with the NMT Biostar device. The primary end-point in this superiority study was a composite of stroke/TIA and mortality (all cause to 30 days and then neurologi-cal out to two years) and as has been reported was negati ve with an event rate of 5.9% in the device arm against 7.7% (P=0.3) in the medical group.

Do we read from this that device closure is unnecessary?

Well this is not straightf orward to answer - at least in part because we do not as yet have the full published dataset and therefore can only comment on the informati on presented at the AHA meeti ng. There are a number of points that should be raised in considering this result. The fi rst is that of its power to detect a real eff ect (as an under-powered study may miss a small but clinically important eff ect) – this study originally intended to recruit 1600 pati ents and due to very slow uptake was terminated early with fewer than 1000 subjects. Concern that this change under-powers the fi ndings is sup-ported by the absence of the usual negati ve eff ect of having a septal aneurysm upon risk and is a parti cular danger in superiority studies. As a result of the reduced size the expected event rate in the treated arm was 2% or less by intenti on to treat analysis. Unfortunately in this study there was a high procedural complicati on rate with only a 90% procedural success rate – the reason for this is not clear although the large number of centres performing small numbers of procedures has been put forward as a potenti al factor. As a result the event rate in the device therapy arm was increased by these early complicati ons and may have biased the outcome.

Hot TopicCardiologist

Dr Brian ClappMA PhD MRCPConsultant CardiologistGuy’s & St Thomas’ HospitalLondon, UK


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The answer is yes, although the Closure I study is certainly food for thought. I think it has probably come at a good ti me, as we have seen a proliferati on of new devices and what feels like a renewed drive

from industry to market these devices. The eff ect of Closure I has been for everyone concerned with PFO device closure to pause and think hard about what are trying to achieve when we close a PFO.

My personal view is that the Closure I results are not that surprising. This is for a number of reasons:

1. The study included TIAs without any evidence of cerebral infarcti on/embolism. We all know that the ‘TIA populati on’ is very heterogenous and oft en there is litt le objecti ve evidence of cerebral embolism in this group. The grey area between migraine and cerebral ischaemia is also diffi cult, but there is oft en pressure from referring doctors to close the PFO in this group.

2. The medical therapy in the ‘best medical/anti coagulati on’ group was heterogenous. Whilst under-treatment should emphasize the benefi ts of device closure, it will not cause any ill-eff ect either. Many pati ents fear being on warfarin in the long-term and there will be an excess of bleeding in anti coagulated pati ents over a more prolonged period

3. The follow-up period was too short.

4. We do not yet know the details of the histories of these pati ents. Many pati ents I see with PFO-related events give a history very suggesti ve of a valsalva just before their neurological symptoms or have evidence of thrombophilia/DVT.

I sti ll feel that if a study was done using a device with a good closure rate in pati ents with defi nite scars on their brains on CT or MRI and a history suggesti ve of paradoxical embolus - it would be positi ve, parti cularly if the medical therapy group was homogenous (warfarin) and included adverse eff ects of anti coagulati on as a composite end-point. I think most PFO opera-tors would agree but we all know the diffi culti es associated with completi ng a trial like this.

The eff ect of Closure I on my own practi ce has been to make me even more reluctant to close PFOs in pati ents with no imaging evidence of cerebral infarcti on and shift me away from the ‘grey area’ towards the more defi nite (good history/cerebral scar) populati on and maybe this is a good thing.

In order to be eff ecti ve device closure needs to have been both necessary and also successful in preventi ng conti nued passage of material across the tunnel. It is possible to questi on both of these points. Firstly only a litt le over half the subjects had a moderate or large shunt at baseline and only one third had a septal aneu-rysm. Therefore a signifi cant proporti on of the recruited populati on had a “low risk” PFO as defi ned by previous cross-secti onal studies. Secondly success, assessed by TOE, was constant at 86% at all ti me points – this means nearly 15% had signifi cant residual shunts despite using an ultrasound technique which tends to under-report shunts due to the diffi culty in performing an adequate Valsalva manoeuvre with a probe in the oesophagus. Both of these factors would work against seeing superi-ority in the device arm.

