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Take a look at a selection of our recent media coverage:
17th April 2024
Supporting patients via telemedicine after experiencing acute coronary syndrome (ACS) can reduce emergency department attendance and prevent hospital readmission, according to a new study.
Published in the Journal of the American College of Cardiology and funded by the British Heart Foundation, the study involved 337 patients (86% men) who came to Hammersmith Hospital with ACS over 15 months and were randomly assigned to receive telemedicine or standard care on discharge.
The standard care group of 167 patients were discharged with medication and asked to go to their GP or hospital if they experienced any cardiac symptoms that caused concern.
The 163 patients in the telemedicine group were provided with a blood pressure monitor, a pulse oximeter and a 12-lead electrocardiogram belt device, along with training on how to use the technologies to measure their vital signs. They were told to send their vital signs to their specialist cardiology team if they identified results indicating a potential heart problem.
Using rules developed by the research team, cardiologists then performed a remote clinical assessment to determine the seriousness of the condition, with patients either being reassured, offered a non-urgent follow-up or advised to attend A&E or call 999.
Principal investigator Dr Ramzi Khamis, consultant cardiologist and BHF research fellow at the National Heart and Lung Institute, Imperial College London, said: ‘The approach we designed and tested is focused on sparing valuable time and resources while reaching a well-informed treatment plan for high-risk patients experiencing worrying symptoms.’
The primary outcome was time to first readmission at six-months, with secondary outcomes including emergency department visits, major adverse cardiovascular events and patient-reported symptoms.
The researchers found that the remote monitoring approach meant patients were 76% less likely to be readmitted to hospital within six months (hazard ratio [HR] 0.24; 95% confidence interval [CI] 0.13 to 0.44; p < 0.001) and 41% less likely to attend an emergency department (HR 0.59; 95% CI 0.59; 95% CI 0.40 to 0.89) compared to those receiving the standard care.
What’s more, patients supported via telemedicine had a 15% lower risk of repeat myocardial infarction after nine months, as well as fewer strokes and fewer unplanned coronary revascularisations (3% in telemedicine group versus 9% in standard therapy group).
The occurrence of chest pain (9% versus 24%), breathlessness (21% versus 39%) and dizziness (6% versus 18%) at six-months was lower in the telemedicine group compared to the standard care group.
For those who were readmitted to hospital, the average length of stay was half a day – a third of the average one and a half days in the standard care group.
The researchers concluded that remote monitoring after ACS could help to tackle pressure on health systems worldwide, and reduce emergency department and cardiology ward waiting lists.
Dr Khamis added: ‘The study clearly showed that sending vital information straight to cardiology teams, coupled with a consultation, led to seemingly better care, reductions in admissions, average length of stay and A&E attendance.
‘This simple strategy can potentially free up thousands of hospital beds and doctors’ hours across the country whilst keeping patients just as safe. We are now looking at working with the NHS and other healthcare systems globally to adopt this strategy and hopefully improve treatment for future patients.’
Earlier this year, an e-health programme for patients with high blood pressure, cardiac arrhythmias or heart failure was rolled out to patients at Amsterdam UMC’s Heart Centre to supplement their care and support cardiologists.
Previous research found that patients with heart failure who receive remote disease monitoring and consultations experienced short-term cardiovascular and mortality benefits.
12th March 2024
Patients with kidney failure are at ‘an unacceptably high risk’ of myocardial infarction and stroke, but simple treatment strategies could make a difference, a study funded by the British Heart Foundation has found.
The research, which ran over 20 years, showed that patients who were either on dialysis or with a kidney transplant were up to eight times more likely to have a myocardial infarction and up to four times more likely to have a stroke than those without the condition.
The study highlighted a higher risk among women than men.
As a result of the significantly elevated risk of myocardial infarction and stroke and associated mortality amongst kidney failure patients, the researchers suggest that patients may benefit from anti-platelet medications and are calling for urgent clinical trials of these and similar medications.
