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Take a look at a selection of our recent media coverage:
4th July 2024
The results of a national audit and quality improvement project looking to optimise cardiovascular care across Italy has recently been presented at the Italian National Association of Hospital Cardiologists conference. Here, Professor Furio Colivicchi speaks to Helen Quinn about the rationale for the audit study, the key findings and next steps, plus the team’s ambitions to widen the scope of the project to support more patients nationally and across Europe.
Cardiovascular diseases (CVDs) are the leading cause of death globally. Figures produced by the World Health Organization (WHO) estimate 17.9 million lives are lost each year as a result of CVDs, with four out of five of these deaths being a result of heart attacks and strokes.
Finding ways to reduce death and ill health related to CVD is a primary goal of many researchers around the globe, including Professor Furio Colivicchi.
After training in internal medicine, Professor Colivicchi moved to clinical cardiology and developed a particular interest in secondary cardiovascular prevention. He joined the San Filippo Neri Hospital in Rome in 1991, becoming its director of cardiology in 2013, and he’s also a professor of cardiovascular medicine at Tor Vergata University of Rome’s School of Medicine.
In Italy, the prevalence of CVD is nearly two-fold higher than the global rate, and Professor Colivicchi is working hard to improve best practice and patient outcomes. He is currently undertaking an audit of cardiovascular care across the country with the Italian National Association of Hospital Cardiologists (ANMCO) for which he is also immediate past president.
The audit analyses admissions and treatment pathways for CVD patients throughout the country and examines whether the guidelines for treatments are being adhered to and how to improve this likelihood.
Current guidelines from the European Society of Cardiology (ESC), published in 2019, advise the use of high-intensity statins and subsequently, ezetimibe and PCSK9 inhibitors to reduce low-density lipoprotein cholesterol (LDL-C) levels below 55 mg/dL within four weeks.
However, such combination therapy is not used as much as it should be in clinical practice, and Professor Colivicchi and his team suggest this is due to therapeutic inertia, where clinicians do not always consider the information contained in such guidelines.
‘There is a gap between what should be done according to the guidelines, what the scientific evidence is about the management of certain cardiovascular conditions and what is actually performed in clinical practice,’ Professor Colivicchi says.
According to the guidelines patients with recurrent cardiac events should be reaching lower LDL-C levels of 40mg/dL – a target Professor Colivicchi describes as ‘rather ambitious’.
‘We have evidence from several observational studies in Europe, the United States and Italy that these levels were not reached in clinical practice. Patients were not following a proper path to the reduction of cardiovascular risk, which is the reduction of ischemic recurrences in particular,’ he explains. ‘Our idea was to have a photo of what was going on and then give feedback to the institutions involved in the project.’
To begin the study, entitled ‘Optimisation of the pathways from hospital discharge to follow up: the APPRO-EVO AUDIT ACS Project’, Professor Colivicchi organised observations in over 50 hospitals throughout Italy, which involved around 500 cardiologists and more than 1,100 patients.
The clinicians involved in the study collected data over four weeks, describing the general management of their patients, the epidemiological features of this population, the kind of lipid-lowering treatment implemented and whether these patients could or could not reach the recommended targets as outlined in the ESC guidelines. The audit and feedback methodology aimed to improve the quality of healthcare given to high-risk patients.
Professor Colivicchi says: ‘This is the general idea about audit; it is a circle in which you have to check what you do, try to improve your practice, and then check again to see what has actually happened. If you close the gap, then there is always an improvement.’
After collecting and analysing the initial data, the researchers undertook a second audit involving more than 1,000 additional patients to see if anything had changed following the feedback from the first audit.
Professor Colivicchi found a ‘striking increase’ in the use of new drugs in the second audit, particularly PCSK9 inhibitors and monoclonal antibodies, to treat the most severe forms of hypercholesterolemia.
The results, which Professor Colivicchi presented at the recent ANMCO conference, show that in the first phase, just 60% of the patients were discharged from hospital with a combination therapy, including a statin plus ezetimibe. The remaining patients were discharged usually with only a statin.
Following the feedback from the first audit, the number of patients receiving combination therapy rose to 75%, and the use of PCSK9 inhibitors rose from 10% to 17% in the second audit. In addition, more than 80% of patients reached the recommended targets in the guidelines.
‘We were able to demonstrate that when there is a particular attention to clinical practice, the healthcare providers tend to improve their performance. Patients were followed more carefully because when you know that someone is observing you and assessing what you’re doing, there is specific care in what is actually done,’ says Professor Colivicchi.
The next stage is to expand the project from 50 to 200 and then 300 hospitals, including minor and community hospitals throughout Italy. Professor Colivicchi hopes that clinicians will perform the assessments every six months.
He adds: ‘When you implement a quality improvement procedure within every single hospital, you can improve the practice and reach the goals recommended by the guidelines. If you reach the target, you can expect to improve clinical outcomes over the medium to long term. So, this is the underlying logic: you need that feedback.’
