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Take a look at a selection of our recent media coverage:
12th July 2024
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.
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.
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.
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.
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.
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?’
28th November 2023
Use of a high-sensitivity cardiac troponin I assay in emergency departments can improve diagnosis for one in five patients who have acute coronary syndrome, according to new research led by the University of Edinburgh.
The assay also helped doctors to better diagnose and treat these patients, reducing death and future myocardial infarction in this group by almost 10% after five years compared to those who received the older, less sensitive test.
The researchers also found that while the new cardiac troponin assay led to improvements for patients with myocardial infarction, those who benefitted most were patients with a heart muscle injury caused by conditions such as heart failure, heart valve conditions and heart arrhythmias.
Published in the BMJ and funded by the British Heart Foundation, the researchers conducted a secondary observational analysis of the High-Sensitivity Troponin in the Evaluation of patients with suspected Acute Coronary Syndrome (High-STEACS) trial.
High-STEACS used a high-sensitivity cardiac troponin assay to improve precision at very low concentrations and improve the diagnosis and risk stratification of patients with suspected acute coronary syndrome.
While these assays are increasingly being adopted worldwide, little is known about their impact on patient outcomes.
For the secondary observational analysis, researchers studied the results for nearly 50,000 people who arrived at 10 emergency departments across Scotland with a suspected acute coronary syndrome between 2013 and 2016. They used routinely collected health record data and the data service DataLoch to follow up all participants for five years.
The primary outcome was any myocardial infarction or all-cause death at five years.
Secondary outcomes were any myocardial infarction; coronary revascularisation; all-cause death; cardiovascular death; cardiac death; and hospital admission for heart failure, ischaemic stroke, and major haemorrhage.
Over 10,000 patients had high troponin levels indicating heart injury using the new cardiac troponin assay, with one in five of these patients only identified by this high-sensitivity assay.
The researchers also observed that improvements in outcomes at five years were greatest in those patients with an index diagnosis of non-ischaemic myocardial injury.
Dr Ken Lee, clinical lecturer in cardiology at the University of Edinburgh, and the lead author of the study, said: ‘In the past, clinicians could have been falsely reassured by the results of the less sensitive troponin test, discharging patients that appeared to not have heart disease.
‘This new high-sensitivity test is the tool they needed, prompting them to look deeper and helping them to identify and treat both heart attacks and less obvious heart problems. In our trial, introducing this test led to an impressive reduction in the number of future heart attacks and deaths seen in this at-risk group.’
Professor Sir Nilesh Samani, medical director at the British Heart Foundation, added: ‘Medical professionals in emergency departments need the most efficient and accurate tools to look after people. This particularly applies to those who arrive with a suspected heart attack. Such a time-sensitive and life-threatening condition requires the very best diagnostic tests.
‘It is very encouraging to see that the new test trialled here is better at predicting long-term outcomes for these patients, whether they had a heart attack or a different kind of heart injury. This can lead to improved care for such patients.’
The new high-sensitivity cardiac troponin assay has been rolled out to emergency departments across the UK, and the researchers hope that more people will receive the specialist heart care they need to avoid more serious events in the future.
15th June 2023
An acute coronary syndrome (ACS) risk stratification tool failed to improve either adherence to treatment guidelines or reduce the incidence of adverse cardiovascular outcomes compared to standard care, according to a recent cluster randomised controlled trial.
Non-ST segment elevation ACS (NSTEACS), which comprises non-ST elevation myocardial infarction (MI) and unstable angina, is a leading cause of disability, hospital admission and death. The Global Registry of Acute Coronary Events (GRACE) risk score (GRS) is designed to stratify risk in patients with ACS and provides an excellent ability to assess the risk for death.
In fact, optimal use of guideline-indicated care for non-ST-elevation myocardial infarction has previously been associated with greater survival gains. However, whether in practice using GRS leads to greater adherence to NSTEACS treatment guidelines and reduces the level of adverse cardiovascular sequalae was uncertain.
In the current study, published in the BMJ, researchers sought to determine if risk stratification using the GRS in patients presenting to hospital with suspected NSTEACS, enhanced the adoption of guideline-recommended therapy and reduced adverse cardiovascular outcomes.
Hospitals were randomised equally to patient management by either standard care or according to the GRS. The primary outcomes of interest were use of guideline recommended management and the time to a composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for a cardiovascular event.
A total of 3,050 participants with a mean age of 65.7 years (69% female) were recruited and 1,440 were randomised to GRS care.
The uptake of guideline-recommended processes was not significantly different between the GRS and standard care groups (odds ratio, OR = 1.16, 95% CI 0.70 – 1.92, p = 0.56). In addition, the time to the first composite cardiac event was not significantly improved by the use of the GRS (hazard ratio, HR = 0.89, 95% CI 0.68 – 1.16, p = 0.37).
Secondary outcomes of interest included the EQ-5D-5L quality of life measure and the mean duration of the hospital admission for NSTEACS. As with the primary outcome, these metrics were not significantly different between the two groups.
The researchers concluded that use of the GRS score failed to improve guideline recommended management for NSTEACS or reduce a composite of adverse cardiovascular outcomes.
