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Heart Rhythm UK 2011 report

The sixth annual Heart Rhythm Congress (HRC) returned to the Hilton Metropole Hotel at Birmingham between 3rd and 6th October 2011 attended by over 3000 delegates – more than ever before, reflecting the growing popularity of this annual meeting. This report summarises the highlights of the 2011 annual meeting of health professionals involved in the care of patients with heart rhythm problems.

The scientific sessions spread over 4 days included education and training updates across a wide spectrum of core topics in the field of arrhythmia, electrophysiology and devices, aimed not only at physicians and physician trainees but also allied health care professionals including nurses, cardiac physiologists and patients. In addition the meeting provided an excellent forum for interaction and collaboration among healthcare professionals from across the United Kingdom.

Education and Training

There was an impressive timetable of educational sessions on a range of topics with eminent speakers, both national and international. The sessions included entertaining debates among experts and opinion leaders on some of the most controversial topics of today, such as the role of newer oral anticoagulants for stroke prevention in atrial fibrillation (AF).

For physician trainees there were the usual favourites such as ‘Cases and traces’ and ‘Diagnosing pacemaker and ICD traces’ – an excellent opportunity to discuss several challenging ‘real-life’ case studies across the range of heart rhythm conditions. The interactive ‘Hands-on’ and ‘How to’ sessions were as usual popular among trainees in particular – the former providing the opportunity to learn practical skills such as device programming on simulators with one-to-one supervision, and the latter covering important generic topics integral for career progression and academic excellence that are rarely taught during clinical training. Similar to last year, the HRUK accreditation course was held over three days, aiming to educate physiologists, arrhythmia nurses and physicians undertaking the Heart Rhythm UK (HRUK) certificate of accreditation examination in 2012. The HR (UK) accreditation is steadily growing in popularity year by year and this course has now firmly established itself in the annual meeting calendar.

An entire day of sessions was specifically devoted to the education of allied health professionals, including a comprehensive round-up of medical advances and updates over the last 12 months. The Primary Cardiovascular Care Society hosted an all-day programme entitled ‘A brave new world- will the NHS reforms really change the landscape?’ – a series of interesting and thought-provoking sessions exploring innovation and change across the NHS in service provision for various heart rhythm conditions. The first day of the conference was once again ‘Patient’s Day’, with meetings arranged by the Arrhythmia Alliance, Atrial Fibrillation Association and STARS (Syncope Trust And Reflex anoxic Seizures). Eminent speakers from across the UK participated in interactive educational sessions to inform and educate patients on AF, syncope and other heart rhythm problems and answer common questions. The exhibition at HRC 2011 offered an opportunity for industry sponsors to exhibit and explain some of the latest technology that is available to support health care professionals in managing patients with heart rhythm problems. Earlier this year the Department of Health published a review of emerging technologies and their potential impact on cardiac services over the next 10 years. This year’s HRC provided a fantastic opportunity for all health professionals, including those with a managerial role within the health service, to see and understand cutting-edge technology that is currently available and in development.

Research and Collaboration

Research and innovation featured once again quite highly on the agenda as in previous years. Throughout the conference there was also the opportunity for researchers to showcase the results of their work through moderated posters and oral presentations. All abstracts selected for HRC 2011 will be published in Europace, Volume 13, Supplement 4. The Young Investigators Competition included six oral presentations by young researchers from across the UK and the winners were selected by an expert panel of four judges. The winners were as follows:

Clinical: W.B. Nicholson, University of Leicester, ‘Novel Restitution Gradient Based Predictor of Ventricular Arrhythmia’.

Basic Science: G.M. Morris, University of Manchester, ‘The Funny Current can be used to Create a Biological Pacemaker by Enhancement of the Pacing Rate of Subsidiary Pacemaker Tissue in a Model of Sick Sinus Syndrome, but the Effectiveness of Different HCN Isoforms Markedly Differs’.

In addition several innovative and potentially ground-breaking technological products, at various stages of development, were displayed by exhibitors from the industry.  These offered interesting insights into the future of heart rhythm care. In the current era of austerity and rising healthcare costs, collaboration between primary, secondary and tertiary care and among different professionals at each level is vital to ensure that patient care continues to improve despite these challenges. It was therefore very encouraging to see a large turnout of allied heath professionals and primary care physicians at the meeting. There were several light-hearted moments too throughout the meeting – such as the entertaining ‘quiz competition’ between the team of GPs vs. cardiologists hosted by the PCCS, which was won by the GPs for the second year running.