Published in the European Heart Journal, the researchers used anonymised healthcare data from over 16,000 Scottish kidney failure patients from 1996 to 2016. They were able to examine whether myocardial infarction and stroke rate, treatments and survival had improved for kidney failure patients.
Over the course of two decades, the rate of myocardial infarction and strokes halved in kidney failure patients, and the associated deaths also fell. Between 1996 and 2016, amongst 16,050 patients with kidney failure (52±15 years; 41.5% women), there were 1,992 incident episodes of myocardial infarction and 996 incident episodes of stroke.
The most common underlying cause of kidney disease was diabetic nephropathy (24.4% [487/1,992] and 26.8% [267/996] for patients with myocardial infarction and stroke, respectively).
The reduction in rates of myocardial infarction and stroke were lower for patients with kidney failure than those seen in the general population over this time, and this gap became more pronounced for women than men.
For women with kidney failure the incidence rate ratio (IRR) for myocardial infarction increased from 6.38 in 1996 to 7.25 in 2014. In men, the IRR increased from 4.80 in 1996 to 5.45 in 2014.
For stroke, the changes in IRR were more modest, for women it was 3.92 in 1996 and 4.04 in 2014, whilst in men it was 2.92 in 1996 and 3.02 in 2014.
Kidney failure patients who had experienced myocardial infarction and stroke during the study had a chance of cardiovascular death at one year of 61.1% (1,217/1,992) and 52.5% (523/996), respectively.
Professor Bryan Williams, chief scientific and medical officer at the British Heart Foundation, said: ‘This comprehensive study shows that, despite some improvements in recent decades, kidney failure patients are still at an unacceptably high risk of having a heart attack or stroke, and in some cases dying.’
The research revealed that simple treatment strategies could improve survival rates among kidney failure patients who have a myocardial infarction or stroke. Following a myocardial infarction, patients who were newly prescribed dual antiplatelet therapy were less likely to die of cardiovascular causes within one year than those who were not (13.6% [41/301] versus 40.5% [75/185]).
Professor Neeraj Dhaun (Bean), professor of nephrology at the University of Edinburgh, who was involved in the research, said: ‘Kidney failure patients are typically excluded from trials of post-heart attack or stroke treatments, like anti-platelet drugs, that become standard for other groups. The resulting lack of data to prove the drugs are safe and effective means there is an understandable reluctance from many doctors to prescribe them for this very high-risk group.
‘However, our results do show that anti-platelet drugs are being prescribed more often for kidney failure patients in recent years and this could bring with it huge improvements in the rate of survival.’
He added: ‘There is an urgent need for a clinical trial of these, and similar, drugs in kidney failure patients. By determining whether they are truly safe and effective, we could potentially bring about a much-needed improvement in treatment for these people.’
7th March 2024
Patients who have a myocardial infarction (MI) are at significantly increased risk of developing other serious long-term health conditions, according to a new study from the University of Leeds.
The research, published in the journal PLOS Medicine, analysed the records of all individuals aged 18 years and over admitted to one of 229 NHS trusts in England between 1 January 2008 and 31 January 2017 – the largest study of its kind.
This amounted to 145,912,852 hospitalisations among 34,116,257 individuals, with 433,361 reports of people with first-time MI. The average age of patients with MI was 67 years, and 66% of these patients were male.
The study looked at 11 non-fatal health outcomes, plus all-cause mortality, within the nine-year study period and compared the results to a control group of 2,001,310 individuals.
Patients who had an MI went on to develop further conditions at a much higher rate when compared to the control group of patients of the same age and sex who had not had one, with the exception of dementia and cancer.
Following MI, the most frequent event was all-cause mortality at 37.8% in the study group compared with 35.3% of the control group.
The most likely health outcome washeart failure, with 29.6% of the study group going on to develop the condition within nine years of their MI, compared with 9.8% of the control group over the same period.
Kidney failure developed in 27.2% of the patients in the study group, compared with 19.8% of the control group, while 22.3% of the study group went on to develop atrial fibrillation, compared with 16.8% of the control group.
In addition, new hospitalisation for diabetes was seen in 17% of the study group, compared with 14.3% of the control group.
