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12th July 2024
With two practice-changing studies under his belt this year alone, Dr Ramzi Khamis is no stranger to the innovative developments and evidence of best practice emerging in cardiovascular care. Speaking to Helen Quinn, he shares his take on the future of the field and where he sees the greatest potential in primary prevention and post-acute coronary syndrome management.
Dr Ramzi Khamis is at the cutting edge of cardiovascular science, improving healthcare through the development of evidence-based innovations. He combines an academic career as a British Heart Foundation (BHF) fellow and reader in cardiology at Imperial College with his clinical work as a consultant cardiologist at Hammersmith Hospital in London, UK, where he specialises in interventional cardiology. He also heads up the cardiovascular specialties at Imperial College Healthcare NHS Trust as clinical director. His research offers a glimpse into the future of the diagnosis and treatment of coronary artery disease.
This year, Dr Khamis has been involved in two key cardiovascular studies providing objective scientific evidence to enhance best practice at opposite ends of the management pathway. The first is concerned with primary prevention through novel antibody treatments, and the second examines the use of telemedicine in secondary prevention of myocardial infarction. Both studies will change how cardiovascular care is practised worldwide.
‘These are scientific advances, so it’s very different from NHS pathways,’ Dr Khamis explains. ‘It is scientific advances that will facilitate care for patients that can be used by health services all over the world to improve risk stratification, but also improve treatment post-event.’
Dr Khamis began his academic career studying the interaction between the innate immune system, atherosclerosis and the risk of heart attacks, setting the foundations for his current academic work. He is currently the clinical director for cardiology and cardiothoracic surgery at Imperial College Healthcare NHS Trust, undertaking clinician work in the cath lab and cardiac interventions.
‘My work spans both the clinical and the academic fields in what I do, and I think it complements each other. If you’re a very good clinical academic, you have to be very good at what you do clinically, and you have to be very good at what you do academically, so it’s a double jeopardy,’ he adds.
Much of Dr Khamis’s research focuses on vulnerable atherosclerotic plaque, which is more prone to rupturing and causing heart attacks. He says that the current ‘gap in the treatment’ of atherosclerosis ‘is not addressed by the reduction in low-density lipoprotein (LDL), by giving statins or by doing procedures like coronary artery bypass grafting or percutaneous coronary intervention’.
He therefore set about looking at alternative therapeutic options and settled on using targeted antibody techniques alongside bespoke imaging to target this vulnerable plaque before it can cause damage.
Dr Khamis and his team have developed novel serological techniques to identify at-risk patients with vulnerable plaques by looking at the levels of oxidised lipoproteins and anti-oxidised LDL levels in patients. The published work provides evidence that patients with higher levels of anti-oxidised LDL antibodies are at a lower risk of a CV event.
‘We have found that on intravascular imaging if the patient has higher levels of immunoglobulin M anti-oxidised LDL antibodies, they are less likely to be vulnerable to having a cardiac event. So, there’s an inverse correlation with plaque vulnerability on intravascular imaging,’ Dr Khamis explains.
The new techniques offer a more effective way of classifying vulnerable plaques and at-risk patients. Dr Khamis says: ‘Classical risk factor analysis misses quite a lot of patients that are at risk, and it over-estimates the risk of some patients and underestimates others.’
With this new understanding, a simple blood test can determine that risk. If a patient’s antibody levels are very low, they are more likely to have dangerous plaque, which would then indicate non-invasive imaging may be helpful in these patients to determine next steps.
‘It’s a more bespoke re-stratification that can lead to imaging if needed,’ Dr Khamis says. ‘If the imaging is showing risk, then you need to decide how to treat the patient, probably medically with more intensive therapies.’ Going forwards, the team would like to integrate blood tests with other biomarkers to improve risk stratification further.
The advances in antibody technology mean it may soon be possible to give patients antibodies that are protective against developing harmful plaques. In fact, one of Dr Khamis’s current PhD students is working on the proof of concept of antibody passive vaccination, which could significantly decrease cardiovascular-related deaths in the future.
The second study evolved from first-hand observations in Dr Khamis’ clinical work. Even though patients were receiving optimal medical therapy after a heart attack, including intervention antiplatelet therapies and statins, patients still present with heart attacks and CVD issues after being discharged.
In the UK, at least seven to 10% of patients are readmitted within the first 30 days of a CV event, but, as Dr Khamis points out, it ‘could be higher’ since there is no accurate data.