Through the study, Professor Colivicchi notes that the CVD patients arriving at the hospital often showed many modifiable risk factors that had not been addressed. These included smoking, being diabetic with suboptimal control of glucose metabolism, hypertension without proper treatment, as well as high cholesterol. The findings from the study show that if antiplatelet therapy is appropriately managed to reduce LDL-C, cardiovascular recurrence events will also be reduced – even in high-risk populations.
‘Prevention is relevant. Secondary prevention is extremely relevant because the effectiveness of preventive procedures is more prevalent in those patients at high cardiac risk. So, you can reduce the number of the events that are recurrent in more than 50% of patients,’ Professor Colivicchi explains.
The team is sharing the data with the Italian Ministry of Health and the local health authorities to provide them with evidence that certain interventions are effective in improving clinical practice. The evidence from the audit allows clinicians to optimise the choice of treatments, ultimately promoting a higher quality of care in a safer and more efficient way.
Professor Colivicchi’s evidence showed that, overall, there was a better use of therapeutic resources in the at-risk population and thus an increased likelihood of achieving the therapeutic targets recommended by the current ESC guidelines.
‘This experience is just one step in the direction of quality improvement. We think we are always doing the best for our patients, but this is not necessarily true. We have to measure what we do every day, and then we must be accountable for what we do. This is an approach we can implement to have some objective evidence of our clinical practice and to improve it properly,’ Professor Colivicchi concludes.
Only time will tell just how extensive the improvements are to patient care throughout Italy as a result of the audit study, but the researchers hope the impact is even more widespread than that. Their process is likely to be applicable to other health services and can help to support the implementation of best practice around the world.
6th June 2024
Speaking at Hospital Healthcare Europe’s Clinical Excellence in Cardiovascular Care event, our panel of three cardiologists considered the role of multidisciplinary teams (MDTs) in cardiac care. Dr Tim Lockie, Dr Clare Appleby and Dr Shazia Hussain shared their views on how MDTs and their collaborative meetings can be most effectively managed.
The way in which care for cardiac patients is managed has changed dramatically in the last twenty years. Previously under the care of a single cardiologist, patients are now looked after by multiple specialists, including nurse practitioners, physiologists and various cardiac experts from interventionalists to radiologists and beyond.
With advances in cardiac imaging and new technologies, more diagnostic tools are available, and greater expertise is needed to interpret the findings. A range of healthcare professionals work together to determine the patient pathway through treatment and care, making multidisciplinary team (MDT) working a key component of contemporary patient care.
All three Clinical Excellence event panellists are heavily involved in MDT working across different areas, including coronary MDTs, structural MDTs and ward work, as well as applying the principles to NHS boardrooms.
They are Dr Tim Lockie, a consultant cardiologist and clinical service lead for cardiology at the Royal Free London NHS Foundation Trust; Dr Clare Appleby, a senior consultant interventionalist and clinical lead for intervention at Liverpool Heart and Chest Hospital; and Dr Shazia Hussain, a consultant interventional cardiologist at Glenfield Hospital, University Hospitals of Leicester NHS Trust.
Along with panel chair Rebecca Dobson, consultant cardiologist specialising in imaging and cardio-oncology at Liverpool Heart and Chest Hospital and the Clatterbridge Cancer Centre, they discuss how to successfully navigate the shared decision-making processes at the heart of MDT care based on their own experiences in clinical practice. As Dr Lockie said: ‘Multidisciplinary team working is what we all strive for. It’s not easy, and it’s not always well done. It has to be really nurtured and cherished.’
Dr Appleby: TAVI [transcatheter aortic valve implantation] is quite a big team. Within the hospital setting, there are the operators, but germane to the team are the nurse specialists who really run our service. They’re extremely important in terms of their role liaising with patients and referring hospitals and GPs in terms of investigations and managing patients’ and relatives’ expectations.
We have a TAVI coordinator who is an administrator, and that’s crucial for any large service. We have the cath lab staff where we actually do the procedure so the operating team. Then we do a lot of work with the wider team, so the referring hospitals around the region, GPs with special interest as well are very important in terms of in diagnosing and then investigating these patients. You have the outpatient setting and then the more procedural setting within the hospital, but I think in terms of something like a TAVI service, it’s really absolutely reliant on having an efficient multidisciplinary function.
Dr Hussain: We all do ward work and there are various teams that are involved in ward decisions like the TAVI team and the coronary revascularisation team. But, on a day-to-day basis, we have the ward multidisciplinary teams, which involve discharge coordinators, input from occupational therapists, physiotherapists, nursing staff, sometimes from the social department and funding.
These are often MDTs for patients where there’s a certain issue that is difficult beyond the medical issue and we see that on a daily basis – maybe there are difficulties at home, safeguarding issues, patients that are difficult to discharge – the voice of every member of that team is as important as the medical voice and, of course, we like to get the patients and their relatives involved themselves.
Dr Appleby: I think it’s probably about the structures that you have. For example, if we take the cath lab, where you’ve got a very high-intensity environment with many different staff groups performing procedures. We have a system, which I think is common to many trusts now, where you try and avoid a hierarchy and you have a more horizontal approach.