The annual Gala Dinner provided yet another focal point for socialising, attended by around 450 delegates. Highlights of the Gala dinner included engrossing speeches by Dr Steve Furniss, current President of HRUK and Prof. A. John Camm on behalf of the Arrhythmia Alliance, as well as the presentation by Trudie Lobban MBE of the Arrhythmia Alliance Excellence in Practice Awards – in recognition of outstanding achievements and contributions to arrhythmia management services. The winners in 2011 were as follows:

  • Award for Outstanding Medical Contribution to Cardiac Rhythm Management Services:  Jayne Mudd, Arrhythmia Nurse; James Cook Hospital, Middlesbrough, UK
  • Allied Professional Award for Outstanding Contribution to Arrhythmia Management:  Jean Maloney, Arrhythmia Nurse Specialist, Sheffield Teaching Hospitals Foundation Trust
  • Charles Lobban Volunteer Award for Outstanding Contribution to Arrhythmia Services: Anita Kiernan, STARS Volunteer
  • Team of the Year: Dorset Cardiac and Stroke Network: Stroke Prevention & Public Awareness Subgroup and the Arrhythmia Subgroup

Updates on specific topics

Atrial fibrillation: prevention of thromboembolic events:

Perhaps the most widely discussed topic at the conference was the role of the newer oral anticoagulants, in particular dabigatran. While the decision of the National Institute for Health and Clinical Excellence (NICE) on the use of dabigatran in AF is not expected until the end of the year, experts debated in several forums the advantages and limitations of the newer anticoagulants vis-à-vis warfarin. One such interesting and entertaining session was a ‘Dragons Den’ style pitch in front of two ‘connoisseurs’ in the field of AF: Professor AJ Camm and Dr D Jenkinson, chaired by well-known TV/radio broadcaster Sue Lawley OBE. While these drugs are undoubtedly promising with some advantages over warfarin, the lack of long-term follow-up beyond 2-3 years, concerns over the absence of an antidote to reverse its effects in the event of life-threatening bleeds, contraindication in patients with eGFR <30 ml/min and cost are some of the limitations. There is also emerging data from post-hoc analyses of clinical trials that the superiority of these newer drugs over warfarin may be limited to those patients on warfarin with time in therapeutic range of <60%. Finally data from the GRASP-AF survey of primary care in the UK shows that warfarin prescription for AF is still inadequate and under-utilised in eligible patients (in line with the rest of the world) and we need to overcome challenges in identifying patients and initiating appropriate anticoagulation for AF in both primary and secondary care settings.

An alternative approach to stroke prevention in AF is the use of left atrial appendage (LAA) closure devices – a fascinating novel technological advancement over the last couple of years. The largest to date published randomised study (PROTECT-AF) enrolled just over 700 patients and concluded that LAA occlusion was non-inferior to warfarin after average follow-up of 18 months but with a higher initial safety event rate due to the procedure-related adverse events (stroke and pericardial effusion). In the absence of any UK-wide guidance on who should be considered for LAA appendage closure devices, current consensus appears to be that their use should be considered only in those with absolute contra-indications to oral anticoagulant use (e.g. oesophageal varices) and those with life-threatening bleeds (e.g. intracranial haemorrhage) while on oral anticoagulants. The implantation of these devices has steadily grown over the last 12 months. At the HRC, experts shared their experiences of LAA appendage closure with the two commercially available devices: the Watchman device and Amplatzer plug; with video demonstrations of cases to show implant techniques and pitfalls to avoid. Many speakers reiterated the importance of appropriate case selection and pre-operative imaging of the LAA with transoesophageal echocardiography (TOE) – given the variations in size and shape of LAA. Finally all speakers echoed the importance of a multi-disciplinary team collaboration (including cardiologists with imaging expertise and anaesthetists) during the procedure and the need for appropriate local clinical governance arrangements when setting up this service.