To reduce the rate of readmissions, Dr Khamis and his team tested a new way to monitor patients after acute coronary syndrome events, undertaking a randomised control trial (RCT) examining patients presenting at Hammersmith Hospital.
One group of patients was assigned the usual post-discharge standard of care, while a second group was supplied with a remote monitoring programme. This included an electrocardiogram (ECG) that could be operated at home by the patient themselves, a blood pressure monitor and a saturation monitor. The researchers also designed a unique care protocol. If the patient had any symptoms, the protocol would instigate an ECG and send an alarm to the research team, resulting in a call with a cardiologist.
The cardiologist would then go through pre-set questions and look at the objective data acquired by the patient at home, ultimately deciding whether to reassure the patient, ask them to go to primary care, get them to call 999 or visit an emergency department. The researchers stopped the remote monitoring intervention at six months but undertook patient follow-up at nine months.
Dr Khamis says the study shows ‘exceptional results’ and ‘a massive reduction in readmissions’. They found that the remote monitoring protocol meant patients were 76% less likely to be readmitted to hospital within six months and 41% less likely to attend an emergency department compared to those receiving the standard care.
‘It seems that having access to the team helps in reducing these readmissions, but also the patient-reported symptoms were much less in the intervention arm. If you’re being monitored, and if you’re being assured, you’ll be much more likely to report symptoms that you’re worried about,’ says Dr Khamis. The telemedicine approach also allows clinicians to trigger an alarm if there is a cause for concern when this may otherwise have been missed.
However, the data also revealed something more surprising. ‘What we didn’t expect is that we were going to find [fewer] heart attacks and strokes in the intervention group; there was no reason for us to think that we thought we would pick up more,’ Dr Khamis explains.
He attributes this to the ‘Hawthorne Effect’, a psychological phenomenon in which individuals alter their behaviour in response to their awareness of being observed. He believes patients may have been more likely to take medication correctly, or that beneficial medication modification could have occurred when an intervention was made, such as during a visit to a GP.
Dr Khamis is currently writing up the study’s cost-benefit analysis for publication. He says: ‘The money saved is significant. It will result in a saving exercise if it’s rolled out throughout the NHS but the initial investment will need to be into training and acquiring monitoring equipment as well as building teams that can run the protocol.’
This will save bed days, allowing clinicians to get on with other procedures. ‘It’s really in the vein of creating more capacity for us to do other work, rather than having to assess these patients in the hospital, we can adequately assess them in the community and have better outcomes,’ Dr Khamis adds.
This study is one of the very few randomised control trials in telemedicine. It proves that remote monitoring and ‘avant-garde medicine’ outside of a hospital are achievable and will provide better outcomes. As Dr Khamis says: ‘The sceptics cannot argue with an RCT. It’s novel because some of these technologies are being implemented without the randomised trials behind them.’
The next research will examine how telemedicine can be built into transcatheter aortic valve implantation (TAVI) care, specifically looking at the feasibility of doing TAVI with same-day discharge and monitoring patients at home with live rather than retrospective monitoring.
In addition to antibody developments and technical advances in post-event care management, Dr Khamis believes gene therapy, artificial Intelligence (AI), and healthy lifestyles will be instrumental in the future of cardiac care and the prevention of CVD.
‘Gene therapy is going to be huge,’ says Dr Khamis. He suggests that AI will be used in diagnosis and aid therapeutic delivery, such as angioplasty work and deciding where to treat. However, the most important thing, he believes, is working to improve unhealthy lifestyles. After all, prevention is better than a cure.
Dr Khamis says it is ‘a privilege’ to be able to do this work, and through his research with the BHF, he hopes to bring the scientific advances in cardiovascular care a little closer to everyone. ‘[The BHF is] trusting me to do this. I just hope that, when the future of technology is being implemented, it is available to everyone, not just for a select population in the Western world.’
He adds: ‘I think there needs to be a global view of how we tackle this. How do we level up the treatment globally for coronary artery disease so that once our developments are available, everyone can benefit from closing the gap?’
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.
13th October 2022
Heart failure patients who receive remote disease monitoring and consultations may experience short-term cardiovascular and mortality benefits.
Digital health interventions (DHIs) have contributed to the transformation of healthcare delivery in the past decade and especially since the COVID-19 pandemic when interventions such as telemedicine for remote consultations became the ‘norm’ in many specialities.
