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Issue 24 • May/Jun 2010

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ECG Challenge Watford & Northampton Site Visits Increasing Lab Performance with Labyrinth The Current Evolution of PCI Journal Reviews Management Assistance

Primary Angioplasty Service - Lessons Learnt


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Only available online Cardiologist Interview

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Dr Alun Harcombe Consultant Interventional Cardiologist Nottingham University Hospitals NHS Trust

Nursing Interview Our Nursing Editor, Mr Dennis  Sandeman interviews Scott McLean, Nurse Consultant in Acute Cardiology,  The Edinburgh Heart Centre, and  President Elect, British Association of Nursing in Cardiovascular Care.

Mr Scott McLean

Read the full interview only available on  our website.

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Contents May / Jun 2010

Round-Up

Latest News

Round Up New Kirkham Young Recruitment Subscription Service

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eading specialist recruitment consultancy Kirkham Young continues its programme of ongoing improvement in the service it offers to its customers by providing a dedicated industry news and job alert system to subscribers. “Our customers have always regarded us as so much more than a CV  service” commented director Tina Young. “We are often asked for information regarding market trends, recruitment law and company news and the launch of our news subscription service is all part of that commitment to being a fully rounded industry specialist.” As part of their pledge to offer an unrivalled service to candidates and companies alike, all registered candidates with the agency now  receive regular alerts for a variety of opportunities including sales, marketing, technical support and management roles as well as being able to keep up to date with current industry bulletins.

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La es News

New Cardioace Plus With Plant Sterols

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itabiotics Cardioace Plus with cholesterol maintaining plant  sterols is the newest addition to the Vitabiotics Cardioace range. Cardioace  Plus  is  the  only  heart  health  supplement  to  combine  plant sterols with 24 other heart  maintaining nutrients. Cardioace  Plus  is  the  most  comprehensive heart health multivitamin  and  its  ingredients  have  been scientifically proven to be of  importance  to  heart  health.   The formulation also utilises advanced technology which offers enhanced bioavailability as well as a natural orange oil odour mask to avoid any aftertaste usually associated with omega-3 fish oil and garlic. Plant sterols occur naturally in various plant-derived foods, including  vegetable oils, nuts, grains and seeds and may be absorbed each day.  The amounts however are often not great enough to have significant cholesterol maintaining effects. Plant sterols have been found beneficial in numerous studies where they can help maintain healthy cholesterol levels by aiding the reduction of cholesterol absorption in the intestines. A regular intake of plant sterols along with a healthy diet and lifestyle may therefore be helpful for those who wish to look  after their heart and circulation. Cardioace Plus is priced at £15.95 for 60 caps. For more information visit www.cardioace.com

For more information or to subscribe log on to www.kirkhamyoung.co.uk

New hope for AF sufferers following NICE guidance rethink

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ecently the Atrial Fibrillation Association and the Arrhythmia Alliance welcomed the decision by NICE to recommend approval of dronedarone as  a second line treatment option for Atrial Fibrillation (AF) patients, reversing its previous draft guidance published in December 2009. NICE’s Appraisal Committee recognised that dronedarone can and should occupy a currently vacant place in the care pathway, and that for a large and growing number of patients it could represent the only treatment option open to them.

www.cardiologyhd.com  May/Jun 2010 5

Labyr nth Software

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Increase Lab Performance

Labyrinth LABYRINTH SOFTWARE: Performing in the Real World “Some staff were a bit apprehensive at first. But now, there’s no way that any of us would go back to the old system.” (Senior Staff Nurse – Cath Labs)

Improving Processes Any changes to processes in one area may impact on others. In the past, knock on effects might take months to appear in the audit data. With Labyrinth, reports are available immediately. The information/evidence produced by Labyrinth has already led to a number of improvements. For instance, Labyrinth logs the opening and closing time of each lab. It became evident that one particular lab was regularly finishing late but on those days it also started late. They could see that all the patients were arriving as scheduled therefore the cause of delay was the time it took to prepare patients. They focussed staff attention on streamlining processes in order to get a particular group of patients ready quickly in the morning and the lab in question is regularly starting and finishing on time.

Reporting A reporting function was built into Labyrinth from the start. This had two purposes; firstly, to produce information for audit purposes and secondly to analyse utilisation of the labs and pinpoint causes of cancellations or delays. This in turn would enable the team to improve processes and test how well those improvements worked in practise. “The information is there whenever you need it, consequently more can be done with it.” (Cardiac Radiology Manager)

This screen shows a Lab View of a typical day’s list. All Lab A’s patients can be seen simultaneously, even though they are coming from different wards.

Background

Ease of use

Labyrinth software was designed to track the patient pathway through any medical department where patients pass through a number of tests, stages, sub-stages and interventional procedures.

The system was designed to be easy to learn and use and this has proved to be the case. Staff need only 15 minutes training. Each day’s list is loaded directly from Tomcat the night before, which means the Lab Co-ordinator no longer has to come in early. Then the patient’s progress through the system is logged with a simple click, as opposed to filling in multiple data fields - and this action simultaneously captures data for audit purposes. “It used to take the first 30 minutes of the day to prepare the day’s list. Now we come in and it has been preloaded into Labyrinth. All staff immediately have a clear picture of the day’s workload.” (Deputy Nursing Manager)

The first version was developed in conjunction with Cath Lab teams at leading London hospitals and was installed at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in October 2009. GSTT has 5 Cath Labs receiving patients from 5 cardiac wards and performing a range of procedures covering Interventional, Electrophysiology and Device Implantation. Labyrinth uses a dashboard screen where patients are shown in rows and procedures are shown in columns. As patients move through the various stages, staff record their progress with a click. The information on screen is continually updated throughout the day. Individual team members can select the view that shows the information they need; some concentrate on a particular ward, lab or procedure whilst others can see the bigger picture and keep an eye on all patients going through the unit. Now, after 6 months and over 2,000 procedures, it’s time to ask how the system has performed and whether or not it has lived up to expectations.

Improved Communication. Improved Co-ordination Labyrinth improves communication in two main ways. Firstly, when a staff member records that a given stage has been completed, this information is immediately sent to everyone who needs to know. They don’t have to go and tell them. Secondly, the information that staff members need appears on the screen in front of them. They don’t have to go and ask. This has brought some valuable benefits. It eliminates the need to run around chasing or transmitting information to multiple MDT members, so stress within the unit is reduced. Team members can concentrate on the job in hand without being interrupted for updates. In fact at GSTT the lab co-ordinator is now able to contribute to clinical work. “It saves a lot of time. Whoever is

Summary

The team at GSTT have found Labyrinth a marked improvement over the paper-based systems they were using before. All data is recorded in real time, as the staff go about their normal work - and this brings three major benefits. There is little chance of data being lost. The information available is always up to date. And there is no time spent manually inputting data for audit purposes; this saves the Head of Radiology 3 days per month.

Labyrinth has succeeded in its stated aims of freeing clinical staff for clinical work, reducing the time spent collecting and auditing data and has contributed to an increased efficiency of the Cath Labs at GSTT.  In fact the team would say that, in most respects the system has exceeded their expectations. “It’s well worth it. I don’t want to go back to paper co-ordination; it’s a much more efficient way of working.” (Deputy Nursing Manager)

Patients on research trials are clearly identified and their treatments can be audited separately as required. Labyrinth records radiation dosage entered by the radiographer and collated in the reporting module. This makes it easier to both monitor current practice and agree Local Dose Reference Levels complying with Ionising Radiation (Medical Exposure) Regulations. It used to take a member of the radiology team two weeks every three months to collate this data by hand. The raw data produced by Labyrinth can be analysed to produce reports on any aspect of the unit’s operation e.g. utilisation, cancellations or delays. This data can be broken down further into any combination of appointments, labs, wards, procedures and periods of time. It’s not just that the information is available; the team can do more with it, learning more about the operation of their unit than ever before.



A epo on 6 mon hs n he Ca h Labs a Guy s and S Thomas

This is a Ward View on the same day. All Ward A’s patients can be seen simultaneously. co-ordinating used to spend all day outside the labs, running around between the labs and wards. Now they are free to spend time back inside the labs where they are just a point of contact for any changes to the list.” (Lab Co-ordinator)

A report on  months’ use of Labyrinth in the Cath Labs at Guy’s and St Thomas’

For further information, go to: www.gallerypartnership.co.uk/labyrinth to join a 30 minute webinar from your desk on Tuesday 25th May at 10am, where you can see Labyrinth in action or call Mark Kemp on 020 7096 2800.

This is an example report which displays a count of delays by reason for the year to date

 May/Jun 2010  www.cardiologyhd.com

Hot Top c 

HOT TOPIC

HOT TOPIC

www.cardiologyhd.com  May/Jun 2010 

Hot Topic Cardiologist

Questions:

general out of hours diagnostic service, the better the programme will work.

1. What have been some of the challenges for your department setting up a Primary Angioplasty Service, and what improvements need to be implemented to ensure continued success in the future?

B. One of the most difficult problems was the establishment of the 24 hour / 7 day week service and in retrospect perhaps  our team might have begun with less logistic difficulties in accepting the two tier 9-5 service with patients presenting between 5pm and 9am either being considered for thrombolysis or if circumstances were to permit, transferring to a neighbouring establishment. I think the lesson there was that a phased introduction of a service to include phasing over weekends was better than the chaos of an all singing dancing band.

erates such enthusiasm and commitment from the staff that there is a risk too much commitment moves the service towards an out of hours diagnostic provision. Angioplasty for  non STEMI is another important arena which many centres are moving towards, but I had resisted the development of this service until a team involved in both daytime and out of hours service were well rehearsed in acute ST segment elevation variety of myocardial infaction.

Dr Rodney Foale Consulting Editor Consultant Cardiologist, Imperial College Healthcare NHS Trust

Answer 1: Of the challenges, the concept of a service specific to the opening of a blocked artery and acute myocardial infarction was the most difficult to stick to. It is very easy to drift and include patients with a wide range of acute coronary syndromes and there is no doubt that this will be required of us in the future with many centres making inroads into this development. However, beginning the service the ‘bulls eye’ clinical presentation was with acute chest pain and ST elevation certain (or within the medical definition of certainty) to be due to an acute coronary occlusion.  This is the area where proven benefit has occurred and widening the clinical ‘atypical chest pain’ and ECG criteria to include left bundle branch block, left ventricular hypertrophy and ST segment changes ie, non ST elevation with indeterminate troponin shifts will both dilute the outcome and increase complications. There is another factor that involves staff satisfaction in seeing an acute myocardial infarction, often in a critical patient, magically resolved with the simple opening of an artery and this gen-

tight clinical criteria referred to above must be recruited to prevent in an underwhelmed unit a sense of utter boredom. There has to be a significant (however defined) number through the A&E department to retain the operational integrity of a programme. Therefore, extremely important are the links with neighbouring hospitals, communities, ambulance services etc. Education, education, education! Community lectures by all staff from nursing to senior consultant, advertising efforts in the local paper to improve awareness, all of these options must be considered in the recruitment drive so that patients don’t escape.

Thus to summarise we must remember what this programme is for. It is not for a late night IVUS with three vessel disease and pressure wires until 4am it is for targeted, high reward, clinical reward procedures that makes the patient, staff and operators feel good about what has been done.

2. Do you believe in the concept of designated ‘heart attack centres’, or do you believe that any Trust can set up a PPCI service?

In considering how to target patients for the most benefit, it’s important to look at randomised trials versus the registries and in meta analyses of the studies it is apparent that some often subjective variation in physician assignment to thrombolysis versus angioplasty can dramatically alter outcome. Thus it might be difficult to show benefit for angioplasty versus thrombolysis, it’s probable that a relatively small number of patients converted to one or other group affect the statistical analysis, we know primary angioplasty for acute ST segment elevation works and thus programmes early stages temptation to extend the service to a clinical presentation should I believe be resisted. In considering this, looking at the difference between randomiseed trials and registries etc and in particular looking at the meta analyses, recent data to be hoped to be published from our group suggests it only takes a couple of patients to be physician assigned to one or other group to fairly drastically alter outcomes. The tighter the entry criteria and the more focussed the early vision is on balloon opening of a blocked artery versus thrombolytic referral versus revision of a

Finally, it is imperative to have all the relevant consultant staff from the A& E department through to interventional cardiologists communicating easily. Regular multidisciplinary meetings to establish communications on first name terms are vital. Social evenings add to the vital sense of team play that such a programme requires. I have been extremely lucky in my medical practice to have had wonderful support from all consultant staff as without new enthusiastic firebrands, names not to be mentioned, these programmes simply would not have continued or survived.

C. Further to the phasing of the service I have had enough experience with late night critical angioplasty and inexperienced staff, not wanting to put less experienced and even younger cardiologists through having to run a heart blocked inferoposterior dominant right angioplasty fully of thrombus and potential dissection not to really need the absence of your favourity radiography, technician and nurse.   There is a lot of “mobility” in cath lab staffing and the planning of a primary angioplasty service, I believe it to be important to maintain the support team disciplines of radiography, physiology and nursing as part of the team. For this appropriate remuneration agreed at the outset of this programme is a key factor. In the UK for example the Agenda for Change initiative means that staff on different Bands will get paid different for the same often stressful duties. The hourly rates at around £10 mean there is not a lot of voluntary enthusiasm. In my experience this remains a significant hurdle.

Answer 2: I have worked in ‘heart disease centres’ I have never been certain what one is. A heart attack we often think of as having a rather narrow definition but attacks of the heart can occur at any time and the public I think are more confused than enlightened by seeing such a somewhat patronising signs neighbouring our A&E and cath labs. So I object to the sign but certainly not the concept.

D. Data entry for local and national databases needs to be planned well ahead of the commencement of such a programme. Retrospective data loses a lot of valuable information about early real life experience and these data very often are important in the clinical perspective of later years. No data should be lost and every intent should be made to the patient’s registered for studies linked with other neighbouring units so academic opportunities are not lost. Unless these issues are embraced early on the training and academic component of such service developments are lost. Plus there is a certain pleasure in slam dunk direct angioplasty and this is why it is important of course to limit the remit the clinical criteria for entry to such a programme. The range of the usual guide cath wires and stents should be ordered to suit the senior operators. I personally discourage too much additional equipment, it is hard to deny the advantages of balloon pump and clot extraction device technology. If a pressure wire or IVUS appears at 3am there will be less technicians available for the following month’s rota. What appears to be an overwhelming demand on establishment of the service particularly in the medical climate of today, the challenge of recruiting enough patients with proper ST segment changes and

Any Trust with a bank of cardiologists will want to set up a PPCI service. Apart from the remuneration from Primary Care Trusts for acute intervention which most often will be a fairly straight forward intervention less than 10 minutes in duration, and given what I have suggested above it is fairly easy to imagine how a cath lab can provide such a service by fast tracking acute ST segment elevation patients straight into the laboratory. The out of hours service which must be driven by catchment area, PCT collaborations and on the ground, sufficient consultant and non medical staff to cover the 24 hour service that is the challenge. With regard to heart disease centres in isolation from an A&E department, certainly in London such challenges have been met with success.

