Cardiovascular Health - Q1 2021

Q1 / 2021

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Cardiovascular Health

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Delays in or avoidance of seeking help can have severe consequences.

The COVID-19 pandemic caused significant anxiety amongst heart failure patients both regarding COVID-19 and heart failure.

AF-related strokes are more likely to be fatal and disabling than strokes related to other causes.

Professor Simon Ray President, British Cardiovascular Society

Nick Hartshorne-Evans CEO, Pumping Marvellous Foundation

Trudie Lobban MBE Founder and CEO, Arrhythmia Alliance

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Reducing obesity rates is key to improving the nation’s cardiovascular health

Delay in seeking help risks poor outcomes

Before the COVID-19 pandemic took hold last year, the UK’s booming obesity rates were one of the biggest public health challenges the country faced.

COVID-19 has placed a major strain on hospitals but, thanks to the efforts of NHS staff, emergency treatment for heart attacks and other heart diseases has continued uninterrupted.

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round 27% of the UK’s adult population has obesity and a further 35% have excess weight. Our nation’s obesity challenge starts early in life. It is a sad fact that if a child has obesity, then they are more likely to grow up to be an adult with obesity, which puts them at greater risk of developing diabetes, as well as having a heart attack or stroke.

This situation has remained largely unaddressed for years.

Once the pandemic hit, the need to address obesity came into sharper focus as it emerged that it was associated with a higher risk of mortality from COVID-19 – the Prime Minister’s own experience is reported to have become a catalyst for the Government’s obesity strategy which was launched last summer.

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arly on in the pandemic, cardiologists across Europe reported seeing a large fall in patients being treated for heart attacks. Similar patterns were reported for stroke and for heart failure.

WRITTEN BY

Professor Simon Ray President, British Cardiovascular Society

It has never been more important for our country to be healthier and more resilient.

Increase in potentially avoidable deaths Delays in or avoidance of seeking help can have severe consequences. The reduction in hospital admissions has been accompanied by an increase in deaths from heart attack, heart failure and stroke to well above pre-COVID levels, with most of these deaths occurring in the community.

There has also been an increase in people suffering a cardiac arrest out of hospital, likely due in part to a reluctance to call for help for chest pains. Some of these excess deaths would have been avoidable with prompt treatment.

The importance of calling for help It is understandable that the public are worried about calling for help during a pandemic, but the message is clear that non-COVID emergencies remain emergencies. The risk of not calling for help far outweighs the risk of contracting severe COVID infection in hospital.

People with severe chest pains, shortness of breath or symptoms of a stroke should call 999, just as before the pandemic. These are time critical illnesses and need to be treated as rapidly as possible. People arriving

Reducing obesity rates The Government’s strategy contains a raft of vital measures for reducing obesity rates. It being fully implemented will be crucial to improving heart and circulatory health. It has never been more important for our country to be healthier and more resilient.

Important legislation is now coming out of the Government’s strategy. A 9pm watershed on promoting junk food on television, as well as robust restrictions on promoting high fat, sugary and salty foods online will do much to reduce rates of heart and circulatory diseases.

It is critical that these are passed into law without being weakened.

Research also shows it pays dividends to encourage industry to reformulate foods. A recent study by Queen Mary University found that Public Health England’s Salt Reduction programme could lead to nearly 200,000 fewer adults developing heart disease and £1.64 billion of healthcare cost savings by 2050.

The COVID-19 pandemic has put obesity back into focus, and it is now essential that the Government follows through on all its commitments as we emerge from the pandemic.

The risk of not calling for help far outweighs the risk of contracting severe COVID infection in hospital. in hospital with these symptoms will be assessed and treated as they were before COVID. Dealing with the backlog The pandemic has meant that non urgent care for heart disease has been delayed. Patients have been reluctant to see their GP and there has been a reduction both in the number of heart tests requested by GPs and in the number of referrals to hospital.

In hospitals, staff and facilities have been diverted to dealing with emergencies and unwell COVID patients. As a result, fewer non urgent procedures have been done, particularly in cardiac surgery. All of this has created a backlog that will take considerable time and effort to work through.

