Cardiovascular Health - Q3 - Sep 2018 by Mediaplanet UK&IE

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Cardiovascular Health

“My ﬁrst attack happened while I was playing basketball. I was a fat kid, but it was nothing to do with that!” Andy Tennant P14

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IN THIS ISSUE

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READ MORE ON HEALTHAWARENESS.CO.UK Virendra Sharma Why every patient should have access to the best heart failure services and specialists

Paul Forsyth Lead Pharmacist for Clinical Cardiology in Primary Care for NHS Greater Glasgow and Clyde, shares his views on why a multidisciplinary approach is essential to effectively treat patients with heart failure

Andy Tennant How one operation allowed him to fulfil his talent as a cyclist, reaching the top of the sport in under five years P14

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PLATELET PRODUCTION SOURCE: ABDULLAH OBAID KHAN, UNIVERSITY OF BIRMINGHAM

Heart health is a human right

Professor David Wood President, World Heart Federation

World Heart Day takes place on 29 September every year and is the World Heart Federation’s – and the world’s – biggest platform for raising awareness about cardiovascular disease (CVD), including heart disease and stroke.

his year, our My Heart, Your Heart campaign focuses on looking after our own hearts and the hearts of our loved ones. It’s about saying to ourselves, the people we care about and individuals all around the world: “What can I do right now to look after my heart... and your heart?” It also champions the vital role of cardiology and healthcare professionals who dedicate themselves to looking after all our hearts. So, on and around the 29 September, we are asking the world to make a promise. A promise as an individual to get more active, say no

to smoking or eat more healthily. A promise as a healthcare professional to save more lives, or as a politician to implement a noncommunicable disease (NCD) action plan. The World Heart Federation and its 200-plus members believe in a world where heart health for everyone is a fundamental human right and a crucial element of global health justice. Regardless of country, region, origin, race, gender, age, education and revenues, each human being is entitled to cardiovascular health and wellbeing through health promotion, access to prevention, control and management of cardiovascular disease.

Heart disease and stroke claim 17.7 million lives a year World Heart Day informs people around the globe that heart disease and stroke are the world’s leading causes of death, claiming 17.7 million lives each year.

factors – such as tobacco use, unhealthy diet and physical inactivity – at least 80% of premature deaths from heart disease and stroke could be avoided. Every year we are astounded at the huge – and growing – number of people who take part in the campaign. People organise activities aimed at promoting better cardiovascular health and help to spread the word via social media and other networks. It is inspiring to see so many people from all countries and backgrounds joining in the ﬁght against the CVD burden, and driving international action to encourage heart-healthy living across the world.

At least 80% of premature deaths from heart disease and stroke could be avoided

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The day highlights the actions that individuals can take to prevent and control CVD. It aims to drive action to educate people that, by controlling risk @MediaplanetUK

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World Heart Day brings together a community of specialists World Heart Day reaches every corner of the planet to help us spread essential awareness of what everyone can do for my heart, for your heart, for all our hearts. It plays a vital role in the World Heart Federation’s mission to bring together the diverse cardiovascular community: the scientiﬁc cardiology societies, heart foundations, health professionals, individual citizens, patients and family members, policymakers, governments and industry, all to advance our cause of heart health for everyone. Because every heartbeat matters.

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CALCIUM REEF SOURCE: BHF SITE, DR RHEURE ALVES-LOPES, UNIVERSITY OF GLASGOW

How to turn back time on heart health Dr Joel Kahn Founder, The Kahn Center for Cardiac LONGEVITY

The fabled anti-ageing secret is deep inside in our own bodies – and harnessing its power might be easier than you might think.

verything we do without even noticing, from moving our limbs to our hearts pumping blood around the body, is driven by mitochondria. Dr Joel Kahn, Founder of the Kahn Center for Cardiac Longevity in Detroit, says: “Everything the body does is based on making energy, and the mitochondria is the way it does that.” The microscopic “power plants” inside every living cell convert food and oxygen into adenosine triphosphate (ATP), the chemical energy that cells need to function and to keep organs like the heart healthy. They also support the cells’ everyday tasks by sending messages

SPONSORED to other components of the cell, tailoring them to perform speciﬁc functions, and controlling the processes of cell growth and self-destruction.