Finally in the data presented it became clear that exhausti ve searches for alternati ve embolic sources may not have occurred, as they were then retrospecti vely found in the majority of pati ents with recurrent events. Of concern for the use of devices in the heart there did appear to be an increased risk of atrial fi brillati on in the acti ve arm, although as the full data has not been pub-lished it is unclear when this occurred and whether it was sustained or related to hazardous end-points.

Where does this study leave the fi eld of PFO device closure?

Clearly in discussing with pati ents one cannot ignore these results and they are the only randomised data available. That being said CLOSURE 1 does not indicate that device closure is never benefi cial, but rather tells us more about the importance of very careful assess-ment of pati ents for alternati ve causes before contem-plati ng closure and the need to concentrate this work within high volume centres who can achieve low pro-cedural complicati on and high closure rates. More clar-ity should come from the publicati on of further studies, parti cularly the RESPECT trial as this is event driven, and help us to defi ne exactly which pati ents should be off ered device therapy and which are bett er served by medical treatment.

Dr Philip MacCarthy BSc PhD FRCPConsultant Cardiologist and Clinical LeadDepartment of CardiologyKing’s College HospitalLondon, UK.


Journals

Atrial Fibrillati on

Predicti ng thromboembolic risk in atrial fi brillati on is a growth indus-try. The simplicity of the CHADS2 scoring system, which seemed too good to be true probably is: the lack of recogniti on of vascular dis-ease and under esti mati on of the risk associated with age in par-ti cular producing falsely reassuring results. A Danish group have examined the predicti ve value of both CHADS2 and the more aggres-sive CHA2DS2vasc in a cohort of over 70 000 pati ents.

Headline fi ndings are: the added risk factors in CHA2DS2vasc hold up well; those with a CHA2DS2vasc of 1 are at genuinely intermediate risk (2%pa) whereas CHADS2 of 1 have an uncomfortably high risk (4.75% pa). Risks are maintained year on year.JB Oleson and others BMJ 2011;342:d124

We know that Dabigatran is more eff ecti ve than warfarin (at high dose) and safer than warfarin (at reduced dose), but is it cost eff ec-ti ve (stop yawning)? A group wanted to fi nd if Dabi was cost eff ecti ve, so, as is the way with these things, they did. The cost per QALY of high dose Dabigatran when compared with warfarin at current US prices was $50K.

The study has many limitati ons including a noti onal cost of warfarin, which seems very high and an assumpti on that observati ons in RE-LY over 2 years can be extrapolated in the long term.JV Freeman and others Ann Intern Med. 2011;154:1-11

Heart Failure and Devices

Heart failure is an ever growing problem due to our ageing popula-ti on, improved revascularisati on techniques, and evidenced based secondary preventi on. Cell therapy is hoping to be the next big thing in treati ng heart failure pati ents. Sadly, the results of the SEISMIC trial of intramyocardial implantati on of autologous skeletal myo-blasts, in a small cohort pati ents, were not earth moving. Whilst the technique appears safe and feasible, there was no benefi t in LVEF, with ‘suggesti ons’ of improvement in symptoms. Further larger stud-ies are awaited.H Duckers and Others EuroInterventi on. 2011;6:794-797

Bett er news for heart failure pati ents comes from the CHAMPION study, in which a wireless implant (CardioMEMS) that monitors haemodynamics has been shown to reduce hospitalisati ons com-pared to standard management. The pulmonary artery pressure sen-sor was implanted in NYHA class III pati ents, improving management and outcome over a 15 month follow up. I suspect this will appeal to device companies, implanters and pati ents, but feel that basic man-agement and heart failure support in the community is needed fi rst.WT Abraham and Others. The Lancet;377:658-666.

Apparent primary preventi on ICD candidates have been shown to lack benefi t and even derive harm when implanted soon aft er an acute event (most studied in MI or CABG). It has become accept-ed, though not parti cularly illuminati ng, to describe this as ICDs changing the mode of death in these populati ons.

Should we be opti mising AV delay in all CRT implants?

No, because it doesn’t make any

diff erence.K Ellenbogen and others Circulati on.

