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

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Issue 29 • Mar/Apr 2011

LATEST PRODUCT NEWS THE FACTS Behind the Headlines

CARDIOLOGIST HOT TOPIC PFO Closure

MANAGEMENT ASSISTANCE Care and Compassion

UK SITE VISIT Barnet Hospital

ECG CHALLENGE JOURNAL REVIEWS CARDIOLOGY EVENTS

Nepal

Lifestyles of Patients with CHD


Rendez-vous in Paris 17th-20th May, 2011

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Interactive programme: use the online search engine

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Mar / Apr 2011

Contents lATEST NEWS

Latest Product News

Latest Product News

Round Up We Want Your Department

New hope for people with heart failure EXTERNAL ENHANCED COUNTER PULSATION (EECP)

QuikClot® THE BLEEDING STOPS HERE! Dot Medical, is delighted to introduce QuikClot® an amazing non-invasive haemostatic bandage for safe and effective control of bleeding.

Dot Medical ltd. is delighted to announce that they are now supplying EECP therapy in the UK. Although EECP is not currently a familiar therapy to many people, Dot Medical aims to change this perception. EECP has an established research pedigree that suggests it should be THE therapy of choice for the management of a wide range of medical conditions. It is non-invasive, cost effective and offers hospitals the opportunity to treat patients on an out-patient basis and can reduce hospitalization times. This makes it extremely exciting given the current economic climate.

We all need to be able to stop bleeding quickly, safely and preferably cost effectively. Kings College Hospital, London

QuikClot® can be used anywhere when there is a need to stop bleeding .

One of the most popular sections in our publication is the Site Visits. Over the last five years we have featured 35 different departments from all over the world, and now we would like to feature yours.

EECP is a non invasive therapy that helps treat heart failure by strengthening the heart muscle simply by pumping more blood back to the heart. The more blood pumped back to the heart, the stronger it gets. EECP increases blood flow to the heart by opening up collateral circulation and creating new blood vessels, while at the same time strengthening the heart. It keeps blood vessels relaxed, open and prevents plaque buildup. EECP reduces arterial stiffness and releases nitric oxide which has an antioxidant effect, making arteries resistant to spasm and clotting. It has a detoxification effect and increases lymphatic circulation.

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

In the coming editions we are going to enhance the Site Visits section, featuring multiple hospitals from not just the UK, but further afield throughout the world. Recently we sent word out on our CardiologyHD Facebook page, so you can now expect Romania and New Zealand to be amongst the first countries featured.

EECP has been FDA approved since 1995 to treat coronary artery angina, cardioogenic shock and heart failure. It has had CE approval for over 10 years and is used for a wide variety of conditions including peripheral vascular disease, erectile dysfunction (an early predictor of heart disease), sudden hearing loss and tinnitus, stroke, restless leg syndrome, peripheral neuropathy and can facilitate sports rehabilitation.

But don’t just take our word for it – QuikClot® is the US Military’s exclusive choice for extreme bleeding in wartime injuries in the combat field – so it has to be good! The active haemostatic ingredient (kaolin) is non-invasive and woven into the hydrophilic bandage, allowing swift control of bleeding. Kaolin has been recognised for more than 50 years as an affective clotting product. It does not use thrombin, fibrinogen or shellfish by-products and so has no known contraindications.

For more information on how your department can be featured contact us at: admin@coronaryheart.com

The investigator-led, multicenter, non-randomized, observational prospective GATEWAY registry will enroll 280 patients at eight sites in the U.K. The governmentapproved GATEWAY study protocol recommends that these patients undergo three months of dual anti-platelet therapy (DAPT) or less following stent implantation. The primary endpoint of the registry is the occurrence of net adverse clinical events (NACE) at 30 days and at one year follow-up.

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“High-risk patients who present with non-ST segment elevation myocardial infarction (NSTEMI) remain a challenge,” said Dr. David Smith of the Regional Cardiac Centre at Morriston Hospital, Swansea, Wales, principal investigator of the trial. “Identification of patients with a higher propensity for bleeding may lead to improvements in NSTEMI care by prompting clinicians to make judicious treatment selections, carefully dose antithrombotic medications and proceed with strategies to optimize individual patient care.”

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For more information, visit www.OrbusNeich.com. Follow all of OrbusNeich’s news on Twitter at http://twitter.com/ OrbusNeich.

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

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GATEWAY Registry Initiated in U.K. to Investigate OrbusNeich’s Genous™ Stent in Patients with Acute Coronary Syndrome (ACS) and High-Risk of Post-Procedural Bleeding

Deve op ng Countr es Dharan Nepa

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For further information contact: Dot Medical: info@dot-medical.com; 01625 668811

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3 Dr David Smith

6 Mar/Apr 2011 www.cardiologyhd.com

THE FACTS

The following articles are courtesy of NHS Choices

Behind The Headlines

The Facts

THE FACTS

www.cardiologyhd.com Mar/Apr 2011 5

The Facts Blood Pressure

Sleep and heart risk link is uncertain

Combined drugs ‘better’ for blood pressure

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

This randomised controlled trial found that starting patients on a combination of hypertension drugs gives a faster and greater reduction in blood pressure than either of the drugs on their own, without any more side effects. The drugs, amlodipine and aliskiren, work to lower blood pressure in different ways.

Cardiac Statins

Synthetic veins for heart bypass

“Lack of sleep is a ‘ticking time bomb’,” The Independent reported. The newspaper said that people who regularly sleep less than six hours a night “have a 48 per cent greater chance of developing or dying from heart disease”.

A newly published study has suggested that “a combination of drugs is better than a single one in treating high blood pressure”, BBC News reported.

Scientists have grown human veins in a laboratory, in a breakthrough that could revolutionise heart bypass surgery, reported the Daily Mail.

Statin benefit for low risk people ‘questionable’

The news comes from research in which scientists developed a method for using human muscle tissue to create human blood vessels in the laboratory. These were then tested in animals, where they showed “excellent” blood flow and resistance to blockages and other complications. The vessels could also be safely refrigerated for up to a year.

“Up to three million people are taking statins needlessly,” says The Daily Telegraph. It reports that a comprehensive study suggests statins are “ineffective in many cases and could be doing more harm than good”.

A device to measure blood pressure at the wrist is not new, and the method does not replace the traditional approach of using a cuff on the upper arm. However, the researchers’ method for combining the two results to estimate CASP appears to have some merit, and may filter into medical care.

This review supports the need for careful consideration of the overall cardiovascular risk of the individual when deciding whether to prescribe a statin. In higher-risk populations, the benefits of a drug often clearly outweigh the risks. However, when lower-risk populations are considered, this balance can often tip the other way. The results here do not support the widespread use of statins in people at low risk of cardiovascular events.

This initial animal research has suggested that it may be possible in the future to use these synthesized vessels in humans, for example in coronary artery bypass operations, which currently rely on patients providing a healthy blood vessel to form their bypass graft. However, this short, preliminary research was in its early stages and therefore scientists will need to undertake many further stages of research before these lab-grown veins are proven to be safe and effective in humans.

The newspapers reported the research accurately, although they tended to reflect the optimism of the scientists rather than the limitations of the research. The Daily Telegraph’s report that the new veins can be “safely transplanted into any patient” is not supported by the research conducted so far. The BBC’s report quoted independent experts who correctly pointed out that this is early research, and the Daily Mail also highlighted that the veins were unlikely to be available to patients for several years.

“Watching TV for four hours a day doubles the risk of a heart attack,” The Sun has reported. “The reason is thought to be that simply sitting for so long causes coronary problems,” the article added. The story is based on a study that surveyed 4,512 people to estimate their television viewing and physical activity, comparing their habits with their risk of death or cardiovascular disease over the next four years. Those viewing TV and video games for four hours or more per day were 48% more likely to die (due to any cause) and 125% more likely to have a cardiovascular-related event (such as a heart attack or stroke) than those who watched less than two hours. The relationship was independent of smoking, social class and how much physical activity people did. This well-conducted study suggests that lengthy periods of recreational viewing may have harmful effects on the cardiovascular system, increasing the risk of heart attacks, strokes and early death.

8 Mar/Apr 2011 www.cardiologyhd.com

Dr Brian Clapp MA PhD MRCP Consultant Cardiologist Guy’s & St Thomas’ Hospital London, UK

trokes are a greatly feared and debilitating event in anyone and perhaps even more so in young people in whom they are thankfully rare. Strokes are ischemic in 80% of cases and, using our current understanding of their causes, the reason can be found in about 60% of these individuals. Recognised precipitants include carotid atheroma, dissections, vasculitis, pro-thombotic states and cardiac sources of emboli such as atrial fibrillation, left ventricular thrombus and endocarditis.

ranging from 3.8-12% and device treated from 0-4.9%). As these are non-randomised studies there was a drive to obtain properly controlled data and to that end five studies were started using different commercially available devices pitched against medical therapy in a fully randomised fashion. The first to report, at the American Heart Association meeting in November 2010 (although not yet in print), was the CLOSURE 1 study. This compared medical therapy, a mixture of anti-coagulation and anti-platelets, to device closure with the NMT Biostar device. The primary end-point in this superiority study was a composite of stroke/TIA and mortality (all cause to 30 days and then neurological out to two years) and as has been reported was negative with an event rate of 5.9% in the device arm against 7.7% (P=0.3) in the medical group.

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

Do we read from this that device closure is unnecessary?

The theory runs that small clots return from the peripheral veins to the heart and instead of passing on to the lungs, and being destroyed by the natural thrombotic pathways there, are able to pass across the PFO into the systemic arterial circulation and cause embolic phenomenon such as a stroke. What is the evidence for this? Support exists in two forms – firstly there are numerous case reports where long clots are found caught in the process of passing through a PFO. Secondly cross-sectional studies have shown that the presence of a PFO (particularly in association with an atrial septal aneurysm) is much more likely in patients with cryptogenic strokes than the general population – increasing in Lechat’s series (NEJM 1988) to over 50%.

Well this is not straightforward to answer - at least in part because we do not as yet have the full published dataset and therefore can only comment on the information presented at the AHA meeting. There are a number of points that should be raised in considering this result. The first is that of its power to detect a real effect (as an under-powered study may miss a small but clinically important effect) – this study originally intended to recruit 1600 patients and due to very slow uptake was terminated early with fewer than 1000 subjects. Concern that this change under-powers the findings is supported by the absence of the usual negative effect of having a septal aneurysm upon risk and is a particular danger in superiority studies. As a result of the reduced size the expected event rate in the treated arm was 2% or less by intention to treat analysis. Unfortunately in this study there was a high procedural complication rate with only a 90% procedural success rate – the reason for this is not clear although the large number of centres performing small numbers of procedures has been put forward as a potential factor. As a result the event rate in the device therapy arm was increased by these early complications and may have biased the outcome.