 May/Jun 2010  www.cardiologyhd.com

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Visit www.volcanocorp.com

The Current Evolution of PCI (an industry perspective)

A

For change to happen, there must be a trigger… a problem that needs to be solved. The challenge interventionalists are presented with today is three fold; 1) Major publicized studies like COURAGE, SYNTAX and HORIZONS have demonstrated that angiographically guided PCI procedures do not always lead to better outcomes than medical therapy or CABG, and that there is still plenty of room to improve on 12-month event rates, especially in more complex patients. 2) Recent studies like FAME, PROSPECT, STLLR, Lindstaedt, Diethrich have highlighted the clear limitations of angiography to assess lesion severity, ischemia, presence of calcium, proper stent diameter, length and expansion. And 3) Clinical trials including FAME, JSAP , ROY , Costantini underline the trend of excellent or comparatively superior outcomes when using precision guided PCI tools like FFR and IVUS. The body of evidence that is accumulating not only supports the dramatic increase in FFR and IVUS usage in the past few years, but also suggests this evolution to precision-guided PCI is a sign of things to come. This clinical need is driving change both in technique and in technology. The days of a heavy, awkward, roll-around console are over. Modern day IVUS and FFR systems (and in the future, OCT, Forward –Looking IVUS and Image Guided Therapy) can now be physically integrated into the cath lab suite, enabling fast, easy access to these products for every room and every patient. Speed and access are requirements for a successful technology and integrated systems have helped to remove those barriers in the modern day cath lab. The imaging catheters and FFR wire technology must change as well. Modern day devices track farther, respond better, and provide more

Different regions have this problem to different extents. I know in some regions main shortage is a lack of cardiac physiologists. Greater Manchester has a population of 3.1 million. For the size of our catchment area even though we have a combined program with Wythenshawe Hospital our main staffing issue is a shortage of operating consultants. We have tried to resolve this issue by incorporating our district interventionalists into our rota. Amongst our District General Hospital (DGH) interventionalists we have those that are not so keen and those that are very enthusiastic. However as yet we have not managed to get any of them on board. This has been due to several factors including their onerous local on call general medicine/cardiology rota, lack of other non-interventional consultants to fill the gaps locally, and unresolved issues surrounding payment and remuneration to the local trust.

Inappropriate transfers: It is always difficult to determine what is ‘inappropriate’. It is maybe easier to determine what is appropriate. We do have Network agreed protocols that outline quite succinctly what to refer on the Primary pathway. It is clear in the protocol we will take ST segment elevation myocardial infarction (STEMI) and new onset Left Bundle Branch Block (LBBB) with good cardiac history within 12 hrs. If the patient satisfies these criteria and there is no other mitigating issues they should send the patient but make sure we get a courtesy call. The selection criteria are exactly the same as what it was for thrombolysis. It has therefore been very surprising for us to have such a high rate of inappropriate referrals (nearly 30%) when

10 May/Jun 2010  www.cardiologyhd.com

13

The Current Evo ution of PC

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ngiography Alone is Not Enough. Physicians are relying more on precise PCI-guidance tools like FFR, IVUS and OCT than ever before. Use of these technologies has increased in every major geography, including Japan where IVUS usage is now estimated at more than 70% of all PCI. Is this just a temporary trend, or a sign that the interventional cardiologists approach to PCI guidance is changing for good?

P ma y Ang op as y Se v ce

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e have been a long time advocator of primary PCI. Our first challenge was to win heart and minds and convince people that Primary PCI (PPCI) is superior to thrombolysis. By in large, except for small pockets of resistance we have now achieved this. The next challenge was to prove the feasibility of a primary PCI program; this was despite the fact that many countries had already established successful PPCI programs. Through several centres taking the lead and starting their own process and also with the National Infarct Angioplasty Project (NIAP), we have past this hurdle too. As a result many heart attack centres now provide or are in the process of providing PPCI. However there are still many issues and challenges remaining. These are mainly related to implementation and sustainability. I will outline some of these below:

Staffing Issues:

“It is not for a late night IVUS with three vessel disease and pressure wires until 4am”

information than previous generations. With opportunity comes innovation, and this innovation is seen in a host of new imaging and physiology product launches planned for 2010. New markets will be developed like OCT and Forward-Looking IVUS to help guide increasingly more complex procedures. To control healthcare costs, these complex procedures will be done with advanced precision-guided tools to reduce in-hospital complications, reduce repeat interventions and eventually replace expensive surgical procedure like CABG with less invasive percutaneous approaches. One day, the evolution of these products will continue to where common therapy devices like angioplasty balloons and stents will have miniaturized imaging transducers or sensors built into the therapy device itself, removing any final barriers to using precision guided tools. Importantly, there will not be a single technology used in every case. Each will have its own advantages and indications. It is the clinical presentation and physician preference that will dictate the selection on a patient by patient or lesion by lesion basis. The key is to make all of these technologies available on a single, integrated system, which is always on, and always ready. Angiography Alone is Not Enough. The Medical Device Industry must be committed to delivering products that can compliment angiography in a fast, simple and convenient fashion. Visit PCR in Paris and BCS ACE in Manchester to see Volcano’s s5i™ Integrated Imaging Suite, and the latest commercial and development products including Eagle Eye Platinum™*, VIBE™* RX (Vascular Imaging Balloon), PrimeWire™ PRESTIGE*, s5i™ 3.2 Software, OCT and Forward-Looking+ IVUS.

An ndus y Pe spective sponso ed by Vo cano

- Michel Lussier, President Volcano Europe * pending CE mark clearance + Development Only, not commercially available

References: 1.

Boden et al. Optimal Medical Therapy with or without PCI for stable coronary disease (COURAGE) New England Journal of Medicine 2007; 356:1503-16 Serruys, P. et al.  “PCI versus CABG for severe coronary artery disease. SYNTAX” NEJM 2009 online, commentary closes March 4th 2009. Stone, G. et al. “HORIZONS AMI One Year Results.” TCT Conference, 2008. Tonino, et al. (FAME) New England Journal of Medicine 2009; 360:213-24 Gregg Stone on behalf of the PROSPECT investigators as presented at TCT 2009 Costa et al. Impact of Stent Deployment Procedural Factors on LongTerm Effectiveness and Safety of Sirolimus-Eluting Stents (Final Results of the Multicenter Prospective STLLR Trial). Am J Cardiol 2008 Jun 15; 101(12):1704-11. Lindstaedt M, et al. Int J Cardiol. 2007;120:254-6 Diethrich et al. Journal of Endovascular Therapy. 2007; 14:676-686 Nishigaki, K. For the JSAP investigators. “PCI Plus Medical Therapy Reduces the Incidence of ACS More Effectively than Initial Medical Therapy Only Among Patients with Low-Risk CAD.” JACC 2008; Vol. 1: No. 5. 10. Roy, P. et al. “The potential clinical utility of IVUS guidance in patients undergoing PCI with DES.” EHJ, 2008. 11. Costantini, C. et al. “Impact of IVUS to Guide DES Implantation Decreasing Long Term Clinical Events.” TCT Conference, 2008. 2. 3. 4. 5. 6.

7. 8. 9.

www.cardiologyhd.com  May/Jun 2010 13

Journa s

SITE VISIT

SITE VISIT

From Left to Right: Emma Timms (Junior Sister), Dr Dominic Cox (Consultant Interventional Cardiologist), Sheila White (Superintendent Radiographer), Cathy Spingys (Sister), Damini Jani (Lead Cardiac Physiologist)

server throughout the hospital; this will be provided by McKesson (Medcon) and Mortara DICOM ECG machines. The benefit of this true Dicom connection will result in the consultant’s ability to review ECG as soon as it is being taken through McKesson (Medcon) Horizon Cardiology.) Monthly cardiology meetings are held between the medical staff and the ambulance team to discuss patients who have had primary PCI’s performed; it is also an opportunity to determine how the process could be improved. In the period April 09 - March 10, 39 patients had primary PCI, with 88% of patients having a door-to-balloon time of less than 90 minutes and for call-to-balloon, 90% of patients under 150 minutes. Both are compatible with the national average for England and Wales. What new procedures have you implemented into the department recently?

A Cardiac Physiologist with the new McKesson Horizon Cardiology System

Introduction of PCI service with primary PCI provided between 8 am and 6 pm, Monday to Friday How is your inventory managed? Combination of McKesson (Medcon) Inventory Management barcoding system and electronic procurement service. Types of procedures? Diagnostic coronary angiography, angioplasty and stenting (including primary PCI), IVUS and PressureWire, basic and advanced cardiac pacing, including bi-ventricular and defibrillator device implantations. We also provide extensive non-invasive imaging, in the forms of transthoracic, transoesophageal and Dobutamine/contrast stress echocardiography and myocardial perfusion scintigraphy. Types of equipment used? The cardiac catheterisation lab opened in June 2008 and has the following equipment: Image modality: Siemens Artis Zee floor-mounted C-arm system with flat-panel detector. Singo workstation with advanced IC3D facility. Haemodynamic System: McKesson (Medcon) Horizon Cardiology. Image Management and Reporting: McKesson (Medcon) Horizon Cardiology, with BCIS export module. IVUS: Boston Scientific i-lab Pressure Wire: St Jude Aeris with integrated FFR on McKesson (Medcon) haemodynamic system. How many procedures are performed a year? Our cath lab runs 4 days per week and in our first year of opening we performed the following number of studies: Angios: 1100 PCI: 344 Pressure Wire: 14 IVUS: 3

Pacemakers: 229 ICD/CRTD: 18 CRT P: 5

How does the lab handle haemostasis? TR-band for radials, Angioseal for femorals, compression device or manual compression if patient unsuitable for Angioseal.

What advantages of having FFR on your haemodynamic system?

What is the best part of working at your facility?

Using the combined St Jude Aeris wireless pressure wire and McKesson Horizon Cardiology system allows direct recording and storage of the FFR into the haemodynamic full-disclosure. The McKesson Horizon Cardiology system has all the software/interactive capabilities of the St Jude stand-alone system, with the benefit of all measurements presented directly in the haemodynamic report without the need for data transfer or integration. The result is automatically presented in the physician report.

In the past, patients requiring interventional procedures were transferred or referred to our neighbouring tertiary centres, over 50 miles away. The introduction of PCI to the Northampton General Hospital has made a significant difference to our patient population. Having the facility to perform primary PCI, in particular, provides effective treatment for the patient, minimising myocardial injury and preserving quality of life.

Direct connectivity with the haemodynamic system, using wireless technology, minimises problems with transfer of data between systems.  From a safety aspect, the new system minimises cable connections and trailing wires around cath lab table. The new system also allows the cardiac physiologist to remain at the haemo station and continue full monitoring/documentation. What protocols has your department implemented to reduce doorto-balloon time? East Midlands Paramedic crews have been trained to recognise STelevation myocardial infarction (STEMI). The Accident and Emergency Department are pre-alerted to the arrival of the patient. As soon as the patient arrives they are assessed by a Cardiac Nurse Practitioner or Cardiac Registrar. At this stage a 12-lead ECG is taken, and the Cardiac Nurse Practitioner brings the 12-lead ECG to the cath lab to be assessed by the Cardiologist on call. (We are in the process of implementing an ECG

Nurses Station

S te V s t No hamp on Gene a Hosp a

1

We are proud to say that the Cath Lab team at the Northampton Heart Centre has evolved into a mature, competent and caring group of healthcare professionals working to provide the best care we can for our patient population. Thank you to all the Cathlab team of Northampton Heart Centre

Special thanks: Dr Dominic Cox, Consultant Interventional Cardiologist Damini Jani, Lead Cardiac Physiologist Sheila White, Superintendent Radiographer Maureen Gardner , Dept. Cardiology Manager Christian Lorentzen, Senior Systems Administrator, IT Department Andrew Beswick, Cardiology Nurse

Recovery

All images copyrighted to Luke Watson, McKesson

www.cardiologyhd.com  May/Jun 2010 19

20

ECG Cha enge

Sophie Blackman’s ECG

Pr mary Ang op asty Serv ce

Our service has benefitted from the good working relationship between our system providers, McKesson (Medcon), St Jude and Siemens. The systems have good connectivity and interaction which ensures a smooth workflow for each patient coming through our Cath Lab.

18 May/Jun 2010  www.cardiologyhd.com

Challenge

08

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w h Soph e B ackman

Ms Sophie Blackman Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

Please note that the ECG was recorded at 25mm/s and 10mm/mV.

Questions 1.

Clinical Background

2.

This ECG was taken on a 42 year old gentleman just prior to his exercise tolerance test. He was referred by a Consultant Cardiologist to whom he  had been known for several years. He had a history of dizzy spells which had recently escalated to syncopal episodes lasting up to a few minutes. The patient is currently being treated with methadone for heroin addiction.

What abnormality is evident on the ECG and how should it be calculated? What syndrome might this patient have based on this ECG?

3.

How is his methadone treatment related to the ECG  finding and does this change his management?

4.

Is this patient suitable for a physiologist led exercise tolerance test? Answer on Page: 28

20 May/Jun 2010  www.cardiologyhd.com

S te V s t

United Kingdom

Site Visit

Wes He tfo dsh e Hosp a s NHS T us

West Hertfordshire Hospitals NHS Trust Watford General Hospital 60 Vicarage Road Watford, WD18 0HB United Kingdom

What are the sizes of your Cardiology Department and Hospital? In March 2009 the phased movement of acute and emergency services from Hemel Hempstead General Hospital and St Albans City Hospital to the Watford General Hospital site was completed and West Hertfordshire Hospitals NHS Trust now boasts the largest Acute Admissions Unit (AAU) in the country. The Cardiology service remains functional at the 3 hospital sites in order to provide local service to local patients, however the 2 Cardiac Catheter labs are found at Watford General, along with a 12-bed gender-segregated day ward, 16bed CCU and 10-bed ICU. What is the geographical intake area and population served by your hospital?

Watford General Hospital

West Hertfordshire Hospitals NHS serves a local population of approximately 500,000 and treats about 1 million patients per year. How many staff, and what are their roles? The Cardiology service has 9 Consultant Cardiologists and 2 Associate Specialists, 23 Clinical Cardiac Physiologists and Cardiographers, 12 Cath Lab Nurses, 3 Cardiac Radiographers, x CCU staff and numerous secretarial, administrative and clerical-support staff. The Clinical Director of Cardiology, Dr Mike van der Watt, is joined by 8 other Consultant Cardiologists that together offer a broad range of specialties including:

Watford General Hospital

• • •

PCI - Dr Mike van der Watt, Dr David Hackett, Dr Masood Khan, Dr Will Wallis and Dr Philip Moore Cardiac imaging - Dr Roland Wensel Cardiac pacing - Dr John Bayliss, Dr Philip Moore, Dr Anthony Nathan, Dr Will Wallis, Dr Mike van der Watt, Dr Masood Khan.

Inherited/familial cardiac disease - Dr Amanda Varnava

Complex devices – Dr Philip Moore and Dr Anthony Nathan

Cardiac Electrophysiology – Dr Anthony Nathan

www.cardiologyhd.com  May/Jun 2010 21

Management Ass stance

Assistance Management

I

n last months’ edition, whilst talking about absenteeism, I mentioned the importance of setting boundaries for your staff. In this edition I want to establish the role of boundaries in a department, how to maintain them, and as a manager how to make these margins work for you.  Boundaries need to be in place in every institution to keep staff and patients safe. Even though a restriction by definition, boundaries actually work to keep your staff dynamic and your department functional. Ms Sophie Blackman Social boundaries are those we learn whilst growing up, such as being aware of what is right and  wrong, and understanding what is socially acceptable behaviour. These social behaviours are both  inherent and learned. Our parents, or significant adult parent figure teach us these values, and in the workplace the departmental manager represents the parent, where their duty is to affirm both these social and professional boundaries.  

Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

2

Se You Bounda es

Management: Set Your Boundaries.

21

In the workplace the boundaries you create for your team helps to allow close  engagement, sets limits, determines acceptable behaviour, clarifies expectations, creates autonomy, and makes everyone accountable – yourself included. There are a number of boundaries you will have already established, such as  an expectation for your staff to arrive on time for work, and to perform their duties in a professional manner to the standards you have set for your department. However, there are some boundaries that we may have in place which  are not entirely functional. The poorly maintained departmental restrictions allow  the  line  between  what  is  acceptable  and  what  is  not,  to  become  not  just bent, but often entirely broken, and this is where a department’s function begins to suffer. Communicating with your staff their goals and limitations is crucial in your department. All staff should know what duties are expected of them, the standards  at  which  they  should  be  working,  and  most  importantly  the  roles  they  are not yet ready to manage alone. Giving your staff freedom to be dynamic and troubleshoot their own problems is to certainly be promoted, but always  within the margins you have set. This in turn encourages your staff to bring you solutions rather than problems, and gives tangible goals which support their professional development.  As their leader you need to be available to discuss the boundaries you have  enforced, and be open to receive feedback for discussion. Without these limitations in place, we lose our power as a manager to enforce standards of care, and professional relationships. That said your staff will often be best placed to know what is actually achievable, so you must verify your reality against them.  Involving staff in the process of creating boundaries and in the negotiation of what are achievable goals, and fair restrictions means that they will be less inclined to push the boundaries.  Undoubtedly some of your staff will test the boundaries you have in place; a subconscious assessment that they are being effectively managed and that you are acting as the parent. However, the most crucial benefit of a clearly defined boundary is that your staff know where that ‘line’ is, they understand that they must work within those boundaries and that if they do not do so they can rightly be disciplined. 

2 May/Jun 2010  www.cardiologyhd.com

2010 sees the 88th British Cardiovascular Society Annual Conference and Exhibition (ACE), a three day meeting of educational and scientific interest in Cardiovascular Medicine. The event be held in the newly renovated Manchester Central. The Conference programme has a broad educational theme including case based presentations interspersed with plenary sessions of a clinical, scientific and translational nature. •

The keynote lectures this year will be given by Prof Patrick Surreys (Thomas Lewis lecture, ‘Biodegradable drug eluting stent or vascular restoration therapy for percutaneous revascularization’) Prof David Crossman (the BCS/RCP Lecture supported by the Joy Edelman Legacy, ‘New discoveries and their translation to man’), and Dr Edward Rowland (BCS Lecture, ‘Managing the cardiac rhythms of life’).

The exhibition will showcase the latest developments in cardiovascular medicine and new technologies. Stands from over 80 companies from the wide arena of Cardiovascular medicine will be present, making our Exhibition the largest in Cardiovascular medicine in the UK. Following on from developments at last years’ event, the Exhibition will include greater number of educational activities such as Moderated Posters, “Meet the Experts” and Cardiac simulator training with opportunities for all to try their hand at the latest equipment available. In addition, the popular “How to” sessions will be held in larger theatres to allow for the high number of attendees that these sessions attract.

Fly, Nuclear Cardiology, Valve Treatment and the Athletes Heart. The ACE 2010 will give attendees the opportunity to gain CPD points and review general cardiovascular knowledge required for revalidation. •

A new highlight will be Educational Spotlight sessions where the focus will be on different topics, each fitting to a 90 minute session. These Spotlights are designed to be digestible education presented in a dynamic format and with robust evidence based take home messages.

This year’s Annual Dinner will be held at the Manchester Town Hall on the Tuesday night, with entertainment from magicians and a jazz band.

At this years’ event there will be a linked meeting with British Atherosclerosis Society and British Society for Cardiovascular Research at the ACE 2010. This joint initiative will include hot topics and developments in cardiovascular research, the Young Investigator award and the BAS John French lecture.

On Monday 7 June, PCCS will be holding afternoon sessions for their members on Cardiovascular Guidelines.

The Future of Cardiac Commissioning – a one day symposium for commissioners and managers on Wednesday 9th June, developed in conjunction with the Department of Health and NHS Improvement, focussing on the challenges of commissioning quality services and showcasing the very latest developments in this area.

2

BCS Annua Conference

BRITISH CARDIOVASCULAR SOCIETY: Annual Conference and Exhibition 7 to 9 June 2010 Manchester Central, Manchester

Ove v ew

21

West Hertfordsh re Hosp ta s NHS Trust

The educational content of the ACE 2010 has been based on the new European Curriculum, and includes a dedicated Trainee day that will have a session from the SAC as well as covering a wide variety of topics such as Cardiac Operations, Cardiac Fitness to For online registration and full details of the programme, go to www.bcs.com.

Simulator in the Exhibition

ECG ANSWER

www.cardiologyhd.com  May/Jun 2010 27

Answer

Sophie Blackman’s ECG Challenge

Table 1: Table Criteria for diagnosis of LQT syndrome Characteristics

References

Points

1.

Clinical history 2

Without stress

2.

1

The QT interval measurement should always be corrected for the  heart rate. Although Bazett ’s QT correction formula is the most commonly used it tends to overcorrect in patients with heart rates >110 and <60 bpm. Therefore in the instance of this patient either Hodges or Framingham correction formulae should be adopted. Using Hodges formula: QTc = QT +1.75(heart rate-60) QTc = 680ms + 1.75(44-60) Therefore: 680 + 1.75(-16)     680 + -28   QTc = 652ms

2. This patient is displaying characteristics of long QT syndrome, including QTc >440ms, sinus bradycardia and notched T waves¹. His symptoms of dizziness and syncope are also suggestive, and so Schwartz criteria² to assist in the diagnosis of long QT should be  used. Refer to Table 1.

3.

a daily dose of methadone (mean, 397±283mg) correlates positively with a prolonged QTc interval (615±77ms) after the analysis is adjusted for variables such as age, structural heart disease and hypokalaemia⁴. Methadone delays cardiac repolarisation by blocking the flow of potassium ions through the HERG channels⁵. The risk associated  with long QT syndrome is torsade de pointes, a polymorphic VT.  Derangements in ion flow leads to prolonged action potentials and the generation of spontaneous upstrokes, resulting in premature ventricular depolarisations. Propagation of premature VEs can initiate torsade de pointes if they occur within the period of enhanced  electrical instability during repolarisation. Termination of methadone treatment can result in normalisation of the QT interval, but methadone should not be stopped abruptly  and has a half-life of up to 190 hours. Additionally termination of methadone, a drug for rehabilitation, would need to be carefully considered in regards to future management of the patients’ heroin addiction. An ICD should be seriously considered for the treatment of ventricular arrhythmias even though termination of methadone could normalise the QT. Interestingly not all patients who take methadone have a long QT, and therefore the suggestion that methadone unmasks an underlying predisposition for long QT syndrome makes the weight of argument for ICD implantation greater.

4. This patients ECG was taken at the time of his ETT. The SCST/BCS Recommendations for Clinical Exercise Tolerance Testing⁶ suggests  that any test for the provocation of arrhythmias should be physician led. Whilst many centres have local protocols, it is important to consider that an ETT for a patient of this type is to establish whether a polymorphic VT can be induced and although in the case of long QT  the episodes of torsade de pointes are often short and self terminating, the episodes have a tendency to occur in rapid succession causing syncope, and sometimes death.

3.

Family members with definite LQT

1

Lamont P and Hunt S. A Twist on Toursade: A prolonged QT interval on Methadone. J Gen Intern Med. 2006;21(11):C9-C12.

Unexplained sudden cardiac death at age <30 y among immediate family members

0.5

4.

Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, Robertson AD, Mehler PS. Toursade de pointes associated with veryhigh-dose methadone. Ann Intern Med. 2002;137:501-4.

3

5.

El-Sherif N, Turrito G. Torsade de pointes. Curr Opin Cardiol. 2003;18:6.

6.

http://www.scst.org.uk/clin_guidance/ETT% 20consensus%20March%202008.pdf.

Electrocardiographic findings† QTc >=480 ms 460-470 ms

2 1

450 ms (in males) Torsade de pointes

Copyright © 200 - 2010 by Coronary Heart Publishing Ltd.

Ca endar Next ssue & Conferences

30

Disclaimer:

2 1

T-wave alternans

1

Notched T wave in 3 leads Low heart rate for age (<2nd percentile)

0.5

All rights reserved.  Material may only be reproduced by prior arrangement and with due  acknowledgment of Coronary Heart Publishing. The publication of an advertisement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Scoring: <=1 point = low probability, 2-3 points = intermediate probability, >=4 points = high probability. Torsade de pointes and syncope are mutually exclusive. * The same family member cannot be counted twice. † In absence of medications or disorders known to affect these electrocardiographic features

CURRENT

Volcano Page 13

Your World Page 25

Kirkham Young & Cardioace Page 5

McKesson Page 17

HRC & Hammersmith Hospital Page 31

Labyrinth Page 6

Bard EP Page 23

BCS Page 32

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Methadone is independently associated with a prolonged QT interval and progression to torsade de pointes³. Studies have shown that 

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2 May/Jun 2010  www.cardiologyhd.com

Heart Rhythm Congress

Cardiology Events

Calendar LIKE TO BE

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June 7-9

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

1

admin@coronaryheart.com

Upcoming Issues* Heart Rhythm Congress 2010

3-6 October 2010 Hilton Birmingham Metropole

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International

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www.heartrhythmcongress.com

+44 (0) 1789 451822 Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias

September 21-25 TCT 2010 Washington Convention Center Washington, DC, USA www.tctconference.com

ECG Challenge 16

September / October 2010 Management Hot Topic: Recruitment challenges. Lead Extraction Problem Solving New Technologies in EP

Echo Buyer’s Guide

EP Education Series Pacemaker and ICD Technologies ECG Challenge 17

* Editorial topics subject to change

October29-30

June 2-5

2

What cardiologists and staff want designed next?

British Society of Echocardiography Annual Meeting & Exhibition Bournemouth, England www.bsecho.org

New Cardiovascular Horizons Conference The Roosevelt Waldorf - Astoria New Orleans, LA, USA www.ncvhonline.com

4

5

NICE Guidelines for Recent Onset of Chest Pain

n on y gy tio ati log Educ chno ersity Te Div

October 3-6

Future of Cardiac Cath Labs Special Edition Transcatheter Aortic Valve Implantations (TAVI)

What’s New in Cardiology - A Clinical Update for Nurses St George’s Hospital London, England E-mail: dcole@sgul.ac.uk

Heart Rhythm Congress 2010 Hilton Birmingham Metropole Birmingham, England www.heartrhythmcongress.com

Hammersmith Echocardiology Hammersmith Conference Centre London, England www.imperial.nhs.uk/hcc July 9

3

4

July / August 2010 ›

BCS Annual Conference and Exhibition 2010 Manchester Central Manchester, England www.bcs.com June 7-11

For a list of conferences and events around the globe visit our website:

30 May/Jun 2010  www.cardiologyhd.com

2

Schwartz PJ, Moss AJ, Vincent GM, et al. Diagnostic criteria for the long QT syndrome: an update. Circulation. 1993;88:782-4.

0.5

Congenital deafness Family history*

1. This 12-ECG shows sinus bradycardia with a heart rate of 44bpm.  Even without formal calculation or indeed measurement it is clear that the patient has a very long QT interval. It can be difficult to establish from which lead the QT interval should be measured as  there can be variance in the QT across the leads, however, due to  the heart rate it would be prudent to measure this QT from the  rhythm strip (lead II) as it can be measured from a few complexes to  ensure accuracy. On measurement the QT is 17 small squares long = 17 x 0.04 = 0.68 seconds or 680ms.

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Ms Sophie Blackman Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

ECG Answer & Advertisers

Schwartz PJ, Malliani A. Electrical alternation of the T wave: clinical and experimental evidence of its relationship with the sympathetic nervous system and with the long QT syndrome. Am Heart J. 1975; 89:45-50.

Syncope With stress

See Page 4 for Contact Details

Question on Page: 20

HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK Telephone: +44 (0) 1789 450 787

HAMMERSMITH ECHOCARDIOLOGY 7-11 June 2010 Course Director: Professor P Nihoyannopoulos MD, FRCP, FACC, FESC A week-long course of contemporary echocardiography designed for cardiologists, cardiac technicians and general physicians with some previous knowledge of echocardiography. This course is geared to those who want to improve their knowledge and keep up-to-date with the ever-expanding ultrasound modalities. This intensive course will consist of lectures from worldwide experts and discussions on controversial subjects. The following topics will be covered: Physics of modern ultrasound technology * Comprehensive transoesophageal echocardiography and colour flow mapping * Congenital heart disease * Stress echocardiography * Echo in coronary heart disease * Valvular heart disease * Endocarditis * Ventricular function and quantitative echocardiography * Video tape demonstrations. Full programme and registration details available from:

Hammersmith Conference Centre Web: www.imperial.nhs.uk/hcc Email: hcc@imperial.nhs.uk Tel: 020 8383 1601/1608

Supported by the British Society of Echocardiography and European Association of Echocardiography

www.cardiologyhd.com  May/Jun 2010 31

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on

Coronary Heart should never be regarded as an authoritative 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 different techniques used by others around the world. Whilst all care is taken in reviewing articles obtained from various companies and contributors, it is not possible to confirm the accuracy of all statements.  Therefore it is the reader’s responsibility that any advice provided in this publication should be carefully checked themselves, by either contacting the companies involved or speaking to those with skills in the specific area. Readers should always re check claims made in this publication before employing them in their own work environment.  Opinions expressed by contributors are their own and  not necessarily those of their institution, Coronary Heart Publishing Ltd or the editorial staff.

www.cardiologyhd.com  May/Jun 2010  3


Experts

Our Cardiology

Mr Tim Larner Director / Founder

Dr Magdi El-Omar Lead Consulting Editor

Dr Richard Edwards Consulting Editor

Mr Ian Wright EP Consulting Editor

Previous Cardiac Radiographer  Manager in Australia, now Senior  Radiographer at the Manchester  Heart Centre.

Consultant Cardiologist,  Manchester Heart Centre,  Central Manchester University Hospitals NHS Foundation Trust

Consultant Cardiologist, Freeman  Hospital, Newcastle-upon-Tyne  Hospitals NHS Trust

Technical Head EP, St Mary’s  Hospital, Imperial College  Healthcare NHS Trust

Dr John Paisey Journal Reviewer

Dr Dan McKenzie Journal Reviewer

Dr Simon Redwood Consulting Editor

Dr Rodney Foale Consulting Editor

Consultant Cardiologist, Royal  Bournemouth and Christchurch  Hospitals NHS Foundation Trust

Consultant Cardiologist,  Musgrove Park Hospital,  Taunton and Somerset NHS  Foundation Trust

Consultant Cardiologist &  Director of the Cath Labs at Guy’s & St Thomas‘ NHS  Foundation Trust

Consultant Cardiologist, Imperial  College Healthcare NHS Trust

Mr Adam Lunghi Echo Consulting Editor

Mr Dennis Sandeman Nursing Consulting Editor

Senior Echo Manager CVS - CardioVascular Services,  Australia

Chest Pain Nurse Specialist NHS Fife, Trustee of the  Scottish Heart and Arterial Risk Prevention (SHARP) charity.

