Arrhythmia Watch

An Educational Resource for Cardiac Rhythm Management

Digoxin dose level monitoring improved

The two new reference materials, which closely match the upper and lower levels for digoxin monitoring, are both certified as European Reference Materials (ERM®) and made under accreditation to ISO Guide 34 for the production of reference materials.

The material (ERM®-DA200a Frozen Human Serum – Digoxin, High Level and ERM®-DA201a Frozen Human Serum – Digoxin, Low Level) are intended for use by clinical laboratories for determining digoxin levels in human serum through method validation and performance monitoring of methods, providing a means of measurement traceability.

Gill Holcombe, Head of Reference Material Production at LGC explains: “Assays for determining levels of digoxin in human serum are independently calibrated but without traceability to an accepted high order reference material. This means that concentration values may not be comparable between different methods or hospital laboratories, posing potential risks to patients”.

“LGC’s new reference materials will improve confidence in measurement, helping clinicians to ensure optimum therapeutic effect and minimise the occurrence of adverse events,” he added.

Liquid chromatography tandem mass spectrometry instrumentation is used in conjunction with LGC’s exact matching isotope dilution procedure, to assign reference values to the digoxin in serum reference materials. Credit: Andrew Brookes, www.andrewbrookes.co.uk

Grim reaper’s walking speed measured

The authors say that for the first time they have estimated the speed at which the Grim Reaper usually walks: about 1.8 miles per hour. He never walked faster than 3 miles per hour.

To assess his role in mortality and walking speed, a team of researchers based at Concord Hospital in Sydney, Australia analysed the walking patterns of 1,705 men aged 70 and over who were participating in The Concord Health and Ageing in Men Project (CHAMP).

The men lived in the inner city and suburbs of Sydney and they were recruited from January 2005 to June 2007. The CHAMP study included a high proportion of immigrants and only 50% of the participants were born in Australia, 20% were born in Italy and the other main countries of birth were Great Britain, Greece and China.

The researchers assessed participants’ walking speed at baseline and survival over the five-year study period.  A total of 266 deaths were observed during the follow-up. The results show that their average walking speed was 0.88 metres per second (m/s). No men with walking speeds of 1.36 m/s (3 miles or 5km per hour) or above had contact with the Grim Reaper.

The authors conclude that the results support their theory “that faster speeds are protective against mortality because fast walkers can maintain a safe distance from the Grim Reaper”.

References

1 Stanaway FF, Gnjidic D, Blyth FM, et al. How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over. BMJ 2011;343:d7679. doi: 10.1136/bmj.d7679

Newspapers exaggerate survival after cardiac arrest

The study, led by Richard Field (Clinical Research Assistant, Heart of England NHS Foundation Trust), examined all UK newspaper articles published between 1 January and 30 June 2010 containing the words ‘cardiac arrest’, ‘CPR’ or ‘resuscitation’. 181 articles were identified as referring to individual cardiac arrests occurring outside hospital. In this group newspapers reported that 17.7% survived to hospital discharge, almost all with good neurological outcome. This compares with an estimated survival rate of less than 10% for out-of-hospital cardiac arrests in Europe.

The public were found to estimate survival rates following CPR at over 50%, whereas survival to discharge is actually less than 10% for out-of-hospital arrests and 10–20% for in hospital arrests. It is likely that the majority of perceptions are formed through the portrayal of resuscitation in fictional medical dramas, researchers say.

Mr Field said: “Public perception of outcome following a cardiac arrest is very important as it has the potential to influence the motivation for learning and performing CPR as well as making and/or supporting do not attempt cardiopulmonary resuscitation (DNACPR) decisions”.

The Resuscitation Council (UK), which funded the study, advocates a joint approach to DNACPR decision-making. This can involve both the patient, or those close to the patient and the clinical team. They emphasise the importance of accurate public perception regarding cardiac arrest survival, to ensure correct decisions are made and expectations are realistic.