Each NHS region is putting in place plans to deal with this, using lessons learned during COVID about the importance of collaboration between hospitals. Remote consultations are replacing many face to face review appointments and other technologies are assisting patients to monitor and manage their own conditions in the community.

WRITTEN BY

Dr Charmaine Griffiths Chief Executive, British Heart Foundation

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Knowing the symptoms of aortic stenosis may save your life

For more information on Aortic Stenosis contact us to receive a free information kit.

Call 01243 216965 Text 07864 299093 Visit newheartvalve.com/UK If you are experiencing any symptoms, do go and ask your GP for a stethoscope check.

Margaret Deem’s lower leg pains and breathlessness weren’t signs of ageing — they were symptoms of a potentially fatal heart valve condition. A minimally invasive valve replacement procedure saved her life.

INTERVIEW WITH

Dr. John Rawlins Consultant Interventional Cardiologist, University Hospital Southampton NHS Trust

INTERVIEW WITH Margaret Deem Patient

INTERVIEW WITH Fiona Woodifield Margaret’s daughter

WRITTEN BY Tony Greenway

Treatment for aortic stenosis Margaret had an electrocardiogram (ECG) and, within a few months, was diagnosed with AS. She was amazed, because she always thought that heart problems would appear as a searing pain in her chest.

Yet Dr. John Rawlins, Consultant Interventional Cardiologist at the University Hospital Southampton NHS Trust, notes that — while chest pain can occur with this condition — breathlessness and a persistent cough, dizziness, and aching legs are all AS symptoms. “Degenerative AS affects roughly 10% of patients over 80,” he explains. “As we age, the aortic valve can progressively degenerate, calcify and narrow, which reduces the flow of blood from the heart.”

Margaret was told she needed transcatheter aortic valve implantation (TAVI), where an artificial valve is inserted into the heart, usually via the main artery in the groin. “The TAVI procedure is less invasive than cardiac surgery,” says Dr Rawlins. “There are still risks to TAVI, but it requires less recuperation time and hospital stay than traditional surgery.”

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argaret Deem’s health problems started with gripping pains in her lower legs, breathlessness and sometimes dizziness, but originally only when climbing the stairs.

Yes, she was in her eighties - naturally she felt some signs of ageing, but she still had an extremely active life, walking with her husband and dog.

When her symptoms continued, her GP told her she had a heart problem.

Margaret didn’t realise that she was experiencing the symptoms of aortic stenosis (AS), a type of heart valve disease which if left untreated can be fatal. “I felt very ill,” she remembers. “After being told the facts, I worked frantically, as if there were no tomorrow, feeling I had to sort important issues whilst I still could.

I felt that if I had been in danger, I would have had agonising heart pains.”

Margaret and her family knew something wasn’t right. “Mum hadn’t been herself for a couple of years.” said Fiona Woodifield, Margaret’s daughter. “It was subtle to start with — so subtle that no one took that much notice. But, over time, the symptoms became more severe.”

After being told the facts, I worked frantically, as if there were no tomorrow, feeling I had to sort important issues whilst I still could. I felt that if I had been in danger, I would have had agonising heart pains.

Seeking help from your GP Margaret was scheduled to have her procedure in early 2020, but when the pandemic struck it was postponed. However, in early July, she deteriorated rapidly. “We went for a walk in the forest and mum felt so unwell she had to keep lying down,” remembers Fiona. “The next day, she went to bed and that was it.”

Feeling her mum could wait no longer, a worried Fiona left messages as well as emails with the specialist and cardiology department. When a member of the TAVI team heard the seriousness of her symptoms, they called back and Margaret was told to come to hospital immediately. She was taken into a separate, COVID-secure room which made her feel safe; she was admitted, monitored and underwent the TAVI procedure as an in-patient.

“I feel fine again,” says Margaret.

“Nobody should be worried about

having this procedure at this time. In both hospitals, extreme precautions were taken to avoid infection.”

Fiona says, “I’m so grateful that the amazing team has made it possible for mum to get through this operation and give her a new lease of life.”