Electrophysiology:

In addition to usual trainee favourites such as interpretation of challenging electrophysiology (EP) traces, ablation for AF and ventricular tachycardia featured widely throughout the conference, in addition to focussed sessions on paediatric EP and novel ablation technologies. While there continue to be a growing number of small studies – both observational and randomised trials – reporting benefits of AF ablation in both paroxysmal and persistent AF, success rates and determinants of success remain variable and data from large clinical trials are still awaited. Ablation continues to play a small but significant role in symptomatic patients in whom anti-arrhythmic drugs are either ineffective or poorly tolerated. In one of the sessions on ‘Innovations on cardiac rhythm management’, Dr Mark O’Neill summarised succinctly the limited published evidence favouring the two opposing strategies of ablation for AF vs. ‘pace and ablate’ strategy in heart failure patients. While there is some evidence to support that the former strategy may result in improvements in LV ejection fraction during follow-up of up to 12 months, these benefits are limited to those in whom sinus rhythm is maintained and therefore careful consideration must be given to the likelihood of procedural success. On the other hand patients with persistent AF receiving cardiac resynchronisation strategy often require AV nodal ablation to achieve >90% bi-ventricular pacing necessary for maximal benefit to patients. A number of case studies of ablation for AF were also presented by experienced consultants highlighting ‘red flags’ to avoid/reduce the likelihood of complications as well as how to deal with rare but serious complications to ensure favourable patient outcomes.

One of the particular highlights of this year’s congress was two entire sessions (and six eminent speakers) dedicated to discuss ventricular tachycardia (VT) in structural heart disease, covering topics such as indications and programming of ICD, role of anti-arrhythmic therapy and role of ablation. One of the inevitable consequences of an ageing population with structural heart disease and widespread use of ICDs among these patients is the need to manage recurrent VT in these patients and this requires a holistic and multidisciplinary approach. In addition to addressing all reversible factors like ischaemia and initiating appropriate anti-arrhythmic drugs (primarily beta-blockers ± amiodarone), there is now an established role for VT ablation as an important adjunctive management strategy in selected patients such as patients with electrical storm unrelated to any reversible factors. Dr J Bourke described the contemporary role of VT ablation in structural heart disease as similar to where AF ablation was a few years ago and VT ablation numbers will grow significantly in the coming decade, thanks to encouraging short and medium-term results from centres worldwide and aided by ongoing advances in mapping and ablation technology.

Device therapy:

There continues to be a progressive increase in the implantation of cardiac resynchronisation therapy (CRT) and implantable defibrillator (ICD) devices worldwide. Despite the increase in numbers seen in UK in recent years, we still lag behind many European countries and HRUK remains committed to training both cardiologists and physiologists in the implantation and follow-up of these patients. A number of sessions focussed on updates regarding evidence to minimise inappropriate shocks from ICDs and maximise benefits from CRT devices. Professor Michael Gold from Charleston, USA gave an eloquent presentation summarising strategies to minimise inappropriate shocks by appropriate ICD programming – routine use of anti-tachycadia pacing (ATP) prior to shocks, longer detect duration for VT and use of appropriate supraventricular tachycardia (SVT) discriminators. He also presented some interesting results from his research group on the relative efficacy of various devices including the Cameron Health subcutaneous ICD on detection of VT and discrimination from SVTs. Other sessions discussed potential factors contributing to lack of benefit from CRT, which may relate to the patient (coexisting comorbidities, RV dysfunction), implantation (LV lead position, presence of LV scar) or programming (sub-optimal AV timing, <90% biventricular pacing), although reasons remain unexplained in some patients. Yet another excellent session entitled: ‘What to do when the battery runs down’ discussed four clinical dilemmas encountered increasingly frequently by device specialists when devices reach end of life; with a review of the limited published evidence currently available to guide best practice.

Device therapy continues to evolve and diversify with the industry developing novel technologies to meet the expanding needs of patients. For example magnetic resonance imaging (MRI) compatible pacemaker systems are now more widely available and MRI-compatible defibrillator systems are in development. Another such innovation that featured prominently at the conference was the availability of remote monitoring for all pacing and defibrillator devices, now offered by most manufacturers. Remote monitoring offers significant benefits to both patients and physicians. Dr J Wright presented their in-house experience of using such technology with excellent results. Benefits include not only quicker identification of potential device issues and prompt reassurance for patients if concerns but also potential cost saving once adopted by a sizeable cohort of patients. In the years to come, data from larger patient cohorts will hopefully provide more robust evidence to support the rapid uptake of this technology across all hospitals in the UK.