These findings may implicate the PFO in cryptogenic strokes; however they do not give insight into the best treatment options. In non-randomised studies patients have either been treated with anti-platelets, formal anti-coagulation or closure of the defect with a prosthesis. Attempts to compare these disparate groups indicated that device closure, particularly in the presence of a septal aneurysm, was superior (annual recurrence rates for medically treated

In order to be effective device closure needs to have been both necessary and also successful in preventing continued passage of material across the tunnel. It is possible to question both of these points. Firstly only a little over half the subjects had a moderate or large shunt at baseline and only one third had a septal aneurysm. Therefore a significant proportion of the recruited population had a “low risk” PFO as defined by previous cross-sectional studies. Secondly success, assessed by TOE, was constant at 86% at all time points – this means nearly 15% had significant residual shunts despite using an ultrasound technique which tends to under-report shunts due to the difficulty in performing an adequate Valsalva manoeuvre with a probe in the oesophagus. Both of these factors would work against seeing superiority in the device arm. Finally in the data presented it became clear that exhaustive searches for alternative embolic sources may not have occurred, as they were then retrospectively found in the majority of patients with recurrent events. Of concern for the use of devices in the heart there did appear to be an increased risk of atrial fibrillation in the active arm, although as the full data has not been published it is unclear when this occurred and whether it was sustained or related to hazardous end-points.

he answer is yes, although the Closure I study is certainly food for thought. I think it has probably come at a good time, as we have seen a proliferation of new devices and what feels like a renewed drive from industry to market these devices. The effect of Closure I has been for everyone concerned with PFO device closure to pause and think hard about what are trying to achieve when we close a PFO. My personal view is that the Closure I results are not that surprising. This is for a number of reasons:

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The study included TIAs without any evidence of cerebral infarction/ embolism. We all know that the ‘TIA population’ is very heterogenous and often there is little objective evidence of cerebral embolism in this group. The grey area between migraine and cerebral ischaemia is also difficult, but there is often pressure from referring doctors to close the PFO in this group.

2.

The medical therapy in the ‘best medical/anticoagulation’ group was heterogenous. Whilst under-treatment should emphasize the benefits of device closure, it will not cause any ill-effect either. Many patients fear being on warfarin in the long-term and there will be an excess of bleeding in anticoagulated patients over a more prolonged period

3.

The follow-up period was too short.

4.

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

Where does this study leave the field of PFO device closure? Clearly in discussing with patients one cannot ignore these results and they are the only randomised data available. That being said CLOSURE 1 does not indicate that device closure is never beneficial, but rather tells us more about the importance of very careful assessment of patients for alternative causes before contemplating closure and the need to concentrate this work within high volume centres who can achieve low procedural complication and high closure rates. More clarity should come from the publication of further studies, particularly the RESPECT trial as this is event driven, and help us to define exactly which patients should be offered device therapy and which are better served by medical treatment.

The study was published in the peer-reviewed Journal of the American College of Cardiology. It was reported accurately, but uncritically, by newspapers.

PFO C osu e

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

T 1.

The study was carried out by researchers from University College London, the University of Queensland, Brisbane and Edith Cowan University and the Heart and Diabetes Institute, Melbourne. The researchers were financially supported by the UK’s National Institute for Health Research, the British Heart Foundation and the Victorian Health Promotion Foundation Public, Australia.

Card o og st Hot Top c

Cardiologist

Hot Topic PFO closure: is there still a future post CLOSURE 1?

However, the study had some limitations, such as not accounting for the influence of diet or time sitting in front of a computer at work. This initial research is of interest, but there is now a need for larger, longer studies to verify the relationship.

10 Mar/Apr 2011 www.cardiologyhd.com

HOT TOPIC

www.cardiologyhd.com Mar/Apr 2011 9

S

The study was carried out by researchers from the University of Leicester, the National Institute for Health Research, Gleneagles Medical Centre in Singapore and Healthstats International in Singapore. The study was financially supported by the Leicester National Institute for Health Research Biomedical Research Unit in Cardiovascular Diseases. The study was published in the peer-reviewed Journal of the American College of Cardiology.

Television heart risk needs more study

The news reports follow a Cochrane systematic review conducted by researchers from the London School of Hygiene and Tropical Medicine and the University of Bristol. The main conclusion of this review is that there is a lack of quality evidence to support the use of statins in people with low cardiovascular risk. This has been generally reflected in the articles by The Daily Telegraph, the Daily Mirror and the Daily Express. However, the Daily Mail’s headline (“Statins ‘may cause loss of memory and depression’”) is incorrect. The researchers’ main concern is that there is not enough reporting of adverse events, not that there is evidence for any particular harm.

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

The study was mostly reported accurately by the BBC, however, the statement that the combined treatment had fewer side effects is incorrect. The proportion of people who withdrew due to side effects was actually the same for combined treatment and the group taking aliskiren plus placebo, but higher (18%) for those taking amlodipine. The claim by the Daily Express that the pill could “prevent 5,000 strokes a year” is not supported by the study, which looked at the effect of different treatments on blood pressure measurements, not on strokes or other cardiovascular outcomes.

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Beh nd he Head nes w h NHS Cho ces

Although news coverage has focussed on the wrist-worn monitor, the research devised a technique to combine blood pressure readings from the wrist and upper-arm to estimate central aortic systolic pressure (CASP). This measure of pressure in the aorta is thought to be a better way of predicting heart problems than traditional measures of blood pressure, such as using an inflatable cuff around the bicep.

It is important to point out that the benefit of statins in people with cardiovascular disease, who have already suffered a heart attack or stroke, or who are considered to be at high risk of an event, is not in question here.

The study was carried out by researchers from Warwick Medical School and the University of Naples in Italy. No sources of funding were reported. The study was published in the peer-reviewed European Heart Journal. The newspapers generally reflected the findings of the research accurately, but did not address the wider issues and limitations of the study.

People who are concerned about their blood pressure or its treatment should visit their GP. The study was carried out by researchers from the University of Cambridge, the British Hypertension Society, the University of Glasgow, Novartis Pharma AG, Switzerland, and Ninewells Hospital and Medical School, Dundee. It was funded by Novartis Pharma AG and two of the study’s authors are employees of this company. The study was published in peer-reviewed medical journal The Lancet.

New Technology

Blood pressure device performs well A watch-like device “could revolutionise blood pressure monitoring”, BBC News has reported. According to the website, the monitor can be used to measure pressure in the wrist, which can then be used to estimate pressure in the aorta, the largest artery in the body.

The news story is based on a review of trials of statins in people who had not (yet) suffered a cardiovascular event such as a heart attack or stroke. There was some evidence that statins reduced the risk of dying from any cause, and the risk of any cardiovascular outcome. However, the trials and review have several limitations, including some indications that adverse events within the trials were not recorded.

The review has some important limitations. For example, many medical, psychological and lifestyle factors can affect both sleep and cardiovascular health but attempts to account for the influence of these factors varied widely between the studies. It is also unclear whether the participants did not have any cardiovascular disease at the start of the studies, so it should not be assumed that poor sleep was the cause of the cardiovascular problems eventually observed. As the researchers say, the reasons behind any associations between sleep and cardiovascular disease are not fully understood.

Doctors currently start patients with high blood pressure on one drug and may add others later if needed. The authors of this well-designed trial suggest that clinical practice should now be changed and that patients with high blood pressure be started on two drugs rather than one. However, although the results of this study are significant, it looked only at two specific types of drug, so cannot make comparisons of the effectiveness of treatment with other classes of blood pressure drug, whether used alone or in combination. Longerterm effects and adverse outcomes beyond 32 weeks (such as stroke, heart attack or early death) have not yet been examined.

I still feel that if a study was done using a device with a good closure rate in patients with definite scars on their brains on CT or MRI and a history suggestive of paradoxical embolus - it would be positive, particularly if the medical therapy group was homogenous (warfarin) and included adverse effects of anticoagulation as a composite end-point. I think most PFO operators would agree but we all know the difficulties associated with completing a trial like this. The effect of Closure I on my own practice has been to make me even more reluctant to close PFOs in patients with no imaging evidence of cerebral infarction and shift me away from the ‘grey area’ towards the more definite (good history/cerebral scar) population and maybe this is a good thing.

12 Mar/Apr 2011 www.cardiologyhd.com

www.cardiologyhd.com Mar/Apr 2011 13

JOURNALS

Journa s

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

A thorough examination of the DINAMIT data sheds some light. Essentially patients at high risk of early arrhythmias are also those at the highest risk of other modes of death (progressive heart failure, recurrent ischaemia, non cardiac morbidity).

Should we be optimising AV delay in all CRT implants? No, because it doesn’t make any difference.

Headline findings are: the added risk factors in CHA2DS2vasc hold up well; those with a CHA2DS2vasc of 1 are at genuinely intermediate risk (2%pa) whereas CHADS2 of 1 have an uncomfortably high risk (4.75% pa). Risks are maintained year on year. JB Oleson and others BMJ 2011;342:d124 We know that Dabigatran is more effective than warfarin (at high dose) and safer than warfarin (at reduced dose), but is it cost effective (stop yawning)? A group wanted to find if Dabi was cost effective, so, as is the way with these things, they did. The cost per QALY of high dose Dabigatran when compared with warfarin at current US prices was $50K.

K Ellenbogen and others Circulation. 2010;122:2660-2668

The study has many limitations including a notional cost of warfarin, which seems very high and an assumption that observations in RE-LY over 2 years can be extrapolated in the long term. JV Freeman and others Ann Intern Med. 2011;154:1-11

Heart Failure and Devices Heart failure is an ever growing problem due to our ageing population, improved revascularisation techniques, and evidenced based secondary prevention. Cell therapy is hoping to be the next big thing in treating heart failure patients. Sadly, the results of the SEISMIC trial of intramyocardial implantation of autologous skeletal myoblasts, in a small cohort patients, were not earth moving. Whilst the technique appears safe and feasible, there was no benefit in LVEF, with ‘suggestions’ of improvement in symptoms. Further larger studies are awaited. H Duckers and Others EuroIntervention. 2011;6:794-797

Coronary Heart Disease

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P Dorian and others Circulation. 2010;122:2645-2652 Risk stratification for sudden death in Brugada syndrome has been controversial since the condition was described. An Italian registry of 320 patients provides a further contribution. Observations arising reinforce the role of a spontaneous type 1 ECG, syncope and male gender, but also resurrect family history and electrophysiological studies as relevant factors. In particular the negative predictive value of EPS when a rigorous and aggressive protocol is followed warrants further evaluation.

