A glimpse into the future of cardiovascular care with Dr Ramzi Khamis

With two practice-changing studies under his belt this year alone, Dr Ramzi Khamis is no stranger to the innovative developments and evidence of best practice emerging in cardiovascular care. Speaking to Helen Quinn, he shares his take on the future of the field and where he sees the greatest potential in primary prevention and post-acute coronary syndrome management.

Dr Ramzi Khamis is at the cutting edge of cardiovascular science, improving healthcare through the development of evidence-based innovations. He combines an academic career as a British Heart Foundation (BHF) fellow and reader in cardiology at Imperial College with his clinical work as a consultant cardiologist at Hammersmith Hospital in London, UK, where he specialises in interventional cardiology. He also heads up the cardiovascular specialties at Imperial College Healthcare NHS Trust as clinical director. His research offers a glimpse into the future of the diagnosis and treatment of coronary artery disease.

This year, Dr Khamis has been involved in two key cardiovascular studies providing objective scientific evidence to enhance best practice at opposite ends of the management pathway. The first is concerned with primary prevention through novel antibody treatments, and the second examines the use of telemedicine in secondary prevention of myocardial infarction. Both studies will change how cardiovascular care is practised worldwide.

‘These are scientific advances, so it’s very different from NHS pathways,’ Dr Khamis explains. ‘It is scientific advances that will facilitate care for patients that can be used by health services all over the world to improve risk stratification, but also improve treatment post-event.’

Dr Khamis began his academic career studying the interaction between the innate immune system, atherosclerosis and the risk of heart attacks, setting the foundations for his current academic work. He is currently the clinical director for cardiology and cardiothoracic surgery at Imperial College Healthcare NHS Trust, undertaking clinician work in the cath lab and cardiac interventions.

‘My work spans both the clinical and the academic fields in what I do, and I think it complements each other. If you’re a very good clinical academic, you have to be very good at what you do clinically, and you have to be very good at what you do academically, so it’s a double jeopardy,’ he adds.

Unmet needs and the current state of cardiovascular care

Much of Dr Khamis’s research focuses on vulnerable atherosclerotic plaque, which is more prone to rupturing and causing heart attacks. He says that the current ‘gap in the treatment’ of atherosclerosis ‘is not addressed by the reduction in low-density lipoprotein (LDL), by giving statins or by doing procedures like coronary artery bypass grafting or percutaneous coronary intervention’.

He therefore set about looking at alternative therapeutic options and settled on using targeted antibody techniques alongside bespoke imaging to target this vulnerable plaque before it can cause damage.

Dr Khamis and his team have developed novel serological techniques to identify at-risk patients with vulnerable plaques by looking at the levels of oxidised lipoproteins and anti-oxidised LDL levels in patients. The published work provides evidence that patients with higher levels of anti-oxidised LDL antibodies are at a lower risk of a CV event.

‘We have found that on intravascular imaging if the patient has higher levels of immunoglobulin M anti-oxidised LDL antibodies, they are less likely to be vulnerable to having a cardiac event. So, there’s an inverse correlation with plaque vulnerability on intravascular imaging,’ Dr Khamis explains.

The new techniques offer a more effective way of classifying vulnerable plaques and at-risk patients. Dr Khamis says: ‘Classical risk factor analysis misses quite a lot of patients that are at risk, and it over-estimates the risk of some patients and underestimates others.’

With this new understanding, a simple blood test can determine that risk. If a patient’s antibody levels are very low, they are more likely to have dangerous plaque, which would then indicate non-invasive imaging may be helpful in these patients to determine next steps.

‘It’s a more bespoke re-stratification that can lead to imaging if needed,’ Dr Khamis says. ‘If the imaging is showing risk, then you need to decide how to treat the patient, probably medically with more intensive therapies.’ Going forwards, the team would like to integrate blood tests with other biomarkers to improve risk stratification further.

The advances in antibody technology mean it may soon be possible to give patients antibodies that are protective against developing harmful plaques. In fact, one of Dr Khamis’s current PhD students is working on the proof of concept of antibody passive vaccination, which could significantly decrease cardiovascular-related deaths in the future.

Advances in post-acute coronary syndrome care

The second study evolved from first-hand observations in Dr Khamis’ clinical work. Even though patients were receiving optimal medical therapy after a heart attack, including intervention antiplatelet therapies and statins, patients still present with heart attacks and CVD issues after being discharged.

