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)

Hastings and Rother NHS Trust, The Conquest Hospital, St Anne’s House, 729 The Ridge, St Leonards-on-Sea, England, TN37 7PT

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

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.”

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/

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

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

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

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

The study population included subjects poorly represented in clinical trials but commonly admitted as heart failure patients – including the very elderly, those with atrial fibrillation (AF), and those previously treated with a pacemaker or other cardiac device.

Analysis of the survey data showed that at, one year (average) follow-up, 81% reported a self-assessed improvement in their symptoms (with 16% no change and 4% a deterioration).  The survey also found that almost 25% of the subjects had died or been re-hospitalised within the 12-month follow-up period.  Patients implanted with a pacing device only (CRT-P) had higher rates of mortality than those whose device had an additional defibrillator (CRT-D).

First author Dr Nigussie Bogale (Stavanger University Hospital, Norway) said: “This is the largest study reporting a difference in outcome between CRT-D and CRT-P. Most patients with an indication for CRT have also an indication for a defibrillator. So unless they have contraindicating co-morbidities, it is now our belief that these patients should be considered for CRT-D implantation”.

And also…

FDA advisory panel approves Medtronic CRT-Ds

Michael R. Gold, M.D., Ph.D

The overall clinical benefits of Medtronic cardiac resynchronization therapy with implantable cardioverter defibrillator (CRT-D) devices outweigh the risks in treating certain mildly symptomatic heart failure patients, according to a recent determination from the US Food and Drug Administration’s (FDA) Circulatory Systems Devices Advisory Panel.

The recommendation was based on data from the RAFT (Resynchronization/Defibrillation in Ambulatory Heart Failure Trial) and REVERSE (REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction) clinical trials. While the CRT-Ds are currently approved for patients with moderate-to-severe heart failure, these studies found that their use could benefit mildly symptomatic heart failure patients by reducing mortality and heart failure hospitalisation rates.

The Advisory Panel voted in favor of the CRT-D devices’ safety (Yes: 5 votes, No: 0 votes) and efficacy (Yes: 3 votes, No: 2 votes) profile in treating a mildly symptomatic patient population. The panel voted in favor of the overall risk-benefit profile (Yes: 3 votes and No: 2 votes)

The FDA will consider the Panel’s feedback as it reviews Medtronic’s request to expand its CRT-D indication to include New York Heart Association (NYHA) Class II heart failure patients with a left ventricular ejection fraction (LVEF) of less than or equal to 30%, left bundle branch block (LBBB), and a QRS duration greater than or equal to 120 milliseconds.

“We look forward to working closely with the FDA during the regulatory process so that we may expand the use of our innovative portfolio of CRT-D devices in an effort to enhance patient outcomes in a broader heart failure population,” said Pat Mackin, president of the Cardiac Rhythm Disease Management business and senior vice president at Medtronic.

“As was seen in the RAFT and REVERSE trials, clinical evidence demonstrates that CRT-D prevents hospitalization and can save lives in mildly symptomatic patients,” said Dr Michael R Gold, REVERSE study investigator and steering committee member (Medical University of South Carolina). “Utilizing this lifesaving therapy earlier in a milder heart failure population would allow us to treat these patients before their symptoms exacerbate, ultimately enabling us to better address this serious, often debilitating and costly disease”.

RAFT Clinical Trial

Findings from the landmark RAFT clinical trial, published in the New England Journal of Medicine, showed that CRT-D significantly reduced mortality for mildly symptomatic heart failure patients (NYHA Class II) by 29% when compared to patients treated with guideline-recommended implantable ICDs and medical therapy. The study also demonstrated a significant reduction (27%) in combined mortality and heart failure hospitalizations for this population, consistent with previously published studies. All patients were followed for at least 18 months, and had an average follow-up of 40 months, making it the longest follow-up and largest patient months-of-experience of any study of CRT therapy.

REVERSE Clinical Trial

With 610 patients studied, REVERSE was the first large-scale, global, randomised, double-blind trial to demonstrate the impact of CRT in mild heart failure patients or asymptomatic patients who previously had heart failure symptoms. All of the randomised subjects received a Clinical Composite Response at 12 months. The Clinical Investigation Plan pre-specified that a comparison would be made between subjects with CRT and those without. The results showed that 21% of subjects without CRT worsened, compared with 16% with CRT.

In a post-hoc analysis, more patients in the trial improved with CRT than without (54% vs. 40%, respectively). The Clinical Composite Response measure for heart failure consists of several different endpoints, including death, hospitalisation for heart failure, crossover to the opposite arm due to worsening heart failure, a progression to a worsened NYHA class, or a moderate or marked worsening of the patient’s self-assessment (administered by the blinded clinician).

Furthermore, the analysis of secondary endpoints in the REVERSE trial showed that CRT leads to improvement in both cardiac structure and function as measured by echocardiography, meaning the heart size improves and beats more effectively. In an additional analysis, REVERSE also demonstrated that CRT delayed the time to first heart failure hospitalisation in this patient group and reduced hospitalisation or death by 51%.

References

1 Bogale N, Priori S, Cleland JGF, et al. The european CRT survey: 1 year (9-15 months) follow-up results.  Eur J Heart Fail 2011; doi:10.1093/eurjhf/hfr158.