Atrial Fibrillation Predicting thromboembolic risk in atrial fibrillation is a growth industry. The simplicity of the CHADS2 scoring system, which seemed too good to be true probably is: the lack of recognition of vascular disease and under estimation of the risk associated with age in particular producing falsely reassuring results. A Danish group have examined the predictive value of both CHADS2 and the more aggressive CHA2DS2vasc in a cohort of over 70 000 patients.

P Delise and others European Heart Journal (2011) 32, 169–176 It is well recognised that ischaemic patients derive less benefit than non ischaemics from CRT. It has always been assumed this is due to a higher burden of full thickness scar. This radionucleide study provides support for this with low scar burden ischaemics doing better post CRT than higher scar burden (regardless of dysynchrony measures). Evan C. Adelstein and others, European Heart Journal (2011) 32, 93–103 After more than ten years one would have hoped we would have got past “two centre non randomised comparison” studies to tell us how to assess dysynchrony in narrow QRS heart failure patients. Sadly we have not, but the latest contribution (for what it is worth) suggest two echo measures: opposite wall delay (OWD) >75ms and anteroseptal posterior wall delay assessed by speckle tracking (ASPD) >107ms.The ROC curve for OWD is particularly unimpressive, but the ASPD cut off suggested gives sensitivity and specificity of 71 and 75% respectively for echocardiographic response to CRT. We look forward to validation of these results by other operators.

WT Abraham and Others. The Lancet;377:658-666. Apparent primary prevention ICD candidates have been shown to lack benefit and even derive harm when implanted soon after an acute event (most studied in MI or CABG). It has become accepted, though not particularly illuminating, to describe this as ICDs changing the mode of death in these populations.

Another novel treatment with recent disappointing results is gene therapy for severe coronary artery disease. The NOVA trial, a small muliticentre randomised, double-blind, placebo (sham)-controlled study of direct intramyocardial injection of genes encoding vascular endothelial growth factor (VGEF), was again safe and feasible, but made no difference to exercise capacity or time to ischaemic threshold. Symptoms improved in both groups, similar to previous findings with transmyocardial revascularisation.

Should a tiered therapy zone be programmed in for primary prevention ICDs? Obviously, according to virtually every experienced implanter or physiologist I’ve met, and yes according to this piece from the PROVE trial. Basically, patients implanted with a device because they’re at risk of ventricular arrhythmias, get ventricular arrhythmias and would rather have them treated by ATP if possible than by shocks. M Saeed and others J Cardiovasc Electrophysiol, Vol. 21, pp. 1349-135 Should we be optimising AV delay in all CRT implants? No because it doesn’t make any difference. K Ellenbogen and others Circulation. 2010;122:2660-2668

Another month, another risk score for cardiovascular patients. The ASSIGN CV risk score has been evaluated against the Framingham and QRISK scores in primary care patients in England and Wales and is as good/bad. All models overestimated risk, particularly for men with low specificity and sensitivity. Family history and ethnicity are important and QRISK2 may be better. B De la Iglesia and Others. Heart 2011;97:491-499. Does Eptibatide (the Glycoprotein IIbIIa inhibitor) given upstream improve outcomes in ACS patients. No, unless the patients are also pre-treated with early clopidogrel loading, but it does lead to more bleeding according to the EARLY-ACS study. T Wang and Others Circulation 2011;123:722-730.

14 Mar/Apr 2011 www.cardiologyhd.com

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Nepa

GLOBAL

Developing Countries

Nepal Lifestyles of Patients with Coronary Heart Disease (CHD) Attending Cardiac OPD of BPKIHS, Dharan, Nepal

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

Mrs. Rosy Shrestha Assistant Professor, Dept. of Medical Surgical Nursing College of Nursing B.P. Koirala Institute of Health Sciences (BPKIHS) Dharan Nepal

CONCLUSION From this study it is concluded that most of the patients were not aware of their disease condition and need for modification of lifestyle for managing cardiac problems.

Nepal Overview

INTRODUCTION Background: Heart disease as a leading cause of morbidity and mortality is of global concern, especially in North American and European societies. In the US, nearly one-quarter of the entire adult US population (about 61 million) lives with some form of heart disease, and approximately one million Americans die of heart disease every year, which accounts for more than 40% of all deaths1. According to a recent report by the World Health Organization (WHO) on reducing risks and promoting healthy life, inactive lifestyles, tobacco use, and low fruit and vegetable intake each account for 20% of deaths and disabilities from cardiovascular disease risk worldwide2.

General Objective: To assess the lifestyle of patients with Coronary Heart Disease attending the Cardiac Outpatient Department of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal.

Population: All clients having CHD attending cardiac OPD, BPKIHS

Mt Everest Dharan

Sample size: sixty cardiac patients. Sampling technique: Purposive sampling technique Research Instruments: Self-prepared semi-structured questionnaire. Research Validity and Reliability: content validity of the instrument was established by seeking opinion from the concerned authority.

Kathmandu

Rationales for the Study: Coronary Heart Disease (CHD) is one of the leading causes of illness and death among the top three disease classifications all over the world. Although CHD is an interesting area of research, in context to Nepal, studies regarding the knowledge of cardiovascular risk factors are limited. This study will help to provide the baseline data on knowledge and prevention of risk factors of CHD. Significance of the Study: This study might be helpful to provide the baseline data about lifestyle factors in relation to CHD. The findings of the study can be used by healthcare personnel to carry out further interventional studies on non-pharmacological management for cardiac patients. It also could be used within health education for cardiac patients to encourage them for regular follow-ups and compliance of treatment modalities.

MATERIALS & METHODS Design of the Study: Cross sectional descriptive study

Nepal

Data collection Procedure: Verbal consent was taken from all subjects before data collection.

Country: Nepal Population: 29,331,000 (2009 est) Official Language: Nepali Nepal is a landlocked country in South-East Asia bordered on the north by the People’s Republic of China, and to the south, east, and west by the Republic of India. Located in the Himalayas, Nepal has eight of the world’s ten tallest mountains, including the highest point on Earth, Mount Everest. The capital city is Kathmandu. Source: Wikipedia

Specific Objectives: •

To assess the lifestyle of patients with coronary heart disease.

To find out the association between lifestyle and selected variables.

To find out the association between lifestyle and clinical characteristics.

16 Mar/Apr 2011 www.cardiologyhd.com

Data analysis Procedure: Data was entered at first in Microsoft Excel & converted in SPSS. It was then analyzed by using descriptive and inferential techniques to assess the association between selected variable and clinical characteristics of cardiac patients.

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

DISCUSSION Cardiovascular disease is becoming a major cause of illness and death in the eastern Mediterranean region, currently accounting for 31% of deaths. This rate is attributable to an ageing population, high rates of smoking, and changes in nutritional behavior habits, along

with sedentary lifestyles. From our study it is depicted that out of the total 60 patients interviewed, the majority of respondents (52%) were females, 31.7% of patients were in the age group >60 years, 17 (28.3%) where in the age group 51-60, 9 (15%) where in the age group 41-50, 7 (11.7%) where in the age group 31-40, and 8 (13.3%) where in the age group 20-30. Patients who were Kirat comprised 17 (28.3%), followed by Chhetri 25%, whilst Vaisya and Brahman were 16.7% respectively. The majority of respondents found 86.7% are Hindus by religion. Most (51.7%) of the respondents were from the rural community. Most of the patients (83.3%) were non- vegetarian, 33.3% were past smokers, and 60% of the patients had history of doing exercise. Among females, 58.3% had menopause. Most of the patients (53.3%) had systolic blood pressure above normal. Also 71.7% of the patients had diastolic blood pressure as normal and below normal. Frequency of overall favorable lifestyle was only 25%, among which those with a good dietary pattern was 28.3%, and non-smoker percentage was 66.7 %. About 68.3% of patients were non-alcoholic, and among all patients 83.3% had a good follow up pattern. On the other hand, patients carrying their prescription papers regularly with them and with a good meditation habit were found to be very rare (26.7%). So there is need for improvement for better lifestyle (75 %), and there was association between the lifestyle and selected variables ie. the residence (p=0.037). There was also association between the lifestyle and clinical characteristics i.e. the physical activity (p=0.000). Findings show that only 25% of the respondents had a good

www.cardiologyhd.com Mar/Apr 2011 17

Management

Assistance Management: Care and Compassion Ms Sophie Blackman Coronary Heart Management and CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust

T

here has recently been great publicity surrounding ‘Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people’. This document first came to my attention after I saw such damning headlines in the national newspapers as: ‘The NHS has failed the elderly’ The Times. I downloaded a copy of the report, and it certainly makes for uncomfortable reading. Of the 10 cases discussed, 9 of the patients died during or as a direct result of the treatment that they received. The stories within the document are truly harrowing, but I would urge you to read them as there is much we can learn.

http://www.ombudsman.org.uk/care-and-compassion/home There has been significant discussion in the press since this report was published and there are a few points that I think are important regarding this document which I have impressed upon my staff. Firstly, ‘the NHS sees over a million people every 36 hours’, Nigel Edwards Chief Executive of the NHS Federation is reported to have said on www.nhs.uk, and so ‘the ten cases included in the report need to be kept in perspective’. While the Ombudsman’s document is ‘powerful and informative regarding the individual cases, it cannot be thought of as reliable evidence that can be applied generally to the care of the elderly across the NHS’.

Nurses can play a vital role in the identification and management of cardiac patients by identifying the risk factors associated with their lifestyle, and by providing referral services in taking care of patients with cardiac related problems. Health education, especially encouragement of healthy lifestyles at the national level should be launched, and an overall policy of health promotion to reduce cardiac problems implemented.

REFERENCES: 1.

Cardiovascular Disease. [serial online] 2003 [cited 2010 January 27]. Available fro: URL:http://www.labtestonlie.org.

2.

WHO Cardiovascular Disease. [serial online] 2009 [cited 2010 January 26]. Available from: URL: http: // www. Who.int.com.

3. 4.

Black H. Cardiovascular Risk Factors. [serial online] 1997 [ cited 2010 January 26]. Available from : URL: http:// www.yahoo.com Cardiovascular Risk Factors for Cardiovascular Diseases. [Serial online] 2005 [cited 2010 January 27]. Available from: URL: http://www.asu. edu.