We have things like halt processes, your safety checks that you go through. We have a very structured approach so that each member of the team within that environment has an opportunity during those safety procedures to say whether they have all the equipment that they need, whether they have anything they want to raise. We do that in a very structured format before the performance of each procedure.
That’s a very particular example to a procedural environment. And that’s very different if you’re in a medical decision-making meeting, or perhaps on a ward base having a patient’s best interest meeting where you might have a much broader audience. But, if you can, structure it to enable other voices to be heard and have the patient at the centre of everything.
Dr Hussain: What’s really made a huge difference to our coronary MDTs is the presence of a neutral chair who is strong, can direct, is well aware of the different parties within the room and allows everyone to have an opportunity.
Sometimes, MDTs can get quite tense between different parties and, at that point, what you need is a chair. We’ve got Gerry McCann, who is our head of imaging, as our chair so he has a neutral perspective and is able to guide the conversation and take everyone’s viewpoint into account and also then decide when it’s time to move on from a conversation. It’s important that any MDT has an atmosphere of safety where everyone can speak, but it is a difficult area to navigate.
Dr Lockie: At the Royal Free we talk about the triumvirate. That works really at every level, whether you’re doing a ward round, whether you’re making decisions on how you’re going to plan your cath lab lists or how you’re planning all your other services.
We very much believe in this triumvirate structure, which is the medical input, the nursing input and then the operations team. At every level within the hospital, from the smallest units within a ward up to the trust executive team, the leadership structure is very much spread between those three. Everyone has a seat at the table, and everyone has a very important voice. Everyone brings something different to the table as well.
Dr Appleby: In the structural MDT, we have the same chair all the way through, whereas on our daily revascularisation MDTs it’s chaired by the surgeon of the week. I think it depends on what environment you are talking about, but for many of the cardiac-specific MDT processes, there are key people involved.
So, for structural, you will have your nurse specialists, your imaging cardiologists, your structural surgeons, your structural cardiologists, so there are key people in the room. But then we will invite, for example, the referring physician to present that patient.
Most of our MDTs are done virtually so that people who are off-site referring patients in can present their patients and advocate for the patients. So, I think it does depend on the specifics of the MDT, but certainly, there will be a key skill mix – our core – who you have to call up for that meeting to run efficiently and to be making safe decisions for patients.
Dr Hussain: The point of the MDT is that it’s a whole group of people making decisions. Certainly, in our structural MDTs we won’t just have one imaging person or one cardiac radiologist, there’ll be two or three of them. And from the cardiac perspective of the interventionalist we’ll be looking at those things as well. So, it’s never a decision that’s based on one person’s expertise.
Again, if we talk about good chairing and safety within the team, you would expect that if one person is talking outside their expertise, then they will have the honesty to say, ‘actually, what I’d like is a second opinion on this because I don’t know the answer’, and that’s the whole point of the MDT.
Dr Lockie: Like all of these things, you need to put the patient back at the focus of everything. There are disagreements about how to approach a particular problem, and I think all of us need to try to put our prejudices and biases outside the room and just look very objectively at what’s going on.
Increasingly, certainly with angiograms, we have got other things we can use now so we can look at intravascular imaging and we use that frequently now to define things further, and we have non-invasive functional data that we can reference. I think the days of disagreeing over angiograms, thankfully, are gone. I think everyone has now bought into a much more objective assessment of the situation.
But disagreements do happen. It will happen in every single MDT because people don’t conform to small, neat boxes and there is almost an infinite number of variables. You need to disagree agreeably, and as long as you keep the emotions out of the room and keep it focused on a particular patient, then that’s the most important thing.
The other thing to remember is that the output from an MDT is also guidance. You can take the output from an MDT, but you shouldn’t feel necessarily obliged to go down one particular path. In medicine, it’s not a black-and-white world, we’re not talking about objective, clear decisions. As the consultant, if your instincts, or your judgement, and the patient’s are different to the output from the MDT, we mustn’t find ourselves going down a particular route that’s been pushed very heavily from an MDT.
We need to be guided by the MDT. You should have a good reason if you do make a decision that goes counter to it. But also, at the same time, they’re not the ones who are either going to operate on the patient, be speaking to the family or having to pick up the pieces afterwards. And I think we always need to remember that this is guidance, not orders and you can always deviate.
Dr Lockie: I think that most hospital committees have some sort of patient representative on the group and including them in the decision-making is increasingly important and potentially difficult to navigate. Patients have their own understanding of things, and they don’t necessarily see the bigger picture.
With all sorts of decisions about services, patients do need to be involved. But as an organisation, and as different members of the triumvirate, we need to understand how to work effectively with patients to get their voice heard, but also to allow services to be planned and difficult decisions to be made.
It’s so important to have people in the room who actually know the patient. We will, unless it’s a real emergency, defer the meeting until the referring doctor, or the person bringing that person forward, whose actually met them, seen them walk across the room, shaken their hand and spoken to the family can be there. Otherwise, you end up making these very, very complex and potentially life-changing decisions based just on an angiogram, or a set of blood results, and we know there’s so much more than that. You’re absolutely right, it has to be patient focused because what might be right for one person will be completely inappropriate for another.