Resuscitations in a public place and involving heroic bystander CPR attempts are more likely to attract the media looking for high-impact news stories, the authors suggest.  In reality around 70% of cardiac arrests occur at home and only 36% of these patients will receive bystander CPR, compared with bystander CPR performed in 75% of events occurring in a public place.

References

1 Field RA, Soar J, Nolan JP, Perkins GD. Epidemiology and outcome of cardiac arrests reported in the lay-press: an observational study.  J R Soc Med. 2011;104:525—31. doi:10.1258/jrsm.2011.110228.

Welcome to new sponsor

Public health doctors top New Year’s Honours list

The study aimed to establish which specialties were more likely to be honoured, and how long doctors needed to practise before an honour is conferred.  Researchers led by Dr Shofiq Islam (Department of Surgery, Birmingham Heartlands Hospital) identified 417 doctors receiving honours between January 2000 and January 2011.

They were stratified into four subgroups: general practitioners (GPs), physicians, surgeons and others and sub-divided again into subspecialties. The top specialties for honours included general practice, paediatrics, psychiatry, public health medicine, pathology, geriatrics, endocrinology and haematology.

GPs head the league table of honours in terms of numbers. Dr Islam says: “This is perhaps not surprising given the fact that GPs collectively constitute the largest single group of the medical workforce. However, when this figure is converted to a percentage of all registered GPs, a relatively small proportion receives honours. Despite ranking fourth overall in absolute numbers, public health medicine comes out top in percentage terms”.

All doctors have to put in at least 30 years of hard graft before they can even expect to be considered for an honour, which the research defined as Knight or Dame, CBE, OBE or MBE. For GPs the mean number of years of clinical practice and subsequent conference of honours is slightly shorter at 31 years, while secondary care clinicians have to work another five years.

Dr Kamran Abbasi, editor of the Journal of the Royal Society of Medicine, said: “The British honours system is one of the oldest in the world and it is extremely competitive. Doctors, like other public sector workers, reach a stage in their careers when they begin to think about being recognised by our honours system. This study has produced two interesting findings. Don’t even think about a gong before you’ve worked for thirty years, and if an honour is your ultimate goal you might want to discard the glamour and scalpels of surgery for a world of hush-puppies and public health”.

References

1 Doctors recognized by the British honours system: A retrospective analysis of the last decade. Islam S, Cole JL, Taylor CJ. JRSM 2011;104:521–4. doi: 10.1258/jrsm.2011.110188.

Concern over NHS relying on consultants’ good will

Dr Andrew Goddard, Director of Royal College of Physicians (RCP) Medical Workforce Unit, said, “This census shows that senior doctor expansion has fallen and that the NHS remains reliant on doctors working longer than their contracted hours. Consultants contracted hours have fallen significantly as hospitals strive to save £20 billion over the next three years. Despite this, consultants continue to work the hours they have done in previous years and so the amount of ‘goodwill work’ is increasing year-on-year”.

“Furthermore, consultants are finding themselves less available to teach trainees, often having to do jobs that would have previously been done by junior doctors. This is really worrying as training of future senior doctors is vital to high quality patient care in the NHS,” he added.

Each week, consultants are working 11.5% of their contracted hours extra free, says the census, this figure jumping to 14% for doctors who work part time. Overall, this ‘goodwill’ work accounts for the equivalent of 1,450 fulltime consultants, up by 205 compared to 2009. Despite working longer hours, 51.8% of consultants say that time available to spend with trainees has reduced during the past three years.  This change may result from the fact that consultants are spending more time doing jobs that would previously have been done by a junior doctor.

The European Working Time Directive (EWTD) continues to be seen by many as the main culprit responsible for the disintegration of the clinical team and training. The 2010 census, in addition to showing that the majority of consultants work more than 48 hours a week, also shows that 29.6% of departments do not work EWTD compliant rotas in practice – despite 94.7% being compliant on paper. Significant concerns remain about the impact of the EWTD on training and patient care.