Nevertheless, while imposed in many therapy areas during the pandemic, there are actually potential benefits for patients cardiovascular disease. For example, connected health technologies, such as mobile phones, smartphones, tablets, wearable devices, smartwatches and personal health sensors, all provide an opportunity to revolutionise cardiovascular disease prevention through personalised, convenient, and easily accessible patient education and behaviour change support.
The value of DHIs for the prevention of cardiovascular disease was explored in a systematic review and meta-analysis in 2015, in which the authors concluded that the available data provide evidence that DHIs can reduce cardiovascular disease (CVD) outcomes and have a positive impact on risk factors for CVD.
However, given that the data used in the aforementioned meta-analysis was collected more than 8 years ago and the COVID-19 pandemic lead to enforced telemedicine and remote monitoring, for the present study, a Malaysian team of researchers sought to update the effectiveness of DHIs for patients with cardiovascular disease.
The researchers included randomised trials, observational and cohort studies that specifically addressed the effect of a telemedicine intervention on cardiovascular outcomes for those either at risk (i.e. for primary prevention) or those with established CVD (secondary prevention).
The primary outcome was cardiovascular-related mortality, whereas secondary outcomes included hospitalisation, all-cause mortality and all-cause hospitalisation. Interventions were categorised as remote consultations; remote monitoring of health or diagnostic measures; transmission of medical data and finally remote case management.
A total of 72 studies with 127,869 participants (65% male) were included in the analysis. The duration of studies ranged from 1 to 79 months and 49 were short-term (< 12 months) and 22 long-term (> 12 months). Overall, 39 studies included patients with heart failure, 19 addressed secondary prevention and 12 primary prevention.
For heart failure patients, combined remote monitoring and consultation were associated with a 17% reduced risk of cardiovascular mortality (risk ratio, RR = 0.83, 95% CI 0.70 – 0.99, p = 0.036). In addition, this combination significantly reduced hospitalisation for a cardiovascular cause (RR = 0.71, 95% CI 0.58 – 0.87, p = 0.0002) though this was largely in short-term (i.e. < 12 month) studies.
However, telemedicine had no effect on all-cause hospitalisation among those with heart failure (RR = 1.02, 95% CI 0.94 – 1.10, p = 0.71).
In secondary prevention studies, the combination of remote monitoring and consultation was associated with a small reduction in systolic blood pressure (mean difference = -3.59, p < 0.0001) but not on diastolic pressure. There was also a small but significant effect of remote consultations on body-mass index (p < 0.0064) in primary prevention.
The authors concluded that a combination of remote disease monitoring and consultation appeared to reduce cardiovascular-related hospitalisation and mortality risk among patients with heart failure in the short-term.
They called for future research to evaluate the sustained effect of telemedicine interventions.
Citation
Kuan PX et al. Efficacy of telemedicine for the management of cardiovascular disease: a systematic review and meta-analysis Lancet Digit Health 2022.
13th September 2021
When members of the public are faced with a medical emergency, such as an injury or an individual collapsing in the street, they contact emergency services and speak with a medical dispatcher for assistance. This is vital for effective triage of a situation and ensures appropriate resource allocation, avoiding any delays for critical conditions. Appropriate triage is extremely important, especially with research showing that over-crowding within emergency departments is associated with a higher level of inpatient mortality. The use of live video from a bystander’s mobile phone could potentially provide dispatchers with more information about the clinical condition of the patient although this topic has poor poorly studied. In fact, its value was seen as an aid to helicopter emergency services in a small UK-based study. In contrast, another study that compared audio and video-assisted cardiopulmonary resuscitation, concluded that there was no survival benefit from video-assistance.
In trying to gather more evidence to ascertain the value of video streaming, a team from the Copenhagen Emergency Medical Services, University of Copenhagen, set out to assess the feasibility and dispatcher’s perceptions and responses after the addition of live video from bystanders making emergency calls. In Denmark, medical dispatchers are trained nurses or paramedics and for the purposes of the study, were able to decide whether or not to utilise live video although it was recommended if the patient was unconscious or potentially had a cardiac arrest. The team collected information on whether the emergency response changed as a result of videoing , e.g., whether an ambulance was dispatched, with or without sirens, if it was deemed non-urgent or if the individual could self-transport to the emergency department. The medical dispatchers were issued with a follow-up questionnaire where they were asked to evaluate the use of live video calls.
