Arrhythmia Watch

An Educational Resource for Cardiac Rhythm Management

Quality of stroke care – SINAP quarterly figures

Hospitals taking part in the Stroke Improvement National Audit Programme (SINAP), the continuous national stroke audit which looks in detail at the first 72 hours of care, have supplied information on aspects of patient care, including:

• How many patients had a brain scan within 1 hour (nationally, 33% compared to 32% in the previous quarter)

• How many patients had a brain scan within 24 hours (nationally, 90% compared to 86% in the previous quarter)

• How many patients saw a stroke consultant within 24 hours (nationally, 83% compared to 82% in the previous quarter)

• Whether or not the patient is admitted directly to a stroke unit, and whether or not they reached the unit within 4 hours (nationally, 62% compared to 61% in the previous quarter)

• Whether or not the patient received thrombolysis (clot busting drug) when they were potentially eligible for it (nationally, 60% compared to 54% in the previous quarter)

• Whether or not the prognosis/diagnosis was discussed with a relative/carer within 72 hours where applicable (nationally, 87% compared to 86% in the previous quarter)

• Whether or not the patient had a continence plan drawn up within 72 hours where applicable (nationally, 70% compared to 68% in the previous quarter)

• Whether the patient was seen by nurse and one therapist within 24 hours and all relevant therapists within 72 hours (nationally, 57% compared to 57% in the previous quarter)

• and other standards, which are included in the full results spreadsheet

The audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP), is carried out on behalf of the Intercollegiate Stroke Working Party by the Royal College of Physicians’ Clinical Standards Department.  It is a continuous audit, taking place all year round until 31^st March 2012, with hospitals submitting data on patients as they are admitted and treated.

Individual hospital results are available on the College website from today and this includes details of hospitals which are eligible to participate in the audit but did not submit sufficient (or any) data.

Donation enables diabetes research

The Foundation’s support will provide Professor Per-Olof Berggren (Karolinska Institutet) and his group with the opportunity to study, in microscopic detail and for long periods, how various signals control the release of insulin in living animals. This knowledge will enable the identification of new targets for more effective drugs against diabetes, the researchers hope.

Professor Per-Olof Berggren (Karolinska Institutet) said: “We are very grateful that the af Jochnick family has shown its confidence in us in this way. The generous grant will enable us to hold a long-term perspective in our research projects. This enables us to work with greater boldness, using more advanced technology in experiments in living organisms”.

The President of Karolinska Institutet, Professor Harriet Wallberg-Henriksson, welcomes the initiative:
“Karolinska Institutet has a long tradition of world-leading diabetes research, and it is for this reason particularly gratifying that we will now have the opportunity to take our successful research forwards. This very generous grant from the af Jochnick Foundation will give us this possibility.”

For more information, see: http://www.afjochnickfoundation.nl

Inexperience predicts AF ablation complications

Researchers led by Dr Rashmee Shah (Stanford University School of Medicine, California) used data from the California State Inpatient Database to identify a large cohort of patients who underwent their first AF ablation in the state from 2005 to 2008. They used multivariable logistic regression to identify predictors of complications and/or 30-day readmissions, and Kaplan-Meier analyses to estimate rates of all-cause and arrhythmia readmissions.

Among a total of 4,156 patients who underwent an initial AF ablation, 5% had periprocedural complications (most commonly vascular) and 9% were readmitted within 30 days. Older age, female, prior AF hospitalisations, and less hospital experience with AF ablation were associated with higher adjusted risk of complications and/or 30-day readmissions. The rate of all-cause hospitalisation was 38.5% by one year. The rate of readmission for recurrent AF, atrial flutter, and/or repeat ablation was 21.7% by one year and 29.6% by two years.

Dr Rashmee Shah

Dr Shah told BJC Arrhythmia Watch: “Atrial fibrillation is a growing health care problem.  Ablation is an exciting new treatment option and is, as we have shown, increasing in use.  Procedural complications and re-hospitalisations for recurrent arrhythmia are concerns as this new treatment modality disseminates.  Studies like ours are important to monitor the progress of ablation and help identify targets for improvement”.

The authors also said: “Our finding of better outcomes among patients treated at centers with more procedural experience in the prior 12 months suggested that higher procedure volumes are needed to gain proficiency, maintain proficiency, or both”.

In an accompanying editorial,² Dr David Haines (Oakland University William Beaumont School of Medicine, Michigan) comments of the study’s findings that “it would appear that one of the most technically challenging procedures in the field of interventional cardiac electrophysiology is commonly being performed by physicians lacking appropriate experience”.