74.9% of consultant said pressure at work had increased. 66.3% of consultant physicians reported their job always, often or sometimes ‘got them down’. The RCP is concerned that this is affecting consultants’ career planning. 51.3% of consultants currently intend to retire at 60 years of age or younger and the main reason given was pressure of work (27.9%).

Overall, consultant expansion slowed in 2010 to 6.7% from 10.2% in 2009. However, the expansion was not evenly spread across the 31 specialties. Large expansions were seen in cardiology and respiratory medicine, accounting for 39% of the new consultants. However, the increases seen in these two specialties were mostly due to improved data collection. If these two specialties are excluded, the expansion was only 4.1%, which is low compared to the last 10 years.

However, the RCP is concerned that six of the 31 specialties saw either no expansion or a reduction in numbers. One of these specialties was geriatric medicine, which is of particular concern since the population in the UK is aging. However, it is likely that some geriatricians have been reclassified as stroke physicians (stroke medicine saw a 48% expansion), and the RCP will be monitoring this specialty carefully in future census surveys to monitor whether the NHS will employ enough geriatricians to treat the increasing numbers of patients who are old and have complex conditions.

References

1 Census of consultant physicians and medical registrars in the UK, 2010. Federation of the Royal Colleges of Physicians. (Available from: http://www.rcplondon.ac.uk/resources/professionalism-and-working-practice/census).

Rivaroxaban approved for prevention of non-valvular AF

The oral anticoagulant has now been granted approval by the European Commission (EC) for use in the UK across two new indications:

- The prevention of stroke and non-central nervous system (CNS) systemic embolism in adult patients with non-valvular AF and one or more risk factors for stroke including congestive heart failure, hypertension, age over 75 years, diabetes and prior stroke, at a fixed dose of 20 mg once-daily.

- The treatment of deep vein thrombosis (DVT) and prevention of recurrent DVT and pulmonary embolism (PE) following an acute DVT in adults.

“The consequences of blood clots can be overwhelming and their prevention and treatment should rightly be considered a health priority,” said Trudie Lobban MBE, Chief Executive and Founder of Atrial Fibrillation Association. “Thrombosis represents a massive burden on patients and the UK health system. VKA eligible AF patients, especially those with a higher risk profile and with significant co-morbidities, tend to require more frequent INR testing. The additional tests have a significant impact on these patients’ quality of life as well as on NHS resources, so the approval of new therapy alternatives that are easier to manage than traditional treatments are welcome”.

“Antithrombotic medicine is a fast-evolving area in which we are continually improving our understanding of how to combat blood clots,” said Professor Keith Fox, Professor of Cardiology at the University of Edinburgh. “Treatments which act at a key point in the blood-clotting process are now emerging as an important therapy option in both short and long-term clinical settings, and have the potential to help re-shape clinical practice”.

24,000 avoidable deaths per year in diabetes patients

The report also found death rates among women aged 15 to 34 with diabetes are up to nine times higher than the average for this age group.  Roughly three quarters of the 24,000 people with diabetes who die each year are aged ≥65. However, the gap in death rates between those who have and do not have diabetes becomes more and more extreme with younger age.

About one in 3,300 women in England will die between the ages of 15 to 34; but this risk increases nine-fold among women with type 1 diabetes to one in 360, and six-fold among women with type 2 diabetes to one in 520.  A similar picture is true for young men with diabetes; men aged 15 to 34 in the English population are much more likely to die than women, at one in every 1,530; but this risk rises four-fold for men with type 1 diabetes to one in 360, and by just under four-fold among those with type 2 diabetes to one in 430.

The findings echo conclusions made earlier this year by the National Diabetes Audit, which found nearly 450,000 children and younger adults (aged up to 54) with diabetes have high risk blood sugar levels that could lead to severe complications. The audit, which is managed by the NHS Information Centre and commissioned by the Healthcare Quality Improvement Partnership (HQIP), also found this age group was the least likely to receive all the basic care checks required to monitor their condition.