Dr Rawlins’ message is simple: if you have symptoms of AS, see your GP immediately and ask them to listen to your heart with a stethoscope. “Our hospital hasn’t changed its activity levels throughout the pandemic and continues to offer the procedure on the basis of its impact of both quantity and quality-of-life post-procedure,” he says. “So COVID or no COVID — don’t delay. Seek a review to discuss your treatment options.”

Paid for by Edwards Lifesciences

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Ensuring heart failure patients access care promptly in the pandemic

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eart failure patients have been significantly affected as a result of the pandemic.

The Pumping Marvellous Foundation released a new patient survey (published in European Society of Cardiology’s Heart Failure Journal) regarding the impact of COVID-19 on services.

The research was designed by patients with heart failure specialists to analyse why people are avoiding hospitals and to ascertain patients’ views regarding newer models of care, such as telehealth.

Outcomes of the research The COVID-19 pandemic caused significant anxiety amongst heart failure patients both regarding COVID-19 and heart failure. Despite older people having a predilection for more severe COVID-19 illness, anxiety is greater amongst younger patients (<60 years).

Cancellation or postponement of scheduled care appointments, investigations, procedures, prescription and monitoring services were implicated as sources of anxiety.

Amongst newer models of care, the majority (71%) chose the ‘one stop diagnostic HF clinic’, (a single visit incorporating heart failure consultant review and echocardiography). Telemanagement was least popular with older patients, who may struggle with hearing impairment and this method of communication.

Recommendations for the future Dr Rajiv Sankaranarayanan Consultant Cardiologist, Heart Failure Clinical Lead (Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust) and lead study author says: “It’s crucial that mistakes of the first wave aren’t repeated such as a unilateral focus or shift of resources exclusively towards COVID in further waves, at the expense of other potentially life-threatening conditions. There must be clear communication with patients at local and national levels that all healthcare services remain fully accessible to diagnose and manage patients with heart failure and other conditions, not exclusively COVID-19.”

Nick Hartshorne-Evans, CEO & Founder of Pumping Marvellous, says: “Many patients with heart failure have been left behind due to disruption to their appointments, delayed access to treatment and counselling. The study’s findings give very real insights into the lives of patients suffering from heart failure during the pandemic and the impact on their mental health. We need to seriously digest this survey and act quickly, to prevent deaths that would normally be avoidable. It gives us an insight into what the future of heart failure services may look like.”

WRITTEN BY Nick Hartshorne-Evans CEO, Pumping Marvellous Foundation Dr Rajiv Sankaranarayanan Consultant Cardiologist

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Freedom from the F Word…

Heart failure. The chill is in the name. Do you know what heart failure is? Would you be able to recognise it?

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WRITTEN BY Lynn Mackay-Thomas CEO, British Society for Heart Failure (BSH)

WRITTEN BY Dr Simon Williams Heart Failure Specialist Consultant Cardiologist, Wythenshawe Hospital, South Manchester; Chair, British Society for Heart Failure (BSH)

eart failure is an insidious condition characterised by symptoms including fatigue, fluid buildup, often noticeable in the ankles and fighting for breath.

It is caused by a structural and or functional abnormality in the heart which leads to reduced cardiac output.

There are approximately one million people with heart failure in the UK and a further 200,000 people are newly diagnosed each year. For half of those with the condition, heart failure is terminal with death occurring within two-five years of diagnosis.

There are approximately one million people with heart failure in the UK and a further 200,000 people are newly diagnosed each year.

Delays in diagnosis For many there are delays in diagnosis which is taking over 12 months. The risk of death from heart failure is higher than for some of the most common cancers. There is a growing school of thought that heart failure should be recognised as a disease as malignant as cancer and treated with the same urgency.

We have seen that patients with existing heart failure are at higher risk of developing complications and death from COVID-19. We have a real concern over the direct and indirect toll of the COVID-19 pandemic with escalation of heart failure cases and those yet to be diagnosed over the coming months.