5.

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

6.

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

7.

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

8.

Goyal A. Yusuf S. Burden of Cardiovascular Disease in the Indian Subcontinent [serial online] 2006 [cited 2010 January 15]. Available from: URL: http: // www.icmr.nic.in

9.

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

10. Adili F. Knowledge and Practice Status and Trend in Risk Factors. [serial online] 2005 [ cited 2010 February 16]. Available from: URL: http: // journals.turns.ac.ir 11. Vanhecke T. Awareness, Knowledge and Perception of Heart Disease. [serial online] 2006 [ cited 2010 February 16]. Available from: URL: http: // journals.lww.com

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Care and Compass on

Kastrup and Others EuroIntervention. 2011;813-818

RJ Van Bommel and others European Heart Journal (2010) 31, 3054–3062 Better news for heart failure patients comes from the CHAMPION study, in which a wireless implant (CardioMEMS) that monitors haemodynamics has been shown to reduce hospitalisations compared to standard management. The pulmonary artery pressure sensor was implanted in NYHA class III patients, improving management and outcome over a 15 month follow up. I suspect this will appeal to device companies, implanters and patients, but feel that basic management and heart failure support in the community is needed first.

L es y es o Patien s w h Co ona y Hea D sease

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12. Jafary et al CARDIOVASCULAR HEALTH Knowledge behavior in patient attendants at four care tertiary hospitals in Pakistan-a cause for concern. [serial online] 2005 [ cited 2010 February 17]. Available from: URL: http: //www.biomedcentral.com. 13. Khan MS. Knowledge of Modifiable Risk Factors of heart disease among patients with acute MI in Karanchi, Pakistan. [serial online] 2006 [cited 2010 February 17]. Available from: URL: http: //www. biomedcentral.com. 14. Frost R. Cardiovascular Risk Modification in College Student. [serial online] 2007 [ cited 2010 February 16]. Available from: URL: http: // www.springerlink.com 15. FHA-Health Belief Model Perceptions, Knowledge of Heart Disease. [serial online] 2006 November 29 [cited 2010 February 1]. Available from: URL: http: ///www.final.health-articles.com. 16. Knowledge and Awareness of Risk Factors for Cardiovascular Risk Factors for Cardiovascular Disease. [serial online] 2008 September 1 [cited 2010 February 1]. Available from: URL: http: ///www.thefreelibrary. com.

18 Mar/Apr 2011 www.cardiologyhd.com

Management Ass stance

19

Ca e and Compass on

Nevertheless, whilst I think it is important is that we keep the report in perspective, for these individuals and families there were crucial errors made in the care received. When you read the report what is so upsetting is how very easily the errors could have been avoided through better communication, better understanding of the patient and families perspectives, and by sometimes pushing the boundaries of our roles. It is evident of a service stretching to its limits, often with insufficient finance and resources and never ending cut backs that sometimes staff are so pushed to get things done to fit a timeframe that is comes at the compromise of the expected standards. I have asked all my staff to read this document because I think it serves as a good reminder for us as we go about our daily work, that despite the endless increases in service demand and external pressures we have, we all came into this profession to care. Irrespective of anything else that is going on, every single patient that we see - young or old - deserves our undivided attention. It reminds us that things we do day in, day out, are unfamiliar and invoke fear in our patients, and we must not take for granted the value and importance of taking an extra few moments to ensure the patient is informed and comfortable, that you are respecting their dignity, and providing them with the best service of care. For surely without providing this level of care, commitment and courtesy for every patient you see you would not be fulfilling your duty of care? Sometimes our duty of care has much wider scope than the exact job description we have on paper, and just a small effort beyond our normal role can help prevent the communication breakdowns, and leave our patients and their relatives with a much more positive experience of our NHS. www.cardiologyhd.com Mar/Apr 2011 19

ECG Cha enge

Sophie Blackman’s ECG

Challenge Online Only.......Sorry! Ms Sophie Blackman

20

w h Soph e B ackman

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

Our ECG Challenge for this edition is only available on our website. This is because the ECG image obtained didn’t quite have the resolution required to look great in this magazine. However here is a quick overview: This ECG was the taken from the first patient diagnosed with short QT syndrome (SQTS). This phenomenon, first described in 1999 by Dr. Preben Bjerregaard MD, DMSc, is still a relatively unknown disease, and due to this may often go undiagnosed.

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

Love our ECG Challenges? We have 20 ECG Challenges on our website just waiting for you to solve, all of which have been featured in this publication over the years. In our May/June edition, Sophie will also be starting a series on ECG Education. This series will be perfect not only for other cardiology professionals but also students and newly qualified staff.

20 Mar/Apr 2011 www.cardiologyhd.com

S te V s t

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Ba ne Hosp a

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BCS Conference

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ACI 2011 : Advanced Cardiovascular Intervention 2011 London Hilton Metropole Hotel London, England www.bcis.org.uk

February 18 BCS Career in Cardiology Hilton Coventry Hotel, Coventry England www.bcs.com March 7-11 BCS & Mayo Clinic Cardiology Review Course RCP, London England www.bcs.com June 13-15 BCS Annual Conference Manchester Central Manchester, England www.bcs.com October 2-5 HRC 2011 Hilton Birmingham Metropole Birmingham, England www.heartrhythmcongress.com October 7-8 British Society of Echocardiography Annual Meeting Edinburgh International Conference Centre Edinburgh, Scotland www.bsecho.org November 24-25 British Society for Heart Failure 14th Annual Autumn Meeting Queen Elizabeth II Conference Centre London, England www.bsh.org.uk

26 Jan/Feb Jan/Feb 2011 www.cardiologyhd.com

ANNUAL CONFERENCE 2011 Venue: Manchester Central, Manchester Date: 13 to 15 June 2011 3 Day educational meeting in Cardiovascular Medicine, with a programme of case based presentations and plenary sessions Exhibition showcasing the latest developments in cardiovascular medicine and new technologies Educational content based on the new European Curriculum, including a Trainee day Gain CPD points and review general cardiovascular knowledge required for revalidation Members of the British Cardiovascular Society can register for free before 31 March 2011. Visit www.bcs.com for online registration and further information.

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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 Mar/Apr 2011 3


Our Cardiology

Experts 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, & Senior Radiographer at multiple sites in the UK.

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

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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

Dr Mojgan Sani Pharmaceutical Editor

Head of Clinical Cardiac Physiology, West Hertfordshire NHS Trust

Head of Clinical Pharmacy, Royal Berkshire Foundation Trust & National Non-medical Prescribing Facilitator, National Prescribing Centre.

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Latest Product News

Round Up We Want Your Department

New hope for people with heart failure EXTERNAL ENHANCED COUNTER PULSATION (EECP) Dot Medical ltd. is delighted to announce that they are now supplying EECP therapy in the UK. Although EECP is not currently a familiar therapy to many people, Dot Medical aims to change this perception. EECP has an established research pedigree that suggests it should be THE therapy of choice for the management of a wide range of medical conditions. It is non-invasive, cost effective and offers hospitals the opportunity to treat patients on an out-patient basis and can reduce hospitalization times. This makes it extremely exciting given the current economic climate. EECP is a non invasive therapy that helps treat heart failure by strengthening the heart muscle simply by pumping more blood back to the heart. The more blood pumped back to the heart, the stronger it gets. EECP increases blood flow to the heart by opening up collateral circulation and creating new blood vessels, while at the same time strengthening the heart. It keeps blood vessels relaxed, open and prevents plaque buildup. EECP reduces arterial stiffness and releases nitric oxide which has an antioxidant effect, making arteries resistant to spasm and clotting. It has a detoxification effect and increases lymphatic circulation. EECP has been FDA approved since 1995 to treat coronary artery angina, cardioogenic shock and heart failure. It has had CE approval for over 10 years and is used for a wide variety of conditions including peripheral vascular disease, erectile dysfunction (an early predictor of heart disease), sudden hearing loss and tinnitus, stroke, restless leg syndrome, peripheral neuropathy and can facilitate sports rehabilitation.

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Kings College Hospital, London One of the most popular sections in our publication is the Site Visits. Over the last five years we have featured 35 different departments from all over the world, and now we would like to feature yours. In the coming editions we will be enhancing the Site Visits section, featuring multiple hospitals from not just the UK, but further afield throughout the world. Recently we sent word out on our CardiologyHD Facebook page, so you can now expect Romania and New Zealand to be amongst the first countries featured. For more information on how your department can be featured contact us at: admin@coronaryheart.com

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www.cardiologyhd.com Mar/Apr 2011 5


lATEST NEWS

QuikClot® THE BLEEDING STOPS HERE! Dot Medical, is delighted to introduce QuikClot® an amazing non-invasive haemostatic bandage for safe and effective control of bleeding. We all need to be able to stop bleeding quickly, safely and preferably cost effectively. QuikClot® can be used anywhere when there is a need to stop bleeding . QuikClot® provides safe, rapid and effective control of bleeding – when you need it and where you need it. It is also effective for use on patients who are taking Warfarin, Aspirin + Warfarin or Aspirin + Clopidogrel. But don’t just take our word for it – QuikClot® is the US Military’s exclusive choice for extreme bleeding in wartime injuries in the combat field – so it has to be good! The active haemostatic ingredient (kaolin) is non-invasive and woven into the hydrophilic bandage, allowing swift control of bleeding. Kaolin has been recognised for more than 50 years as an affective clotting product. It does not use thrombin, fibrinogen or shellfish by-products and so has no known contraindications.

GATEWAY Registry Initiated in U.K. to Investigate OrbusNeich’s Genous™ Stent in Patients with Acute Coronary Syndrome (ACS) and High-Risk of Post-Procedural Bleeding The investigator-led, multicenter, non-randomized, observational prospective GATEWAY registry will enroll 280 patients at eight sites in the U.K. The governmentapproved GATEWAY study protocol recommends that these patients undergo three months of dual anti-platelet therapy (DAPT) or less following stent implantation. The primary endpoint of the registry is the occurrence of net adverse clinical events (NACE) at 30 days and at one year follow-up. “High-risk patients who present with non-ST segment elevation myocardial infarction (NSTEMI) remain a challenge,” said Dr. David Smith of the Regional Cardiac Centre at Morriston Hospital, Swansea, Wales, principal investigator of the trial. “Identification of patients with a higher propensity for bleeding may lead to improvements in NSTEMI care by prompting clinicians to make judicious treatment selections, carefully dose antithrombotic medications and proceed with strategies to optimize individual patient care.” For more information, visit www.OrbusNeich.com. Follow all of OrbusNeich’s news on Twitter at http://twitter.com/ OrbusNeich.