The report also found:

• There is a strong link between deprivation and increased mortality rates. Among under-65s with diabetes the number of deaths among people from the most deprived backgrounds is double that of those from the least deprived backgrounds.

• Death rates among people with diabetes vary according to where they live. London has the lowest rates for both type 1 and type 2 diabetes, at 1.8% and 1.2% respectively, while the highest rate for both type 1 and type 2 diabetes was in the North East, at 2.4% and 1.7% respectively.

Audit lead clinician Dr Bob Young, consultant diabetologist and clinical lead for the National Diabetes Information Service, said: “For the first time we have a reliable measure of the huge impact of diabetes on early death. Many of these early deaths could be prevented. The rate of new diabetes is increasing every year. So, if there are no changes, the impact of diabetes on national mortality will increase. Doctors, nurses and the NHS working in partnership with people who have diabetes should be able to improve these grim statistics”.

References

1 NHS The Information Centre. National Diabetes Audit 2007/8 Mortality Analysis.  The Health and Social Care Information Centre, 2011.

Rising premature mortality in European men

Lead author Professor Alan White presented the findings at an Expert Symposium on Men’s Health as part of the recent launch of the University’s Institute for Health & Wellbeing.  He said: “The report shows that the old are getting older and the reduction of men of working age across Europe will create major new challenges to the health and social care sectors, as well as for the workforce, employers and economies.  In the UK however, our low birth rate is being masked by the migration of people of working age”.

The report highlights a persistent trend of higher rates of premature mortality not just in men as compared to women, but when comparing men from different socio-economic and cultural backgrounds.

In terms of the differences between men and women:

• Life expectancy for the EU27 stands at 76.07 for men and 82.21 for women, ranging from 80 years in Iceland and Lichtenstein to 66.3 years in Lithuania (a gap of 13.7 years)

• A clear gap exists between the Eastern European Countries as compared to Western Europe

• It is key to note that there are big differences within each member state so no country can be complacent

In 2007, there were over 630,000 male deaths between the ages of 15 and 64 years of age as compared to 300,000 female deaths. Across EU27, deaths in this 15-64 age group account for 26% of total male deaths compared to 13% of female deaths.  However, these proportions vary considerably between countries: ranging from nearly 44% of total male deaths occurring in this age group in Lithuania to 18% in Sweden.  For every country, this has significant implications for family and community life, and for the economy.

When the causes of these deaths were analysed they extended across the majority of conditions that should be seen to affect men and women equally.  Although men’s increased susceptibility to cardiovascular disease and deaths as a result of accidents in their earlier years is quite well known, their vulnerability to such a wide range of conditions is less well recognised.

The higher rates of deaths in both communicable and non-communicable disease are, in part, a result of men’s riskier lifestyles but are also underpinned by the social determinants of men’s health, the report says. In all Member States, men who live in poorer material and social conditions are likely to eat less healthily, take less exercise, be overweight/obese, consume more alcohol, be more likely to smoke, engage in substance misuse, and to engage in more risky sexual behaviours.  All of these have significant impacts on length and quality of life.

The report provides the first complete picture of the breadth of issues affecting men’s health. It shows clearly that right across Europe, men are more likely to die prematurely than women, and that men in lower socio-economic groups have significantly poorer health than those in higher groups. This applies to every country within the EU27.

References

1 White A, de Sousa B, de Visser R, et al.  The state of men’s health in Europe: extended report. European Union 2011.  (Available at: http://ec.europa.eu/health/population_groups/docs/men_health_extended_en.pdf)

Heart Rhythm UK 2011 report

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 23^rd – 26^th September at The ICC, Birmingham UK; further details will be available in due course on the website www.heartrhythmcongress.com.

Author

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

Dr Karthik Viswanathan