In the UK, at least seven to 10% of patients are readmitted within the first 30 days of a CV event, but, as Dr Khamis points out, it ‘could be higher’ since there is no accurate data.

To reduce the rate of readmissions, Dr Khamis and his team tested a new way to monitor patients after acute coronary syndrome events, undertaking a randomised control trial (RCT) examining patients presenting at Hammersmith Hospital.

One group of patients was assigned the usual post-discharge standard of care, while a second group was supplied with a remote monitoring programme. This included an electrocardiogram (ECG) that could be operated at home by the patient themselves, a blood pressure monitor and a saturation monitor. The researchers also designed a unique care protocol. If the patient had any symptoms, the protocol would instigate an ECG and send an alarm to the research team, resulting in a call with a cardiologist.

The cardiologist would then go through pre-set questions and look at the objective data acquired by the patient at home, ultimately deciding whether to reassure the patient, ask them to go to primary care, get them to call 999 or visit an emergency department. The researchers stopped the remote monitoring intervention at six months but undertook patient follow-up at nine months.

‘Exceptional results’

Dr Khamis says the study shows ‘exceptional results’ and ‘a massive reduction in readmissions’. They found that the remote monitoring protocol meant patients were 76% less likely to be readmitted to hospital within six months and 41% less likely to attend an emergency department compared to those receiving the standard care.

‘It seems that having access to the team helps in reducing these readmissions, but also the patient-reported symptoms were much less in the intervention arm. If you’re being monitored, and if you’re being assured, you’ll be much more likely to report symptoms that you’re worried about,’ says Dr Khamis. The telemedicine approach also allows clinicians to trigger an alarm if there is a cause for concern when this may otherwise have been missed.

However, the data also revealed something more surprising. ‘What we didn’t expect is that we were going to find [fewer] heart attacks and strokes in the intervention group; there was no reason for us to think that we thought we would pick up more,’ Dr Khamis explains.

He attributes this to the ‘Hawthorne Effect’, a psychological phenomenon in which individuals alter their behaviour in response to their awareness of being observed. He believes patients may have been more likely to take medication correctly, or that beneficial medication modification could have occurred when an intervention was made, such as during a visit to a GP.

Driving efficiencies and expanding scope

Dr Khamis is currently writing up the study’s cost-benefit analysis for publication. He says: ‘The money saved is significant. It will result in a saving exercise if it’s rolled out throughout the NHS but the initial investment will need to be into training and acquiring monitoring equipment as well as building teams that can run the protocol.’

This will save bed days, allowing clinicians to get on with other procedures. ‘It’s really in the vein of creating more capacity for us to do other work, rather than having to assess these patients in the hospital, we can adequately assess them in the community and have better outcomes,’ Dr Khamis adds.

This study is one of the very few randomised control trials in telemedicine. It proves that remote monitoring and ‘avant-garde medicine’ outside of a hospital are achievable and will provide better outcomes. As Dr Khamis says: ‘The sceptics cannot argue with an RCT. It’s novel because some of these technologies are being implemented without the randomised trials behind them.’

The next research will examine how telemedicine can be built into transcatheter aortic valve implantation (TAVI) care, specifically looking at the feasibility of doing TAVI with same-day discharge and monitoring patients at home with live rather than retrospective monitoring.

Future advances in cardiovascular care

In addition to antibody developments and technical advances in post-event care management, Dr Khamis believes gene therapy, artificial Intelligence (AI), and healthy lifestyles will be instrumental in the future of cardiac care and the prevention of CVD.

‘Gene therapy is going to be huge,’ says Dr Khamis. He suggests that AI will be used in diagnosis and aid therapeutic delivery, such as angioplasty work and deciding where to treat. However, the most important thing, he believes, is working to improve unhealthy lifestyles. After all, prevention is better than a cure.

Dr Khamis says it is ‘a privilege’ to be able to do this work, and through his research with the BHF, he hopes to bring the scientific advances in cardiovascular care a little closer to everyone. ‘[The BHF is] trusting me to do this. I just hope that, when the future of technology is being implemented, it is available to everyone, not just for a select population in the Western world.’

He adds: ‘I think there needs to be a global view of how we tackle this. How do we level up the treatment globally for coronary artery disease so that once our developments are available, everyone can benefit from closing the gap?’