However, Dr Simon Williams, Chair of the British Society for Heart Failure (BSH) comments: “Whilst it remains a burdensome, debilitating condition, with appropriate management, it is possible for people to live well with heart failure and outcomes can be improved through earlier diagnosis and treatment with guideline recommended therapies. This is an important aim of the care we provide as heart failure specialists.”

Empowering patients Earlier detection, diagnosis and treatment of those with heart failure, as well as empowerment of patients to self-manage, will improve outcomes for people living with heart failure.

One of the keys to early detection of heart failure is self-recognition of the symptoms and seeking medical help.

Use of the blood test for NT-pro BNP in General Practice is another key step as it indicates if symptoms are likely to be due to heart failure and how urgently a patient may then need referral to a heart failure specialist.

To help us help you, learn to recognise the symptoms of heart failure and seek help.

The cost of heart failure: y Despite the 2010 NICE guidance, one in five patients are not being offered a simple diagnostic blood test for heart failure at any point during their diagnosis. y 80% of heart failure is diagnosed in hospital and 40% had symptoms that should have triggered an earlier assessment in primary care. y Survival and outcomes of people with heart failure admitted to hospital around the time of diagnosis was significantly worse than in those not requiring hospital admission. y Hospital admissions and the management of heart failure accounts for 2% of the entire NHS budget (around £2 billion) - 70% of which is spent on emergency hospital admissions.

FREEDOM FROM THE F WORD: Fighting for breath, fatigue and fluid build-up. Join the movement.

For more info download the British Society for Heart Failure App visit the website bsh.org.uk/the-f-word/

y Heart failure accounts for a total of one million inpatient bed days (2% of all NHS hospital bed occupancy).

Impact of COVID-19 on those with heart failure: y Patients with heart failure nearly double their risk of dying if they get COVID-19. y The COVID-19 pandemic is causing disruption to heart failure care with four in 10 patients having had a heart failure appointment cancelled and one in three avoiding going to the hospital. y The risk of complications from heart failure outweighs the risk of dying from COVID-19.

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COVID-19 accelerates adoption of new tech in healthcare The COVID-19 pandemic has triggered a rapid and sudden shift to using digital technology in healthcare.

he doctor will see you now” has taken on a very different meaning during the COVID-19 pandemic. “Virtual” conversations – on the telephone or via a videocall – have replaced more than 90% of patient-doctor appointments since March 2020, when the UK went into its first lockdown.

Accelerating adoption of remote technology Before COVID-19 hit, only a minority of doctors used remote consultation or monitoring in their daily practice.

Although it has been technically feasible to collect health data from patients living in their own homes, through stand-alone equipment or more complex systems, until 2020 this was the exception rather than the rule.

Overnight this changed. With face-toface contacts being heavily restricted to reduce the risk of transmission of COVID-19, the only way a patient could get advice or support during the lockdowns was remotely.

As a cardiologist advising people living with heart failure – and with an interest in digital technologies – I had been using remote monitoring systems for years. However, I had always found it hard to convince colleagues (and those who fund healthcare) that such an approach was “better” than our usual system of clinic appointments months apart and urgent admission to hospital if things went wrong.

No return to old ways This has now changed, not only in the UK, but right across the world. It is unlikely we will go back to “business as usual” once the pandemic fades.

Prevent the person from becoming a patient

Everyone now realises it is better to be able to offer a range of options to patients and their families: faceto-face appointments when needed (particularly useful when a new diagnosis is suspected), supplemented by telephone or video calls (which can include, for example, your GP, a specialist, a pharmacist or other allied professional, and family members who may live far away or not be able to take time off work).

We need to focus on preventing atrial fibrillation (AF) as well as detecting it with a simple pulse check to protect against AF-related stroke.

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F is the most common type of arrhythmia (heart rhythm disorder) and is associated with an increased risk of stroke. Without anti-coagulation therapy, a person with AF may be five times more likely to have an ischaemic stroke than someone without AF. AF-related strokes are more likely to be fatal and disabling than strokes related to other causes. Therefore, the AF Association has long advocated the need to detect AF with a simple manual pulse check to protect against AF-related stroke with anti-coagulation (not aspirin).