Dr Appleby: I know of another trust when they are presenting on the aortic valve disease pathway, they have a photo of the patient just to try and keep focus because sometimes the revascularisation MDT can become a bit of a bun fight – a robust atmosphere. Sometimes we just need to bring back and focus on the patients.
I don’t think it’s feasible to have video links live with patients, you’re just not going to be able to get through the numbers. But if you have ways of bringing the patient into that environment, I think it can be quite helpful.
Dr Lockie: I think that everyone needs that to feel valued. Mutual respect and kindness – these are things that need to come from all the people in senior leadership positions and really emphasise that on a daily basis. It’s about clear communication, it’s about respect for others, it’s about allowing others to have their voice in the space. I think it’s up to all of us to remember that. We have to set a culture where we want to work and where we want our colleagues to feel valued. The knock-on benefit in terms of staff happiness, retention, the overall atmosphere of the team can be really transformed by the simple things.
As soon as you have an environment where people get intimidated or, when they do speak, they’re made to feel as if their point is either irrelevant or not valuable in any way, then people are much less likely to speak out again. Whether you’re talking about the micro unit down on a ward, discussing an individual patient, discussing patients in a meeting, sitting in a boardroom, or you’re presenting a business case, I think that culture really permeates.
On one level, a negative culture can be terrible in terms of staff morale and retention, and you end up with people getting stressed and burnt out, not coming to work. But on another level, we’ve also had situations where there are genuine patient safety concerns because you get to the stage where certain individuals are so unwilling to actually listen to what other people say that people then stop raising concerns. Then things get missed and that is the sign of a properly dysfunctional team.
We’ve got quite a good system at the Royal Free called ‘what matters to you’ – a sort of formalisation of the speaking up process. It starts off with an opportunity to submit feedback online and then they have sessions where they bring it all together and you then have a constructive output and you repeat the process. It’s been really effective in sorting out some of these team relationships and building the kind of the structure which we all seek to have.
If things aren’t good or the communication isn’t there and you don’t have mutual respect, kindness and opportunity for people to speak out, it’s important to speak to your organisation about doing something to change that.
Dr Appleby: We are in the process of moving to a new single point of access pathway in terms of aortic stenosis. As part of that, we’ve had to engage with the different members of the team, particularly our surgeons, and agreeing criteria for where we would, up to the point of referral, triage them direct to surgery versus to the cardiologist.
It’s about really engaging the key members first. So, you can agree criteria for which we will triage them. And then when you’ve worked out a provisional pathway, we then opened it up to the wider team for comments. Now we’ve signed it off, which wasn’t a single event, I’m now in the process of going to the region, through our various partner hospitals and taking it through the clinic cardiology clinical leads.
There’s always going to be people who don’t enjoy the change. You have to explain why it’s very necessary, why it’s going to happen and then try and engage people who are perhaps the biggest opponents in designing that so that they feel they have some ownership of it. Then it’s about engaging the whole team and getting feedback before you roll it out.
And it’s getting across to the team that it’s not going to be a one-stop shop where we introduce it and suddenly everything’s great. It’ll be an evolving process. Things will come out of the woodwork we hadn’t anticipated which we’re going to need to deal with. So, managing expectations is also quite a big part of that.
Dr Hussain: It’s great to be able to engage all the key stakeholders from the beginning, but sometimes you just can’t and then you’ve got to go ahead and do it in the best way you can. We’re not talking about utopia where everyone’s going to agree, but as long as you know that it’s in the best interest, you’ve got the majority of people on board and, of course, management and the data behind it, then ultimately, if it’s for patient benefit, then you just have to go ahead.
26th February 2024
An e-health programme developed by the Cardiology Centres Netherlands (CCN) has been rolled out to patients at Amsterdam UMC’s Heart Centre to supplement their care and support cardiologists.
The HartWacht mobile app (HeartGuard, in English) is suitable for patients with high blood pressure, cardiac arrhythmias or heart failure and uses a small measurement instrument, around the size of a cereal bar, to monitor their blood pressure and arrythmias at home.
Making it possible to take an ECG remotely, the app means patients need to visit their cardiologist less frequently. It also gives clinicians more precise measurements and enables them to act faster where necessary.
Amsterdam UMC is the first academic hospital to use this e-health programme, which was developed in 2016 by CCN where it is already being used to track data from more than 3,000 patients.
Michiel Winter, cardiologist at Amsterdam UMC, leader of the HartWacht project, and chairman of CCN’s Board of Directors, said: ‘Since we started the e-health programme we have seen a decrease in the number of ambulance-calls for these patients, and, because we can see what is going on with the patient from a distance, we can immediately reassure and advise or intervene where necessary.’
In addition, CCN analyses show the system results in fewer visits to the emergency department, and that patients who use HartWacht come to the outpatient clinic less often and need fewer nursing days.
Dr Winter said home monitoring with the e-health tool offers peace of mind for patients who often have to deal with lifelong heart disease. ‘It is very reassuring for patients [as] they immediately receive feedback in the app after a measurement,’ he added.
