Understanding the importance of teamwork in cardiology

Dr José López-Sendón, clinical cardiologist and scientific director at La Paz University Hospital’s Institute for Health Research, discusses the Institute’s work, the importance of teamwork and the current and future challenges in cardiology.

Spending much of his working life within intensive care cardiology, Dr José López-Sendón is the former director of the cardiology department, La Paz University Hospital and the Autonomous University of Madrid. Although now retired from clinical practice, he is is involved in research and administration at La Paz University Hospital’s Institute for Health Research (IdiPAZ), where he serves as the scientific director.

IdiPAZ belongs to the Carlos III network of biomedical research institutes in Spain and includes La Paz University Hospital, the Autonomous University of Madrid, Getafe University Hospital, the European University and the Foundation for Biomedical Research. It has strong links with the major areas of research in La Paz University Hospital’s cardiology department, which is itself a specialist centre covering a population of over one million people.

The department undertakes all major procedures in invasive cardiology including advance heart failure and complex adult congenital heart diseases, transplant and advanced heart failure. Other major research areas of the IdiPaz include neurosciences, infectious diseases and immunity, cancer and human molecular genetics, maternal and infant child and youth, surgery, transplant, and health technologies.

Dr López-Sendón describes the strength of La Paz University Hospital as being built upon three key pillars: treatment of patients, education and research. The hospital and the cardiology department have, over many years, been consistently classed as a renowned centre.

He feels that there are three main reasons why the hospital has continued to remain a high-ranking centre: belonging to a prestigious university, teamwork between the directors of the hospital and the university, and ensuring that the institution has an exceptional basic and clinical team of staff. In short, he believes the ultimate value for a biomedical research institute arises largely because of the people working within it.

Although IdiPAZ, which is made up of nearly 1,000 staff, has collaborative links across Spain and abroad, another underlying reason behind its success, Dr López-Sendón says, is the collaborative mentality of the various departmental directors.

There’s a natural tendency, he explains, for directors to attract funding or expertise to their own department, but he has sought to overcome this bias with ‘a kind of roundtable, with representatives from the universities and the hospitals’. Dr López-Sendón’s main aim is to convince members of the importance of a collective benefit; that the whole is greater than the sum of the individual parts.

Key areas of research

IdiPaz is currently involved in several areas of research and has a large involvement in clinical trials. For instance, the department has had a relationship with the TIMI Study Group for more than 20 years, and is actively collaborating on secondary prevention work. The Covid-19 pandemic provided another opportunity for research and the Institute has studied both the cardiac effects of Covid-19 and the role of anticoagulants in its management.

Another area of research Dr López-Sendón has worked on is the cardiotoxic effects of chemotherapy. This collaborative project involved colleagues from cardiology, oncology, hemato-oncology, radiology and radiotherapy oncology within Spain and overseas.

Cardiotoxicity is a concept that has been growing over the last 10 years, and this work has revealed that rather than it being binary – patients either have or don’t have cardiotoxicity – it is best described along a continuum of severity. The group has published work that helps clinicians to define the characteristics of cardiotoxicity that have to be treated, in other words, most patients will experience some level of insult on the heart but not all need to stop their chemotherapy.

‘Severe cardiotoxicity that would require cessation of chemotherapy is needed in only about 2-3% of cases and most cases occurred in patients who have a previous heart disease,’ he says.

Interestingly, traditional risk factors for heart disease, such as smoking, type 2 diabetes, and elevated cholesterol, also pose a risk for cardiotoxicity during chemotherapy. It’s this point that Dr López-Sendón feels is often not appreciated by oncologists or even by cardiologists. As an example, the prevalence of common cardiovascular risk factors remains unchanged during and after chemotherapy, in spite of close teamwork with cancer and cardiology specialists. The advice to remain as physically active as possible is not enough, which he thinks is a mistake.

Dr López-Sendón notes that to date the majority of oncology treatment guidelines attach a low level of evidence that is based only on expert opinion. This is largely due to the lack of much needed strong evidence from large, multicentre clinical trials.

Challenges in cardiology

Cardiovascular disease remains the largest global cause of mortality, and the number of people with cardiovascular diseases is increasing. While mortality from specific cardiovascular causes is actually constantly decreasing, longer life expectancy offsets this decrease, as older people are more susceptible to cardiovascular disease.

‘Forty years ago, the mortality from acute myocardial infarction was 30% whereas now it is only 5%,’ says Dr López-Sendón. ‘When you take out those arriving at hospital with cardiogenic shock, the mortality reduces to 2%.’ In short, it is the prevention of cardiovascular diseases that is an increasingly important challenge.

A further major challenge in cardiology, Dr López-Sendón notes, is to ‘improve the quality of life for people with chronic cardiovascular diseases’, but what this means in practice is far from clear. After all, a current limitation in cardiovascular research is that patient’s priorities – what they perceive as required to improve their own quality of life – are invariably absent in trials.

Things could change in the coming years as regulatory authorities – who are the principal funders of healthcare – demand a clearer view of benefit. For instance, when a patient says, ‘I want to live more and better at no cost’, this only serves to confound the issue and raises further questions. What is meant by more, how do you define better and what should be deemed as cost effective? Greater awareness of the patient’s perceived unmet needs must be developed.

While aligned with virtually all cardiologists on the importance of patient education on lifestyle risk factor modification as a way to reduce the risk of cardiovascular disease, Dr López-Sendón accepts this messaging often fails to be implemented in practice. ‘It is so difficult because it involves changing someone’s way of life,’ he says.

While focusing on this behaviour modification is important, he believes it is equally important to educate the younger generation about these risks: not starting smoking, making exercise a part of their life and adopting a healthy diet. Ensuring healthy behaviours are entrenched in people from a young age means difficult changes in beliefs and attitudes will not be required further down the line.

Looking to the future

Dr López-Sendón anticipates that the pace of innovation and change will accelerate in all areas of cardiology, demanding a subspecialisation that is already in practice. Artificial intelligence, for example, will increasingly be involved in the diagnosis and treatment of cardiovascular diseases. He imagines that simple robotics, such as smartphones and wearable and implant technologies, will play an even greater and more important role in everyday clinical practice.

A major challenge, however, is teamwork between different protagonists. With basic research more active than ever, Dr López-Sendón says healthcare providers, legislators, scientific associations, the industry, regulatory agencies and the patients must work together and not ignore, or work against, each other.

Finally, Dr López-Sendón maintains that patient education will continue to be vital in helping patients to understand the importance and need to adopt healthy lifestyle measures to reduce their risk of developing cardiovascular disease in the future.

‘Wise men and women predict that cardiovascular diseases will no longer be a problem for the future generations born in 2050 and this will be mainly the result of effective CV prevention,’ he says. ‘Then, the healthcare challenges with be different, but let’s wait and see.’