“It is problematic that complex procedures continue to be performed at very low-volume centers in the U.S. medical system. As long as a hospital is able to profit from supporting interventional procedures by its physicians, there will be a tendency to set a low bar for granting privileges to any doctor who claims proficiency,” he continued.

References

1 Shah RU, Freeman JV, Shilane D, Wang PJ, Go AS, Hlatky MA.  Procedural complications, rehospitalizations, and repeat procedures after catheter ablation for atrial fibrillation.  JACC 2012;59:143–9.

2 Haines D.  Atrial fibrillation ablation in the real world.  JACC 2012;59:150–2.

BCS recommendations on acute cardiac care

The development of coronary care units (CCUs) in the mid 20^th century was a major advance in cardiology practice as it allowed the concentration of patients with ST elevation myocardial infarction (STEMI) in an area with specialist monitoring, nursing and medical care. This became particularly important as the medical management of STEMI became more aggressive and specialised. The development of primary angioplasty (PPCI) programs for STEMI following Roger Boyle’s report ‘Mending hearts and brains’¹ in 2006 has led to a further shift in the role of the CCU. Some units no longer admit STEMI patients, while in PPCI centres the concentrated influx of patients previously treated across a network has placed CCU beds and staff under considerable pressure.

However, the workload of CCUs has been changing for many years and the development of PPCI cannot be considered in isolation. For example, it is well recognised that there is an increasing proportion of elderly patients presenting acutely with complex problems, particularly related to heart disease. The incidence and detection of non-ST elevation MI is rising with the use of high sensitivity troponin and there is good evidence that aggressive management impacts on outcomes. Hospital Episode Statistics² suggest that acute coronary syndromes represent only a relatively small proportion of the acute cardiology intake, with heart failure and arrhythmias (particularly atrial fibrillation (AF)) much more common. The availability of new procedures for previously untreatable conditions (e.g. TAVI for aortic stenosis in the elderly population with co-morbidities), has also had an impact.

Dr David Walker

More importantly there is now data to suggest that patients presenting with acute cardiac conditions fare better under the care of specialist cardiology teams. Data from MINAP demonstrate quite clearly that management within a CCU environment leads to shorter length of stay, more evidence based medication (aspirin, statins, beta blockers, ACE inhibitors etc.), more coronary angiography and lower mortality. Yet currently, less than half the patients presenting with NSTEMI are managed within a CCU.

The National Heart Failure Audit³ supports similar conclusions for heart failure, showing that the mortality is halved from 12% to 6% for patients managed within cardiology by trained specialists (data adjusted for confounding variables). These patients also have better access to disease modifying treatment and specialist nurse follow-up. Similar data (though not from the UK) exists for the management of AF.

The net result of these changes is that CCUs remain busy but that the nature of the workload is changing with admission of older, sicker and more complex patients. In practical terms, units are no longer CCUs but are better described as Acute Cardiac Care Units.

British Cardiovascular Society Working Group on acute cardiac care

Over the last year, a working group of the BCS has been considering the organisation and provision of care for all acute cardiac conditions, including staffing, location, diagnostic requirements and the role of specialist nurses and cardiac physiologists.  The final report, published in October 2011, is available on the website⁴ and was developed with input from all the affiliated groups of the BCS, together with representatives from commissioning, NHS improvement and the British Heart Foundation.

There have been some controversial areas – for example should all acute hospitals be able to provide temporary pacing or pericardiocentesis on site at all times? Although relatively infrequently required, these patients often present as an emergency and a formal local/network arrangement must be in place in advance to ensure appropriately skilled staff are available. Currently the numbers of consultant cardiologists remain too low to provide access to senior cardiology care 24/7 in all hospitals, but this must surely be our aim.

The main conclusions of the report are:

• Patients presenting with cardiac conditions managed in specialised cardiac wards have demonstrably better outcomes;
• A significant proportion of these patients are not currently managed within a cardiac service leading to increased morbidity and mortality, and cost to the NHS;
• Patients presenting with acute cardiac conditions should be managed by a specialist, multidisciplinary cardiac team and have access to key cardiac investigations, and interventions at all times;
• All hospitals admitting unselected acute medical patients should have an “acute cardiac care unit” (ACCU) where high-risk patients with a primary cardiac diagnosis should be managed;
• All high-risk cardiac patients must have access to an ACCU, and access should not be restricted to patients with ACS

Dr David Walker
Consultant Cardiologist
(David.walker@esht.nhs.uk)