When it came to mental health, the researchers found the hospitalisation records indicated depression occurred in 8.9% of people – which was 6% more likely following a MI than in the control group.
Women were more likely to develop depression after an MI than men, especially those who experienced it at a younger age. Some 21.5% of women who were under the age of 40 at the time of their mi had hospitalisation records for depression compared with 11.5% of men in the same age category.
The study also found that people from more socioeconomically deprived backgrounds were more likely to die or develop serious long-term health conditions following MI – in particular heart and kidney failure – compared to people from less deprived backgrounds of a similar age.
However, there was no overall difference in the risk of dementia following a MI compared with the control group. Whilst the risk of vascular dementia was more likely in the study group, the difference observed was small at 2.3% in the study group and 2.1% in the control group.
The research also showed that cancer was less pronounced in the study group than in the control group. Some 13.5% of the study group went on to develop cancer after their MI, compared with 21.5% of the control. However, the researchers stated that there are many likely factors affecting this finding and that the specific reasons ‘remain unclear and require further investigation’.
Morag Foreman, head of discovery researchers at Wellcome, which part funded the study alongside the British Heart Foundation, said: ‘As survival rates following a myocardial infarction improve, understanding the longer-term impacts on physical and mental health is crucial.
‘This research shows how cohort studies and analysis of large data sets can further our understanding of key health challenges and demonstrates the value to supporting discovery research in the field of population and public health.’
The researchers noted that as the study included only secondary care data, there is potential for an underestimation of the total burden of disease following MI as diagnoses may be made in other settings.
Nevertheless, with around 1.4 million MI survivors in the UK who are at high risk of developing further serious health conditions, lead author Dr Marlous Hall, associate professor of cardiovascular epidemiology at the Leeds School of Medicine and Multimorbidity Research in the Leeds Institute for Data Analytics, said the study ‘highlights the need for individual care plans to be revised to take into account the higher demand for care’.
She added: ‘Our study provides accessible online information of the risk of these health outcomes for specific age, sex and socioeconomic deprivation groups so that individuals surviving a heart attack can be well informed about their future risks, in order to support informed healthcare decision making with their doctor.
‘Effective communication of the likely course of disease and risk of adverse long-term outcomes between patients and healthcare professionals can promote positive lifestyle changes, encourage patients to stick to treatment, and improve patient understanding and quality of life.’
In 2023, a genetic study revealed that the use of clopidogrel in British patients of south Asian ancestry was less effective at preventing recurrent MI than in those of European descent.
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.
12th January 2024
Heart treatments given to patients with takotsubo cardiomyopathy do not protect them and the condition is not being treating correctly, according to a new study comparing these patients with myocardial infarction patients and the general population.
Published in the journal JACC: Advances and funded by the British Heart Foundation, the researchers analysed health records from 3,720 people in Scotland to investigate cardiovascular mortality and medication use after takotsubo cardiomyopathy – for which there is no expert consensus on treatment.
They found that takotsubo cardiomyopathy patients were prescribed the same medication as patients with myocardial infarction despite having unobstructed coronary arteries.
Cardiovascular therapies were consistently associated with better survival in patients with myocardial infarction but not in those with takotsubo syndrome.
These patients were found to be more likely to die than the general population and just as vulnerable to dying as patients who had suffered a myocardial infarction.
A total of 153 (25%) patients with takotsubo cardiomyopathy died over the median of 5.5 years follow-up. This exceeded mortality rates in the general population (N = 374 [15%]; HR: 1.78 [95% CI: 1.48-2.15], P < 0.0001), especially for cardiovascular (HR: 2.47 [95% CI: 1.81-3.39], P < 0.001) but also non-cardiovascular (HR: 1.48 [95% CI: 1.16-1.87], P = 0.002) deaths.
Mortality rates were lower for patients with takotsubo cardiomyopathy than those with myocardial infarction (31%, 195/620; HR: 0.76 [95% CI: 0.62-0.94], P = 0.012), which was attributable to lower rates of cardiovascular (HR: 0.61 [95% CI: 0.44-0.84], P = 0.002) but not non-cardiovascular (HR: 0.92 [95% CI: 0.69-1.23], P = 0.59) deaths.