Ms Sophie Blackman Management & CRM Consulting Editor Head of Clinical Cardiac  Physiology,  West Hertfordshire NHS Trust

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Latest News

Round Up New Kirkham Young Recruitment Subscription Service

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eading specialist recruitment consultancy Kirkham Young continues its programme of ongoing improvement in the service it offers to its customers by providing a dedicated industry news and job alert system to subscribers. “Our customers have always regarded us as so much more than a CV  service” commented director Tina Young. “We are often asked for information regarding market trends, recruitment law and company news and the launch of our news subscription service is all part of that commitment to being a fully rounded industry specialist.” As part of their pledge to offer an unrivalled service to candidates and companies alike, all registered candidates with the agency now  receive regular alerts for a variety of opportunities including sales, marketing, technical support and management roles as well as being able to keep up to date with current industry bulletins.

New Cardioace Plus With Plant Sterols

V

itabiotics Cardioace Plus with cholesterol maintaining plant  sterols is the newest addition to the Vitabiotics Cardioace range. Cardioace  Plus  is  the  only  heart  health  supplement  to  combine  plant sterols with 24 other heart  maintaining nutrients. Cardioace  Plus  is  the  most  comprehensive heart health multivitamin  and  its  ingredients  have  been scientifically proven to be of  importance  to  heart  health.   The formulation also utilises advanced technology which offers enhanced bioavailability as well as a natural orange oil odour mask to avoid any aftertaste usually associated with omega-3 fish oil and garlic. Plant sterols occur naturally in various plant-derived foods, including  vegetable oils, nuts, grains and seeds and may be absorbed each day.  The amounts however are often not great enough to have significant cholesterol maintaining effects. Plant sterols have been found beneficial in numerous studies where they can help maintain healthy cholesterol levels by aiding the reduction of cholesterol absorption in the intestines. A regular intake of plant sterols along with a healthy diet and lifestyle may therefore be helpful for those who wish to look  after their heart and circulation. Cardioace Plus is priced at £15.95 for 60 caps. For more information visit www.cardioace.com

For more information or to subscribe log on to www.kirkhamyoung.co.uk

New hope for AF sufferers following NICE guidance rethink

R

ecently the Atrial Fibrillation Association and the Arrhythmia Alliance welcomed the decision by NICE to recommend approval of dronedarone as  a second line treatment option for Atrial Fibrillation (AF) patients, reversing its previous draft guidance published in December 2009. NICE’s Appraisal Committee recognised that dronedarone can and should occupy a currently vacant place in the care pathway, and that for a large and growing number of patients it could represent the only treatment option open to them.

www.cardiologyhd.com  May/Jun 2010  5


Advertisement

Increase Lab Performance

Labyrinth LABYRINTH SOFTWARE: Performing in the Real World A report on 6 months’ use of Labyrinth in the Cath Labs at Guy’s and St Thomas’ “Some staff were a bit apprehensive at first. But now, there’s no way that any of us would go back to the old system.” (Senior Staff Nurse – Cath Labs)

This screen shows a Lab View of a typical day’s list. All Lab A’s patients can be seen simultaneously, even though they are coming from different wards.

Background

Ease of use

Labyrinth software was designed to track the patient pathway through any medical department where patients pass through a number of tests, stages, sub-stages and interventional procedures.

The system was designed to be easy to learn and use and this has proved to be the case. Staff need only 15 minutes training. Each day’s list is loaded directly from Tomcat the night before, which means the Lab Co-ordinator no longer has to come in early. Then the patient’s progress through the system is logged with a simple click, as opposed to filling in multiple data fields - and this action simultaneously captures data for audit purposes. “It used to take the first 30 minutes of the day to prepare the day’s list. Now we come in and it has been preloaded into Labyrinth. All staff immediately have a clear picture of the day’s workload.” (Deputy Nursing Manager)

The first version was developed in conjunction with Cath Lab teams at leading London hospitals and was installed at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in October 2009. GSTT has 5 Cath Labs receiving patients from 5 cardiac wards and performing a range of procedures covering Interventional, Electrophysiology and Device Implantation. Labyrinth uses a dashboard screen where patients are shown in rows and procedures are shown in columns. As patients move through the various stages, staff record their progress with a click. The information on screen is continually updated throughout the day. Individual team members can select the view that shows the information they need; some concentrate on a particular ward, lab or procedure whilst others can see the bigger picture and keep an eye on all patients going through the unit. Now, after 6 months and over 2,000 procedures, it’s time to ask how the system has performed and whether or not it has lived up to expectations.

  May/Jun 2010  www.cardiologyhd.com

Improved Communication. Improved Co-ordination Labyrinth improves communication in two main ways. Firstly, when a staff member records that a given stage has been completed, this information is immediately sent to everyone who needs to know. They don’t have to go and tell them. Secondly, the information that staff members need appears on the screen in front of them. They don’t have to go and ask. This has brought some valuable benefits. It eliminates the need to run around chasing or transmitting information to multiple MDT members, so stress within the unit is reduced. Team members can concentrate on the job in hand without being interrupted for updates. In fact at GSTT the lab co-ordinator is now able to contribute to clinical work. “It saves a lot of time. Whoever is


This is a Ward View on the same day. All Ward A’s patients can be seen simultaneously. co-ordinating used to spend all day outside the labs, running around between the labs and wards. Now they are free to spend time back inside the labs where they are just a point of contact for any changes to the list.” (Lab Co-ordinator)

Reporting A reporting function was built into Labyrinth from the start. This had two purposes; firstly, to produce information for audit purposes and secondly to analyse utilisation of the labs and pinpoint causes of cancellations or delays. This in turn would enable the team to improve processes and test how well those improvements worked in practise. “The information is there whenever you need it, consequently more can be done with it.” (Cardiac Radiology Manager) The team at GSTT have found Labyrinth a marked improvement over the paper-based systems they were using before. All data is recorded in real time, as the staff go about their normal work - and this brings three major benefits. There is little chance of data being lost. The information available is always up to date. And there is no time spent manually inputting data for audit purposes; this saves the Head of Radiology 3 days per month. Patients on research trials are clearly identified and their treatments can be audited separately as required. Labyrinth records radiation dosage entered by the radiographer and collated in the reporting module. This makes it easier to both monitor current practice and agree Local Dose Reference Levels complying with Ionising Radiation (Medical Exposure) Regulations. It used to take a member of the radiology team two weeks every three months to collate this data by hand. The raw data produced by Labyrinth can be analysed to produce reports on any aspect of the unit’s operation e.g. utilisation, cancellations or delays. This data can be broken down further into any combination of appointments, labs, wards, procedures and periods of time. It’s not just that the information is available; the team can do more with it, learning more about the operation of their unit than ever before.

Improving Processes Any changes to processes in one area may impact on others. In the past, knock on effects might take months to appear in the audit data. With Labyrinth, reports are available immediately. The information/evidence produced by Labyrinth has already led to a number of improvements. For instance, Labyrinth logs the opening and closing time of each lab. It became evident that one particular lab was regularly finishing late but on those days it also started late. They could see that all the patients were arriving as scheduled therefore the cause of delay was the time it took to prepare patients. They focussed staff attention on streamlining processes in order to get a particular group of patients ready quickly in the morning and the lab in question is regularly starting and finishing on time.

Summary Labyrinth has succeeded in its stated aims of freeing clinical staff for clinical work, reducing the time spent collecting and auditing data and has contributed to an increased efficiency of the Cath Labs at GSTT. In fact the team would say that, in most respects the system has exceeded their expectations. “It’s well worth it. I don’t want to go back to paper co-ordination; it’s a much more efficient way of working.” (Deputy Nursing Manager)

For further information, go to:   www.gallerypartnership.co.uk/labyrinth to join a 30 minute webinar from your desk on Tuesday 25th May at 10am, where you can see Labyrinth in action or call Mark Kemp on 020 7096 2800.

This is an example report which displays a count of delays by reason for the year to date

www.cardiologyhd.com  May/Jun 2010  


Hot Topic Cardiologist

Questions: 1. What have been some of the challenges for your department setting up a Primary Angioplasty Service, and what improvements need to be implemented to ensure continued success in the future? 2. Do you believe in the concept of designated ‘heart attack centres’, or do you believe that any Trust can set up a PPCI service?

erates such enthusiasm and commitment from the staff that there is a risk too much commitment moves the service towards an out of hours diagnostic provision.

Dr Rodney Foale Consulting Editor Consultant Cardiologist, Imperial College Healthcare NHS Trust

Answer 1: Of the challenges, the concept of a service specific to the opening of a blocked artery and acute myocardial infarction was the most difficult to stick to. It is very easy to drift and include patients with a wide range of acute coronary syndromes and there is no doubt that this will be required of us in the future with many centres making inroads into this development. However, beginning the service the ‘bulls eye’ clinical presentation was with acute chest pain and ST elevation certain (or within the medical definition of certainty) to be due to an acute coronary occlusion. This is the area where proven benefit has occurred and widening the clinical ‘atypical chest pain’ and ECG criteria to include left bundle branch block, left ventricular hypertrophy and ST segment changes ie, non ST elevation with indeterminate troponin shifts will both dilute the outcome and increase complications. There is another factor that involves staff satisfaction in seeing an acute myocardial infarction, often in a critical patient, magically resolved with the simple opening of an artery and this gen-

  May/Jun 2010  www.cardiologyhd.com

Angioplasty for non STEMI is another important arena which many centres are moving towards, but I had resisted the development of this service until a team involved in both daytime and out of hours service were well rehearsed in acute ST segment elevation variety of myocardial infaction. In considering how to target patients for the most benefit, it’s important to look at randomised trials versus the registries and in meta analyses of the studies it is apparent that some often subjective variation in physician assignment to thrombolysis versus angioplasty can dramatically alter outcome. Thus it might be difficult to show benefit for angioplasty versus thrombolysis, it’s probable that a relatively small number of patients converted to one or other group affect the statistical analysis, we know primary angioplasty for acute ST segment elevation works and thus programmes early stages temptation to extend the service to a clinical presentation should I believe be resisted. In considering this, looking at the difference between randomiseed trials and registries etc and in particular looking at the meta analyses, recent data to be hoped to be published from our group suggests it only takes a couple of patients to be physician assigned to one or other group to fairly drastically alter outcomes. The tighter the entry criteria and the more focussed the early vision is on balloon opening of a blocked artery versus thrombolytic referral versus revision of a


HOT TOPIC general out of hours diagnostic service, the better the programme will work. Thus to summarise we must remember what this programme is for. A. It is not for a late night IVUS with three vessel disease and pressure wires until 4am, it is for targeted, high reward, clinical reward procedures that makes the patient, staff and operators feel good about what has been done. B. One of the most difficult problems was the establishment of the 24 hour / 7 day week service and in retrospect perhaps our team might have begun with less logistic difficulties in accepting the two tier 9-5 service with patients presenting between 5pm and 9am either being considered for thrombolysis or if circumstances were to permit, transferring to a neighbouring establishment. I think the lesson there was that a phased introduction of a service to include phasing over weekends was better than the chaos of an all singing dancing band. C. Further to the phasing of the service I have had enough experience with late night critical angioplasty and inexperienced staff, not wanting to put less experienced and even younger cardiologists through having to run a heart blocked inferoposterior dominant right angioplasty fully of thrombus and potential dissection not to really need the absence of your favourite radiographer, technician and nurse. There is a lot of “mobility” in cath lab staffing and the planning of a primary angioplasty service, I believe it to be important to maintain the support team disciplines of radiography, physiology and nursing as part of the team. For this appropriate remuneration agreed at the outset of this programme is a key factor. In the UK for example the Agenda for Change initiative means that staff on different Bands will get paid different for the same often stressful duties. The hourly rates at around £10 mean there is not a lot of voluntary enthusiasm. In my experience this remains a significant hurdle. D. Data entry for local and national databases needs to be planned well ahead of the commencement of such a programme. Retrospective data loses a lot of valuable information about early real life experience and these data very often are important in the clinical perspective of later years. No data should be lost and every intent should be made to the patient’s registered for studies linked with other neighbouring units so academic opportunities are not lost. Unless these issues are embraced early on the training and academic component of such service developments are lost. Plus there is a certain pleasure in slam dunk direct angioplasty and this is why it is important of course to limit the remit of the clinical criteria for entry to such a programme. The range of the usual guide cath wires and stents should be ordered to suit the senior operators. I personally discourage too much additional equipment, it is hard to deny though the advantages of balloon pump and clot extraction device technology. If a pressure wire or IVUS appears at 3am there will be less technicians available for the following month’s rota. What appears to be an overwhelming demand on establishment of the service particularly in the medical climate of today, the challenge

of recruiting enough patients with proper ST segment changes and tight clinical criteria referred to above must be recruited to prevent in an underwhelmed unit a sense of utter boredom. There has to be a significant (however defined) number through the A&E department to retain the operational integrity of a programme. Therefore, extremely important are the links with neighbouring hospitals, communities, ambulance services etc. Education, education, education! Community lectures by all staff from nursing to senior consultant, advertising efforts in the local paper to improve awareness, all of these options must be considered in the recruitment drive so that patients don’t escape. Finally, it is imperative to have all the relevant consultant staff from the A& E department through to interventional cardiologists communicating easily. Regular multidisciplinary meetings to establish communications on first name terms are vital. Social evenings add to the vital sense of team play that such a programme requires. I have been extremely lucky in my medical practice to have had wonderful support from all consultant staff as without new enthusiastic firebrands, names not to be mentioned, these programmes simply would not have continued or survived.

“It is not for a late night IVUS with three vessel disease and pressure wires until 4am” Answer 2: I have worked in ‘heart disease centres’ I have never been certain what one is. A heart attack we often think of as having a rather narrow definition but attacks of the heart can occur at any time and the public I think are more confused than enlightened by seeing such a somewhat patronising signs neighbouring our A&E and cath labs. So I object to the sign but certainly not the concept. Any Trust with a bank of cardiologists will want to set up a PPCI service. Apart from the remuneration from Primary Care Trusts for acute intervention which most often will be a fairly straight forward intervention less than 10 minutes in duration, and given what I have suggested above it is fairly easy to imagine how a cath lab can provide such a service by fast tracking acute ST segment elevation patients straight into the laboratory. The out of hours service which must be driven by catchment area, PCT collaborations and on the ground, sufficient consultant and non medical staff to cover the 24 hour service, that is the challenge. With regard to heart disease centres in isolation from an A&E department, certainly in London such challenges have been met with success.

www.cardiologyhd.com  May/Jun 2010  


HOT TOPIC Dr Farzin Fath-Ordoubadi

Ms Samantha Chapman

Consultant Interventional Cardiologist Manchester Heart Centre Manchester

Acute MI project manager Manchester Heart Centre Manchester

W

e have been a long time advocator of primary PCI. Our first challenge was to win heart and minds and convince people that Primary PCI (PPCI) is superior to thrombolysis. By in large, except for small pockets of resistance we have now achieved this. The next challenge was to prove the feasibility of a primary PCI program; this was despite the fact that many countries had already established successful PPCI programs. Through several centres taking the lead and starting their own process and also with the National Infarct Angioplasty Project (NIAP), we have past this hurdle too. As a result many heart attack centres now provide or are in the process of providing PPCI. However there are still many issues and challenges remaining. These are mainly related to implementation and sustainability. I will outline some of these below:

Staffing Issues: Different regions have this problem to different extents. I know in some regions main shortage is a lack of cardiac physiologists. Greater Manchester has a population of 3.1 million. For the size of our catchment area even though we have a combined program with Wythenshawe Hospital our main staffing issue is a shortage of operating consultants. We have tried to resolve this issue by incorporating our district interventionalists into our rota. Amongst our District General Hospital (DGH) interventionalists we have those that are not so keen and those that are very enthusiastic. However as yet we have not managed to get any of them on board. This has been due to several factors including their onerous local on call general medicine/cardiology rota, lack of other non-interventional consultants to fill the gaps locally, and unresolved issues surrounding payment and remuneration to the local trust.