Conquest Hospital, The Ridge, St Leonards-on-Sea, East Sussex, TN37 7RD

References

1 Mending hearts and brains – clinical case for change: Report by Professor Roger Boyle, National Director for heart disease and stroke. Professor Roger Boyle. Department of Health 2006.  Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063282

2 Hospital Episode Statistics online – www.hesonline.nhs.uk

3 National Heart Failure Audit 2010. The NHS Information Centre 2010. Available from: http://www.bsh.org.uk/Default.aspx?tabid=142

4 The full report is available at: http://www.bcs.com/pages/news_full.asp?NewsID=19792012

Working Group members

D Walker Chair, BCS
N West Deputy Chair, BCS
S Ray VP Clinical Standards, BCS
S Bridge, CEO Papworth Hospital
S Furniss, Heart Rhythm UK
J Keenan, British Association for Nursing in Cardiovascular Care
M Knapton, British Heart Foundation
C Knight, British Cardiovascular Intervention Society
G Lloyd, British Society for Echocardiography
C Marley, NHS Improvement: Heart
T McDonagh, British Society for Heart Failure
T Quinn, MINAP
D Ritchley, Society for Cardiological Science and Technology
K Timmis, Heart Care Partnership
K Wilmer, Royal College of Physicians

BHF campaigns for hands-only CPR

Nearly half of people are reluctant to help in emergencies due to a lack of knowledge about CPR, a BHF poll showed.  A fifth of respondents worried specifically about the thought of the kiss of life or catching an infectious disease. The UK-wide survey also revealed four in 10 people feared being sued if they did something wrong.

Ellen Mason, BHF Senior Cardiac Nurse, said: “The kiss of life can often be daunting for untrained bystanders who want to help when someone has collapsed with a cardiac arrest.  Hands-only CPR should give lots of people the confidence and know-how to help save someone in cardiac arrest, the ultimate medical emergency. It’s been shown that hard, fast and uninterrupted chest compressions are better than stopping compressions for ineffective rescue breaths”.

“It’s very simple; call 999 and then push hard and fast in the centre of the chest at a tempo similar to Stayin’ Alive by the Bee Gees. If you’re untrained or unconfident about the kiss of life give Hands-only CPR a go instead – it could help save someone’s life.”

The national awareness campaign includes a new TV advert featuring Hollywood hard man Vinnie Jones.  Former Chelsea footballer Jones said: “There really shouldn’t be any messing about when it comes to CPR. If you’re worried about the kiss of life just forget it and push hard and fast in the centre of the chest to Stayin’ Alive”.

“Hands-only CPR should give have-a-go heroes the confidence to step in and help when somebody is in cardiac arrest.”

NHS Future Forum publish second phase report

Future Forum Chair Professor Steve Field said: “We are making robust and ambitious recommendations to the NHS and to Government. We have heard an enormous amount of support for the shift to patient-centred care but also frustration that this has not yet been achieved. This must now become a reality for patients across England and health and social care professionals must lead the way”.

Over four months the Forum listened to more than 12,000 people and attended more than 300 events. In this phase, the Forum set out to listen to more patients and carers and sought more input from local authorities, housing and social care providers.

The government has responded to the Future Forum and accepted its recommendations.²

Highlights from the Future Forum’s reports include:

Professor Steve Field

• Integration should be defined around the patient, not the system – outcomes, incentives and system rules (i.e. competition and choice) need to be aligned accordingly.
• Health and wellbeing boards should drive local integration – through a whole-population, strategic approach that addresses local priorities.
• Local commissioners and providers should be given freedom and flexibility to ‘get on and do’ – through flexing payment flows and enabling planning over a longer term.

Education and training

• The new local education and training boards must have the governance in place to deliver strong partnerships across healthcare providers, academia and education.
• Quality must be at the heart of education and training with systems in place at all levels to reward high quality education and embed continuing professional development.
• There needs to be a review of the principles and aims of the Tooke Report into medical education.
• A properly structured process to support individual nurse and midwife development in post-qualification career pathways should be developed nationally.

Information

• Patients should have access to their online GP-held records by the end of this Parliament.
• The NHS must move to using its IT systems to share data about individual patients and service users electronically in the interests of high quality care.
• The Government should set a clear deadline within the current Parliament by which all information about clinical outcomes is put in the public domain.