The only cardiovascular therapy associated with lower mortality in patients with takotsubo cardiomyopathy was angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy (P = 0.0056), but unlike in myocardial infarction, cardiovascular medications were not consistently associated with better long-term survival.
Professor Dana Dawson, professor of cardiovascular medicine and consultant cardiologist at the University of Aberdeen and Aberdeen Royal Infirmary, who led the study, said: ‘Our data shows quite starkly that we are not treating this condition correctly. It is vital that we identify precise ways to treat this unique group of people, and that is what we plan to do as we continue our research.
‘This study has identified one drug as a potential breakthrough with promising therapeutic benefit, however, further research is needed to establish if this is the key to treating this devastating illness.’
8th December 2023
The first clinical trial to challenge the routine use of implantable cardioverter defibrillators (ICDs) in myocardial infarction survivors with heart failure has enrolled its first patient.
With modern drug treatments demonstrating the ability to lower the risk of sudden death in these patients, there is potentially less of a need for life-saving ICD shocks.
The PROFID EHRA trial will therefore test whether in post-myocardial infarction patients with symptomatic heart failure and reduced left ventricular ejection fraction (35% or less) drug treatment alone is not inferior to drug treatment plus an ICD for preventing sudden death.
Dr Nikolaos Dagres, chief investigator of the trial, said: ‘The PROFID EHRA trial is set to influence clinical practice around the world by closing a huge evidence gap that has existed for the past 20 years.
‘The trial is re-evaluating the role of ICD implantation in post-myocardial infarction patients in the context of contemporary medical treatment and will provide vital new information to optimally guide therapy and address this serious health issue.’
Over the next 30 months, the trial will recruit some 3,595 patients from 180 hospitals in 13 countries: Austria, Belgium, Czechia, Denmark, France, Germany, Hungary, Israel, Poland, Spain, Sweden, the Netherlands and the UK.
The first patient was enrolled from the Heart Centre Segeberger Kliniken in Germany.
Participants will be randomly allocated to either optimal medical therapy alone or optimal medical therapy plus ICD implantation. Participants will be followed up for around 2.5 years for the primary outcome of all-cause death.
The investigators will also examine the impact of the two treatment strategies on death from cardiovascular causes, sudden cardiac death, hospital readmissions for cardiovascular causes, length of stay in hospital, quality of life and cost effectiveness.
The study is due to last for approximately 49 months, with results expected in early 2027.
Professor Gerhard Hindricks, chief investigator of the trial, said: ‘PROFID EHRA is a ground-breaking study that could change the prevention of sudden cardiac death in clinical practice.
‘Currently, many patients who receive an ICD never need one, while some who could benefit miss out.
‘This trial will provide novel, randomised evidence on which patients should receive a defibrillator, and which patients can be spared an unnecessary procedure, which typically requires an overnight stay in hospital and may lead to complications or unintended shocks from the device.’
The PROFID EHRA trial is part of the PROFID project, which aims to personalise the prevention of sudden cardiac death after myocardial infarction.
The project involves a consortium of 21 multidisciplinary partners, including the European Society of Cardiology, and has received funding from the European Union’s Horizon 2020 research and innovation programme.
30th August 2023
A genetic study has revealed how the use of clopidogrel in British patients of south Asian ancestry appears to be less effective at preventing recurrent myocardial infarction than in those of European descent.
The study, which was published in the journal JACC: Advances, sought to assess the prevalence of common CYP2C19 genotype polymorphisms in a British south Asian population and correlate these with recurrent myocardial infarction risk in participants prescribed clopidogrel.
Researchers used data from the East London Genes & Health (ELGH) database – a community-based, long-term study of health and disease in British Bangladeshi and British Pakistani people in east London. ELGH incorporates cutting-edge genomics with electronic health record data linkage and targeted recall-by-genotype studies.
Using data from 44,396 individuals, researchers found a high prevalence (57%) of intermediate or poor CYP2C19 metabolisers, with at least one loss-of-function CYP2C19 allele.