2010;122:2660-2668




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A thorough examinati on of the DINAMIT data sheds some light. Essenti ally pati ents at high risk of early arrhythmias are also those at the highest risk of other modes of death (progressive heart failure, recurrent ischaemia, non cardiac morbidity).P Dorian and others Circulati on. 2010;122:2645-2652

Risk strati fi cati on for sudden death in Brugada syndrome has been controversial since the conditi on was described. An Italian registry of 320 pati ents provides a further contributi on. Observati ons arising reinforce the role of a spontaneous type 1 ECG, syncope and male gender, but also resurrect family history and electrophysiological studies as relevant factors. In parti cular the negati ve predicti ve value of EPS when a rigorous and aggressive protocol is followed warrants further evaluati on.P Delise and others European Heart Journal (2011) 32, 169–176

It is well recognised that ischaemic pati ents derive less benefi t than non ischaemics from CRT. It has always been assumed this is due to a higher burden of full thickness scar. This radionucleide study provides support for this with low scar burden ischaemics doing bett er post CRT than higher scar burden (regardless of dysynchrony measures).Evan C. Adelstein and others, European Heart Journal (2011) 32, 93–103

Aft er more than ten years one would have hoped we would have got past “two centre non randomised comparison” studies to tell us how to assess dysynchrony in narrow QRS heart failure pati ents. Sadly we have not, but the latest contributi on (for what it is worth) suggest two echo measures: opposite wall delay (OWD) >75ms and anter-oseptal posterior wall delay assessed by speckle tracking (ASPD) >107ms.The ROC curve for OWD is parti cularly unimpressive, but the ASPD cut off suggested gives sensiti vity and specifi city of 71 and 75% respecti vely for echocardiographic response to CRT. We look forward to validati on of these results by other operators.RJ Van Bommel and others European Heart Journal (2010) 31, 3054–3062 Should a ti ered therapy zone be programmed in for primary pre-venti on ICDs? Obviously, according to virtually every experienced implanter or physiologist I’ve met, and yes according to this piece from the PROVE trial. Basically, pati ents implanted with a device because they’re at risk of ventricular arrhythmias, get ventricular arrhythmias and would rather have them treated by ATP if possible than by shocks.M Saeed and others J Cardiovasc Electrophysiol, Vol. 21, pp. 1349-135

Should we be opti mising AV delay in all CRT implants? No because it doesn’t make any diff erence.K Ellenbogen and others Circulati on. 2010;122:2660-2668

Coronary Heart Disease

Another novel treatment with recent disappointi ng results is gene therapy for severe coronary artery disease. The NOVA trial, a small muliti centre randomised, double-blind, placebo (sham)-controlled study of direct intramyocardial injecti on of genes encoding vascular endothelial growth factor (VGEF), was again safe and feasible, but made no diff erence to exer-cise capacity or ti me to ischaemic threshold. Symptoms improved in both groups, similar to previous fi ndings with transmyocardial revascularisati on. Kastrup and Others EuroInterventi on. 2011;813-818

Another month, another risk score for cardiovascular pati ents. The ASSIGN CV risk score has been evaluated against the Framingham and QRISK scores in primary care pati ents in England and Wales and is as good/bad. All models overesti mated risk, parti cularly for men with low specifi city and sensiti vity. Family history and ethnicity are important and QRISK2 may be bett er. B De la Iglesia and Others. Heart 2011;97:491-499.

Does Epti bati de (the Glycoprotein IIbIIa inhibitor) given upstream improve outcomes in ACS pati ents. No, unless the pati ents are also pre-treated with early clopidogrel loading, but it does lead to more bleeding according to the EARLY-ACS study.T Wang and Others Circulati on 2011;123:722-730.


NepalLifestyles of Pati ents with Coronary Heart Disease (CHD) Att ending Cardiac OPD of BPKIHS, Dharan, Nepal

Developing Countries

INTRODUCTION

Background: Heart disease as a leading cause of morbidity and mor-tality is of global concern, especially in North American and Euro-pean societi es. In the US, nearly one-quarter of the enti re adult US populati on (about 61 million) lives with some form of heart disease, and approximately one million Americans die of heart disease every year, which accounts for more than 40% of all deaths1. According to a recent report by the World Health Organizati on (WHO) on reducing risks and promoti ng healthy life, inacti ve lifestyles, tobacco use, and low fruit and vegetable intake each account for 20% of deaths and disabiliti es from cardiovascular disease risk worldwide2.