Findings
A total of 1020 live video calls were attempted and successful in 838 (82.2%) of cases with over half (53.7%) for male patients and a third (33%) were for patients aged 10 to 39 years of age. Live video calls were made for a large number of symptoms including unconscious adults (12.4%), seizures/convulsions (9.1%), accidents (8.6%) and wounds/fractures/minor injuries (7.3%).
There were 637 medical dispatchers who responded to the follow-up questionnaire, of whom, 88.6% stated that the use of video was either “extremely useful” or “very useful”. In addition, dispatchers stated that their assessment of the patient had changed in 51.1% of the live video calls, with 12.9% deemed more critical and 38.2% less critical. This resulted in a change to the emergency response in 27.5% of cases compared to not using live video, such that the odds for changing the emergency response were 58% higher (odds ratio, OR = 1.58, 95% CI 1.30–1.91). Interestingly, in 9.9% of live video calls, the dispatchers reported that seeing the patient enabled them to recognise another problem.
The authors discussed how the use of live video calls was both feasible and of benefit to medical dispatchers, giving them “eyes”, which improved their situational awareness. While this innovation was clearly of value, the authors suggested that a paradigm shift is required to implement these changes because medical dispatchers are currently trained in traditional protocols based on verbal questions and answers.
Citation
Linderoth G et al. Live video from bystanders’ smartphones to medical dispatchers in real emergencies. BMC Emerg Med 2021
25th June 2021
In a 2010 report from the World Health Organization (WHO), it was suggested that information and communication technologies (ICT) have a great potential to address some of the challenges faced by both developed and developing countries in the provision of accessible, cost-effective and high-quality health care. The WHO reported recommended that countries capitalise on the potential of ICT so that ultimately telemedicine strengthens, rather than competes with, other health services. While a 2012 observational study found that the value of virtual consultations was broadly similar to traditional face-to-face methods, a 2015 systemic review concluded that electronic consultations (or e-consults), are feasible in a variety of settings, flexible and facilitate timely speciality advice. Fast forward 10 years and in the midst of the global COVID-19 pandemic, health service providers have been forced into augmenting their ICT to enable continuity of clinical care. But what are today’s clinician’s perception of telemedicine consultations was a question addressed by a team from the department of medicine, Yale university, US. The team focused on physicians working in the area of infectious diseases (ID) and recruited two groups of participants: referring providers, i.e., physician assistants, advanced nurse practitioners and the ID consultants themselves based at the hospital.
The team created a web-based survey and defined an electronic consult or “e-consult” as a telemedicine consultation. The level of satisfaction with e-consults was assessed via perceptions of the quality, timeliness and amount of verbal communication compared with traditional face-to-face consultations, based on three categories: worse, the same or better. In addition, using the same three categories, respondents were asked “compared to traditional consults, e-consults provided good clinical care”.
Findings
A total of 130 surveys were analysed, representing a 23.6% response rate and completed by 107 referring providers and 23 ID consultants. Considering e-consults to traditional methods, in terms of quality, overall, 66.9% of respondents stated that these were either the same or better; with respect to timeliness, 95% reported that e-consults were the same or better and finally, 80% of respondents felt that communication was the same or better. In total, 80% of respondents agreed that e-consults provided good clinical care. However, there were some differences between the two groups of respondents. For instance, the majority (73.9%) of consultants rated the quality of care as being worse than face-to-face versus 24.3% for providers and 91.3% of consultants (versus 44.9% of referring providers) reported that timeliness was better for e-consults. Furthermore, a higher proportion of consultants felt that there were specific situations where face-to-face consultations were necessary (87% vs 33.6%).
In a discussion of their findings, the authors reported that it was reassuring to see an overall high level of agreement that e-consults provided good clinical care. While it was not explored in the study, they suspected that the poor rating for the quality of e-consults among consultants was probably a reflection of the need to undertake a physical examination of a patient with an infective disease. They concluded that future studies should explore the reasons for consultant dissatisfaction with telemedicine and the effect of virtual consultations on infectious disease outcomes.
Citation
Canterino JE, Wang K, Golden M. Provider Satisfaction with Infectious Diseases Telemedicine Consults for Hospitalised Patients During the COVID-19 Pandemic. Clin Infect Dis 2021
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