NHS’s role in the public’s health

• The NHS must do more to prevent poor health, so it can reduce health inequalities and continue to provide high quality care for future generations.
• Every healthcare professional should make every contact count – use every contact with the public to help them improve their health. This should be a core staff responsibility in the NHS Constitution.
• The NHS must do more to support the wellbeing of its own staff too, helping a workforce of 1.4 million to live healthily and spread healthy messages with family, friends and patients.

References

1 NHS Future Forum recommendations to Government – second phase. NHS Future Forum 2012.  Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132026

2 Government response to NHS Future Forum’s second report. Department of Health 2012.  Available from: http://www.dh.gov.uk/health/2012/01/forum-response/

Cardiovascular benefits of yoga for AF

Researchers led by Dr Dhanunjaya Lakkireddy (University of Kansas Hospital, Kansas City) announced plans to study the effects of yoga on heart-rate variability and cardiac autonomic parameters.  This follows an earlier study of yoga in 49 patients with paroxysmal atrial fibrillation (AF),² which found that AF episodes were significantly reduced, with 22% having no new AF episodes while practicing Iyengar yoga.

The researchers conducted a correlation analysis to determine if the benefits to resting heart rate and systolic/diastolic blood pressure demonstrated were produced by stress reduction, or independently linked to yoga. The analysis found a nonsignificant trend toward a change in anxiety levels influencing the AF episodes, but a larger study might show a statistically significant relationship, the authors said.

Despite the benefits found, the researchers have encountered resistance to the programme. Only about 50% of patients originally enrolled adhered to the prescribed routine after study completion.

Lakkireddy’s group suggests that the benefits of yoga may be due to improved plasticity and stability of the autonomic nervous system, or the other lifestyle changes which often accompany adherence to the practice, such as weight loss and lower alcohol intake.

References

1 Lakkireddy D. Role of yoga and stress reduction techniques in the management of AF. Boston Atrial Fibrillation Symposium 2012; January 12, 2012; Boston, MA

2 Sue Hughes.  Yoga found to reduce AF episodes.  TheHeart.org 2011.  Available from: http://www.theheart.org/article/1204423/print.do

Report highlights inequity in UK device implantation

The Cardiac Rhythm Management: UK National Clinical Audit report tracks treatment with implantable cardiac devices available to patients at risk of major cardiac events.  The provision of arrhythmia care within the UK was found to be uneven, based on the quality of cardiac care services varying between locations. Patients in Dorset were found to be 80% more likely to get the treatment they required than those living in Warwickshire.

Speaking to BJC Arrhythmia Watch Morag Cunningham, Project Manager, said that:

“The principle purpose of the report is to inform on the volume and equity of provision of the major cardiac implantable device therapies – pacemakers for bradycardia (PM), cardioverter defibrillators for cardiac arrest (ICD/CRTd) and cardiac resynchronisation therapy for advanced heart failure (CRTp/CRTd) across the Cardiac networks of England and Wales. This data is further broken down by Primary Care Trust (PCT) within cardiac networks, and by hospital.

Morag Cunningham

“The report opens with an overview of the “big picture” showing the UK continuing to languish near the bottom of the European table of implantation rate for PM and ICD. One bright spot is the implantation of CRT devices, where we are second only to Belgium for CRTp and mid table for CRTd. Clearly the relatively new technology of CRT has been warmly embraced by UK clinicians.

“Using age and sex adjusted data, the report continues to show inequity of provision for all classes of devices across the cardiac networks and PCTs of England and Wales, although overall implant rates show some progress towards the national targets for device implantation set by Heart Rhythm UK (HRUK). This is particularly true for the complex devices (ICD/CRTp/CRTd), but there was a disappointing 0.6% decline in simple pacemaker implantation across the country, thus falling even further behind our major European counterparts.

“Across cardiac networks, the new implantation rate for simple pacemakers varies from 360/million to 690/million. This variation is even more pronounced for the complex devices – a patient is more than four times more likely to get an implantable cardioverter defibrillator fitted if they live in North East London than rural Herefordshire & Worcestershire.

“As well as reporting on numbers of implants, the report has sections looking at specific areas of outcomes and best practice, including pacing mode for sick sinus syndrome (one of the NICE guidelines relating to pacemaker implantation).

“For the first time, the 2010 reports carries additional detailed sections on clinical data associated with CRT implantation, and also some preliminary data on cardiac ablation procedures. The report continues to evolve from a number crunching exercise to a fully developed audit on current practise in cardiac device implantation.”

The report’s authors are keen to hear suggestions for additional content. Morag Cunningham can be reached on 01505 612829, or at morag.cunningham@ucl.ac.uk.