Rati onales for the Study: Coronary Heart Disease (CHD) is one of the leading causes of illness and death among the top three disease classifi cati ons all over the world. Although CHD is an interesti ng area of research, in context to Nepal, studies regarding the knowledge of cardiovascular risk factors are limited. This study will help to pro-vide the baseline data on knowledge and preventi on of risk factors of CHD.

Signifi cance of the Study: This study might be helpful to provide the baseline data about lifestyle factors in relati on to CHD. The fi ndings of the study can be used by healthcare personnel to carry out fur-ther interventi onal studies on non-pharmacological management for cardiac pati ents. It also could be used within health educati on for cardiac pati ents to encourage them for regular follow-ups and com-pliance of treatment modaliti es.

General Objecti ve: To assess the lifestyle of pati ents with Coronary Heart Disease att ending the Cardiac Outpati ent Department of B.P. Koirala Insti tute of Health Sciences (BPKIHS), Dharan, Nepal.

Specifi c Objecti ves:

• To assess the lifestyle of pati ents with coronary heart disease.• To fi nd out the associati on between lifestyle and selected

variables.• To fi nd out the associati on between lifestyle and clinical

characteristi cs.

Mrs. Rosy ShresthaAssistant Professor, Dept. of Medical Surgical NursingCollege of NursingB.P. Koirala Insti tute of Health Sciences (BPKIHS) DharanNepal

Nepal Overview

Kathmandu

Dharan

Mt EverestNepal

Country: NepalPopulation: 29,331,000 (2009 est)Official Language: Nepali

Nepal is a landlocked country in South-East Asia bordered on the north by the People’s Republic of China, and to the south, east, and west by the Republic of India. Located in the Him-alayas, Nepal has eight of the world’s ten tallest mountains, including the highest point on Earth, Mount Everest. The capital city is Kathmandu.

Source: Wikipedia


MATERIALS & METHODS

Design of the Study: Cross secti onal descripti ve study

Populati on: All clients having CHD att ending cardiac OPD, BPKIHS

Sample size: Sixty cardiac pati ents.

Sampling technique: Purposive sampling technique

Research Instruments: Self-prepared semi-structured questi onnaire.

Research Validity and Reliability: Content validity of the instrument was established by seeking opinion from the concerned authority.

Data collecti on Procedure: Verbal consent was taken from all sub-jects before data collecti on.

Data analysis Procedure: Data was entered at fi rst in Microsoft Excel & converted in SPSS. It was then analyzed by using descripti ve and inferenti al techniques to assess the associati on between selected variable and clinical characteristi cs of cardiac pati ents.

FINDINGS OF THE STUDY

Please visit our website www.cardiologyhd.com for a detailed breakdown of the study data.

DISCUSSION

Cardiovascular disease is becoming a major cause of illness and death in the eastern Mediterranean region, currently accounti ng for 31% of deaths. This rate is att ributable to an ageing populati on, high rates of smoking, and changes in nutriti onal behavior habits, along

with sedentary lifestyles. From our study it is depicted that out of the total 60 pati ents interviewed, the majority of respondents (52%) were females, 31.7% of pati ents were in the age group >60 years, 17 (28.3%) where in the age group 51-60, 9 (15%) where in the age group 41-50, 7 (11.7%) where in the age group 31-40, and 8 (13.3%) where in the age group 20-30. Pati ents who were Kirat comprised 17 (28.3%), followed by Chhetri 25%, whilst Vaisya and Brahman were 16.7% respecti vely. The majority of respondents found 86.7% are Hindus by religion. Most (51.7%) of the respondents were from the rural community.

Most of the pati ents (83.3%) were non-vegetarian, 33.3% were past smokers, and 60% of the pati ents had history of doing exer-cise. Among females, 58.3% had menopause. Most of the pati ents (53.3%) had systolic blood pressure above normal. Also 71.7% of the pati ents had diastolic blood pressure as normal and below normal.

Frequency of overall favorable lifestyle was only 25%, among which those with a good dietary patt ern was 28.3%, and non-smoker per-centage was 66.7%. About 68.3% of pati ents were non-alcoholic, and among all pati ents 83.3% had a good follow up patt ern. On the other hand, pati ents carrying their prescripti on papers regularly with them and with a good meditati on habit were found to be very rare (26.7%).