CoQ10 protects the mitochondria; we produce less CoQ10 as we age Dr Kahn explained that how well the mitochondria can do their job is dependent on an antioxidant produced naturally by the body, called CoQ10. “CoQ10 is so important for every cell. We make a lot of it in our youth, but that becomes less and less as we get older. It’s a normal part of the ageing process,” he said.

The result is an open-door policy for oxidative stress, or “free radicals”. Free radicals are generated by the cells’ biochemical processes. Exposure to pollution, a poor diet and a sedentary lifestyle also increase the body’s levels of the cell-damaging free radicals. It means that mitochondrial function starts to slow down at around the age of 30, and after that declines by about 10% every decade. This has been linked to more than 200 health conditions, as cells are left without the energy they need to do their job. It is those that need the largest amount of energy, such as the heart muscle cells, that are the worse affected.

Science shows CoQ10 supplements work But Dr Kahn said there was a simple, scientifically proven, but often overlooked, solution in the shape of CoQ10 supplements. “We do not have an easy way of testing for mitochondrial function, but we can test for levels of CoQ10 in the blood and supplement if needed,” he said. “This is all supported by hundreds of research studies and there are so many beneﬁts. We know that it boosts heart function and reduces the risk of congestive heart failure.” A recent Swedish randomised controlled trial, the highest level of trusted evidence, found that people

MitoQ® is breakthrough CoQ10 technology that improved heart health in six weeks Taking a simple supplement can turn back time when it comes to heart health, found a landmark first-inhuman study. Researchers at the University of Colorado Boulder concluded that taking MitoQ® every day for six weeks significantly improved the vascular function of healthy adults aged between 60 and 79. “As people age, they are at greater risk for cardiovascular health issues that can be caused by poor diets and a lack of exercise,” said Greg Macpherson, CEO of supplement manufacturer MitoQ®, the advanced CoQ10 technology tested in the study. “MitoQ® is a significant advanced on standard CoQ10 supplements, because it actively targets the mitochondria, delivering meaningful levels of CoQ10 exactly where it is needed most. This is a world first andshows that MitoQ® represents a very promising complementary or alternative heart health strategy for maintaining flexible arteries and reducing cardiovascular health issues.”

over the age of 70 who took a CoQ10 supplement lived longer, for example. Dr Kahn added: “I have patients who are highly motivated to live a good life, free from disease. “If there is a randomised study to say that a freely available vitamin, along with all the other components of a healthy life, may help your chances of doing that, why wouldn’t you recommend it?”

Flexible arteries The study, published in journal Hypertension, found the supplement improved the arteries’ ability to dilate by 42%. This ﬂexibility is essential for healthy blood pressure. The supplement also signiﬁcantly reduced the stiffness of the arteries, a classic risk factor for heart disease. Levels of plasma-oxidized LDL, a marker of free radical cell damage, also dropped. Authors of the randomised controlled study said: “Our results provide initial support for the idea that MitoQ, and potentially other mitochondria-targeted antioxidants, may be an effective treatment for improving vascular function.” It could also decrease the risk of cardiovascular health issues and other common clinical disorders of ageing, including cognitive dysfunction and chronic kidney health issues, they added. Amanda Barrell

Read more at oxfordbiotherapeutics.com

REFERENCE: ALEHAGEN, URBAN, ET AL. "STILL REDUCED CARDIOVASCULAR MORTALITY 12 YEARS AFTER SUPPLEMENTATION WITH SELENIUM AND COENZYME Q10 FOR FOUR YEARS: A VALIDATION OF PREVIOUS 10-YEAR FOLLOW-UP RESULTS OF A PROSPECTIVE RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL IN ELDERLY."PLOS ONE13.4 (2018): E0193120. AVAILABLE AT: HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC5894963/ [ACCESSED 29 AUGUST 2018]

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Access to heart failure services should be fair and equitable

IMAGE: GETTYIMAGES

Living positively with heart failure

Every patient should have access to sufficiently resourced and well funded heart failure services and specialists says one MP. The only way to ensure this happens is to invest more money in this vital area of healthcare.