NOAF occurred in 44 patients at a median time of 48 hours following TAVI, and its incidence was increased in patients with larger left atrial size and those undergoing transapical TAVI.  Up to 40% of the NOAF episodes occurred either during or within the 24 h following the procedure (figure 1).  NOAF was associated with a higher rate of stroke/systemic embolism, but not a higher mortality, at 30 days and at 1-year follow-up.

Figure 1. Timing of first atrial fibrillation (AF) episodes following transcatheter aortic valve implantation in 44 patients with new-onset AF. Adapted from original

Figure 2. Duration of new-onset atrial fibrillation episodes following transcatheter aortic valve implantation. Adapted from original

The authors say the increase in cardioembolic events associated with NOAF offers an  “important new insight into the mechanisms of cerebrovascular events following TAVI. Indeed, some…events seemed to be related to the no initiation of anticoagulant therapy upon documentation of the AF episode, which further emphasizes the clinical relevance of optimizing antithrombotic treatment in this high-risk subset of patients”.

They add that “future studies will have to determine the potential usefulness of implementing preventive strategies to reduce the occurrence of NOAF and its potentially devastating consequences in the setting of TAVI”.

References

1 Amat-Santos IJ, Rodés-Cabau J, Urena M, et al. Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation. JACC 2012;59. doi:10.1016/j.jacc.2011.09.061.

“These studies open the way for the early identification of myocardial damage at the subclinical level, thereby allowing clinicians to identify patients who might benefit from either changes in cancer therapy or the delivery of protective treatments,” says European Association of Echocardiograpy (EAE) president Dr Luigi Badano (University of Padua, Italy).

The cardiotoxic effects of cancer treatments encompass a heterogeneous group of disorders, says Dr Helder Dores (Santa Cruz Hospital/São Francisco Xavier Hospital, Lisbon, Portugal): “They range from relatively benign arrhythmias, and hypertension, to potentially lethal conditions such as thromboembolism, myocardial infarction and cardiomyopathy with symptomatic heart failure”.

In October 2011 the EAE announced that it is working with the American Society of Echocardiography (ASE) and American Society of Clinical Oncology (ASCO) to issue joint recommendations on the usefulness of echocardiographic evaluations in cancer patients, expected to be published in 2012. “The document should lay down guidance for the frequency of assessment with different chemotherapy agents, and also identify when patients should stop treatment or be prescribed protective treatments,” says Dr Badano.

In the first study Dr Dores and colleagues set out to identify early warning signs of adverse cardiac effects in women treated with trastuzumab for breast cancer. In the study 51 consecutive women, enrolled for treatment between May and September 2010, were assessed at baseline with echocardiography and then again at three months.
The investigators found that within the first three months no patients presented with overt signs of heart failure or significant left ventricular systolic function deterioration, although almost one-fifth developed impaired ventricular relaxation.

“Patients with impaired ventricular relaxation are known to be at higher risk for progression to advanced stages of cardiac dysfunction (both systolic and diastolic), making it important for these patients to be subject to more frequent evaluations both during and after therapy,” says Dr Dores.

Further studies are now needed, he says, to assess whether impaired ventricular relaxation occurs in larger populations of patients prescribed trastuzumab.  “We need studies identifying the women who go on to develop overt cardiac dysfunction to see whether we can more accurately determine predictors of these adverse events at an earlier stage of treatment.”

In the second study Dr Radulescu and colleagues used echo-Doppler echocardiography to investigate whether the ACE inhibitor lisinopril and the statin rosuvastatin might confer a cardio protective effect on patients treated with anthracyclines for a range of malignancies.

“While the exact mechanism of anthracycline related cardiotoxicity is not fully understood, animal studies have pointed to oxidative stress and inflammation.   Both ACE inhibitors and statins are known to play an important role in reducing oxidative stress and inflammation at the level of the heart muscle cells,”says Dr Andreea Parv.

In the prospective study left ventricular ejection fractions and LV diastolic function were compared for the study group of 26 patients treated with the anthracycline epirubicin who were also given the cardio protective treatments Lisinopril 10 mg and Rosuvastatin 10 mg, and a control group of 31 gender and age-matched patients who received epirubicin but had no accompanying cardioprotective treatments.

Results show that in comparison with patients receiving cardio protection the patients who receive no protection showed further deterioration of LV diastolic function, calculated as the ratio of early diastolic filling velocity(E) to filling velocity after atria contraction E/A (p<0.02).
“This is the first human prospective study documenting the cardioprotective effect of lisinopril and rosuvastatin in anthracycline induced cardiotoxicity,” says Dr Radulescu.  Further studies, she adds, are now needed in larger numbers of patients, exploring a range of different types of malignancies.



References

1 Dores H, Gandara F, Correia MJ et al. Early Trastuzumab induced cardiotoxicity in breast cancer patients.  Abstract P315
(Available from: http://spo.escardio.org/AbstractDetails.aspx?id=101200&eevtid=49).

2 Radulescu L, Radulescu D, Andreea P et al. Cardioprotective role of lisinopril and rosuvastatin in the prevention of anthracycline induced cardiotoxicity.  Abstract P316 (Available from http://spo.escardio.org/AbstractDetails.aspx?id=101201&eevtid=49).

Full scientific programme available here: http://www.escardio.org/congresses/euroecho2011/Pages/welcome.aspx