So there is need for improvement for bett er lifestyles (75%), and there was an associati on between the lifestyle and selected variables ie. the residence (p=0.037). There was also associati on between the lifestyle and clinical characteristi cs i.e. the physical acti vity (p=0.000). Findings show that only 25% of the respondents had a good lifestyle. In this study, respondents with a lifestyle score greater than 14.4 out of 24 (>60%) were considered to have a good lifestyle.

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Right: B.P. Koirala Insti tute of Health Sciences (BPKIHS) in Dharan, Nepal


CONCLUSION

From this study it is concluded that most of the pati ents were not aware of their disease conditi on and need for modifi cati on of life-style for managing cardiac problems.

Nurses can play a vital role in the identi fi cati on and management of cardiac pati ents by identi fying the risk factors associated with their lifestyle, and by providing referral services in taking care of pati ents with cardiac related problems. Health educati on, especially encour-agement of healthy lifestyles at the nati onal level should be initi ated, and an overall policy of health promoti on to reduce cardiac prob-lems implemented.

REFERENCES:1. Cardiovascular Disease. [serial online] 2003 [cited 2010 January 27].

Available fro: URL:htt p://www.labtestonlie.org. 2. WHO Cardiovascular Disease. [serial online] 2009 [cited 2010 January

26]. Available from: URL: htt p: // www. Who.int.com.3. Black H. Cardiovascular Risk Factors. [serial online] 1997 [ cited 2010

January 26]. Available from : URL: htt p:// www.yahoo.com4. Cardiovascular Risk Factors for Cardiovascular Diseases. [Serial online]

2005 [cited 2010 January 27]. Available from: URL: htt p://www.asu.edu.

5. Barett S. Risk Factors For Cardiovascular Diseases. [serial online] 2000 [ cited 2010 January 28]. Available from: URL: htt p: // www.quackwatch.org

6. Prevalence and incidence of Cardiovascular Disease[ serial online] 2010 [ cited 2010 January 28]. Available from: URL: htt p: // www. silverbook.org

7. Prevalence of Cardiovascular Disease. [serial online] 2006 [ cited 2010 January 28]. Available from: URL: htt p: // www. wrongdiagnosis.com

8. Goyal A. Yusuf S. Burden of Cardiovascular Disease in the Indian Sub-conti nent [serial online] 2006 [cited 2010 January 15]. Available from: URL: htt p: // www.icmr.nic.in

9. Smith D. University Students Knowledge of Cardiovascular Disease Risk Factors. [serial online] 2006 [cited 2010 February 16]. Available from: URL: htt p: // www. cababstractplus.org

10. Adili F. Knowledge and Practi ce Status and Trend in Risk Factors. [serial online] 2005 [ cited 2010 February 16]. Available from: URL: htt p: //journals.turns.ac.ir

11. Vanhecke T. Awareness, Knowledge and Percepti on of Heart Disease. [serial online] 2006 [ cited 2010 February 16]. Available from: URL: htt p: // journals.lww.com

12. Jafary et al CARDIOVASCULAR HEALTH Knowledge behavior in pati ent att endants at four care terti ary hospitals in Pakistan-a cause for concern. [serial online] 2005 [ cited 2010 February 17]. Available from: URL: htt p: //www.biomedcentral.com.

13. Khan MS. Knowledge of Modifi able Risk Factors of heart disease among pati ents with acute MI in Karanchi, Pakistan. [serial online] 2006 [cited 2010 February 17]. Available from: URL: htt p: //www.biomedcentral.com.

14. Frost R. Cardiovascular Risk Modifi cati on in College Student. [serial online] 2007 [ cited 2010 February 16]. Available from: URL: htt p: //www.springerlink.com

15. FHA-Health Belief Model Percepti ons, Knowledge of Heart Disease. [serial online] 2006 November 29 [cited 2010 February 1]. Available from: URL: htt p: ///www.fi nal.health-arti cles.com.

16. Knowledge and Awareness of Risk Factors for Cardiovascular Risk Fac-tors for Cardiovascular Disease. [serial online] 2008 September 1 [cited 2010 February 1]. Available from: URL: htt p: ///www.thefreelibrary.com.