Clinicians can also help patients in a timelier manner with less unnecessary care, as all patient data collected by the app is analysed by a central team before any abnormal readings are shared with the patient’s cardiologist.
Jasper Selder, cardiologist and biomedical engineer at Amsterdam UMC and co-leader of the e-health project, said: ‘It relieves us of our worries because all non-abnormal health measurements are filtered out – often the bulk of all measurements – so that we can focus on patients with abnormal measurements.
‘As a cardiologist, instead of having to look at dozens of heart rhythm and blood pressure measurements during the – often busy – outpatient check-ups, we now receive an immediate notification if one of those measurements falls outside the expected range, so there is more time for the cardiologist to focus on patient care.
‘Deviations also come to light more quickly and not only during checks. Based on the abnormality detected, we can immediately determine whether action is needed, such as adjusting medication or an extra check-up.’
According to Amsterdam UMC, further applications for diabetes and cardiovascular risk management will be added to the e-health programme this year.
12th February 2024
A recent study suggests takotsubo cardiomyopathy is consistently being treated incorrectly, and questions have been raised about the future of its management. Here, Professor Dana Dawson speaks to Helena Beer about her experiences of researching this unique condition and what her findings might mean for clinicians and patients.
For Dana Dawson, professor of cardiovascular medicine and consultant cardiologist at the University of Aberdeen and Aberdeen Royal Infirmary, the acute nature of cardiovascular medicine was the draw towards this speciality from the early days of her medical training.
She thrives on the urgency required in the care that she provides, not to mention the ‘huge professional satisfaction’ from resolving life-threatening situations. And an area of her practice where she’s making a particular difference here is around the management of takotsubo cardiomyopathy.
Described in the early 1990s by Japanese cardiologists, takotsubo cardiomyopathy is so named because the shape of the heart in an acute presentation resembles a takotsubo – the Japanese for ‘a pot used for trapping octopus’.
The narrow neck of the takotsubo mirrors the small part of the heart that still functions normally and sustains life, and its bulbous body is reflective of a portion of the left ventricle that balloons out and stops contracting.
Put simply, ‘it’s a very unusual condition and quite unlike anything else’, says Professor Dawson.
Prior to taking up a consultant post in 2010, Professor Dawson had seen no more than two cases of takotsubo cardiomyopathy. When on call, she came across her third, and she admits that she was ‘clueless’ as to why it had occurred. As was the patient.
‘I looked at it and I thought, what on earth is this?’ she says. ‘And I thought, “surely this is something that we need to dig into a bit further? I’m not going to let this go”.’
She stayed true to her word. Some 14 years later, having established the Scottish Takotsubo Registry and with multiple takotsubo research projects under her belt – including some impressive recent results – she’s heading up the European task force group on takotsubo and working towards a consensus on this unique and fascinating condition.
Imagine you’re in the community and someone becomes unwell and they clutch their chest, they’ve got pain, they’re breathless and pale. You immediately think of a heart attack and so does the patient.
An ambulance is called, they take an ECG and a blood test and they immediately think the same.
Up until that stage everyone thinks it’s a heart attack and it’s not until a little bit later on in their journey when they come to the cardiac catheterisation laboratory that we see that the heart arteries are actually not obstructed as in a myocardial infarction.
None of the heart arteries are obstructed, and yet the heart muscle is not functioning. So that’s bizarre and that’s when we think, well, the fault is not with the arteries therefore it must be with the muscle.
We put dye in the heart cavity and then see that the balloon is there and that’s when we first think of the takotsubo cardiomyopathy diagnosis.
The number of cases is increasing because of better knowledge among doctors and increased awareness of the public as well. We see this fairly frequently now and in our centre, which is by no means a large centre, we see about three to four cases a month.
There is another pointer to it being takotsubo: it’s a psychosomatic interaction. The condition is sometimes called stress-induced cardiomyopathy.
It’s possibly the strongest psychosomatic interaction in medicine. The hallmark of the condition is that patients will usually have been through a stressful, emotional, unpleasant or even a very happy episode – a strong emotion of some nature.
But equally these emotions can be triggered by a physical condition. This could be in somebody who’s experiencing an exacerbation or an acute episode of another disease. And here, the jury’s out to decide what was emotional and what was physical because with any acute disease there’s going to be some invested emotional involvement as well.
These triggering emotions are usually quite distinct and important in that person’s life. Patients usually volunteer that information to begin with or if they’re prompted.
So, whatever happens in that individual’s brain, it seems to be able to connect somehow with the heart muscle and the heart muscle takes a stance and balloons.
Obviously, the first question that most of these patients are asking you after they recover is, ‘why has this happened to me, and will this happen to me again?’
It’s perhaps unsatisfactory, but we’re not afraid to tell people we don’t really quite know why this has happened to them.
There have been proposals that any great emotion causes a surge of adrenaline and it’s the surge of adrenaline that causes this impact on the heart.
I personally don’t think it’s quite as simple as that. I think there’s a lot more to it and it’s our professional duty to go and find out as much as we possibly can.