It literally does what it says on the tin - QuikClot®! QuikClot® NOW AVAILABLE IN THE UK

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3 Dr David Smith

6 Mar/Apr 2011 www.cardiologyhd.com


The following articles are courtesy of NHS Choices

Behind The Headlines

The Facts Blood Pressure

Combined drugs ‘better’ for blood pressure A newly published study has suggested that “a combination of drugs is better than a single one in treating high blood pressure”, BBC News reported. This randomised controlled trial found that starting patients on a combination of hypertension drugs gives a faster and greater reduction in blood pressure than either of the drugs on their own, without any more side effects. The drugs, amlodipine and aliskiren, work to lower blood pressure in different ways. Doctors currently start patients with high blood pressure on one drug and may add others later if needed. The authors of this well-designed trial suggest that clinical practice should now be changed and that patients with high blood pressure be started on two drugs rather than one. However, although the results of this study are significant, it looked only at two specific types of drug, so cannot make comparisons of the effectiveness of treatment with other classes of blood pressure drug, whether used alone or in combination. Longerterm effects and adverse outcomes beyond 32 weeks (such as stroke, heart attack or early death) have not yet been examined. People who are concerned about their blood pressure or its treatment should visit their GP. The study was carried out by researchers from the University of Cambridge, the British Hypertension Society, the University of Glasgow, Novartis Pharma AG, Switzerland, and Ninewells Hospital and Medical School, Dundee. It was funded by Novartis Pharma AG and two of the study’s authors are employees of this company. The study was published in peer-reviewed medical journal The Lancet. The study was mostly reported accurately by the BBC, however, the statement that the combined treatment had fewer side effects is incorrect. The proportion of people who withdrew due to side effects was actually the same for combined treatment and the group taking aliskiren plus placebo, but higher (18%) for those taking amlodipine. The claim by the Daily Express that the pill could “prevent 5,000 strokes a year” is not supported by the study, which looked at the effect of different treatments on blood pressure measurements, not on strokes or other cardiovascular outcomes.

8 Mar/Apr 2011 www.cardiologyhd.com

Sleep and heart risk link is uncertain “Lack of sleep is a ‘ticking time bomb’,” The Independent reported. The newspaper said that people who regularly sleep less than six hours a night “have a 48 per cent greater chance of developing or dying from heart disease”. The news is based on research that combined data on almost 475,000 adults, drawn from 15 studies on sleep duration and the risk of strokes and heart attacks. The review found that, compared with a normal 7-8 hours’ sleep a night, shorter or longer sleep was associated with increased risk of these heart problems. The review has some important limitations. For example, many medical, psychological and lifestyle factors can affect both sleep and cardiovascular health but attempts to account for the influence of these factors varied widely between the studies. It is also unclear whether the participants did not have any cardiovascular disease at the start of the studies, so it should not be assumed that poor sleep was the cause of the cardiovascular problems eventually observed. As the researchers say, the reasons behind any associations between sleep and cardiovascular disease are not fully understood. The study was carried out by researchers from Warwick Medical School and the University of Naples in Italy. No sources of funding were reported. The study was published in the peer-reviewed European Heart Journal. The newspapers generally reflected the findings of the research accurately, but did not address the wider issues and limitations of the study.


THE FACTS

Synthetic veins for heart bypass

Cardiac Statins

Scientists have grown human veins in a laboratory, in a breakthrough that could revolutionise heart bypass surgery, reported the Daily Mail.

Statin benefit for low risk people ‘questionable’

The news comes from research in which scientists developed a method for using human muscle tissue to create human blood vessels in the laboratory. These were then tested in animals, where they showed “excellent” blood flow and resistance to blockages and other complications. The vessels could also be safely refrigerated for up to a year.

“Up to three million people are taking statins needlessly,” says The Daily Telegraph. It reports that a comprehensive study suggests statins are “ineffective in many cases and could be doing more harm than good”. The news story is based on a review of trials of statins in people who had not (yet) suffered a cardiovascular event such as a heart attack or stroke. There was some evidence that statins reduced the risk of dying from any cause, and the risk of any cardiovascular outcome. However, the trials and review have several limitations, including some indications that adverse events within the trials were not recorded. It is important to point out that the benefit of statins in people with cardiovascular disease, who have already suffered a heart attack or stroke, or who are considered to be at high risk of an event, is not in question here.

This initial animal research has suggested that it may be possible in the future to use these synthesized vessels in humans, for example in coronary artery bypass operations, which currently rely on patients providing a healthy blood vessel to form their bypass graft. However, this short, preliminary research was in its early stages and therefore scientists will need to undertake many further stages of research before these lab-grown veins are proven to be safe and effective in humans. The study was carried out by researchers from East Carolina University, Duke University, Yale University and Humacyte Inc, a company involved in commercially developing products for vascular disease. The research was also funded by Humacyte and the study was published in the peer-reviewed journal, Science Translational Medicine. The newspapers reported the research accurately, although they tended to reflect the optimism of the scientists rather than the limitations of the research. The Daily Telegraph’s report that the new veins can be “safely transplanted into any patient” is not supported by the research conducted so far. The BBC’s report quoted independent experts who correctly pointed out that this is early research, and the Daily Mail also highlighted that the veins were unlikely to be available to patients for several years.

This review supports the need for careful consideration of the overall cardiovascular risk of the individual when deciding whether to prescribe a statin. In higher-risk populations, the benefits of a drug often clearly outweigh the risks. However, when lower-risk populations are considered, this balance can often tip the other way. The results here do not support the widespread use of statins in people at low risk of cardiovascular events. The news reports follow a Cochrane systematic review conducted by researchers from the London School of Hygiene and Tropical Medicine and the University of Bristol. The main conclusion of this review is that there is a lack of quality evidence to support the use of statins in people with low cardiovascular risk. This has been generally reflected in the articles by The Daily Telegraph, the Daily Mirror and the Daily Express. However, the Daily Mail’s headline (“Statins ‘may cause loss of memory and depression’”) is incorrect. The researchers’ main concern is that there is not enough reporting of adverse events, not that there is evidence for any particular harm.

www.cardiologyhd.com Mar/Apr 2011 9


THE FACTS

New Technology

Blood pressure device performs well A watch-like device “could revolutionise blood pressure monitoring”, BBC News has reported. According to the website, the monitor can be used to measure pressure in the wrist, which can then be used to estimate pressure in the aorta, the largest artery in the body. Although news coverage has focussed on the wrist-worn monitor, the research devised a technique to combine blood pressure readings from the wrist and upper-arm to estimate central aortic systolic pressure (CASP). This measure of pressure in the aorta is thought to be a better way of predicting heart problems than traditional measures of blood pressure, such as using an inflatable cuff around the bicep. A device to measure blood pressure at the wrist is not new, and the method does not replace the traditional approach of using a cuff on the upper arm. However, the researchers’ method for combining the two results to estimate CASP appears to have some merit, and may filter into medical care.

Television heart risk needs more study “Watching TV for four hours a day doubles the risk of a heart attack,” The Sun has reported. “The reason is thought to be that simply sitting for so long causes coronary problems,” the article added. The story is based on a study that surveyed 4,512 people to estimate their television viewing and physical activity, comparing their habits with their risk of death or cardiovascular disease over the next four years. Those viewing TV and video games for four hours or more per day were 48% more likely to die (due to any cause) and 125% more likely to have a cardiovascular-related event (such as a heart attack or stroke) than those who watched less than two hours. The relationship was independent of smoking, social class and how much physical activity people did. This well-conducted study suggests that lengthy periods of recreational viewing may have harmful effects on the cardiovascular system, increasing the risk of heart attacks, strokes and early death.

10 Mar/Apr 2011 www.cardiologyhd.com

The study was carried out by researchers from the University of Leicester, the National Institute for Health Research, Gleneagles Medical Centre in Singapore and Healthstats International in Singapore. The study was financially supported by the Leicester National Institute for Health Research Biomedical Research Unit in Cardiovascular Diseases. The study was published in the peer-reviewed Journal of the American College of Cardiology.

However, the study had some limitations, such as not accounting for the influence of diet or time sitting in front of a computer at work. This initial research is of interest, but there is now a need for larger, longer studies to verify the relationship. The study was carried out by researchers from University College London, the University of Queensland, Brisbane and Edith Cowan University and the Heart and Diabetes Institute, Melbourne. The researchers were financially supported by the UK’s National Institute for Health Research, the British Heart Foundation and the Victorian Health Promotion Foundation Public, Australia. The study was published in the peer-reviewed Journal of the American College of Cardiology. It was reported accurately, but uncritically, by newspapers.


Cardiologist

Hot Topic PFO closure: is there still a future post CLOSURE 1? Dr Brian Clapp MA PhD MRCP Consultant Cardiologist Guy’s & St Thomas’ Hospital London, UK

S

trokes are a greatly feared and debilitating event in anyone and perhaps even more so in young people in whom they are thankfully rare. Strokes are ischemic in 80% of cases and, using our current understanding of their causes, the reason can be found in about 60% of these individuals. Recognised precipitants include carotid atheroma, dissections, vasculitis, pro-thombotic states and cardiac sources of emboli such as atrial fibrillation, left ventricular thrombus and endocarditis. In the absence of any of these factors numerous alternative mechanisms for “cryptogenic” strokes have been proposed and most popular amongst these are intra-cardiac communications that allow unfiltered venous blood to bypass the pulmonary circuit and enter the arterial tree. Of these communications the most common is the patent foramen ovale (PFO) which is a foetal structure that allows oxygenated blood to pass from the right to left atrium and from pathology studies remains patent in 20-25% of adults in the general population. The theory runs that small clots return from the peripheral veins to the heart and instead of passing on to the lungs, and being destroyed by the natural thrombotic pathways there, are able to pass across the PFO into the systemic arterial circulation and cause embolic phenomenon such as a stroke. What is the evidence for this? Support exists in two forms – firstly there are numerous case reports where long clots are found caught in the process of passing through a PFO. Secondly cross-sectional studies have shown that the presence of a PFO (particularly in association with an atrial septal aneurysm) is much more likely in patients with cryptogenic strokes than the general population – increasing in Lechat’s series (NEJM 1988) to over 50%. These findings may implicate the PFO in cryptogenic strokes; however they do not give insight into the best treatment options. In non-randomised studies patients have either been treated with anti-platelets, formal anti-coagulation or closure of the defect with a prosthesis. Attempts to compare these disparate groups indicated that device closure, particularly in the presence of a septal aneurysm, was superior (annual recurrence rates for medically treated

12 Mar/Apr 2011 www.cardiologyhd.com

ranging from 3.8-12% and device treated from 0-4.9%). As these are non-randomised studies there was a drive to obtain properly controlled data and to that end five studies were started using different commercially available devices pitched against medical therapy in a fully randomised fashion. The first to report, at the American Heart Association meeting in November 2010 (although not yet in print), was the CLOSURE 1 study. This compared medical therapy, a mixture of anti-coagulation and anti-platelets, to device closure with the NMT Biostar device. The primary end-point in this superiority study was a composite of stroke/TIA and mortality (all cause to 30 days and then neurological out to two years) and as has been reported was negative with an event rate of 5.9% in the device arm against 7.7% (P=0.3) in the medical group.