In addition, the prevalence of poor metabolisers, characterised by two CYP2C19 loss-of-function alleles was 13%, which was higher than that in previously studied European (2.4%) and central/south Asian populations (8.2%).
In the cohort, 69% were diagnosed with an acute myocardial infarction and prescribed clopidogrel. Poor metabolisers were found to be significantly more likely to have a recurrent myocardial infarction (Odds ratio, OR = 3.1, 95% CI 1.2 – 8.1, p = 0.019).
Dr Emma Magavern, lead author from Queen Mary University of London, said: ‘This study highlights the importance of using genetics to determine who can benefit from clopidogrel after a heart attack, and how not doing so is likely to disproportionately disadvantage specific groups, such as south Asians.
‘British peoples of south Asian ancestry suffer from high rates of cardiovascular disease and therefore have both a high risk of needing an anti-platelet medication and a high risk of treatment failure with clopidogrel.’
The P2Y12-inhibiting agent clopidogrel, which can be used post-myocardial infarction to reduce the risk of a second infarction, as well as to lower the risk of bleeding following a percutaneous coronary invention, is metabolised by the hepatic enzyme CYP2C19. This transformation converts the inactive pro-drug into an active metabolite.
25th August 2023
Survivors of a myocardial infarction (MI) who discontinue aspirin remain at an elevated risk of a subsequent infarction, stroke or even death over the next eight years compared to those who remain adherent to treatment.
These were the findings of a a study presented at the recent European Society of Cardiology (ESC) Congress 2023 in Amsterdam.
While the use of aspirin is no longer recommended for use as a primary preventative strategy, despite continued use, especially in the elderly, it remains an essential component of secondary prevention treatment.
Researchers used Danish nationwide health registries to look at patients aged 40 years and over who had a first MI and were prescribed aspirin during the first year after it. Their aim was to examine the extent to which MI survivors collected a prescription for aspirin over the next two, four, six and eight years and the clinical consequences of not taking the drug.
Adherence to aspirin at each of the four time points was assessed as the proportion of days patients had collected the drug over the preceding two years.
Non-adherence was defined when survivors used aspirin for 80% or less of the time and patients were excluded at each time point if they had experienced another heart attack, a stroke, died, or had been started on other anticoagulants or P2Y12 inhibitors.
The researchers analysed whether patients who did not take aspirin as prescribed had a higher risk of the composite outcome of recurrent heart attack, stroke or death compared with those who consistently took aspirin.
The study included 40,114 patients with a first-time MI. Adherence to aspirin progressively declined with each time point, from 90% at two years post-MI, to 84% at four years, 82% at six years and 81% at eight years.
At each of the time-points, adherence to aspirin was associated with a reduced risk of the composite outcome. For example, when compared to adherent patients, non-adherent patients had a 29%, 40%, 31% and 20% higher likelihood of recurrent heart attack, stroke or death at two, four, six and eight years post-MI, respectively.
Commenting on the findings, study author Dr Anna Meta Kristensen of Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark, said: ‘Our findings suggest that not taking aspirin as prescribed after a heart attack is linked to a higher risk of having another heart attack, a stroke or dying.‘
However, she added: ‘Our results should be interpreted with caution because they show an association but do not establish causality. Since the study is registry-based, we do not have information about the specific reasons as to why patients did not take their aspirin.
‘Furthermore, our findings cannot be generalised to all patients who experience a heart attack, as our study specifically focused on those who received treatment with a coronary stent and were not taking other medications to prevent blood clot formation.
‘With that in mind, the results support current guidelines recommending long-term aspirin after a heart attack.‘
Recognising the signs and symptoms of a myocardial infarction is linked with faster life-saving treatment and reduced in-hospital mortality, according to a recent study presented at the 2023 European Society of Cardiology (ESC) congress in Amsterdam.
Researchers in the Republic of Korea have found a correlation between symptom recognition, time to treatment and mortality in those experiencing a myocardial infarction.