In 2016, Daniel suffered severe heart failure secondary to dilated cardiomyopathy. Peer support groups have helped him get back on his feet. “Heart failure is not a death sentence,” he says.

Virendra Sharma Labour MP, Ealing Southall

Daniel Smith Patient Educator, Pumping Marvellous

t started in August 2012. I was 36 years old and an electrician. I kept myself ﬁt with boxing, running and football, so I knew something wasn’t right when I got out of breath just moving my tool box. The doctor kept saying it was stress and gave me medication, but it steadily got worse from there. I was rushed into casualty three times with what I thought were heart attacks (but were severe panic attacks) but the ECGs didn’t ﬁnd anything. Just a few days, later I collapsed at my mum’s house with multiple organ failure, dilated cardiomyopathy and quite severe heart failure caused by a virus. Multiple blood tests, a CAT scan and a right heart catheter helped diagnose my condition. I was put on the transplant list. I was in complete shock. Over the next three weeks, the excellent multidisciplinary team stabilised my condition and I was sent home. After three years’ waiting, new medication took me off the transplant list; hopefully for good.

Patients need to know that heart failure is not a death sentence. You can lead a fairly normal life if you are efficiently diagnosed and then given the right information and tools to understand your condition. Peer support groups have been the best thing for me. I thought I was alone, but finding people my own age to ask questions helped me the most. It takes more than one conversation to understand what you are going to be living with. I’m still learning, so that support is invaluable. It’s a very common story in our closed group that GPs too often misdiagnose heart failure in younger people – with serious consequences. We advocate a simple blood test, which is a great tool for diagnosis of heart failure. Not everywhere is set up to do the test but it could give people a second shot at life. For me it’s now about spending as much time possible with my sons – they’re the biggest thing in my life. Alex van den Broek

ore investment is needed in heart failure services if they are to be ﬁt for purpose in 21st century Britain, says Virendra Sharma, Labour MP for Ealing Southall. We should never forget that, while heart failure and cardiac diseases cost the NHS billions every year, there is a human cost, too, on individuals, families, carers and friends. “If heart failure services and resources are not available, then people who need them are going to suffer,” says Sharma.

Heart failure services are being reduced in some areas of the country Sharma says the public are concerned that, in some areas, heart failure services are either being reduced or closed down completely and looks at his own constituency as a barometer of what is happening across the country. “Generally, Ealing has been a good hospital,” he says. “But in the last two years, it’s been deteriorating and people are not getting the services they expect. Unfortunately, I don’t think it is different from any other hospital.”

Equitable access to services and specialists Sharma says that, thanks to the meetings that parliamentarians and policy-makers have with organisations working in the cardiac ﬁeld, there’s a high level of awareness — across the House — about the importance of heart failure services. Sadly, however, this understanding is not yet ﬁltering through into the health system. For instance, Sharma says that everyone should have access to heart specialists, and also BNP testing — a blood test which could speed up diagnosis and save the NHS money. Yet not everyone does. It’s a postcode lottery, in other words. “I personally believe there should be more investment in heart failure and cardiac services,” he says. “Ultimately, we need more training for local GPs, more nurses, and more staff who can assist people when they need it. We also need to better inform the public so that they are aware of symptoms, and encourage them to take part in activities that can reduce their risk of heart failure.” Tony Greenway

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Detecting heart failure early saves lives Dr Paul Kalra Chairman, British Society for Heart Failure