Do we read from this that device closure is unnecessary? Well this is not straightforward to answer - at least in part because we do not as yet have the full published dataset and therefore can only comment on the information presented at the AHA meeting. There are a number of points that should be raised in considering this result. The first is that of its power to detect a real effect (as an under-powered study may miss a small but clinically important effect) – this study originally intended to recruit 1600 patients and due to very slow uptake was terminated early with fewer than 1000 subjects. Concern that this change under-powers the findings is supported by the absence of the usual negative effect of having a septal aneurysm upon risk and is a particular danger in superiority studies. As a result of the reduced size the expected event rate in the treated arm was 2% or less by intention to treat analysis. Unfortunately in this study there was a high procedural complication rate with only a 90% procedural success rate – the reason for this is not clear although the large number of centres performing small numbers of procedures has been put forward as a potential factor. As a result the event rate in the device therapy arm was increased by these early complications and may have biased the outcome.


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

In order to be effective device closure needs to have been both necessary and also successful in preventing continued passage of material across the tunnel. It is possible to question both of these points. Firstly only a little over half the subjects had a moderate or large shunt at baseline and only one third had a septal aneurysm. Therefore a significant proportion of the recruited population had a “low risk” PFO as defined by previous cross-sectional studies. Secondly success, assessed by TOE, was constant at 86% at all time points – this means nearly 15% had significant residual shunts despite using an ultrasound technique which tends to under-report shunts due to the difficulty in performing an adequate Valsalva manoeuvre with a probe in the oesophagus. Both of these factors would work against seeing superiority in the device arm. Finally in the data presented it became clear that exhaustive searches for alternative embolic sources may not have occurred, as they were then retrospectively found in the majority of patients with recurrent events. Of concern for the use of devices in the heart there did appear to be an increased risk of atrial fibrillation in the active arm, although as the full data has not been published it is unclear when this occurred and whether it was sustained or related to hazardous end-points.

Where does this study leave the field of PFO device closure? Clearly in discussing with patients one cannot ignore these results and they are the only randomised data available. That being said CLOSURE 1 does not indicate that device closure is never beneficial, but rather tells us more about the importance of very careful assessment of patients for alternative causes before contemplating closure and the need to concentrate this work within high volume centres who can achieve low procedural complication and high closure rates. More clarity should come from the publication of further studies, particularly the RESPECT trial as this is event driven, and help us to define exactly which patients should be offered device therapy and which are better served by medical treatment.

T

he answer is yes, although the Closure I study is certainly food for thought. I think it has probably come at a good time, as we have seen a proliferation of new devices and what feels like a renewed drive from industry to market these devices. The effect of Closure I has been for everyone concerned with PFO device closure to pause and think hard about what are trying to achieve when we close a PFO. My personal view is that the Closure I results are not that surprising. This is for a number of reasons: 1.

The study included TIAs without any evidence of cerebral infarction/ embolism. We all know that the ‘TIA population’ is very heterogenous and often there is little objective evidence of cerebral embolism in this group. The grey area between migraine and cerebral ischaemia is also difficult, but there is often pressure from referring doctors to close the PFO in this group.

2.

The medical therapy in the ‘best medical/anticoagulation’ group was heterogenous. Whilst under-treatment should emphasize the benefits of device closure, it will not cause any ill-effect either. Many patients fear being on warfarin in the long-term and there will be an excess of bleeding in anticoagulated patients over a more prolonged period

3.

The follow-up period was too short.

4.

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

I still feel that if a study was done using a device with a good closure rate in patients with definite scars on their brains on CT or MRI and a history suggestive of paradoxical embolus - it would be positive, particularly if the medical therapy group was homogenous (warfarin) and included adverse effects of anticoagulation as a composite end-point. I think most PFO operators would agree but we all know the difficulties associated with completing a trial like this. The effect of Closure I on my own practice has been to make me even more reluctant to close PFOs in patients with no imaging evidence of cerebral infarction and shift me away from the ‘grey area’ towards the more definite (good history/cerebral scar) population and maybe this is a good thing.

www.cardiologyhd.com Mar/Apr 2011 13


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

Atrial Fibrillation Predicting thromboembolic risk in atrial fibrillation is a growth industry. The simplicity of the CHADS2 scoring system, which seemed too good to be true probably is: the lack of recognition of vascular disease and under estimation of the risk associated with age in particular producing falsely reassuring results. A Danish group have examined the predictive value of both CHADS2 and the more aggressive CHA2DS2vasc in a cohort of over 70 000 patients. Headline findings are: the added risk factors in CHA2DS2vasc hold up well; those with a CHA2DS2vasc of 1 are at genuinely intermediate risk (2%pa) whereas CHADS2 of 1 have an uncomfortably high risk (4.75% pa). Risks are maintained year on year. JB Oleson and others BMJ 2011;342:d124 We know that Dabigatran is more effective than warfarin (at high dose) and safer than warfarin (at reduced dose), but is it cost effective (stop yawning)? A group wanted to find if Dabi was cost effective, so, as is the way with these things, they did. The cost per QALY of high dose Dabigatran when compared with warfarin at current US prices was $50K.

Should we be optimising AV delay in all CRT implants? No, because it doesn’t make any difference. K Ellenbogen and others Circulation. 2010;122:2660-2668

The study has many limitations including a notional cost of warfarin, which seems very high and an assumption that observations in RE-LY over 2 years can be extrapolated in the long term. JV Freeman and others Ann Intern Med. 2011;154:1-11

Heart Failure and Devices Heart failure is an ever growing problem due to our ageing population, improved revascularisation techniques, and evidenced based secondary prevention. Cell therapy is hoping to be the next big thing in treating heart failure patients. Sadly, the results of the SEISMIC trial of intramyocardial implantation of autologous skeletal myoblasts, in a small cohort patients, were not earth moving. Whilst the technique appears safe and feasible, there was no benefit in LVEF, with ‘suggestions’ of improvement in symptoms. Further larger studies are awaited. H Duckers and Others EuroIntervention. 2011;6:794-797

14 Mar/Apr 2011 www.cardiologyhd.com

Better news for heart failure patients comes from the CHAMPION study, in which a wireless implant (CardioMEMS) that monitors haemodynamics has been shown to reduce hospitalisations compared to standard management. The pulmonary artery pressure sensor was implanted in NYHA class III patients, improving management and outcome over a 15 month follow up. I suspect this will appeal to device companies, implanters and patients, but feel that basic management and heart failure support in the community is needed first. WT Abraham and Others. The Lancet;377:658-666. Apparent primary prevention ICD candidates have been shown to lack benefit and even derive harm when implanted soon after an acute event (most studied in MI or CABG). It has become accepted, though not particularly illuminating, to describe this as ICDs changing the mode of death in these populations.


JOURNALS A thorough examination of the DINAMIT data sheds some light. Essentially patients at high risk of early arrhythmias are also those at the highest risk of other modes of death (progressive heart failure, recurrent ischaemia, non cardiac morbidity).

Coronary Heart Disease

P Dorian and others Circulation. 2010;122:2645-2652 Risk stratification for sudden death in Brugada syndrome has been controversial since the condition was described. An Italian registry of 320 patients provides a further contribution. Observations arising reinforce the role of a spontaneous type 1 ECG, syncope and male gender, but also resurrect family history and electrophysiological studies as relevant factors. In particular the negative predictive value of EPS when a rigorous and aggressive protocol is followed warrants further evaluation. P Delise and others European Heart Journal (2011) 32, 169–176 It is well recognised that ischaemic patients derive less benefit than non ischaemics from CRT. It has always been assumed this is due to a higher burden of full thickness scar. This radionucleide study provides support for this with low scar burden ischaemics doing better post CRT than higher scar burden (regardless of dysynchrony measures). Evan C. Adelstein and others, European Heart Journal (2011) 32, 93–103 After more than ten years one would have hoped we would have got past “two centre non randomised comparison” studies to tell us how to assess dysynchrony in narrow QRS heart failure patients. Sadly we have not, but the latest contribution (for what it is worth) suggest two echo measures: opposite wall delay (OWD) >75ms and anteroseptal posterior wall delay assessed by speckle tracking (ASPD) >107ms.The ROC curve for OWD is particularly unimpressive, but the ASPD cut off suggested gives sensitivity and specificity of 71 and 75% respectively for echocardiographic response to CRT. We look forward to validation of these results by other operators. RJ Van Bommel and others European Heart Journal (2010) 31, 3054–3062 Should a tiered therapy zone be programmed in for primary prevention ICDs? Obviously, according to virtually every experienced implanter or physiologist I’ve met, and yes according to this piece from the PROVE trial. Basically, patients implanted with a device because they’re at risk of ventricular arrhythmias, get ventricular arrhythmias and would rather have them treated by ATP if possible than by shocks. M Saeed and others J Cardiovasc Electrophysiol, Vol. 21, pp. 1349-135 Should we be optimising AV delay in all CRT implants? No because it doesn’t make any difference. K Ellenbogen and others Circulation. 2010;122:2660-2668

Another novel treatment with recent disappointing results is gene therapy for severe coronary artery disease. The NOVA trial, a small muliticentre randomised, double-blind, placebo (sham)-controlled study of direct intramyocardial injection of genes encoding vascular endothelial growth factor (VGEF), was again safe and feasible, but made no difference to exercise capacity or time to ischaemic threshold. Symptoms improved in both groups, similar to previous findings with transmyocardial revascularisation. Kastrup and Others EuroIntervention. 2011;813-818 Another month, another risk score for cardiovascular patients. The ASSIGN CV risk score has been evaluated against the Framingham and QRISK scores in primary care patients in England and Wales and is as good/bad. All models overestimated risk, particularly for men with low specificity and sensitivity. Family history and ethnicity are important and QRISK2 may be better. B De la Iglesia and Others. Heart 2011;97:491-499. Does Eptibatide (the Glycoprotein IIbIIa inhibitor) given upstream improve outcomes in ACS patients. No, unless the patients are also pre-treated with early clopidogrel loading, but it does lead to more bleeding according to the EARLY-ACS study. T Wang and Others Circulation 2011;123:722-730.

www.cardiologyhd.com Mar/Apr 2011 15


Developing Countries

Nepal Lifestyles of Patients with Coronary Heart Disease (CHD) Attending Cardiac OPD of BPKIHS, Dharan, Nepal

Mrs. Rosy Shrestha Assistant Professor, Dept. of Medical Surgical Nursing College of Nursing B.P. Koirala Institute of Health Sciences (BPKIHS) Dharan Nepal

Nepal Overview

INTRODUCTION Background: Heart disease as a leading cause of morbidity and mortality is of global concern, especially in North American and European societies. In the US, nearly one-quarter of the entire adult US population (about 61 million) lives with some form of heart disease, and approximately one million Americans die of heart disease every year, which accounts for more than 40% of all deaths1. According to a recent report by the World Health Organization (WHO) on reducing risks and promoting healthy life, inactive lifestyles, tobacco use, and low fruit and vegetable intake each account for 20% of deaths and disabilities from cardiovascular disease risk worldwide2.