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Cultural Understanding

The Nepalese caste system is highly complex and continues the traditional system of social stratification defining the social classes by a number of hierarchical groups. In basic terms it refers to socio-economic classes, however once you are born into that class that is where you remain. Low-caste people are often deprived of utilizing most of the temples, funeral places, drinking water taps and wells, restaurants, shops and other public places.

High to Low Caste: Brahman, Chhetri, Vaisya, & Kirat

Source: Wikipedia


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

There has recently been great publicity surrounding ‘Care and Compassion? Report of the Health Service Ombudsman on ten investi gati ons into NHS care of older people’.

This document fi rst came to my att enti on aft er I saw such damning headlines in the nati onal newspapers as: ‘The NHS has failed the elderly’ The Times.

I downloaded a copy of the report, and it certainly makes for uncom-fortable reading. Of the 10 cases discussed, 9 of the pati ents died during or as a direct result of the treatment that they received. The stories within the document are truly harrowing, but I would urge you to read them as there is much we can learn.

htt p://www.ombudsman.org.uk/care-and-compassion/home

There has been signifi cant discussion in the press since this report was published and there are a few points that I think are important regarding this document which I have impressed upon my staff .

Firstly, ‘the NHS sees over a million people every 36 hours’, Nigel Edwards Chief Executi ve of the NHS Federati on is reported to have said on www.nhs.uk, and so ‘the ten cases included in the report need to be kept in perspecti ve’. While the Ombudsman’s document is ‘powerful and informati ve regarding the individual cases, it cannot be thought of as reliable evidence that can be applied generally to the care of the elderly across the NHS’.

Nevertheless, whilst I think it is important is that we keep the report in perspecti ve, for these individuals and families there were crucial errors made in the care received. When you read the report what is so upsetti ng is how very easily the errors could have been avoided through bett er communicati on, bett er understanding of the pati ent and families perspecti ves, and by someti mes pushing the boundaries of our roles. It is evident of a service stretching to its limits, oft en with insuffi cient fi nance and resources and never ending cut backs that someti mes staff are so pushed to get things done to fi t a ti me-frame that is comes at the compromise of the expected standards.

I have asked all my staff to read this document because I think it serves as a good reminder for us as we go about our daily work, that despite the endless increases in service demand and external pres-sures we have, we all came into this profession to care.Irrespecti ve of anything else that is going on, every single pati ent that we see - young or old - deserves our undivided att enti on. It reminds us that things we do day in, day out, are unfamiliar and invoke fear in our pati ents, and we must not take for granted the value and importance of taking an extra few moments to ensure the pati ent is informed and comfortable, that you are respecti ng their dignity, and providing them with the best service of care.

For surely without providing this level of care, commitment and courtesy for every pati ent you see you would not be fulfi lling your duty of care? Someti mes our duty of care has much wider scope than the exact job descripti on we have on paper, and just a small eff ort beyond our normal role can help prevent the communicati on break-downs, and leave our pati ents and their relati ves with a much more positi ve experience of our NHS.

AssistanceManagement


Sophie Blackman’s ECG

Challenge

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust United Kingdom

We have 20 ECG Challenges on our website just waiti ng for you to solve, all of which have been featured in this publicati on over the years.

In our May/June editi on, Sophie will also be starti ng a series on ECG Educati on. This series will be perfect not only for other cardiol-ogy professionals but also students and newly qualifi ed staff .

Our ECG Challenge for this editi on is only avail-able on our website. This is because the ECG image obtained didn’t quite have the resoluti on required to look great in this magazine.

However here is a quick overview:This ECG was the taken from the fi rst pati ent diagnosed with short QT syndrome (SQTS). This phenomenon, fi rst described in 1999 by Dr. Preben Bjerregaard MD, DMSc, is sti ll a rela-ti vely unknown disease, and due to this may oft en go undiagnosed.

Check out this ECG, the questi ons, and the answers on our website: www.cardiologyhd.com

Online Only.......Sorry!

Love our ECG Challenges?


Barnet Hospital

Site VisitUnited Kingdom

What are the sizes of your Cardiology Department and Hospital?

Barnet and Chase Farm Cardiac Services

Cardiology Service

The specialty of cardiology lies within the directorate of General Medicine and Pharmacy. The specialty provides a combinati on of inpati ent work, a large outpati ent service, and a full range of cardiac investi gati ons. In additi on there are electi ve and emergency proce-dures undertaken mainly as day cases.