Additionally, it raises awareness of the need to correct the irregular rhythm with access to appropriate treatments and to perfect the patient care pathway.

However, in the new AF White Paper, launched by the AF Association, it also acknowledges the need to prevent AF from developing in the first place.

While some risk factors for AF, such as older age, are non-modifiable, some risk factors are modifiable including obesity, smoking, excess alcohol intake and high blood pressure (hypertension). Therefore, by focusing on these modifiable risk factors, we can prevent AF or rather reduce the risk of it developing.

‘Virtual’ conversations – on the telephone or via a videocall – have replaced more than 90% of patientdoctor appointments since March 2020, when the UK went into its first lockdown.

This may be more efficient for both professionals, patients and their families, reduce the carbon footprint of hospital visits, and in theory at least allow more frequent and rapid input when required. There are risks of course – a webcam view is not as good as physically examining someone – and it may take longer to develop rapport and trust with someone at the end of a phone rather than faceto-face. But as we all have realised in lockdown – when times are hard, we have to adapt.

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WRITTEN BY Professor Martin R Cowie Professor of Cardiology, Imperial College London & Consultant Cardiologist, Royal Brompton Hospital (Guy’s and St Thomas’ NHS Foundation Trust) Chair, Digital Health Committee, European Society of Cardiology

©W I N G EDWO L F

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On the right track Existing public health campaigns and strategies to reduce risk factors for cardiovascular disease, such as obesity, can help to prevent AF. For example, the NHS Health Check programme is designed to identify and address the early signs of heart disease (and other conditions) in adults aged between 40 and 74 via check-ups every five years.

If a person is identified as having high blood pressure via a check-up, they could be given medication or lifestyle advice to help reduce their blood pressure and, as a result, reduce their risk of developing AF.

WRITTEN BY Trudie Lobban MBE Founder and CEO, Arrhythmia Alliance

Everyone should get into the habit of knowing your pulse, as getting to know your heart rhythm “could save your life”. An irregular rhythm may be a sign of AF. Providing support in prevention In fact, any medical contact — whether this is at the primary, secondary, or tertiary care level — is an opportunity to provide guidance, information and support on leading a healthy lifestyle and risk factor management to optimise lifelong cardiovascular health and, thus, prevents AF. Everyone should get into the habit of knowing your pulse, as getting to know your heart rhythm “could save your life”. An irregular rhythm may be a sign of AF. The AF Association’s new AF White Paper — Put People First — calls for people with, or at risk of developing, atrial fibrillation (AF) to be at the centre of decision-making. This should be in the context of the charity’s Prevent, Detect, Protect, Correct, and Perfect strategy: https://bit.ly/AFAWhitePaper For more information visit Arrhythmia Alliance www.heartrhythmalliance.org AFA Association www.afa.org.uk Know Your Pulse campaign www.knowyourpulse.org

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How AI-enabled remote monitoring is helping heart patients The NHS is embracing proven, innovative technologies to continuously monitor patients for cardiovascular conditions within their own homes.

A INTERVIEW WITH Glyn Barnes Director of Strategic Marketing EMEA, iRhythm Technologies Ltd

WRITTEN BY:

Mark Nicholls

Paid for by iRhythm

Technologies Ltd

trial fibrillation (AF) affects about 1.5 million people in the UK and causes a fivefold increased risk of stroke, which can be devastating for patients and creates a significant financial impact on healthcare systems. New technologies are needed that allow physicians to diagnose arrhythmias more quickly and begin appropriate medical intervention sooner to avoid more serious downstream medical events.

A new wireless biosensor device, attached to a patient’s chest to continuously collect ECG (electrocardiogram) data, is currently being evaluated for wider NHS use. The solution focuses on heart rhythm disorders, such as AF and other arrhythmias. It uses artificial intelligence (AI) to analyse results.

With COVID-19 restrictions meaning fewer face-to-face consultations, remote monitoring is already proving its value by continuing the monitoring and assessment of patients at home.