The problems of faulty technology were also discussed.  Malfunctioning ICD leads – though not a very frequent occurrence – continue to create difficulties for physicians and are a highly emotive subject for patients, with potentially serious adverse consequences such as inappropriate shocks and the withholding of appropriate therapy. Management of patients with faulty ICD leads was discussed extensively with emphasis on early recognition of the problem using programmable alerts and remote monitoring, and then tailoring further management to the individual patient. Other sessions focussed on strategies to minimise complications such as haematomas and infections during device implants, as these can have serious adverse consequences. Many experts agreed that, to minimise bleeding and haematomas in high risk patients where anticoagulant therapy cannot be interrupted (e.g. prosthetic metallic valves), anecdotal evidence strongly favoured the continuation of warfarin therapy with international normalised ratio (INR) no more than three rather than the use of bridging therapy with heparin or low molecular weight heparin (LMWH), although published evidence on this topic is still limited. Simple measures such as maintaining strict asepsis and performing implants in a theatre environment are also important to minimise infection. HRUK are strongly advocating robust audit data collection from all implanting centres across the UK via the Central Cardiac Audit Database (CCAD), as data is currently patchy.

Syncope and sudden cardiac death:

Since the publication of the NICE guidance on transient loss of consciousness (TLoC), there has been keen interest in setting up of TLoC clinics – as a one-stop opportunity to offer a comprehensive evaluation by a multidisciplinary team of health professionals with expertise in cardiac syncope and epilepsy. At the HRC, a series of sessions covered comprehensively the spectrum of topics on this subject spread over two days. The first afternoon focussed on the evaluation of patients with TLoC with perspectives from a range of specialities: primary care, Emergency department, cardiology, neurology and elderly care experts. The second day focussed on setting up services to effectively manage patients with TLoC. The common theme that emerged was the importance of collaboration between different specialities and need for locally agreed patient pathways to match the varied aspirations of health professionals, managers and patients. Evidence from multidisciplinary clinics set up in recent years appears to suggest that this approach not only leads to swift and accurate diagnosis, but is also cost-effective and has elicited good feedback from patients. In association with STARS, a dedicated website has been designed to support the set-up and management of a triage tool for new TLoC clinics; the website is www.starsloc.org.

The HRC provided an opportunity for physicians to update their knowledge on inherited heart conditions that are seen less frequently but can have potentially serious consequences for patients, including sudden cardiac death. Every year the number of confirmed cases is increasing, identified by three distinct strategies: identification of disease phenotype in new index cases, phenotypical disease identified by cascade familial screening and asymptomatic first-degree relatives of patients identified by genetic screening. Most cardiac networks have a hub-and-spoke model with specialist inherited cardiac conditions clinics that comprise of health professionals with expertise in both cardiology and genetics. World-renowned experts provided updates on when to consider defibrillators in the four common inherited conditions: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome and Brugada syndrome. There is general consensus that patients with cardiac arrest or symptomatic ventricular arrhythmias should be offered ICDs for secondary prevention. However prophylactic ICD implantation remains controversial in low-to-intermediate risk patients, especially given the lifetime risk of lead extraction / redo procedures and inappropriate shocks in young patients. All speakers emphasised the absence of a large body of evidence for risk stratification in asymptomatic and minimally symptomatic patients and the changing patient demographics and risk profile in these conditions. Dr Perry Elliott who spoke on hypertrophic cardiomyopathy stressed the importance of taking into account the patient’s age and progression of disease while weighing up risk factors to consider a prophylactic ICD implant e.g. spontaneous non-sustained VT on Holter is an important risk factor in young individuals but is perhaps less significant in older patients or patients with co-existing coronary artery disease (CAD). Decision making regarding ICD implantation needs to be individualised after a frank discussion with the patients about the risks and uncertainties regarding benefit.

On the whole HRC 2011 was once again of immense educational value to all delegates, providing comprehensive updates from world-renowned experts and showcasing the latest in research and innovation, while at the same time being an enjoyable event – offering something for everyone. HRC 2012 will be held from 23rd – 26th September at The ICC, Birmingham UK; further details will be available in due course on the website www.heartrhythmcongress.com.

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Author

Dr Karthik Viswanathan, Specialist registrar (EP and devices), Leeds General Infirmary, West Yorkshire

Dr Karthik Viswanathan

Dr Karthik Viswanathan

Published on: December 1, 2011

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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