Nepal

Dharan

Kathmandu

Rationales for the Study: Coronary Heart Disease (CHD) is one of the leading causes of illness and death among the top three disease classifications all over the world. Although CHD is an interesting area of research, in context to Nepal, studies regarding the knowledge of cardiovascular risk factors are limited. This study will help to provide the baseline data on knowledge and prevention of risk factors of CHD. Significance of the Study: This study might be helpful to provide the baseline data about lifestyle factors in relation to CHD. The findings of the study can be used by healthcare personnel to carry out further interventional studies on non-pharmacological management for cardiac patients. It also could be used within health education for cardiac patients to encourage them for regular follow-ups and compliance of treatment modalities. General Objective: To assess the lifestyle of patients with Coronary Heart Disease attending the Cardiac Outpatient Department of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal.

16 Mar/Apr 2011 www.cardiologyhd.com

Mt Everest

Country: Nepal Population: 29,331,000 (2009 est) Official Language: Nepali Nepal is a landlocked country in South-East Asia bordered on the north by the People’s Republic of China, and to the south, east, and west by the Republic of India. Located in the Himalayas, Nepal has eight of the world’s ten tallest mountains, including the highest point on Earth, Mount Everest. The capital city is Kathmandu. Source: Wikipedia

Specific Objectives: •

To assess the lifestyle of patients with coronary heart disease.

To find out the association between lifestyle and selected variables.

To find out the association between lifestyle and clinical characteristics.


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

MATERIALS & METHODS Design of the Study: Cross sectional descriptive study Population: All clients having CHD attending cardiac OPD, BPKIHS Sample size: Sixty cardiac patients. Sampling technique: Purposive sampling technique Research Instruments: Self-prepared semi-structured questionnaire. Research Validity and Reliability: Content validity of the instrument was established by seeking opinion from the concerned authority. Data collection Procedure: Verbal consent was taken from all subjects before data collection. Data analysis Procedure: Data was entered at first in Microsoft Excel & converted in SPSS. It was then analyzed by using descriptive and inferential techniques to assess the association between selected variable and clinical characteristics of cardiac patients.

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

DISCUSSION Cardiovascular disease is becoming a major cause of illness and death in the eastern Mediterranean region, currently accounting for 31% of deaths. This rate is attributable to an ageing population, high rates of smoking, and changes in nutritional behavior habits, along

with sedentary lifestyles. From our study it is depicted that out of the total 60 patients interviewed, the majority of respondents (52%) were females, 31.7% of patients were in the age group >60 years, 17 (28.3%) where in the age group 51-60, 9 (15%) where in the age group 41-50, 7 (11.7%) where in the age group 31-40, and 8 (13.3%) where in the age group 20-30. Patients who were Kirat comprised 17 (28.3%), followed by Chhetri 25%, whilst Vaisya and Brahman were 16.7% respectively. The majority of respondents found 86.7% are Hindus by religion. Most (51.7%) of the respondents were from the rural community. Most of the patients (83.3%) were non-vegetarian, 33.3% were past smokers, and 60% of the patients had history of doing exercise. Among females, 58.3% had menopause. Most of the patients (53.3%) had systolic blood pressure above normal. Also 71.7% of the patients had diastolic blood pressure as normal and below normal. Frequency of overall favorable lifestyle was only 25%, among which those with a good dietary pattern was 28.3%, and non-smoker percentage was 66.7%. About 68.3% of patients were non-alcoholic, and among all patients 83.3% had a good follow up pattern. On the other hand, patients carrying their prescription papers regularly with them and with a good meditation habit were found to be very rare (26.7%). So there is need for improvement for better lifestyles (75%), and there was an association between the lifestyle and selected variables ie. the residence (p=0.037). There was also association between the lifestyle and clinical characteristics i.e. the physical activity (p=0.000). Findings show that only 25% of the respondents had a good lifestyle. In this study, respondents with a lifestyle score greater than 14.4 out of 24 (>60%) were considered to have a good lifestyle.

www.cardiologyhd.com Mar/Apr 2011 17


GLOBAL

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

CONCLUSION From this study it is concluded that most of the patients were not aware of their disease condition and need for modification of lifestyle for managing cardiac problems. Nurses can play a vital role in the identification and management of cardiac patients by identifying the risk factors associated with their lifestyle, and by providing referral services in taking care of patients with cardiac related problems. Health education, especially encouragement of healthy lifestyles at the national level should be initiated, and an overall policy of health promotion to reduce cardiac problems implemented.

REFERENCES: 1.

Cardiovascular Disease. [serial online] 2003 [cited 2010 January 27]. Available fro: URL:http://www.labtestonlie.org.

2.

WHO Cardiovascular Disease. [serial online] 2009 [cited 2010 January 26]. Available from: URL: http: // www. Who.int.com.

3.

Black H. Cardiovascular Risk Factors. [serial online] 1997 [ cited 2010 January 26]. Available from : URL: http:// www.yahoo.com

4.

Cardiovascular Risk Factors for Cardiovascular Diseases. [Serial online] 2005 [cited 2010 January 27]. Available from: URL: http://www.asu. edu.

5.

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

6.

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

7.

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

8.

Goyal A. Yusuf S. Burden of Cardiovascular Disease in the Indian Subcontinent [serial online] 2006 [cited 2010 January 15]. Available from: URL: http: // www.icmr.nic.in

9.

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

18 Mar/Apr 2011 www.cardiologyhd.com

10. Adili F. Knowledge and Practice Status and Trend in Risk Factors. [serial online] 2005 [ cited 2010 February 16]. Available from: URL: http: // journals.turns.ac.ir 11. Vanhecke T. Awareness, Knowledge and Perception of Heart Disease. [serial online] 2006 [ cited 2010 February 16]. Available from: URL: http: // journals.lww.com 12. Jafary et al CARDIOVASCULAR HEALTH Knowledge behavior in patient attendants at four care tertiary hospitals in Pakistan-a cause for concern. [serial online] 2005 [ cited 2010 February 17]. Available from: URL: http: //www.biomedcentral.com. 13. Khan MS. Knowledge of Modifiable Risk Factors of heart disease among patients with acute MI in Karanchi, Pakistan. [serial online] 2006 [cited 2010 February 17]. Available from: URL: http: //www. biomedcentral.com. 14. Frost R. Cardiovascular Risk Modification in College Student. [serial online] 2007 [ cited 2010 February 16]. Available from: URL: http: // www.springerlink.com 15. FHA-Health Belief Model Perceptions, Knowledge of Heart Disease. [serial online] 2006 November 29 [cited 2010 February 1]. Available from: URL: http: ///www.final.health-articles.com. 16. Knowledge and Awareness of Risk Factors for Cardiovascular Risk Factors for Cardiovascular Disease. [serial online] 2008 September 1 [cited 2010 February 1]. Available from: URL: http: ///www.thefreelibrary. com.


Management

Assistance Management: Care and Compassion Ms Sophie Blackman Coronary Heart Management and CRM Consulting Editor Head of Clinical Cardiac Physiology West Hertfordshire NHS Trust

T

here has recently been great publicity surrounding ‘Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people’. This document first came to my attention after I saw such damning headlines in the national newspapers as: ‘The NHS has failed the elderly’ The Times. I downloaded a copy of the report, and it certainly makes for uncomfortable reading. Of the 10 cases discussed, 9 of the patients died during or as a direct result of the treatment that they received. The stories within the document are truly harrowing, but I would urge you to read them as there is much we can learn.

http://www.ombudsman.org.uk/care-and-compassion/home There has been significant discussion in the press since this report was published and there are a few points that I think are important regarding this document which I have impressed upon my staff. Firstly, ‘the NHS sees over a million people every 36 hours’, Nigel Edwards Chief Executive of the NHS Federation is reported to have said on www.nhs.uk, and so ‘the ten cases included in the report need to be kept in perspective’. While the Ombudsman’s document is ‘powerful and informative regarding the individual cases, it cannot be thought of as reliable evidence that can be applied generally to the care of the elderly across the NHS’. Nevertheless, whilst I think it is important is that we keep the report in perspective, for these individuals and families there were crucial errors made in the care received. When you read the report what is so upsetting is how very easily the errors could have been avoided through better communication, better understanding of the patient and families perspectives, and by sometimes pushing the boundaries of our roles. It is evident of a service stretching to its limits, often with insufficient finance and resources and never ending cut backs that sometimes staff are so pushed to get things done to fit a timeframe that is comes at the compromise of the expected standards. I have asked all my staff to read this document because I think it serves as a good reminder for us as we go about our daily work, that despite the endless increases in service demand and external pressures we have, we all came into this profession to care. Irrespective of anything else that is going on, every single patient that we see - young or old - deserves our undivided attention. It reminds us that things we do day in, day out, are unfamiliar and invoke fear in our patients, and we must not take for granted the value and importance of taking an extra few moments to ensure the patient is informed and comfortable, that you are respecting their dignity, and providing them with the best service of care. For surely without providing this level of care, commitment and courtesy for every patient you see you would not be fulfilling your duty of care? Sometimes our duty of care has much wider scope than the exact job description we have on paper, and just a small effort beyond our normal role can help prevent the communication breakdowns, and leave our patients and their relatives with a much more positive experience of our NHS. www.cardiologyhd.com Mar/Apr 2011 19


Sophie Blackman’s ECG

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

Our ECG Challenge for this edition is only available on our website. This is because the ECG image obtained didn’t quite have the resolution required to look great in this magazine. However here is a quick overview: This ECG was the taken from the first patient diagnosed with short QT syndrome (SQTS). This phenomenon, first described in 1999 by Dr. Preben Bjerregaard MD, DMSc, is still a relatively unknown disease, and due to this may often go undiagnosed.