I find takotsubo cardiomyopathy fascinating because of its multi-organ involvement, the circumstances that generate the onset of the condition and the way it manifests itself.
When we started looking into it, we first established that the levels of energy in the heart muscle were extremely reduced. In fact, they were so reduced that to us it looked almost incompatible with life.
We checked and rechecked our data and when we were certain of what we saw we submitted it for publication.
It was immediately accepted and widely spoken about because it was the first evidence of this energy reduction in takotsubo cardiomyopathy.
We still don’t know why the heart doesn’t generate enough energy so there’s more research to be done there.
The next thing we looked into was what else characterised the heart muscle. We started off with postmortem studies of hearts that were donated by patients who unfortunately died during the acute condition, and that’s when we found there were numerous inflammatory cells in the heart muscle.
A lot of the patrolling immune cells in blood were actually infiltrating the heart muscle because they were perceiving that there was a problem in there.
Then we asked ourselves the question: are these cells there only in this particular subset of patients who are unfortunate enough to not survive, and is that why they died? Or do these infiltrative cells characterise the disease in everybody?
So, we set out a clinical trial and we looked at patients’ hearts with very sophisticated imaging and we concluded that they were present to a certain extent in everyone’s hearts at the time of presentation.
And then by about six months, the cells were going away and the swelling and the inflammation in the heart was recovering. It took about half a year for recovery to happen, so quite a slow process, despite the fact that the function of the heart recovered much quicker.
We then started to look at the medium to long term recovery of takotsubo cardiomyopathy and looked at patients who had an episode at least a year before. We figured out that about 60% of them were actually not fully recovering.
There were still elements of subtle discoordination and altered movements in the heart muscle. Although it recovered a great deal, it still wasn’t a fully normal functioning muscle.
So, that means that you know the sequelae were there much longer term than we appreciated initially when we were looking at the patients acutely.
Back in 2015, we set out the basis of a national registry in Scotland. Each person in Scotland has a unique identifier number and all the conditions that they have in their lives and all their prescriptions are coded against that number.
All that data is centrally held by Public Health Scotland, obviously in an anonymous format, and because we knew of this resource, we set up the registry.
We had to allow some time for it to accrue takotsubo cases and follow up to be able to draw the first conclusions from what happens at national level.
We then looked into the medication and how we treat these patients. There is no designated treatment for takotsubo cardiomyopathy because in medical timelines it’s only just been described.
In the absence of that, what most cardiologists had done was to extrapolate the medication that is normally prescribed to patients with heart attacks because these patients present like a heart attack.
But we found that almost none of these medicines actually are serving these people. Their survival is not influenced at all by any of these standard medications that we extrapolated from the heart attack cohorts.
So, I think the journey only starts here in finding something that helps this condition because the mechanism of it is so different.
So, fortuitously, we’re possibly not starting from scratch. In the longer term, some takotsubo patients developed a form of heart failure with ‘preserved’ ejection fraction.
Perhaps unsurprisingly then, the only medication that had some signal in our analysis of the cohort was the first line therapy commonly used for patients with heart failure.
But because these data come from a registry, there’s a lot of potential bias by prescriber and by indication.
It’s therefore not really an allocation at random, which is what a gold standard clinical trial does. It would have to be tested in a format like that to decide whether it’s suitable, particularly as we’re not discussing the very acute stage, we’re discussing longer-term survival.
It would be exciting to be able to go ahead and look at that in the future.
Interestingly enough, takotsubo cardiomyopathy is a condition that occurs by vast majority in women. So, for every nine women affected by the condition, you only have one man.
Cardiovascular diseases are less diagnosed in women so the population base from which to recruit is smaller. But with this condition we found it quite the opposite and it’s been almost like a revolution.
Women were actually very keen in searching for what caused their presentation of takotsubo and were very keen to return to find out whether their heart was better, how it compared with others and even returning in later years to help with longer-term outcome research.
I’ve got two avenues of interest in the next decade of research around takotsubo cardiomyopathy.
The first thing I’d like to try and learn more about would be the ‘why?’ question. We’ve got some ideas in mind, and we’ve got some pilot data in house, and I would like to follow those avenues of thought.
The brain and heart interaction – how and why they interact and the means through which they interact – is where I would like to delve in further.
That is fascinating from a scientific perspective to see what happens to the to the human body to be able to go through multiple decades of life and then suddenly to develop a predisposition towards this.
Or perhaps they had that predisposition all the way along. Perhaps it’s something genetic, but perhaps it’s something acquired. We’re looking into both.
And the second avenue is looking into the therapeutic level based on what we know now about takotsubo cardiomyopathy. We know that this is a condition where the heart doesn’t quite recover is well as it should do. This predisposes these people to be more vulnerable and have reduced survival compared to their peers.
And if that is the case, we’ve got the signal of one medication that is already there, so we can try to test it and see whether that can help in the interim and for the longer term.
I head a European task force group called the European Society of Cardiology (ESC)’s Takotsubo Disease Study Group, which is under the auspices of the Heart Failure Association of the ESC.