8th November 2021
Acute coronary syndrome (ACS) presentations using emergency medical services increased after the introduction of a public health ‘warning signs’ campaign. This was the finding of a retrospective study by researchers from the department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
Any delay in ACS presentations has a major impact on outcomes for patients, despite major advances in the care of such patients yet few fully understand the importance of early treatment. For example, a focus group study revealed a general ignorance of ACS symptoms and this has arisen in part, due to the perceptions derived from films and TV in which heart attack symptoms were displayed as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. The study also highlighted a lack of awareness of the benefits of rapid action and using emergency service transport (EST) to hospital over alternative methods for reaching hospital. In fact, other work has shown that only 60% of patients used EST when experiencing ST-segment–elevation myocardial infarction.
The National Heart Foundation of Australia (NHFA) in recognising the importance of EST for patients with suspected ACS, launched a mass media campaign to improve Australian’s ACS symptom knowledge and address barriers to emergency transport use. Nevertheless, despite the media campaign, in a subsequent survey of 100 patients hospitalised with an acute myocardial infarction (AMI) only 26% recognised that they were having an AMI and only 34% had called an ambulance. This led the researchers from Monash University to examine the impact of the NHFA warning signs campaign on ACS EST use and to explore any pre- and post-campaign changes on ED presentations via general practitioners for those with unspecified chest pain (U-CP). The team used the Victorian Department of Health and Human Services administrative database to collect information of ED admissions, patient characteristics, mode of arrival and referral sources. The primary outcomes of interest were ACS arrivals via ETS and ED presentations. Data were collected from 2003 to 2015, that included the period of the campaign which ran from 2009 to 2013. In their analysis, the researchers adjusted for factors such as age, gender, ethnicity, residential status (i.e., living alone etc) and location.
Findings
Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 612,758 with U-CP. There was an 11% increase in ED presentations for ACS (incidence rate ratio, IRR = 1.11, 95% CI 1.07 – 1.15) during the campaign compared to the pre-campaign period. Similarly, there was an 8% increase (IRR = 1.08, 95% CI 1.05 – 1.12) for U-CP compared to the pre-campaign period.
For patients with ACS, 58% had arrived using emergency transport and compared with the pre-campaign period there was a slight increase in the adjusted odds of direct arrival via emergency transport (odds ratio, OR = 1.10, 95% CI 1.05 – 1.17) and a significant decrease in the adjusted odds of a GP referral (OR = 0.77, 95% CI 0.70 to 0.86). For U-CP, there was a modest increase during the campaign period of emergency transport arrivals (OR = 1.03, p = 0.019) but a more substantial reduction in GP referral compared to pre-campaign levels (OR = 0.79, 96% CI 0.75 – 0.82, p < 0.0001).
The authors concluded that the NHFA’s warning signs campaign was associated with an increase in ACS presentations and use of emergency transport and a reduction in GP referrals to ED.
Citation
Eastwood K et al. Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome. BMJ Open heart 2021
4th October 2021
Acute chest pain is a common reason for attendance at an emergency department, accounting for approximately 10% of non-injury-related visits. While chest pain can arise from non-cardiac causes, all those presenting with chest pain will be assessed for acute coronary syndrome (ACS). Prompt treatment is required for patients with obvious clinical signs and symptoms of ACS whereas those deemed to be at either a low or intermediate risk initially undergo observation and further testing only if ACS is suspected. One strategic approach to the assessment of low risk ACS patients, is early computed tomography (CT) coronary angiography (CTCA). This technique has been increasingly used to assess patients with stable chest pain because it has high sensitivity and specificity for the detection of coronary heart disease. Within an emergency care department, CTCA therefore allows for a rapid evaluation of patients presenting with acute chest pain. In fact, one systematic review concluded that the use of CTCA is associated with a reduced length of hospital stay compared to usual care. Furthermore, a 2018 study examining the use of CTCA in patients with stable chest pain, found that over a 5-year period, there was a significantly lower rate of death from coronary heart disease or non-fatal myocardial infarction compared to standard care. However, while studies have focused on patients at low risk of ACS, whether early CTCA is of value in those patients deemed to be at an intermediate risk of ACS is less clear.
In trying to assess the value of early CTCA in patients presenting with acute chest pain and at an intermediate level of risk for acute coronary syndrome, researchers from Edinburgh University, established the RAPID CTCA study. The trial enrolled adult patients with suspected or a provisional diagnosis, of acute coronary syndrome and prior coronary heart disease. These individuals where then randomised 1:1 after admission to hospital to early CT coronary angiography with standard care or standard care alone. The primary outcome was the time to the first event of all-cause death or a subsequent non-fatal type 1 (spontaneous) or type 4b (related to stent thrombosis) myocardial infarction at one-year. Secondary outcomes included the cause of death and subsequent myocardial infarction.
Findings
The study recruited and randomised 1748 patients with a mean age of 61.6 years (64% men), of whom 877 received early CTCA. Overall, 89% of patients had chest pain as their primary complaint, 34% had existing coronary heart disease, 57% raised cardiac troponin levels and 61% an abnormal ECG. The primary outcome all cause death or non-fatal myocardial infarction (both types) occurred in 5.8% of those in the early CTCA group and 6.1% of those assigned to usual care (adjusted hazard ratio, aHR = 0.91, 95% CI 0.62 – 1.35, p = 0.65). Furthermore, there were no significant differences in any of the secondary outcomes. The need for invasive coronary angiography occurred in 54% of those in the CTCA group and 60.8% in the usual care group (aHR = 0.81, 95% CI 0.72 – 0.92, p = 0.001).
The authors concluded that early CTCA for patients with an intermediate risk of ACS did not alter overall coronary therapeutic interventions or one year clinical outcomes but did reduce the need for invasive angiography.
Citation
Gray AJ et al. Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial. BMJ 2021
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