The ward base consists of 8 bedded CCUs on both sites, a 24 bed-ded cardiology ward, Rowan, at Barnet, and 11 beds on Melbourne ward at Chase Farm, with access to further beds on Toronto ward at Chase Farm. There are cardiac departments providing a full range of non-invasive cardiac investi gati ons at both Barnet and Chase Farm, with a more limited service at Edgware hospital. Outpati ent clinics are run from these sites as well as Cheshunt Community Hospital and Pott ers Bar, and include 7 Rapid access chest pain clinics weekly. Cardiac Rehabilitati on is off ered as an inpati ent and outpati ent ser-vice at both sites and extended into the community. Outreach heart failure clinics are run for Enfi eld pati ents at Forest Road. Myocardial perfusion scanning is also undertaken at Barnet in the Radiology department.

The cardiac catheterisati on lab and a six bedded day case unit is sited at Barnet, opening in April 2008. This is a trust-wide service providing faciliti es for diagnosti c cardiac catheterisati on, CRT, ICD and perma-nent pacemaker implantati on for electi ve and emergency admis-sions. We are expecti ng to increase our service to include electi ve PCI in 2011.

Barnet Hospital forms part of the Barnet and Chase Farm Hospitals NHS Trust and is located in north London. The hospital was modernised between 1999 and 2002 through a private fi nance initi ati ve and was re-opened in 2003 by HRH The Princess Royal. The Care Quality Commission recently publicly congratulated the Trust as one of the 13 most improved NHS trusts in the country.

Barnet HospitalWellhouse LaneBarnet, HertsEN5 3DJUnited Kingdom

BarnetHospital

courtesy Google


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The purpose built cardiology department at Barnet carries out:• 12 lead interpretati ve ECG• Treadmill exercise testi ng• Nuclear scanning• M-Mode, 2D, 3D, Doppler, Stress and trans-oesophageal

echocardiography• Trans-telephonic monitoring• 24 hour ambulatory rhythm monitoring• Event recording• 24 hour ambulatory blood pressure monitoring What is the geographical intake area and populati on served by your hospital?Barnet and Chase Farm hospitals are part of the North Central Sec-tor which has a catchment of 1 million, 50% of which being served by Barnet and Chase Farm Hospital

How many staff ? Roles?Staffi ng

• 7 Consultants, all with commitments at other hospitals/community services.

• 1 Associate specialists• 2 Specialty doctors• 4 SpRs• 4 ST grade juniors• 2 FY grade juniors• 1 Physician Assistant• 2 Consultant Cardiac Surgeons – 1 PA acti vity weekly each• 2 Consultant Electrophysiologists – 2 PA total acti vity weekly.

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The Cath Lab Team (from left): Naveena Patel, Sara Fershi, Dr Ameet Bakhai, Beryl Broadhurst, Carolyn Forte, Claire Roaf, Louise Harney


Horizon Cardiology

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McKesson (Medcon), UKPremier House 112 Station RoadEdgware, MiddlesexHA8 7BJ United KingdomPhone: 0208 [email protected]/cardiology

Copyright © 2010 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.

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AllAboutCVIS.com/ffr


Nursing

Cardiology matron.Cardiology Nurse Specialists5 WTE – RACPC, Heart Failure, Pre assessment and Revascularisa-ti on and Research

CCU (Barnet)19.5 WTE

Cath Lab, Day Unit, Pre assessment 15.29 WTE

Barnet cardiology ward27.95 WTE

Chase Farm Melbourne (CCU & step down) ward26.24 WTE

Cardiac Rehab team4.5 WTE

Cardiac Physiologists22 WTE (all sites, and including respiratory service)

Admin Staff 8 WTE (all sites, and including waiti ng list management)

Secretarial support8.5 WTE

Types of procedures?Currently performing diagnosti c Angiography.