Inappropriate transfers: It is always difficult to determine what is ‘inappropriate’. It is maybe easier to determine what is appropriate. We do have Network agreed protocols that outline quite succinctly what to refer on the Primary pathway. It is clear in the protocol we will take ST segment elevation myocardial infarction (STEMI) and new onset Left Bundle Branch Block (LBBB) with good cardiac history within 12 hrs. If the patient satisfies these criteria and there is no other mitigating issues they should send the patient but make sure we get a courtesy call. The selection criteria are exactly the same as what it was for thrombolysis. It has therefore been very surprising for us to have such a high rate of inappropriate referrals (nearly 30%) when we have patients referred from local A+Es. One of the things that have always been mentioned is that we had a very good thrombolysis service. This proves that perhaps in

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It has therefore been very surprising for us to have such a high rate of inappropriate referrals (nearly 30%) when we have patients referred from local A+Es. reality this was not the case. We may have been good at achieving door to needle target, but not so much with the rest of the process. In the past the rate of inappropriate thrombolysis or procedure related to identification of failed thrombolysis was not scrutinised as much as door to needle time. I think failure to establish such processes over the last 20 years of the thrombolysis era is the reason behind such high inappropriate referrals that is only now coming to surface as these patients are now referred on. On the other hand we should not expect 100% appropriate referral. If so it would almost certainly mean that we are missing some perfectly legitimate cases. Some of the people have difficulty with this concept. My answer to this is that one of the reasons that a primary PCI service is superior to thrombolysis is not the actual procedure itself, but it is due to the fact that it gives patients direct and rapid access to expert cardiologist opinions. In difficult or borderline cases this is critical as it may avoid unnecessary or potentially hazardous inappropriate thrombolysis amongst other things. We have agreed that a 10% ‘false positive/inappropriate’ call rate is acceptable, and have indeed factored this figure into our future planning for resources. We do feel that reducing and minimising inappropriate referrals is part of our responsibility. We are advocating a stronger educational programme for all the DGH A&E departments, providing regular feedback via a Governance network to enable A&E staff to see the outcomes of the patients that are sent across to the Tertiary Centres. This will hopefully provide a learning platform. It should be noted at this point that our rate of false negatives is split fairly evenly between Direct Transfers (12 lead ECG analysed and diagnosed by paramedic crews) and those coming from DGHs. We have offered to open our doors to paramedic crews to provide training and education and have secured industry support for away days and road shows. Unfortunately, another frustration is the apparent


HOT TOPIC reluctance of our colleagues at the North West Ambulance Service (NWAS) to engage in this potentially exciting project to support their crews.  There is a lot of enthusiasm and willingness to learn by the  paramedic crews. We also advocate some kind of telemetry system.

Cardiogenic Shock/ Out of hospital cardiac arrest: Although  the  numbers  of  shock  cases  are  falling  we  do  get  more  referrals  as  part  of  the  PPCI  service.  There  is  a  lack  of  consistency  amongst consultants and centres as to patients they are willing to take on. This is made worse by worries around operator’s procedural  mortality  which  is  clearly  higher  for  those  who  are  willing  to  take  on these cases. Data collection and risk adjustment is critical here. We also need better infrastructure in terms of after care for these patients. Balloon pumps as a means of a supportive bridge to myocardial recovery is not adequate. We do need access to assist devices or stronger percutaneous assist devices such as Impella, and we do  need to involve our cardiac anaesthetic colleagues in management of these patients that often may require ventilation and respiratory support.

pain occurred, right through to their date of discharge (and beyond  into rehab) or in some cases, unfortunately, their death. The timings of the patients’ journey are crucial to assess how well we are performing in relation to National Guidelines. In order to demonstrate our success rate at achieving a door to balloon of under 150  minutes, accurate recordings of the patients call for help, the times the ambulances arrived, left the scene, arrived at hospital, went in the lab, needle to skin………………………the list goes on. But to show we are delivering a quality service to our patients it is not just about how speedily we get to the myocardium, it’s about the adjunct therapies, pharmacology, documentation, follow up and rehabilitation.

Beds & Patriation:

The system used to collect data for patients going through the Labs at the Manchester Heart Centre is Cardex and although I have had a lot  of experience with it’s use I was surprised to find out just what information I could obtain, how data is entered and what it is used for. This system is supported by our own Heart Centre IT Team who have  patiently and tolerantly (only the occasionally eye rolling episode!!) guided me through this maze of information.

One of the other common themes are a lack of beds despite a shorter length of hospital stay. We therefore do need to either patriate or repatriate patients. This we found to be difficult on many occasions and we do have ongoing discussions with our referring hospitals to  resolve this issue.

One thing that I have learned is that usually there is someone, somewhere who is already collecting some of this data. The challenges have been to find out who the ‘who’ is and to build relationships to develop some data sharing rather than duplicating.

Data collection:

Unfortunately even our National databases do not talk to each other so there is not much of a chance……………..

The progress and effectiveness of any new initiative can only be measured by robust audit. This is only achieved with collection of data.  All of you working in health care know the only way to get a  medics attention is to ‘talk data’! The data has to be relevant.  So when it comes to Primary PCI the  challenge has been to gather data that is relevant to all stakeholders.  This includes the North West Ambulance Trust, all our District General Hospital Colleagues (A&E and Cardiology), Greater Manchester  and Cheshire Cardiac and Stroke Network, ‘in house’ Consultant Cardiologists and Senior Managers all the way to the Trust Board.  No  surprise then, that this has been one of the biggest challenges in my  role. Initially this seemed quite a straightforward exercise as data was already being collected for Myocardial Infarction Audit Project (MINAP) purposes.  However, ‘the devil is in the detail’ and to provide all our interested parties with what they required we needed to strip down each patient’s journey into a step  by  step  account  from  when  that first ‘twinge’ of  chest 

At the Heart Centre we have a fantastic Data and Information Team, headed by Suzanne Chaisty. Their support and help in directing me to the right people and systems has been invaluable. Surprisingly our ability to obtain accurate ambulance times has proved to be the most time consuming and frustrating issues to date. It is difficult to determine the factors behind this and whether this is just a local issue. The North West Ambulance NHS Trust has been submitting their electronically recorded ambulance times to our Chest Pain nurses for MINAP purposes for a long time but since the extension of our PPCI programme in April 2009 there have been  problems  with  their  ability  to  meet  the  formally  agreed  standards  and targets for getting this information across to us.

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HOT TOPIC

3.

Maintaining safety/audit - quality of the service is of paramount importance. We closely audit our door-balloon times as well as our complications and outcomes. In non-shocked STEMI patients, our in-patient mortality is now <2%. All or our audit data is submitted to UK-CCAD, the central database. Any pPCI service needs IT investment from the outset - you cannot  rely on existing IT support. Secretarial support is also needed - reports need to be generated out-of-hours and go out quickly.

4.

Introducing new techniques - we have regular meetings to review new evidence and developments in the field of pPCI. This includes the changing evidence base supporting adjunctive pharmacotherapy (eg. Bivalirudin), the advantage of radial procedures and the use of thrombectomy catheters

5.

Bed management - this is perhaps our biggest challenge,  because patients arrive with little notice, requiring varying amounts of support. When patients have been intubated, ITU are involved from the time that the call is received and we are extremely lucky to have excellent ITU support here at King’s. I would suggest that ITU colleagues are closely involved in any service at its inception

Dr Philip MacCarthy BSc PhD FRCP Consultant Cardiologist and Clinical Lead Department of Cardiology King’s College Hospital London, UK.

Answer 1: We have been doing 24/7 pPCI at King’s since 1st Sept 2003 and were one of the 7 UK NIAP (National Infarct Angioplasty Project) pilot centres. We have certainly been able to refine our service in the intervening years. The challenges have been: 1.

2.

Minimizing door-balloon times - we learnt early on that direct transfer by the London Ambulance Service from home (thus bypassing local and our A&E department) was by far the  best way to achieve acceptable Door-to-Balloon times. This was initially resisted because of fears about accuracy of ECG diagnosis by Paramedics but these fears have been allayed by  excellent Paramedic triage. We have developed a very detailed in-hospital patient pathway which gets patients to our cath lab extremely efficiently, with a competent (ALS-trained) team around them at all times. Patients and paramedics are met at our front door by our SHO (Senior House Officer) and escorted to the cath lab. Developing acceptable staffing rotas - these have been a challenge and the success of our program has depended a lot on  the goodwill of all staff groups. All individuals involved in the service have stated that the main reward for them is the effect timely primary PCI has on patient well-being. Patients literally get better during the procedure, which is rewarding for the whole team. Acceptable and workable staffing rotas are fundamental for a sustainable service

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Answer 2: I absolutely believe in HACs - pPCI is not a procedure that should  be done in low volume centres and this has been shown in several  studies. pPCI operators should be experienced interventionalists who can safely deal with anything that is served up to them at any  hour. However, it is more than operator volume that is important  - an HAC should have access to excellent CCU/ITU facilities, Cardiothoracic surgery, perfusion and LVAD support - including use of IABPs and the Impella device, which we are using increasingly. To  do these cases in a smaller centre without these facilities would be inappropriate.


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The Current Evolution of PCI (an industry perspective)

A

ngiography Alone is Not Enough. Physicians are relying more on precise PCI-guidance tools like FFR, IVUS and OCT than ever before. Use of these technologies has increased in every major geography, including Japan where IVUS usage is now estimated at more than 70% of all PCI. Is this just a temporary trend, or a sign that the interventional cardiologists approach to PCI guidance is changing for good? For change to happen, there must be a trigger… a problem that needs to be solved. The challenge interventionalists are presented with today is three fold; 1) Major publicized studies like COURAGE, SYNTAX and HORIZONS have demonstrated that angiographically guided PCI procedures do not always lead to better outcomes than medical therapy or CABG, and that there is still plenty of room to improve on 12-month event rates, especially in more complex patients. 2) Recent studies like FAME, PROSPECT, STLLR, Lindstaedt, Diethrich have highlighted the clear limitations of angiography to assess lesion severity, ischemia, presence of calcium, proper stent diameter, length and expansion. And 3) Clinical trials including FAME, JSAP , ROY , Costantini underline the trend of excellent or comparatively superior outcomes when using precision guided PCI tools like FFR and IVUS. The body of evidence that is accumulating not only supports the dramatic increase in FFR and IVUS usage in the past few years, but also suggests this evolution to precision-guided PCI is a sign of things to come. This clinical need is driving change both in technique and in technology. The days of a heavy, awkward, roll-around console are over. Modern day IVUS and FFR systems (and in the future, OCT, Forward –Looking IVUS and Image Guided Therapy) can now be physically integrated into the cath lab suite, enabling fast, easy access to these products for every room and every patient. Speed and access are requirements for a successful technology and integrated systems have helped to remove those barriers in the modern day cath lab. The imaging catheters and FFR wire technology must change as well. Modern day devices track farther, respond better, and provide more

information than previous generations. With opportunity comes innovation, and this innovation is seen in a host of new imaging and physiology product launches planned for 2010. New markets will be developed like OCT and Forward-Looking IVUS to help guide increasingly more complex procedures. To control healthcare costs, these complex procedures will be done with advanced precision-guided tools to reduce in-hospital complications, reduce repeat interventions and eventually replace expensive surgical procedure like CABG with less invasive percutaneous approaches. One day, the evolution of these products will continue to where common therapy devices like angioplasty balloons and stents will have miniaturized imaging transducers or sensors built into the therapy device itself, removing any final barriers to using precision guided tools. Importantly, there will not be a single technology used in every case. Each will have its own advantages and indications. It is the clinical presentation and physician preference that will dictate the selection on a patient by patient or lesion by lesion basis. The key is to make all of these technologies available on a single, integrated system, which is always on, and always ready. Angiography Alone is Not Enough. The Medical Device Industry must be committed to delivering products that can compliment angiography in a fast, simple and convenient fashion. Visit PCR in Paris and BCS ACE in Manchester to see Volcano’s s5i™ Integrated Imaging Suite, and the latest commercial and development products including Eagle Eye Platinum™*, VIBE™* RX (Vascular Imaging Balloon), PrimeWire™ PRESTIGE*, s5i™ 3.2 Software, OCT and Forward-Looking+ IVUS. - Michel Lussier, President Volcano Europe * pending CE mark clearance + Development Only, not commercially available

References: 1.

Boden et al. Optimal Medical Therapy with or without PCI for stable coronary disease (COURAGE) New England Journal of Medicine 2007; 356:1503-16 2. Serruys, P. et al. “PCI versus CABG for severe coronary artery disease. SYNTAX” NEJM 2009 online, commentary closes March 4th 2009. 3. Stone, G. et al. “HORIZONS AMI One Year Results.” TCT Conference, 2008. 4. Tonino, et al. (FAME) New England Journal of Medicine 2009; 360:213-24 5. Gregg Stone on behalf of the PROSPECT investigators as presented at TCT 2009 6. Costa et al. Impact of Stent Deployment Procedural Factors on LongTerm Effectiveness and Safety of Sirolimus-Eluting Stents (Final Results of the Multicenter Prospective STLLR Trial). Am J Cardiol 2008 Jun 15; 101(12):1704-11. 7. Lindstaedt M, et al. Int J Cardiol. 2007;120:254-6 8. Diethrich et al. Journal of Endovascular Therapy. 2007; 14:676-686 9. Nishigaki, K. For the JSAP investigators. “PCI Plus Medical Therapy Reduces the Incidence of ACS More Effectively than Initial Medical Therapy Only Among Patients with Low-Risk CAD.” JACC 2008; Vol. 1: No. 5. 10. Roy, P. et al. “The potential clinical utility of IVUS guidance in patients undergoing PCI with DES.” EHJ, 2008. 11. Costantini, C. et al. “Impact of IVUS to Guide DES Implantation Decreasing Long Term Clinical Events.” TCT Conference, 2008.