Although AI-based tools are becoming potentially valuable as an aid to quickly diagnose a myocardial infarction, if patients are capable of recognising the most common symptoms, this too could ensure they receive prompt treatment.
The current study, ‘Effect of symptoms recognition in patients with recurrent acute myocardial infarction: from KRAMI-RCC stratification in acute coronary syndromes’, used data from KRAMI-RCC – a registry of myocardial infarction patients in the Republic of Korea.
Trained nurses consulted with survivors of myocardial infarction, asking them if they recognised six sets of symptoms: chest pain; shortness of breath; cold sweat; radiating pain to the jaw, shoulder or arm; dizziness, vertigo, lightheadedness, loss of consciousness; and stomach ache.
Patients were then classified as ‘recognised symptoms‘ if they could identify at least one symptom, otherwise they were classified as ‘did not recognise symptoms‘.
The study included 11,894 myocardial infarction patients, of whom 90.4% had a first-time event and 9.6% a repeat event. Overall, just over half (52.3%) of patients recognised the symptoms.
The majority of patients (92.9%) could identify chest pain as a symptom. However, only a third (32.1%) identified shortness of breath and cold sweats (31.4%) and just 1.3% recognised stomach ache.
Among 57.4% of patients who correctly identified the symptoms, treatment was received within two hours, compared to 47.2% of those who did not recognise the symptoms.
Moreover, the in-hospital mortality rate was much lower for those able to recognise symptoms (1.5% vs 6.7%).
For patients with recurrent myocardial infarction, the recognition rate was 57.5% for those previously enrolled in KRAMI-RCC and just 14.4% of patients with a first-time myocardial infarction could identify the symptoms.
Study author Dr Kyehwan Kim of Gyeongsang National University Hospital in Jinju, Republic of Korea, said: ‘The findings indicate that education is needed for the general public and heart attack survivors on the symptoms that should trigger calling an ambulance.
‘In our study, patients who knew the symptoms of a heart attack were more likely to receive treatment quickly and subsequently survive. Women, older patients, those with a low level of education and people living alone may particularly benefit from learning the symptoms to look out for.‘
24th August 2023
Patients with greater levels of self-reported pain one year after a myocardial infarction (MI) have a significantly higher risk of subsequent mortality, according to a new study.
It is recognised that in patients with symptomatic chest pain, markers such as coronary artery calcium score and cystatin C levels are linked to a higher risk of all-cause mortality.
In addition, self-reported chronic pain is also linked to a higher risk of adverse cardiovascular outcomes including MI and stroke, independently of established cardiovascular risk factors. The extent to which any post-MI pain impacts on subsequent mortality is to be determined.
To this end, in the recent study, published in the Journal of the American Heart Association, Swedish researchers aimed to examine various levels of pain severity one year after an MI as a potential risk for all-cause mortality.
The team collated data from patients who had a registered MI event between 2004 and 2013 with measurements of potential cardiovascular risk indicators at hospital discharge from the Swedish quality register SWEDEHEART database.
Self-reported levels of experienced pain according to EuroQol-5 dimension instrument were recorded in secondary prevention clinics one year after their hospital discharge. The researchers set the primary outcome as all‐cause mortality.
A total of 18,376 patients with complete data were included in the analysis, and all-cause mortality data were collected up to 8.5 years (median 3.4 years) after the one-year visit. There were 1,067 recorded deaths.
Self-reported moderate pain and extreme pain were reported by 38.2% and 4.5% of included patients, respectively.
In fully adjusted models, the mortality risk among those with self-reported moderate severity pain was 35% higher than for those not reporting pain (hazard ratio, HR = 1.35, 95% CI 1.18 – 1.55, p < 0.0001).
But in those reporting severe pain, the risk was more than doubled (HR = 2.06, 95% CI 1.63 – 2.60, p < 0.0001). In fact, pain was a stronger mortality predictor than smoking.
The researchers suggested that clinicians managing post-MI patients should recognise the need to consider those with self-reported pain as a prognostic factor, which is comparable to persistent smoking, and to address this when tailoring secondary prevention treatments.
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