Device implantati on including, temporary and Permanent Pacemak-er inserti on, ICD, and CRT-P. We have completed our training and BCIS evaluati on and hope to commence PCI in the early part of 2011

Types of equipment used?• Siemens Axiom Arti s (X-Ray)• McKesson – Medcon: Horizon Cardiology (CVIS and

Haemodynamic)• Philips iE33 (Echo)• Siemens Cyprus (Echo)

How many procedures are performed a year?Acti vity

Y2008/9 Y2009/10

Electi ve angio 932 1089

Emergency angio 645 446

Electi ve Device implantati on 185 204

Emergency device implantati on

155 179

Total 1917 1918

What is the approximate percentage of cath lab cases performed radially compared with femoral?Approximately 36%

Does your department off er a Primary Angioplasty Service?Barnet Hospital hope to start a PCI service in 2011, Primary Angio-plasty will remain in the established centres.

What new procedures / techniques have you implemented into the department recently? Future?CRT, ICD, future PCI, FFR

What are the benefi ts to pati ents att ending your facility?They no longer need to commute into London for treatment.

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How is your inventory managed?Electronic Stock ordering through EROS, will use McKesson - Medcon inventory module for consignment and PCI when we start.

How does the lab handle haemostasis?TR Band for Radial approach, Angioseal for approximately 80 percent of femoral access, remainder of femoral Manual compression.

What measures has the department implemented to cut costs?Careful stock management, stock rotati on, consignment stock, early diagnosti c procedures to reduce length of stay.

What kind of training can new employees expect to receive?Off site training under honorary contract with the London Chest for PCI procedures, we hope to access the same support through Bart’s for Complex device therapies.

We also schedule training days on site during Lab down ti me, invit-ing external trainers and industry to ensure ongoing educati on and training.

What kinds of competency checks do staff have to undergo once employed?General competencies relati ve to all trained nurses.

Department specifi c competencies such as IABP set up and transpor-tati on, ECG interpretati on, IV Cannulisati on, BLS, ILS. Assisti ng with Cardiac interventi onal procedures. Scrub Technique.

How do you deal with late fi nishing of cases? For example staggered working hours or just staff overti me? Nursing Staff work Long days 07.30-19.00 so as to overlap the lab operati ng ti me of 09.00-17.00. Physiologists and radiographers claim overti me for overruns or take ti me back.

What is the best part of working at your facility?We are well supported by our Managers to provide an excellent ser-vice for our pati ents, waiti ng ti me for electi ve Angiography is usually less than three weeks. Great People, hard working, a busy lab that gets through a large volume of work for a single Lab with no aft er hours work. It is a great environment for learning, and our young staff are proving to be excellent Cath lab professionals who will no doubt remain in this speciality for many years to come.

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ITWould you like your department featured here?

Write to us at [email protected] for more details.



June 29 - July 1Hands-on Cardiac MorphologyNati onal Heart and Lung Insti tute (NHLI)London, Englandwww.cardiacmorphology.org

July 4-8The Southampton practi cal cardiac MRI courseSouthampton General HospitalSouthampton, Englandwww.suht.nhs.uk/cardiacmricourse



October 17-18PCR London Valves 2011London Englandwww.pcrlondonvalves.com


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LIKE TO BEFEATURED?

For further details on how your event can be featured here contact us at:

[email protected]

For a list of conferences and events around the globe visit our website:www.cardiologyhd.com

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Events

ANNUAL CONFERENCE 2011

Venue: Manchester Central, Manchester Date: 13 to 15 June 2011

3 Day educational meeting in Cardiovascular Medicine, with a programme of case based presentations and plenary sessions

Exhibition showcasing the latest developments in cardiovascular medicine and new technologies

Educational content based on the new European Curriculum, including a Trainee day

Gain CPD points and review general cardiovascular knowledge required for revalidation

Members of the British Cardiovascular Society can register for free before 31 March 2011. Visit www.bcs.com for online registration and further information.

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valve implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at

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was 40%.1 For more information, visit edwards.com/EU.

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

The Edwards SAPIEN transcatheter heart valve and delivery systems bearing the CE conformity marking comply with the requirements of the European Medical Device Directive 93/42/EEC. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

Edwards and Edwards SAPIEN are trademarks of Edwards Lifesciences Corporation. Edwards Lifesciences, the stylized E logo, and PARTNER are trademarks of Edwards Lifesciences Corporation and are registered in the United States Patent and Trademark Office. © 2011 Edwards Lifesciences Corporation. All rights reserved. E1775/12-10/THV.

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Documents

Coronary Heart #29