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Journals Dr John Paisey Journal Reviewer

Dr Dan McKenzie Journal Reviewer

Consultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Consultant Cardiologist, Musgrove Park Hospital,   Taunton and Somerset NHS Foundation Trust

Antiplatelet/Anticoagulation The issue of antiplatelet ‘drug resistance’ continues to vex interventionists. There is debate over the definition of clopidogrel (and aspirin) resistance, how we should test for it and how it affects clinical outcomes. A publication in JAMA that compares 5 different methods (light transmittance aggregometry, VerifyNow P2Y12 assay, Plateletworks assay, IMPACT-R, and the platelet function analysis system (PFA-100) in 1,069 consecutive patients undergoing elective PCI over a 2 year period. Cut-off values for high on-treatment platelet reactivity (essentially resistance by another name) were established by receiver operating characteristic curve analysis. The primary endpoint was a composite of all-cause death, nonfatal acute myocardial infarction, stent thrombosis, and ischemic stroke. The primary safety endpoint included TIMI major and minor bleeding. Patients with high ‘resistance’ when assessed by light transmittance aggregometry (11.7% vs. 6.0%, p < 0.001), VerifyNow (13.3% vs. 5.7%, p < 0.001) and Plateletworks assay (12.6% vs. 6.1%, p = 0.005) were more likely to meet the primary endpoint. The other assays were unable to discriminate between those with or without subsequent ischemic events. None of the tests were predictive of bleeding events. Sadly, all three assays were only moderately predictive of future events (area under the curves of 0.63, 0.62 and 0.61 respectively) limiting utility in clinical practice. NJ Breet and others. JAMA 2010;303:754-762. Current European guidelines are confusing when it comes to anticoagulation and PCI with several options available including unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux (a factor-Xa inhibitor), bivalirudin (a direct thrombin (IIa) inhibitor) and glycoprotein IIbIIIa antagonists (abciximab, eptifibitide and tirofiban). Recommendations vary depending on the patient presentation – ST elevation vs. non-ST elevation ACS, urgent vs. non-urgent and on the bleeding vs. ischaemic risk balance. Now we have another option to add to the melting pot. M118, an engineered heparin, has potent anticoagulant properties, can be monitored using point-of-care ACT assays, does not activate platelets and is completely reversible (overcoming some of the disadvantages of the LMWH enoxaparin). The EMINENCE trial randomised 503 patients undergoing elective PCI at 43 centres (preloaded with

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aspirin and clopidogrel) to standard IV UFH (70U/kg) or one of three doses of M117 (50IU/kg, 75IU/kg, or 100IU/kg). The primary endpoint was a huge composite of death, MI, repeat revascularisation and stroke at 30 days, major or minor bleeding or thrombocytopenia at 24hours, intraprocedural catheter thrombus (a concern with bivalirudin) or bailout use of glycoproteinIIbIIIa inhibitors. The primary endpoint was reached in 31% (UFH), 22.7% (M118 50IU/kg), 28.3% (M118 75IU/kg) and 30.1% (M118 100IU/kg) of patients (non-inferior to UFH on pooled analysis of all doses of M118) and bleeding complications were similar. Head to head studies against bivalirudin and fondaparinux are sure to follow. Sunil V.Rao and others. Circulation 2010;121:1713-1721.

Revascularisation Only 38% of patients with suspected coronary artery disease (CAD) undergoing elective coronary angiography actually have obstructive CAD. A national registry in the US shows that the current non-invasive methods for assessing patients’ risk of coronary disease prior to referral for coronary angiography have low predictive value. The notes of almost 400000 patients without known coronary artery disease undergoing elective coronary angiography at 663 hospitals in the American College of Cardiology National Cardiovascular Data Registry (NCDR) were reviewed. A non-invasive test was performed in 84% of patients and suggested the presence of coronary artery disease (CAD) in 68.6%, whilst actual obstructive CAD (≥50% of the left main stem or ≥70% of a major epicardial vessel) was seen in only 41%. Obstructive CAD was more likely to be found in those with a positive non-invasive test than those who did not undergo non-invasive testing (35%), those when the testing was equivocal (27.1%) and those where it was negative (23.8%). Overall only 38% of patients undergoing coronary angiography had obstructive CAD. The authors comment that we need better strategies to risk stratifying patients, which include good history taking (difficult to measure objectively) and better use and interpretation of non-invasive tests, which will include stress echocardiography, MRI and CT angiography. Manesh R. Patel and others N Engl J Med 2010;362:886-95.


Some interventionists are questioning whether we should be using the current zotarolimus eluting stent. The SORT OUT III showed better results for the sirolimus-eluting Cypher stent (Cordis / Johnson & Johnson, Warren, NJ) compared to the zotarolimus-eluting Endeavor stent (Medtronic, Santa Rosa, CA). This trial randomised 2,332 ‘realworld’ patients with at least one coronary lesion in 5 centres in Denmark to either the Endeavor or Cypher stent and followed them up for 18 months. The primary endpoint (MACE rate – a composite of death, MI and TVR) was significantly higher with Endeavor (9.7%) vs. Cypher (4.5%), p<0.0001, driven mainly by a TVR rate of 7.9% vs. 3.3% respectively, p< 0.0001. All cause death (4.4% vs. 2.7%, p = 0.035) and MI (2.1% vs. 0.9%, p=0.029) were also statistically significantly different. The PROTECT trial has randomised 8,800 patients to Cypher or Endeavor for 3 years and should provide more information. Klauss Rasmussen and others. Lancet 2010;375:1090-1099. I was interested to see the 1 year results of the ENDEAVOR IV trial. Not because of the results (the zotarolimus-eluting Endeavor stent was non-inferior to the paclitaxel-eluting Taxus Express stent (Boston Scientific)), but because the 2 year results have already been published (Endeavor demonstrated comparable efficacy and cost-effectiveness to Taxus Express with fewer MIs (p=0.022). I look forward to the 6-month results next year. Martin B. Leon and others. 2010;55:543-554. JACC Martin B. Leon and others. JACC Cardiol. Intv. 2009;2:1208-1218. I have always been interested in risk stratification in PCI, but I am fairly certain that few people actively do it. There is now another model available using the data from the American College of Cardiology (ACC) National Cardiovascular Data Registry for catheterization or PCI (NCDRCathPCI). Data from 181,775 procedures were used to develop the risk model based on preprocedural and/or angiographic factors. A longer (21 variables) and shorter (8 variables) version were tested and both showed strong association with 30-day mortality. The simplified model included age, cardiogenic shock, prior congestive heart failure, peripheral vascular disease, chronic lung disease, GFR, NYHA functional class, and PCI status (STEMI or NSTEMI). Most UK interventionists enter data into the British Cardiovascular Intervention Society (BCIS) database (and this is uploaded to CCAD – the Central Cardiac Audit Database), which uses the North West Quality Improvement Program (NWQIP) scoring system to calculate a risk for patients undergoing PCI in the UK. There are several risk calculators available on-line e.g. the New York PCI calculator for in-hospital mortality at http://www.zunis.org/PCI%20Risk%20Calculator2. htm or the Mayo clinic calculator to predict in-hospital death and adverse events at http://www.zunis.org/Mayo%20Clinic%20-%20D eath%20and%20MACE%20After%20PCI%20-%20Risk%20Calculator %202007.htm Eric D. Peterson and others JACC published online Mar 31, 2010 as doi:10.1016 /j.jacc.2010.02.005

External Defibrillation The provision of automated external defibrillators in public places to facilitate effective resuscitation is an attractive concept. Two important studies published recently have cast light in on their efficacy. In Japan, where there is a programme to increase provision of appliances, outcomes are significantly improved following out of hospital VF from a survival with good neurological recovery of 14.4% overall increased to 31.6% in those treated by an AED. Over the course of the study there was an increase in the number of AEDs and the familiarity of the devices to the public with a resultant decrease in time to shock from 3.7 to 2.2 minutes. Over the course of the study areas in which the number of AEDs per square Km of inhabited land rose to 4 the number of survivors of OOH arrest with good neurological outcome rose from 2.4 to 8.9 per million population.

In the North American context the provision of AEDs is less coordinated. Observational data on this population records only 2.1% of OOH arrest are assessed and treated with an AED before the arrival of emergency services but that among these lucky few survival to hospital discharge is increased from 9 to 24% Tetsuhisa Kitamura and others, N Engl J Med 2010;362:994-1004 Myron L. Weisfeldt and others, J Am Coll Cardiol 2010;55:1713–20

Atrial Fibrillation What is the significance of new onset AF post cardiac surgery? An increase in both in hospital and long-term mortality according to registry data from 16 169 patients 18.5% of whom developed post operative AF. The excess death risk independently predicted by post operative AF amounts to 15% over 6 years follow up. This appears to be significantly ameliorated by formal anticoagulation. Mikhael F. El-Chami, J Am Coll Cardiol 2010;55:1370–6 A group of eminent electrophysiologists in centres across Europe and North America contributed data sets to a registry examining the risk of thromboembolic disease post AF ablation. They found the risk of stroke disease to be extremely low and slightly higher in the group receiving anticoagulation than in those not. The authors seek to portray this as evidence that anticoagulation may not be required in the long term post AF ablation. An excellent accompanying editorial however points out the small proportion of patients with CHADS2 scores of 2 or more, highlights the relatively short follow up and reminds us of the international guidelines recommend anticoagulation decisions be made based on risk factors and not apparent achievement of rhythm control. We (should) await randomised data to change our management. Sakis Themistoclakis and others, J Am Coll Cardiol 2010;55:735–43 Ivan Cakulev and Albert L. Waldo, JACC Vol 2010: 55:744–6 We like to think medical management of atrial fibrillation has a firm evidence base but guidelines have recommended strict rate control without any evidence to demonstrate that this is better than a more relaxed approach. In randomised study of 614 patients with atrial fibrillation in whom a decision had been made to pursue a strategy of rate control were assigned either tight (<80 resting, <110 exertion) or lax (<110 resting) control. There was no difference in a composite outcome including stroke, heart failure and arrhythmia whilst the lax group required less medication and hospital visits. Isabelle C. Van Gelder and others for the RACE II Investigators N Engl J Med 2010;362:1363-73

Call for Papers Coronary Heart is pleased to receive original contributions, case reports and reviews to be considered for publication in print and on line. Contributions will be subject to peer review. •

Please send manuscripts in word or similar compatible formats with figures embedded. If accepted for publication higher quality files will be requested.

Please send moving pictures in windows compatible formats such as MPEG or WMV.

Send all contributions by email to, john.paisey@rbch.nhs.uk

www.cardiologyhd.com  May/Jun 2010  15


Completed with the assistance of McKesson

United Kingdom

Site Visit

Northampton General Hospital Northampton Heart Centre Northampton General Hospital Cliftonville Northampton, NN1 5BD United Kingdom

Northampton Heart Centre is one of the first of the FFR upgrades for McKesson (formally Medcon) within the UK. McKesson Horizon Cardiology provides a fully integrated FFR haemodynamic system. The McKesson haemodynamic system is unique as it uses the same database as the Cath reporting module, thus all the data and information that is placed in the haemodynamic system will be already within the cardiologist’s report, this helps to generate reports faster and more accurately. What are the sizes of your Cardiology Department and Hospital? Northampton General Hospital

Northampton General Hospital has over 600 beds, serving a population of 360,000 on a regional basis. The Heart Centre consists of a nine-bedded day ward, a cardiac cath lab and a pacing theatre.  The  Cardiology Ward consists of a four-bedded coronary care unit and 26 cardiology beds.   What is the geographical intake area and population served by your hospital?  Our hospital supports the south Northamptonshire area, with a population of 360,000

Overhead View

How many staff? Roles? We have six cardiologists: three on-site interventional cardiologists, one visiting interventional cardiologist, one diagnostic cardiologist and one pacing/device cardiologist. Cath Lab staff: Chief Cardiac Physiologist (daily rotation of one cardiac technician from the Cardiac Dept for Cath Lab) Superintendant Radiographer, (with rotation of Radiographers from Radiology Dept), Cath Lab Sister, Recovery area Sister and 10 nursing staff rotating within Cath Lab and recovery ward area.  The implementation responsibility and working of FFR as part of the McKesson Horizon Cardiology lab is within the Cardiac Physiologist’s remit and training has been completed.

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Horizon Cardiology™

Horizon Cardiology™ Delivers Fully Integrated Fractional Flow Reserve (FFR) Support FFR support with Horizon Cardiology further improves cath lab workflow and ensures critical data is instantaneously available to cardiologists. t Support for all major FFR vendors’ pressure wires t Reduce capital expense by eliminating the need to purchase separate FFR analyzers t Easily incorporate the FFR result to a lesion via an intuitive user interface t Automatically store FFR pressure waveforms and numeric results in patient’s central cardiac file t Eliminate time and errors associated with manual data entry

Visit us for a personal demonstration at the BCS Annual Conference, June 7-9, 2010, Manchester Central

Booth 164 McKesson (Medcon), UK

Premier House 112 Station Road Edgware, Middlesex HA8 7BJ United Kingdom Phone: 0208 9511110 sales@medcon.com

AllAboutCVIS.com 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.


SITE VISIT

From Left to Right: Emma Timms (Junior Sister), Dr Dominic Cox (Consultant Interventional Cardiologist), Sheila White (Superintendent Radiographer), Cathy Spingys (Sister), Damini Jani (Lead Cardiac Physiologist)

Types of procedures? Diagnostic coronary angiography, angioplasty and stenting (including primary PCI), IVUS and PressureWire, basic and advanced cardiac pacing, including bi-ventricular and defibrillator device implantations.

Pacemakers: 229 ICD/CRTD: 18 CRT P: 5 What advantages of having FFR on your haemodynamic system?

We also provide extensive non-invasive imaging, in the forms of transthoracic, transoesophageal and Dobutamine/contrast stress echocardiography and myocardial perfusion scintigraphy. Types of equipment used? The cardiac catheterisation lab opened in June 2008 and has the following equipment: Image modality: Siemens Artis Zee floor-mounted C-arm system with flat-panel detector. Singo workstation with advanced IC3D facility. Haemodynamic System: McKesson (Medcon) Horizon Cardiology. Image Management and Reporting: McKesson (Medcon) Horizon Cardiology, with BCIS export module. IVUS: Boston Scientific i-lab Pressure Wire: St Jude Aeris with integrated FFR on McKesson (Medcon) haemodynamic system. How many procedures are performed a year? Our cath lab runs 4 days per week and in our first year of opening we performed the following number of studies: Angios: 1100 PCI: 344 Pressure Wire: 14 IVUS: 3

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Using the combined St Jude Aeris wireless pressure wire and McKesson Horizon Cardiology system allows direct recording and storage of the FFR into the haemodynamic full-disclosure. The McKesson Horizon Cardiology system has all the software/interactive capabilities of the St Jude stand-alone system, with the benefit of all measurements presented directly in the haemodynamic report without the need for data transfer or integration. The result is automatically presented in the  physician report. Direct connectivity with the haemodynamic system, using wireless technology, minimises problems with transfer of data between systems. From a safety aspect, the new system minimises cable connections and trailing wires around cath lab table. The new system also allows the cardiac physiologist to remain at the haemo station and continue full monitoring/documentation. What protocols has your department implemented to reduce doorto-balloon time? East Midlands Paramedic crews have been trained to recognise STelevation myocardial infarction (STEMI). The Accident and Emergency Department are pre-alerted to the arrival of the patient. As soon as the patient arrives they are assessed by a Cardiac Nurse Practitioner or Cardiac Registrar. At this stage a 12-lead ECG is taken, and the Cardiac Nurse Practitioner brings the 12-lead ECG to the cath lab to be assessed by the Cardiologist on call. (We are in the process of implementing an ECG


SITE VISIT server throughout the hospital; this will be provided by McKesson (Medcon) and Mortara DICOM ECG machines. The benefit of this true Dicom connection will result in the consultant’s ability to review ECG as soon as it is being taken through McKesson (Medcon) Horizon Cardiology.) Monthly cardiology meetings are held between the medical staff and the ambulance team to discuss patients who have had primary PCI’s performed; it is also an opportunity to determine how the process could be improved. In the period April 09 - March 10, 39 patients had primary PCI, with 88% of patients having a door-to-balloon time of less than 90 minutes and for call-to-balloon, 90% of patients under 150 minutes. Both are compatible with the national average for England and Wales. What new procedures have you implemented into the department recently?