What we discussed only in January was coming up with a European – or possibly an international – consensus. Not a textbook, just a brief expert consensus of what takotsubo cardiomyopathy is, what we need to be mindful of in the acute scenario and in the longer-term scenario, how we treat these patients according to what we know today, and how we follow them up.
We’re leading the multi-centre work in the UK and there are also centres in Sweden, Switzerland, Italy and Germany looking into the condition. We’ve all looked at different areas and from different angles because there’s so much to investigate and we feel there’s enough knowledge now to join forces together and provide an expert consensus.
We’ve asked the ESC if they would endorse the proposal, and we’ll see what their answer is.
1st February 2024
Kicking off on 19 March 2024, Clinical Excellence in Cardiovascular Care is a one-day cardiology event for the multidisciplinary team exploring the latest advances in cardiology – and registration is now open.
Back for a second year, the Clinical Excellence events series brings together renowned experts from recognised Centres of Excellence and other UK and European hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.
This year’s spring cardiovascular care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts, including event chair Rebecca Dobson, consultant cardiologist (imaging & cardio-oncology) at Liverpool Heart and Chest Hospital, UK.
Topics include the multidisciplinary team in cardiac care, cardiorenal syndrome, stroke care and cardiovascular diseases, and new advances in cardiac imaging.
The work of the multidisciplinary team is a theme running throughout the event, focusing on how cardiologists, surgeons, pharmacists, nurses and members of the wider clinical team can effectively and efficiently work together to provide better outcomes for patients.
The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.
Pick and choose sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.
With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us on 19 March and on demand.
Don’t forget to check out Hospital Healthcare Europe’s cardiology Clinical Excellence section, brimming with content including interviews with prominent physicians to complement the event’s offering.
More Clinical Excellence events are in development for cardiovascular care and other specialities, which will be launching throughout 2024.
31st August 2023
The total cost of cardiovascular disease (CVD) in the EU reached an estimated €282bn in 2021, according to new research presented at the European Society of Cardiology (ESC) Congress 2023.
Cardiovascular healthcare accounted for €130bn (46%) of the expenditure, while productivity losses associated with absenteeism and retirement due to illness and disability (5%) and premature death (12%) were estimated at €15bn and €32bn, respectively.
This is the first study to use Europe-wide patient registries and surveys rather than relying on assumptions and, for the first time, includes the costs of long-term social care, which accounted for €25bn (9%) of the total.
A wide variation between countries was identified in the proportion of healthcare budgets spent on CVD, ranging from 6% in Denmark to 19% in Hungary.
The total cost of CVD equated to €630 per EU citizen, varying from €381 in Cyprus to €903 in Germany.
A collaboration between the ESC and the UK’s University of Oxford, this was the most comprehensive and up-to-date analysis of the economic costs of CVD to EU society since 2006.
Study author Dr Ramon Luengo-Fernandez, associate professor at the University of Oxford, said: ‘CVD had a significant impact on the EU27 economy, costing a total of €282bn in 2021. That’s equivalent to 2% of Europe’s GDP and is significantly more than the entire EU budget itself [€186.6bn in 2023], used to fund research, agriculture, infrastructure and energy across the Union.’
In the study, healthcare included primary care, emergency care, hospital care, outpatient care and medications, while social care included long-term institutionalised care, and care at home.
The main contributor to the expenditure was hospital care at €79bn, representing 51% of CVD-related care costs, and CVD medications accounted for €31 billion (20%). Residential nursing care home costs totalled €15bn (9%).
Informal care, which includes the work or leisure time, valued in monetary terms, that relatives and friends gave up to provide unpaid care accounted for €79bn (28%) of the costs. The research found 7.5 billion hours of unpaid care were provided by relatives and friends for patients with CVD.
What’s more, million working-days were lost in the EU in 2021 because of CVD illness and disability, while 1.7 million people died due to CVD across the EU, representing 1.3 million working-years lost.
ESC board member and study author Professor Victor Aboyans, head of cardiology at University Hospital Limoges in France, said: ‘This study underscores the urgent need to act collectively on the European scale to better combat the cardiovascular risk of European citizens, in particular through regulations for better cardiovascular prevention and investment in research.
‘By choosing not to invest in cardiovascular disease we are simply deferring the cost. These data force us to ask the question: do we invest in cardiovascular health today or be forced to pay more at a later stage?’
Professor Panos Vardas, chief strategy officer of the European Heart Agency, added: ‘It is evident that there is significant fragmentation among EU countries in terms of cardiovascular disease healthcare expenditures. This necessitates a re-evaluation by the EU as a whole, and the 27 EU countries individually, to better address the outstanding needs and invest more effectively in supporting those suffering from cardiovascular disease.’
26th April 2023
Hospital Healthcare Europe‘s new editor Helena Beer discusses her journey to healthcare journalism and exciting new developments for the publication, including the launch of Clinical Excellence events – the first of which focuses on cardiology
At the age of 12, I was admitted to hospital with appendicitis. There are a few stand-out moments from the few days I spent in the NHS’ care, not least seeing my kidney on an ultrasound scan, which fascinated me. But it was the unparalleled level of healthcare I was afforded by the A&E staff, nurses and my surgeon, that made a lasting impression.