ECG analysed by AI Director of Strategic Marketing at iRhythm Technologies, Glyn Barnes says: “If a patient needs an ECG, their consultant contacts us and we post the device directly to that patient. Once fitted, the biosensor collects ECG data continuously for up to 14 days capturing any arrhythmias that may occur. When it is sent back, we upload it to the AI algorithm which then analyses up to 336 hours of continuous ECG. “That can take a human ECG technician a significant amount of time to review, but the AI algorithm does it in a matter of minutes.

This produces a provisional result for our own technicians to compose a final written report, which is then uploaded to a web-based portal for the prescribing clinician to review.”

Real-world evaluation Through NHSX – iRhythm has been awarded funding to supply the Zio ECG service to trusts for real-world evaluation. This has the potential

This is an example of how the NHS is embracing new types of technologies so patients can be seen more efficiently, be diagnosed accurately and receive therapy much quicker.

to inform commissioning decisions and wider adoption of Zio in the NHS. “With 98% patient compliance and a very high level of accuracy, the Zio service is recommended by NICE (National Institute for Clinical Excellence). It also minimises the need for repeat testing, saving time for healthcare professionals and helping to reduce waiting lists whilst also being cost-effective for the NHS”, says Barnes.

“The algorithm has been trained to accurately identify 10 different arrhythmias and published papers show that its accuracy matches that of cardiologists in making analyses,” he adds.

“This is an example of how the NHS is embracing new types of technologies so patients can be seen more efficiently, be diagnosed accurately and receive therapy much quicker.”

Read more at irhythmtech.co.uk

Helping patients through cardiac surgery Every heart operation is where an individual puts their trust in the surgical team: to get them through surgery safely; to improve their symptoms; to improve their quality of life; to prolong their life. Every patient has great courage to consent to have their heart operation.

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ardiac surgical teams in the UK have accepted their responsibility to be accountable to the patients they serve, the vast majority of whom are treated by the National Health Service.

WRITTEN BY

Simon Kendall President, Society for Cardiothoracic Surgery, Great Britain and Ireland

Transparency in care The NHS in the United Kingdom can be proud of the quality of its cardiac surgery. No other nation has such a complete audit of its cardiac surgery, since 2005 all the activity and outcomes have been transparent and published.

These results have shown that survival after heart surgery is world leading and that survival has improved over the last 20 years, despite the patients undergoing cardiac surgery being older and sicker. This is described in our latest SCTS Blue Book.

Looking to the future Looking forwards, there can be justified optimism that reporting and reviewing other outcome measures beyond survival will result in further quality improvement.

In the last year, COVID-19 has caused around a 50% reduction in cardiac surgery and the coming months will be challenging as demand for such surgery returns. However, as every heart operation needs an intensive care bed for safe recovery, we have to be cogniscent and compassionate for our intensive care medical and nursing colleagues who have endured so much in the last year. It would be unreasonable to expect them to return to full activity too quickly.

To help lessen the demand on intensive care, all cardiac surgical teams should carefully consider embracing

These results have shown that survival after heart surgery is world leading and that survival has improved over the last 20 years, despite the patients undergoing cardiac surgery being older and sicker.

Enhanced Recovery After Surgery (ERAS). This improves the patient experience, decreases complications, length of stay in hospital and the time needed to be spent in intensive care.

As the years have progressed, the national audit has shown more and more consistent high-quality outcomes across the whole nation. The surgical teams and the surgeons are achieving excellent results and patients can be more assured than ever of the service they receive.

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NEARLY 1 MILLION PEOPLE IN THE UK STRUGGLE WITH A HEART PUMP PROBLEM CALLED HEART FAILURE. FAILURE IT CAN BE DIAGNOSED AND IS TREATABLE

Without the public we can’t help people live as full a life as possible. We are needed now more than ever.

D O N AT E AT W W W. P U M P I N G M A R V E L LO U S . O R G

Let’s #BeatHF together B REATHLESS E XHAUSTION A NKLE SWELLING T IME FOR A SIMPLE BLOOD TEST, ASK YOUR GP Help us make heart failure clearer for everyone hearts@pumpingmarvellous.org www.pumpingmarvellous.org Registered Charity No 1151848 • Company No 08370761