A Cardiac Physiologist with the new McKesson Horizon Cardiology System

Introduction of PCI service with primary PCI provided between 8 am and 6 pm, Monday to Friday How is your inventory managed? Combination of McKesson (Medcon) Inventory Management barcoding system and electronic procurement service. How does the lab handle haemostasis? TR-band for radials, Angioseal for femorals, compression device or manual compression if patient unsuitable for Angioseal. What is the best part of working at your facility? In the past, patients requiring interventional procedures were transferred or referred to our neighbouring tertiary centres, over 50 miles away. The introduction of PCI to the Northampton General Hospital has made a significant difference to our patient population. Having the facility to perform primary PCI, in particular, provides effective treatment for the patient, minimising myocardial injury and preserving quality of life.

Nurses Station

Our service has benefitted from the good working relationship between our system providers, McKesson (Medcon), St Jude and Siemens. The systems have good connectivity and interaction which ensures a smooth workflow for each patient coming through our Cath Lab. We are proud to say that the Cath Lab team at the Northampton Heart Centre has evolved into a mature, competent and caring group of healthcare professionals working to provide the best care we can for our patient population. Thank you to all the Cathlab team of Northampton Heart Centre

Special thanks: Dr Dominic Cox, Consultant Interventional Cardiologist Damini Jani, Lead Cardiac Physiologist Sheila White, Superintendent Radiographer Maureen Gardner , Dept. Cardiology Manager Christian Lorentzen, Senior Systems Administrator, IT Department Andrew Beswick, Cardiology Nurse

Recovery

All images copyrighted to Luke Watson, McKesson

www.cardiologyhd.com  May/Jun 2010  19


Sophie Blackman’s ECG

Challenge Ms Sophie Blackman Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

Please note that the ECG was recorded at 25mm/s and 10mm/mV.

Clinical Background This ECG was taken on a 42 year old gentleman just prior to his exercise tolerance test. He was referred by a Consultant Cardiologist to whom he  had been known for several years. He had a history of dizzy spells which had recently escalated to syncopal episodes lasting up to a few minutes. The patient is currently being treated with methadone for heroin addiction.

Questions 1.

What abnormality is evident on the ECG and how should it be calculated?

2.

What syndrome might this patient have based on this ECG?

3.

How is his methadone treatment related to the ECG  finding and does this change his management?

4.

Is this patient suitable for a physiologist led exercise tolerance test? Answer on Page: 28

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United Kingdom

Site Visit West Hertfordshire Hospitals NHS Trust Watford General Hospital 60 Vicarage Road Watford, WD18 0HB United Kingdom

What are the sizes of your Cardiology Department and Hospital? In March 2009 the phased movement of acute and emergency services from Hemel Hempstead General Hospital and St Albans City Hospital to the Watford General Hospital site was completed and West Hertfordshire Hospitals NHS Trust now boasts the largest Acute Admissions Unit (AAU) in the country. The Trust maintains outpatient Cardiology services at all 3 hospital sites in order to provide local service to local patients, however all acute and inpatient treatment is undertaken at the Watford General Hospital. Watford General Hospital has 2 Cardiac Catheter labs, along with a 12-bed gendersegregated day ward, 15 general Cardiology beds, a 17-bed CCU and 10-bed ICU. Watford General Hospital

What is the geographical intake area and population served by your hospital? West Hertfordshire Hospitals NHS Trust serves a local population of approximately 550,000 and treats about 1 million patients per year. How many staff, and what are their roles?

Watford General Hospital

The Cardiology service has 9 Consultant Cardiologists and 2 Associate Specialists, 12 junior doctors including 4 Specialist Registrars, 23 Clinical Cardiac Physiologists and Cardiographers, 12 Cath Lab Nurses, 3 Cardiac Radiographers, 24 CCU staff and numerous secretarial, administrative and clerical-support staff. The Clinical Lead of Cardiology, Dr Mike van der Watt, is joined by 8 other Consultant Cardiologists that together offer a broad range of specialties. Types of Procedures and Tests Our Cath Labs see a wide range of trans-catheter procedures including coronary angiography (femoral, brachial and radial access), PCI, PPCI, pressure-wire studies, IVUS, IABP insertion, basic and complex device implantation including ILRs, pacemakers, ICDs and CRT-P and

www.cardiologyhd.comâ&#x20AC;&#x192; May/Jun 2010â&#x20AC;&#x192; 21


SITE VISIT Cath Lab Team (left to right): Sophie Blackman, Dr. Philip Moore, Louise Watts, Michael Blackwell, Barbara Bosch, Judy Gallant, Dr. David Hackett, Karen O’Brien, Anita Colwill, Sajed Ali, Joshua Sunderaraj, Obed Sardar

CRT-D, as well as cardiac electrophysiology and ablation. We shall be introducing Rotablation procedures in the near future. The Clinical Cardiac Physiology service offers 12-Lead ECGs, ambulatory BP and ECG application and analysis, physiologist led ETTs, RACPC,  CPC,  transthoracic  echocardiography,  TOE,  DSE,  contrast  bubble studies, 3D echocardiography, and ILR, pacemaker, ICD, CRTP, CRT-D follow up clinics and cardiac device remote viewing clinics.  What have been some of the challenges in setting it up your Primary Angioplasty Service? We do offer a Primary PCI service between 08:30 and 16:30. Out of hours patients are taken directly to the Harefield Hospital or the Hammersmith Hospital. The process of setting up our Trust for this service has been very well managed by our Cath Lab Business Manager, Alison Robinson, and has therefore been very successful. We put great effort into the educational aspects of this service to ensure that the service could be introduced with minimal complication. This has enabled us a smooth delivery of these patients to the cath labs with minimal door to balloon time, and we have been able to ensure that protocols were in place for the use of new equipment on CCU and ICU – such as the IABP.

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What new procedures/techniques have you implemented into the department recently?  In July 2009 West Herts Hospital started an EP service. The process of setting up the service was managed by Sophie Blackman, and Dr Anthony Nathan. We perform electrophysiology studies and RF and Cryo ablations for all arrhythmias currently with the exception of AF and VT.  West Herts has only 3 device specialist cardiac physiologists, but even so it is because of this small, yet incredibly efficient, robust and high-quality pacing service that it has been relatively easy to expand to include complex devices. West Hertfordshire NHS Trust was the leading pacemaker implant centre in England and Wales (per million population) in the 2007/08 National Devices Survey under the lead of Dr John Bayliss, and maintained a good position last year despite the process of consolidating services at the Watford General site. With the arrival of Dr Philip Moore we expanded our service to the implantation and management of complex cardiac devices. At the 2009 HRC conference Dr Nathan was named as the Consultant  with the highest rate of ICD implantations in the country, and West Herts was recognised as one of the leaders in the use of the CCAD  database which provides data for the National Devices Agency.


SITE VISIT Pacing & Complex Device Team (left to right): Wai-Ling Smalley, Dr Anthony Nathan, Jane Eldridge, Barbara Bosch, Sophie Blackman, Dr John Bayliss, Diane Saunders, Dr Philip Moore

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SITE VISIT Cardiac Device Remote Viewing is another new service offered to all ICD and CRT-D patients receiving their devices at West Herts. We feel this offers closer monitoring and management of the complex cardiac device patient whilst alleviating some of the pressure on the device clinics. Our complex echo service continues to grow and we have recently gained a GE Vivid 9 echo machine in order to expand the stress echo service and to allow dyssynchrony assessments.

tioned the Cath Lab staff are able to receive a lot of educational training in the labs as all cases are Consultant delivered. We hold daily lunchtime multi-disciplinary team meetings to discuss and plan cases and these are excellent for making sure our service is cohesive and evidence based. A lot of consideration has been put into the training of the Clinical Cardiac Physiologists and Cardiographers. Sophie Blackman, our Head of Clinical Cardiac Physiology is undertaking a project that uses confidence score rating to establish areas where training needs to be given to the individual and this is then specifically tailored, and she aims to implement these training programs this year.

What are the benefits to patients attending your facility? Whether patients are attending the Clinical Cardiac Physiology department, the Cath Labs, CCU or AAU they can expect to receive an excellent standard of care. West Hertfordshire Hospitals has the largest AAU in the country and the Cardiologists perform 2 ward rounds a day during the week, and one on each day of the weekend. This helps with the rapid diagnostic and therapeutic care of all cardiac patients at West Herts. Additionally West Herts was recently recognised as having the shortest length of stay for patients presenting with acute coronary syndromes compared to all other hospitals in the North West London Cardiac Network. The cardiac procedures are Consultant delivered, so patients receive excellent treatment, and the training to SpRs and other disciplines is exceptional. All patients for the cath lab are pre-assessed so we have a very low rate of procedural cancellations, and we swab all patients at the pre-assessment for MRSA making the levels of MRSA in our Trust one of the best in the country. West Herts is one of the best performing Trusts in the country in regards to C.Diff and we meet national targets for 18-weeks. It was in the redesign and restructure of the Cardiology department that we were able to review our entire facility to ensure that we offer patients a more holistic diagnostic and treatment service, and this ethos is certainly being felt by our staff and patients alike. What kind of training can new employees expect to receive? Training among the different disciplines varies. As previously men-

Additionally, great effort is made to ensure Cardiology training is offered to other medical disciplines to help encourage better referral patterns and to streamline services. What kind of competency checks do staff have to undergo once employed? We have been able, in the process of the merger, to review the competency of staff, and in the lab we are about to embark on a process of assessing all staff in the set-up, calibration and use of equipment. In Clinical Cardiac Physiology Sophie’s physiologists are all currently RCCP registered, or awaiting their RCCP number. Cardiographers are undertaking a 12-module ECG application and interpretation in-house training course that will guide them to their SCST Part 1 exams. All staff working in Clinical Cardiac Physiology will be assessed by workbased assessors in the areas within which they work to demonstrate competency and to encourage an ethos of training, development and evidence based practice. As the Head of Clinical Cardiac Physiology is an examiner for the SCST all physiology staff are regularly assessed to ensure that they provide exceptional working standards. All the physiologist working in echocardiography have BSE accreditation and the device physiologists are IBHRE or HRUK accredited. What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit? Dr David Hackett, our lead Consultant for the Cardiac Catheter Labs was one of the first Consultants to question the role of reps within the lab, and in his capacity of Vice President of BC he wrote the BSC guidelines on this. He insisted that the role of the rep in the lab should be exclusively to contribute a positive technical or clinical input into the patient management. Sales staff cannot be influential in the decisions that are made by clinicians. Our policy is strict in that reps can come to our lunchtime MDT meetings , provide food, and present a lecture on a product or service they offer, but they are not permitted to be present when the clinical element of the meeting begins. . Additionally reps can only be seen at a scheduled appointment time, as ‘dropping-in’ has been found to be disruptive to the working schedule.

Sajed Ali and Dr. David Hackett

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SITE VISIT What is the best part of working at your facility? I think that different staff groups would answer this in a variety of ways; however, the general feel of our department is that we always work to the best interest of the patient. We do not perform unnecessary test or procedures, and our team is very close. As all procedures are Consultant delivered we know that patients receive an excellent standard of care and therefore we try to match this with excellent diagnostics and technical expertise. We encourage an ethos of multi-disciplinary decision making, and this all-staff inclusion in decision making and care pathways means that the whole team believe in the strategy. This creates compliance and opportunities for staff of all disciplines to have an input and an opinion, as well as promoting a good-natured and enjoyable atmosphere within the department. Essentially we respect each other, and this really does create a cohesive unit where the most excellent patient care can be delivered. Joshua Sunderaraj (Radiographer) & Karen O’Brien (Cardiac Physiologist)

Your World have all the latest temporary and permanent positions available throughout the UK and Northern Ireland. Visit the team at the BCS Annual Conference and Exhibition Stand 102 , 7-9 June 2010 Manchester Central, Manchester

www.cardiologyhd.com  May/Jun 2010  25


Assistance Management

Management: Set Your Boundaries.

I

n last months’ edition, whilst talking about absenteeism, I mentioned the importance of setting boundaries for your staff. In this edition I want to establish the role of boundaries in a department, how to maintain them, and as a manager how to make these margins work for you.  Boundaries need to be in place in every institution to keep staff and patients safe. Even though a restriction by definition, boundaries actually work to keep your staff dynamic and your department functional. Ms Sophie Blackman Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

Social boundaries are those we learn whilst growing up, such as being aware of what is right and  wrong, and understanding what is socially acceptable behaviour. These social behaviours are both  inherent and learned. Our parents, or significant adult parent figure teach us these values, and in the workplace the departmental manager represents the parent, where their duty is to affirm both these social and professional boundaries.   In the workplace the boundaries you create for your team helps to allow close  engagement, sets limits, determines acceptable behaviour, clarifies expectations, creates autonomy, and makes everyone accountable – yourself included. There are a number of boundaries you will have already established, such as  an expectation for your staff to arrive on time for work, and to perform their duties in a professional manner to the standards you have set for your department. However, there are some boundaries that we may have in place which  are not entirely functional. The poorly maintained departmental restrictions allow  the  line  between  what  is  acceptable  and  what  is  not,  to  become  not  just bent, but often entirely broken, and this is where a department’s function begins to suffer. Communicating with your staff their goals and limitations is crucial in your department. All staff should know what duties are expected of them, the standards  at  which  they  should  be  working,  and  most  importantly  the  roles  they  are not yet ready to manage alone. Giving your staff freedom to be dynamic and troubleshoot their own problems is to certainly be promoted, but always  within the margins you have set. This in turn encourages your staff to bring you solutions rather than problems, and gives tangible goals which support their professional development.  As their leader you need to be available to discuss the boundaries you have  enforced, and be open to receive feedback for discussion. Without these limitations in place, we lose our power as a manager to enforce standards of care, and professional relationships. That said your staff will often be best placed to know what is actually achievable, so you must verify your reality against them.  Involving staff in the process of creating boundaries and in the negotiation of what are achievable goals, and fair restrictions means that they will be less inclined to push the boundaries.  Undoubtedly some of your staff will test the boundaries you have in place; a subconscious assessment that they are being effectively managed and that you are acting as the parent. However, the most crucial benefit of a clearly defined boundary is that your staff know where that ‘line’ is, they understand that they must work within those boundaries and that if they do not do so they can rightly be disciplined. 