It impacted me so much that not only did I name a soft toy I was given during my recovery after this surgeon – a duck named Roly for those of you wondering – I decided I wanted to become a paediatrician. And at Great Ormond Street, no less. Now, my science grades may not have resulted in an application to medical school, but, one history degree and a journalism master’s later, I was on the road to becoming a magazine journalist instead.
At first, it didn’t occur to me that my interest in healthcare could align with my new chosen career. It wasn’t until I started working for the magazine of a well-known weight loss and wellness brand that I first dipped my toe into healthcare by writing about diabetes and hypothyroidism. This too, I found fascinating, and I realised I could pursue this interest professionally after all. I could make a real difference through my writing and help people just as the healthcare professionals had helped 12-year-old me, if a little more indirectly.
I found my niche and I haven’t looked back. Almost a decade later, having spent much time focusing on consumer healthcare and community pharmacy, and most recently the other side of the coin in pharmaceuticals, I’m now delighted to have joined Hospital Healthcare Europe and Hospital Pharmacy Europe as Editor.
It’s an exciting time for both brands. We have brilliant new content in the pipeline and have recently launched Hospital Healthcare Europe Clinical Excellence events. These virtual events, which can be accessed live or on demand to suit your schedule, are guided by strong advisory boards and bring together a host of renowned experts from recognised Centres of Excellence. The aim? To share best practice and explore the latest advances in clinical care, building on Hospital Healthcare Europe’s existing portfolio of valuable content.
Cardiology takes centre stage for the inaugural event – a clinical area we know is of major interest to our readers. What’s more, we have also created new and unique content to support the event which sits in a Clinical Excellence section on the Hospital Healthcare Europe website. Here, experts discuss their pioneering approaches to optimising and achieving excellence in patient care in cardiology.
For example, we share an insightful interview with our advisory board member and event speaker Amitava Banerjee, professor of clinical data science and honorary consultant cardiologist at UCL and Barts Health NHS Trusts. The interview discusses why the trend of using electronic patient record data to predict outcomes and prognosis is here to stay. Professor Banerjee also shines a light on the prevalence, incidence and outcomes of cardiovascular diseases in homeless individuals.
Join us on 10 May 2023 to explore the latest advances in cardiovascular care from heart failure to interventional cardiology. Understand how to best utilise multidisciplinary teams, gain ideas for improving patient care and much more. Free to attend and delivered virtually live and on demand, this event offers a convenient opportunity to gain CPD hours.
Find out more about Clinical Excellence in Cardiovascular Care and register here.
And stay tuned for details on future Clinical Excellence events as well as more content covering different clinical areas on our website. Dates for a Respiratory event will be shared soon, with more set to be announced later in the year.
21st April 2023
Hospital Healthcare Europe is delighted to welcome cardiologist Dr Andrew Coats as an advisory board member and speaker at the upcoming Clinical Excellence in Cardiovascular Care event on 10 May 2023.
Dr Coats, Scientific Director and CEO at Sydney’s Heart Research Institute, will chair a panel discussion on the use and misuse of modern technology in the treatment of the heart. He will be joined by consultant cardiologists Matthew Kahn and Jennifer Peal from Liverpool Heart and Chest Hospital and Newcastle’s Freeman Hospital, respectively.
This inaugural event in HHE’s Clinical Excellence series brings together renowned experts from recognised Centres of Excellence to share best practice and explore the latest advances in cardiovascular care from heart failure to interventional cardiology.
Providing the opportunity to gain CPD hours, the day-long event will also focus on how to best use multidisciplinary teams and improve patient care in this area. The agenda has been created by HHE with the support of four advisory board members to offer cardiologists and members of the multidisciplinary team a comprehensive overview of this broad clinical area.
To coincide with the event, a new Clinical Excellence section has been added to the HHE website with a whole host of additional content and interviews with prominent cardiologists from Centres of Excellence and beyond. This includes a fascinating interview with Dr Coats, who is also editor-in-chief of the Cardiac Failure Review journal. HHE spoke to him about his career in cardiology, and heart failure in particular, as well as his pioneering approach to optimising and achieving excellence in patient care.
Find out more about Clinical Excellence in Cardiovascular Care, including the timings and agenda, and register for free, here.
Further events in HHE’s Clinical Excellence series will be announced soon, with respiratory coming first in the summer of 2023.
6th April 2023
In support of our mission to provide high-quality clinical education, Hospital Healthcare Europe is proud to announce a new series of events in 2023: the HHE Clinical Excellence programme.
Kicking off with cardiology and developed in conjunction with an expert advisory board of renowned key opinion and thought leaders from UK Centres of Excellence, our first one-day event on 10 May 2023 will allow you to explore the latest advances and innovations in cardiovascular care.
The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.
Why should you attend?
What’s on the agenda?
How do you attend?
Tickets to attend the HHE Clinical Excellence events are free. Book them here. Tickets allow virtual access to all the talks throughout the day. And if you miss any of the sessions, catch up on-demand at a time to suit your schedule!
Save the date! And register to join us on 10 May 2023!
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