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

Love our ECG Challenges? We have 20 ECG Challenges on our website just waiting for you to solve, all of which have been featured in this publication over the years. In our May/June edition, Sophie will also be starting a series on ECG Education. This series will be perfect not only for other cardiology professionals but also students and newly qualified staff.

20 Mar/Apr 2011 www.cardiologyhd.com


United Kingdom

Site Visit Barnet Hospital Barnet Hospital Wellhouse Lane Barnet, Herts EN5 3DJ United Kingdom

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

What are the sizes of your Cardiology Department and Hospital?

Barnet and Chase Farm Cardiac Services Cardiology Service

Barnet Hospital

The specialty of cardiology lies within the directorate of General Medicine and Pharmacy. The specialty provides a combination of inpatient work, a large outpatient service, and a full range of cardiac investigations. In addition there are elective and emergency procedures undertaken mainly as day cases. The ward base consists of 8 bedded CCUs on both sites, a 24 bedded cardiology ward, Rowan, at Barnet, and 11 beds on Melbourne ward at Chase Farm, with access to further beds on Toronto ward at Chase Farm. There are cardiac departments providing a full range of non-invasive cardiac investigations at both Barnet and Chase Farm, with a more limited service at Edgware hospital. Outpatient clinics are run from these sites as well as Cheshunt Community Hospital and Potters Bar, and include 7 Rapid access chest pain clinics weekly. Cardiac Rehabilitation is offered as an inpatient and outpatient service at both sites and extended into the community. Outreach heart failure clinics are run for Enfield patients at Forest Road. Myocardial perfusion scanning is also undertaken at Barnet in the Radiology department.

courtesy Google

The cardiac catheterisation lab and a six bedded day case unit is sited at Barnet, opening in April 2008. This is a trust-wide service providing facilities for diagnostic cardiac catheterisation, CRT, ICD and permanent pacemaker implantation for elective and emergency admissions. We are expecting to increase our service to include elective PCI in 2011. www.cardiologyhd.com Mar/Apr 2011 21


SITE VISIT

The Cath Lab Team (from left): Naveena Patel, Sara Fershi, Dr Ameet Bakhai, Beryl Broadhurst, Carolyn Forte, Claire Roaf, Louise Harney The purpose built cardiology department at Barnet carries out:

How many staff? Roles?

12 lead interpretative ECG

Staffing

Treadmill exercise testing

Nuclear scanning

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

M-Mode, 2D, 3D, Doppler, Stress and trans-oesophageal echocardiography

1 Associate specialists

2 Specialty doctors

Trans-telephonic monitoring

4 SpRs

24 hour ambulatory rhythm monitoring

4 ST grade juniors

Event recording

2 FY grade juniors

24 hour ambulatory blood pressure monitoring

1 Physician Assistant

2 Consultant Cardiac Surgeons – 1 PA activity weekly each

2 Consultant Electrophysiologists – 2 PA total activity weekly.

What is the geographical intake area and population served by your hospital? Barnet and Chase Farm hospitals are part of the North Central Sector which has a catchment of 1 million, 50% of which being served by Barnet and Chase Farm Hospital

22 Mar/Apr 2011 www.cardiologyhd.com

.


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. • Support for all major FFR vendors’ pressure wires • Reduce capital expense by eliminating the need to purchase separate FFR analyzers • Easily incorporate the FFR result to a lesion via an intuitive user interface • Automatically store FFR pressure waveforms and numeric results in patient’s central cardiac file • Eliminate time and errors associated with manual data entry

Please contact our sales team for an onsite demonstration

McKesson (Medcon), UK Premier House 112 Station Road Edgware, Middlesex HA8 7BJ United Kingdom Phone: 0208 9511110 uksales@medcon.com www.mckesson.com/cardiology

AllAboutCVIS.com/ffr 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. www.cardiologyhd.com Mar/Apr 2011 23


SITE VISIT

Types of equipment used? •

Siemens Axiom Artis (X-Ray)

McKesson – Medcon: Horizon Cardiology (CVIS and Haemodynamic)

Philips iE33 (Echo)

Siemens Cyprus (Echo)

How many procedures are performed a year? Activity Y2008/9

Y2009/10

Elective angio

932

1089

Emergency angio

645

446

Elective Device implantation

185

204

Nursing

Emergency device implantation

155

179

Cardiology matron.

Total

1917

1918

Cardiology Nurse Specialists 5 WTE – RACPC, Heart Failure, Pre assessment and Revascularisation and Research CCU (Barnet) 19.5 WTE Cath Lab, Day Unit, Pre assessment 15.29 WTE Barnet cardiology ward 27.95 WTE Chase Farm Melbourne (CCU & step down) ward 26.24 WTE Cardiac Rehab team 4.5 WTE Cardiac Physiologists 22 WTE (all sites, and including respiratory service) Admin Staff 8 WTE (all sites, and including waiting list management) Secretarial support 8.5 WTE Types of procedures? Currently performing diagnostic Angiography. Device implantation including, temporary and Permanent Pacemaker insertion, ICD, and CRT-P. We have completed our training and BCIS evaluation and hope to commence PCI in the early part of 2011

24 Mar/Apr 2011 www.cardiologyhd.com

What is the approximate percentage of cath lab cases performed radially compared with femoral? Approximately 36% Does your department offer a Primary Angioplasty Service? Barnet Hospital hope to start a PCI service in 2011, Primary Angioplasty will remain in the established centres. What new procedures / techniques have you implemented into the department recently? Future? CRT, ICD, future PCI, FFR What are the benefits to patients attending your facility? They no longer need to commute into London for treatment.


Write to us at admin@coronaryheart.com for more details.

SITE VISIT

Would you like your department featured here?

How is your inventory managed? Electronic Stock ordering through EROS, will use McKesson Medcon inventory module for consignment and PCI when we start. How does the lab handle haemostasis? TR Band for Radial approach, Angioseal for approximately 80 percent of femoral access, remainder of femoral Manual compression. What measures has the department implemented to cut costs? Careful stock management, stock rotation, consignment stock, early diagnostic procedures to reduce length of stay.

What kind of training can new employees expect to receive? Off site training under honorary contract with the London Chest for PCI procedures, we hope to access the same support through Bart’s for Complex device therapies. We also schedule training days on site during Lab down time, inviting external trainers and industry to ensure ongoing education and training.

What kinds of competency checks do staff have to undergo once employed? General competencies relative to all trained nurses. Department specific competencies such as IABP set up and transportation, ECG interpretation, IV Cannulisation, BLS, ILS. Assisting with Cardiac interventional procedures. Scrub Technique.

How do you deal with late finishing of cases? For example staggered working hours or just staff overtime? Nursing Staff work Long days 07.30-19.00 so as to overlap the lab operating time of 09.00-17.00. Physiologists and radiographers claim overtime for overruns or take time back.

What is the best part of working at your facility? We are well supported by our Managers to provide an excellent service for our patients, waiting time for elective Angiography is usually less than three weeks. Great People, hard working, a busy lab that gets through a large volume of work for a single Lab with no after hours work. It is a great environment for learning, and our young staff are proving to be excellent Cath lab professionals who will no doubt remain in this speciality for many years to come.

www.cardiologyhd.com Mar/Apr 2011 25


Events LIKE TO BE

FEATURED?

June 13-15

1

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

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

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3

5

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BCS Annual Conference Manchester Central Manchester, England www.bcs.com June 29 - July 1 Hands-on Cardiac Morphology National Heart and Lung Institute (NHLI) London, England www.cardiacmorphology.org July 4-8 The Southampton practical cardiac MRI course Southampton General Hospital Southampton, England www.suht.nhs.uk/cardiacmricourse October 2-5 HRC 2011 Hilton Birmingham Metropole Birmingham, England www.heartrhythmcongress.com October 7-8 British Society of Echocardiography Annual Meeting Edinburgh International Conference Centre Edinburgh, Scotland www.bsecho.org October 17-18 PCR London Valves 2011 London England www.pcrlondonvalves.com November 24-25

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26 Mar/Apr 2011 www.cardiologyhd.com

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British Society for Heart Failure 14th Annual Autumn Meeting Queen Elizabeth II Conference Centre London, England www.bsh.org.uk


ANNUAL CONFERENCE 2011 Venue: Manchester Central, Manchester Date: 13 to 15 June 2011 3 Day educational meeting in Cardiovascular Medicine, with a programme of case based presentations and plenary sessions Exhibition showcasing the latest developments in cardiovascular medicine and new technologies Educational content based on the new European Curriculum, including a Trainee day Gain CPD points and review general cardiovascular knowledge required for revalidation Members of the British Cardiovascular Society can register for free before 31 March 2011. Visit www.bcs.com for online registration and further information.


sTAndArd TreATmenT

20%

reduction in all-cause mortality at one year1 BAlloon-expAndABle TrAnscATheTer AorTic VAlVe implAnTATion (TAVi)

A new option for your high-risk patients with aortic stenosis In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1 Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.1 For more information, visit edwards.com/EU. Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607. The Edwards SAPIEN transcatheter heart valve and delivery systems bearing the CE conformity marking comply with the requirements of the European Medical Device Directive 93/42/EEC. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards and Edwards SAPIEN are trademarks of Edwards Lifesciences Corporation. Edwards Lifesciences, the stylized E logo, and PARTNER are trademarks of Edwards Lifesciences Corporation and are registered in the United States Patent and Trademark Office. © 2011 Edwards Lifesciences Corporation. All rights reserved. E1775/12-10/THV.

Edwards Lifesciences Irvine, USA I Nyon, Switzerland edwards.com

I Tokyo, Japan I Singapore, Singapore I São Paulo, Brazil

Coronary Heart #29  

Features Lifestyles of Patients with CHD in Nepal, Behind the Headlines, Barnet Hospital Site Visits, and a PFO Closure Hot Topic.

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