2  May/Jun 2010  www.cardiologyhd.com


BRITISH CARDIOVASCULAR SOCIETY: Annual Conference and Exhibition 7 to 9 June 2010 Manchester Central, Manchester

2010 sees the 88th British Cardiovascular Society Annual Conference and Exhibition (ACE), a three day meeting of educational and scientific interest in Cardiovascular Medicine. The event be held in the newly renovated Manchester Central. The Conference programme has a broad educational theme including case based presentations interspersed with plenary sessions of a clinical, scientific and translational nature. •

The keynote lectures this year will be given by Prof Patrick Surreys (Thomas Lewis lecture, ‘Biodegradable drug eluting stent or vascular restoration therapy for percutaneous revascularization’) Prof David Crossman (the BCS/RCP Lecture supported by the Joy Edelman Legacy, ‘New discoveries and their translation to man’), and Dr Edward Rowland (BCS Lecture, ‘Managing the cardiac rhythms of life’). The exhibition will showcase the latest developments in cardiovascular medicine and new technologies. Stands from over 80 companies from the wide arena of Cardiovascular medicine will be present, making our Exhibition the largest in Cardiovascular medicine in the UK. Following on from developments at last years’ event, the Exhibition will include greater number of educational activities such as Moderated Posters, “Meet the Experts” and Cardiac simulator training with opportunities for all to try their hand at the latest equipment available. In addition, the popular “How to” sessions will be held in larger theatres to allow for the high number of attendees that these sessions attract.

Fly, Nuclear Cardiology, Valve Treatment and the Athletes Heart. The ACE 2010 will give attendees the opportunity to gain CPD points and review general cardiovascular knowledge required for revalidation. •

A new highlight will be Educational Spotlight sessions where the focus will be on different topics, each fitting to a 90 minute session. These Spotlights are designed to be digestible education presented in a dynamic format and with robust evidence based take home messages.

This year’s Annual Dinner will be held at the Manchester Town Hall on the Tuesday night, with entertainment from magicians and a jazz band.

At this years’ event there will be a linked meeting with British Atherosclerosis Society and British Society for Cardiovascular Research at the ACE 2010. This joint initiative will include hot topics and developments in cardiovascular research, the Young Investigator award and the BAS John French lecture.

On Monday 7 June, PCCS will be holding afternoon sessions for their members on Cardiovascular Guidelines.

The Future of Cardiac Commissioning – a one day symposium for commissioners and managers on Wednesday 9th June, developed in conjunction with the Department of Health and NHS Improvement, focussing on the challenges of commissioning quality services and showcasing the very latest developments in this area.

The educational content of the ACE 2010 has been based on the new European Curriculum, and includes a dedicated Trainee day that will have a session from the SAC as well as covering a wide variety of topics such as Cardiac Operations, Cardiac Fitness to For online registration and full details of the programme, go to www.bcs.com.

Simulator in the Exhibition www.cardiologyhd.com  May/Jun 2010  27


Answer

Sophie Blackman’s ECG Challenge

Question on Page: 20

Ms Sophie Blackman Coronary Heart Management and  CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust United Kingdom

1. This 12-ECG shows sinus bradycardia with a heart rate of 44bpm.  Even without formal calculation or indeed measurement it is clear that the patient has a very long QT interval. It can be difficult to establish from which lead the QT interval should be measured as  there can be variance in the QT across the leads, however, due to  the heart rate it would be prudent to measure this QT from the  rhythm strip (lead II) as it can be measured from a few complexes to  ensure accuracy. On measurement the QT is 17 small squares long = 17 x 0.04 = 0.68 seconds or 680ms. The QT interval measurement should always be corrected for the  heart rate. Although Bazett ’s QT correction formula is the most commonly used it tends to overcorrect in patients with heart rates >110 and <60 bpm. Therefore in the instance of this patient either Hodges or Framingham correction formulae should be adopted. Using Hodges formula: QTc = QT +1.75(heart rate-60) QTc = 680ms + 1.75(44-60) Therefore: 680 + 1.75(-16)     680 + -28   QTc = 652ms

2. This patient is displaying characteristics of long QT syndrome, including QTc >440ms, sinus bradycardia and notched T waves¹.   His symptoms of dizziness and syncope are also suggestive, and so Schwartz criteria² to assist in the diagnosis of long QT should be  used. Refer to Table 1.

3. Methadone is independently associated with a prolonged QT interval and progression to torsade de pointes³. Studies have shown that 

2  May/Jun 2010  www.cardiologyhd.com

a daily dose of methadone (mean, 397±283mg) correlates positively with a prolonged QTc interval (615±77ms) after the analysis is adjusted for variables such as age, structural heart disease and hypokalaemia⁴.  Methadone delays cardiac repolarisation by blocking the flow of potassium ions through the HERG channels⁵. The risk associated  with long QT syndrome is torsade de pointes, a polymorphic VT.  Derangements in ion flow leads to prolonged action potentials and the generation of spontaneous upstrokes, resulting in premature ventricular depolarisations. Propagation of premature VEs can initiate torsade de pointes if they occur within the period of enhanced  electrical instability during repolarisation. Termination of methadone treatment can result in normalisation of the QT interval, but methadone should not be stopped abruptly  and has a half-life of up to 190 hours. Additionally termination of methadone, a drug for rehabilitation, would need to be carefully considered in regards to future management of the patients’ heroin addiction. An ICD should be seriously considered for the treatment of ventricular arrhythmias even though termination of methadone could normalise the QT. Interestingly not all patients who take methadone have a long QT, and therefore the suggestion that methadone unmasks an underlying predisposition for long QT syndrome makes the weight of argument for ICD implantation greater.

4. This patients ECG was taken at the time of his ETT. The SCST/BCS Recommendations for Clinical Exercise Tolerance Testing⁶ suggests  that any test for the provocation of arrhythmias should be physician led. Whilst many centres have local protocols, it is important to consider that an ETT for a patient of this type is to establish whether a polymorphic VT can be induced and although in the case of long QT  the episodes of torsade de pointes are often short and self terminating, the episodes have a tendency to occur in rapid succession causing syncope, and sometimes death.


ECG ANSWER Table 1: Table Criteria for diagnosis of LQT syndrome Characteristics

References

Points

1.

Schwartz PJ, Malliani A. Electrical alternation of the T wave: clinical and experimental evidence of its relationship with the sympathetic nervous system and with the long QT syndrome. Am Heart J. 1975; 89:45-50.

2.

Schwartz PJ, Moss AJ, Vincent GM, et al. Diagnostic criteria for the long QT syndrome: an update. Circulation. 1993;88:782-4.

3.

Lamont P and Hunt S. A Twist on Toursade: A prolonged QT interval on Methadone. J Gen Intern Med. 2006;21(11):C9-C12.

0.5

4.

Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, Robertson AD, Mehler PS. Toursade de pointes associated with veryhigh-dose methadone. Ann Intern Med. 2002;137:501-4.

>=480 ms

3

5.

460-470 ms

2

El-Sherif N, Turrito G. Torsade de pointes. Curr Opin Cardiol. 2003;18:6.

450 ms (in males)

1

6.

http://www.scst.org.uk/clin_guidance/ETT% 20consensus%20March%202008.pdf.

Clinical history Syncope With stress

2

Without stress

1 0.5

Congenital deafness Family history* Family members with definite LQT

1

Unexplained sudden cardiac death at age <30 y among immediate family members Electrocardiographic findings† QTc

Torsade de pointes

2

T-wave alternans

1

Notched T wave in 3 leads

1

Low heart rate for age (<2nd percentile)

0.5

Scoring: <=1 point = low probability, 2-3 points = intermediate probability,   >=4 points = high probability. Torsade de pointes and syncope are mutually exclusive.

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The Current Evolution of PCI (an industry perspective)

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ngiography Alone is Not Enough. Physicians are relying more on precise PCI-guidance tools like FFR, IVUS and OCT than ever before. Use of these technologies has increased in every major geography, including Japan where IVUS usage is now estimated at more than 70% of all PCI. Is this just a temporary trend, or a sign that the interventional cardiologists approach to PCI guidance is changing for good? For change to happen, there must be a trigger… a problem that needs to be solved. The challenge interventionalists are presented with today is three fold; 1) Major publicized studies like COURAGE, SYNTAX and HORIZONS have demonstrated that angiographically guided PCI procedures do not always lead to better outcomes than medical therapy or CABG, and that there is still plenty of room to improve on 12-month event rates, especially in more complex patients. 2) Recent studies like FAME, PROSPECT, STLLR, Lindstaedt, Diethrich have highlighted the clear limitations of angiography to assess lesion severity, ischemia, presence of calcium, proper stent diameter, length and expansion. And 3) Clinical trials including FAME, JSAP , ROY , Costantini underline the trend of excellent or comparatively superior outcomes when using precision guided PCI tools like FFR and IVUS. The body of evidence that is accumulating not only supports the dramatic increase in FFR and IVUS usage in the past few years, but also suggests this evolution to precision-guided PCI is a sign of things to come. This clinical need is driving change both in technique and in technology. The days of a heavy, awkward, roll-around console are over. Modern day IVUS and FFR systems (and in the future, OCT, Forward –Looking IVUS and Image Guided Therapy) can now be physically integrated into the cath lab suite, enabling fast, easy access to these products for every room and every patient. Speed and access are requirements for a successful technology and integrated systems have helped to remove those barriers in the modern day cath lab. The imaging catheters and FFR wire technology must change as well. Modern day devices track farther, respond better, and provide more

information than previous generations. With opportunity comes innovation, and this innovation is seen in a host of new imaging and physiology product launches planned for 2010. New markets will be developed like OCT and Forward-Looking IVUS to help guide increasingly more complex procedures. To control healthcare costs, these complex procedures will be done with advanced precision-guided tools to reduce in-hospital complications, reduce repeat interventions and eventually replace expensive surgical procedure like CABG with less invasive percutaneous approaches. One day, the evolution of these products will continue to where common therapy devices like angioplasty balloons and stents will have miniaturized imaging transducers or sensors built into the therapy device itself, removing any final barriers to using precision guided tools. Importantly, there will not be a single technology used in every case. Each will have its own advantages and indications. It is the clinical presentation and physician preference that will dictate the selection on a patient by patient or lesion by lesion basis. The key is to make all of these technologies available on a single, integrated system, which is always on, and always ready.

4. 5. 6.

7. 8. 9. 10. 11.

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Boden et al. Optimal Medical Therapy with or without PCI for stable coronary disease (COURAGE) New England Journal of Medicine 2007; 356:1503-16 Serruys, P. et al.  “PCI versus CABG for severe coronary artery disease. SYNTAX” NEJM 2009 online, commentary closes March 4th 2009. Stone, G. et al. “HORIZONS AMI One Year Results.” TCT Conference, 2008. Tonino, et al. (FAME) New England Journal of Medicine 2009; 360:213-24 Gregg Stone on behalf of the PROSPECT investigators as presented at TCT 2009 Costa et al. Impact of Stent Deployment Procedural Factors on LongTerm Effectiveness and Safety of Sirolimus-Eluting Stents (Final Results of the Multicenter Prospective STLLR Trial). Am J Cardiol 2008 Jun 15; 101(12):1704-11. Lindstaedt M, et al. Int J Cardiol. 2007;120:254-6 Diethrich et al. Journal of Endovascular Therapy. 2007; 14:676-686 Nishigaki, K. For the JSAP investigators. “PCI Plus Medical Therapy Reduces the Incidence of ACS More Effectively than Initial Medical Therapy Only Among Patients with Low-Risk CAD.” JACC 2008; Vol. 1: No. 5. Roy, P. et al. “The potential clinical utility of IVUS guidance in patients undergoing PCI with DES.” EHJ, 2008. Costantini, C. et al. “Impact of IVUS to Guide DES Implantation Decreasing Long Term Clinical Events.” TCT Conference, 2008.

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* The same family member cannot be counted twice. † In absence of medications or disorders known to affect these electrocardiographic features

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Cardiology Events

Calendar LIKE TO BE

United Kingdom

FEATURED?

June 7-9

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

1

admin@coronaryheart.com

BCS Annual Conference and Exhibition 2010 Manchester Central Manchester, England www.bcs.com June 7-11

For a list of conferences and events around the globe visit our website:

2

Hammersmith Echocardiology Hammersmith Conference Centre London, England www.imperial.nhs.uk/hcc July 9

3

What’s New in Cardiology - A Clinical Update for Nurses St George’s Hospital London, England E-mail: dcole@sgul.ac.uk October 3-6

4

Heart Rhythm Congress 2010 Hilton Birmingham Metropole Birmingham, England www.heartrhythmcongress.com October29-30

5 1

British Society of Echocardiography Annual Meeting & Exhibition Bournemouth, England www.bsecho.org

International June 2-5 New Cardiovascular Horizons Conference The Roosevelt Waldorf - Astoria New Orleans, LA, USA www.ncvhonline.com

4

2 5

30  May/Jun 2010  www.cardiologyhd.com

3

September 21-25 TCT 2010 Washington Convention Center Washington, DC, USA www.tctconference.com


Heart Rhythm Congress

Upcoming Issues* Heart Rhythm Congress 2010

3-6 October 2010 Hilton Birmingham Metropole

July / August 2010 ›

Future of Cardiac Cath Labs Special Edition

Transcatheter Aortic Valve Implantations (TAVI)

NICE Guidelines for Recent Onset of Chest Pain

What cardiologists and staff want designed next?

ECG Challenge 16

September / October 2010 ›

Management Hot Topic: Recruitment challenges.

Lead Extraction Problem Solving

New Technologies in EP

Echo Buyer’s Guide

EP Education Series

Pacemaker and ICD Technologies

ECG Challenge 17

* Editorial topics subject to change

n o y i g t o a l c y o u t n i d s h E r Tec Dive www.heartrhythmcongress.com melanie@heartrhythmcongress.org.uk

+44 (0) 1789 451822 Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK Telephone: +44 (0) 1789 450 787

HAMMERSMITH ECHOCARDIOLOGY 7-11 June 2010 Course Director: Professor P Nihoyannopoulos MD, FRCP, FACC, FESC A week-long course of contemporary echocardiography designed for cardiologists, cardiac technicians and general physicians with some previous knowledge of echocardiography. This course is geared to those who want to improve their knowledge and keep up-to-date with the ever-expanding ultrasound modalities. This intensive course will consist of lectures from worldwide experts and discussions on controversial subjects. The following topics will be covered: Physics of modern ultrasound technology * Comprehensive transoesophageal echocardiography and colour flow mapping * Congenital heart disease * Stress echocardiography * Echo in coronary heart disease * Valvular heart disease * Endocarditis * Ventricular function and quantitative echocardiography * Video tape demonstrations. Full programme and registration details available from:

Hammersmith Conference Centre Web: www.imperial.nhs.uk/hcc Email: hcc@imperial.nhs.uk Tel: 020 8383 1601/1608

Supported by the British Society of Echocardiography and European Association of Echocardiography

www.cardiologyhd.com  May/Jun 2010  31


ANNUAL CONFERENCE AND EXHIBITION 2010 Venue: Manchester Central, Manchester Date: 7 to 9 June 2010 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 2010. Visit www.bcs.com for online registration and further information.


Coronary Heart #24