References

1 Cunningham D, Charles R, Cunningham M, de Lange A.  Cardiac Rhythm Management: UK National Clinical Audit 2010.  HRUK Audit Group 2011.  Available from: http://www.devicesurvey.com

Fried food not linked to CVD risk

The authors, led by Professor Pilar Guallar-Castillón (Autonomous University of Madrid), surveyed the cooking methods of 40,757 adults aged 29–69 over an 11-year period.  All participants were free of coronary heart disease at baseline.

Trained interviewers asked participants about their diet and cooking methods. Fried food was defined as food for which frying was the only cooking method used. Questions were also asked about whether food was fried, battered, crumbed or sautéed. 
The participants’ diet was divided into ranges of fried food consumption, the first quartile related to the lowest amount of fried food consumed and the fourth indicated the highest amount.

During the follow-up there were 606 events linked to heart disease and 1,134 deaths.

 The authors conclude: “In a Mediterranean country where olive and sunflower oils are the most commonly used fats for frying, and where large amounts of fried foods are consumed both at and away from home, no association was observed between fried food consumption and the risk of coronary heart disease or death”.

The authors stress, however, that their study took place in Spain, a Mediterranean country where olive or sunflower oil is used for frying and their results would probably not be the same in another country where solid and re-used oils were used for frying.

In an accompanying editorial,² Professor Michael Leitzmann (University of Regensburg, Germany) says the study explodes the myth that “frying food is generally bad for the heart” but stresses that this “does not mean that frequent meals of fish and chips will have no health consequences”. He adds that specific aspects of frying food are relevant, such as the type of oil used.

References

1 Guallar-Castillón P, Rodríguez-Artalejo F, Lopez-Garcia E, et al.  Consumption of fried foods and risk of coronary heart disease: Spanish cohort of the European Prospective Investigation into Cancer and Nutrition study. BMJ 2012;344:e363 http://dx.doi.org/10.1136/bmj.e363

2 Leitzmann MF, Kurth T.  Fried foods and the risk of coronary heart disease. BMJ 2012;344:d8274 http://dx.doi.org/10.1136/bmj.d8274

What is good for our hearts is good for our heads

Researchers, led by Archana Singh-Manoux (Centre for Research in Epidemiology and Population Health in France/University College London), argue that “understanding cognitive ageing will be one of the challenges of this century,” especially as life expectancy continues to rise.

Participants’ cognitive functions were assessed three times over the study period. Individuals were tested for memory, vocabulary and aural and visual comprehension skills. The latter include recalling in writing as many words beginning with “S” (phonemic fluency) and as many animal names (semantic fluency) as possible. 

Differences in education level were taken into account.

The results show that cognitive scores declined in all categories (memory, reasoning, phonemic and semantic fluency) except vocabulary and there was faster decline in older people.

The findings also reveal that over the 10-year study period there was a 3.6% decline in mental reasoning in men aged 45-49 and a 9.6% decline in those aged 65-70.  The corresponding figures for women were 3.6% and 7.4%.

The authors argue that robust evidence showing cognitive decline before the age of 60 has important ramifications because it demonstrates the importance of promoting healthy lifestyles, particularly cardiovascular health, as there is emerging evidence that “what is good for our hearts is also good for our heads”.  They add that targeting patients who suffer from one or more risk factors for heart disease (obesity, high blood pressure and high cholesterol levels) could not only protect their hearts but also safeguard them from dementia in later life.

The authors also argued that “understanding cognitive ageing will be one of the challenges of this century,” especially as life expectancy continues to rise.  They add that it is important to investigate the age at which cognitive decline begins because medical interventions are more likely to work when individuals first start to experience mental impairment.

Therefore the authors observed 5,198 men and 2,192 women over a 10-year period from 1997. They were all civil servants aged between 45 and 70 and were part of the Whitehall II cohort study established in 1985.

In an accompanying editorial,² Francine Grodstein, Associate Professor of Medicine at Brigham and Women’s Hospital in Boston, says the study “has profound implications for prevention of dementia and public health”.
  She adds that more creative research, perhaps using telephone and computer cognitive assessments, needs to be undertaken.

References

1 Singh-Manoux A, Kivimaki M, Glymour MM, et al. Timing of onset of cognitive decline: results from Whitehall II prospective cohort study. BMJ 2012;344 http://dx.doi.org/10.1136/bmj.d7622

2 Grodstein F. How early can cognitive decline be detected? BMJ 2012;344 http://dx.doi.org/10.1136/bmj.d7652