Almost one million people in the UK have heart failure. Yet lack of recognition compounded by inequitable access to crucial tests means that many patients suffer because of late diagnosis. This results in poor quality of life, frequent and prolonged hospitalisation and early risk of death.

arly diagnosis could save lives – but huge numbers of people living with the condition are undiagnosed, and untreated. Dr Paul Kalra, Chairman of the British Society for Heart Failure (BSH), said the condition’s “major and increasing burden on the NHS could be lessened if patients were diagnosed and treated earlier”. “Quite simply, if people with suspected heart failure are identiﬁed, referred to specialist services and put on the right treatment, they live longer and better,” said Dr Kalra, Consultant Cardiologist at Portsmouth NHS Trust.

primarily related to heart failure. A staggering 9% (almost 1 in 10) of those die from the condition during the hospital admission. Securing routine access to a simple blood test, which has been recommended by the National Institute for Clinical Excellence (NICE) initially in 2010 and then again this month, can tell GPs if someone needs to be referred to specialist heart failure services. A negative test means they don’t have heart failure. Once there, they can be formally diagnosed, treatment initiated and placed under the care of a multidisciplinary team of specialist doctors, nurses and other experts.

Heart failure cases are increasing

Depending on where you live, you may have restricted access to tests

He added that, between 2002 and 2014, the total number of cases had increased by almost a quarter (23%). In England and Wales alone, there are over 80,000 emergency hospital admissions a year that are

The commissioners who decide which tests and services are provided in each area do not always prioritise heart failure, due to a lack of appreciation around the burden

SUBARACHNOID VESSELS SOURCE: BHF SITE, MATT MACGREGOR SHARP, PHD STUDENT

and importance of heart failure, amongst other priorities. This means the NT-proBNP and B-type natriuretic peptide (BNP) blood tests, are not available in many parts of the country. Dr Kalra has called on the healthcare community and patient groups to unite to demand fair, equal and early diagnosis. “The number of new cases per year has increased to 190,000. That’s similar to the four most common forms of cancer put together. If we had friends or relatives with cancer, we would want them to be seen urgently by cancer specialists,” he said. “We would want to make sure the diagnosis was 100% accurate and that all the treatment options were explained and understood. Heart failure needs to be given the same priority.”

Heart failure is not ‘just part of getting older’ Part of the problem is a lack of

awareness and understanding among the public and healthcare professionals alike, he said. “Because the average age to develop heart failure is late 70s, many people accept or explain the symptoms as part of getting older,” he noted. “Older people are more likely to be living with other health conditions, such as COPD, high blood pressure or type 2 diabetes. Symptoms of heart failure, which include shortness of breath and fatigue, are often attributed to these conditions.” The BSH is working with other professional and patient organisations to drive awareness of the condition as well as the clinical and cost-effectiveness of the blood (BNP/NTproBNP) tests.

health service as well as on a personal level to the individual patient and their families,” he said, adding that tests and treatments were relatively cheap in comparison. “We all need to be sending that message to the commissioners who set the healthcare priorities in their area.” In the meantime, Dr Kalra has a simple message: “Think heart failure and help improve lives. If anyone who is not known to have heart failure presents with swollen ankles, shortness of breath or fatigue, heart failure needs to be at the forefront of your mind, whether you are a patient or healthcare provider.vAccess to specialist services saves lives.” Amanda Barrell

If we can treat the condition early, we can save NHS time and money “The average length of hospital stay for patients with heart failure is around 10 days. That’s a huge cost for the

Find more at thelancet.com/journals/ lancet/article/PIIS01406736(17)32520-5/fulltext

REFERENCES: 1. CONRAD, N., JUDGE, A., TRAN, J., MOHSENI, H., HEDGECOTT, D., CRESPILLO, A.P., ALLISON, M., HEMINGWAY, H., CLELAND, J.G., MCMURRAY, J.J. AND RAHIMI, K., 2018. TEMPORAL TRENDS AND PATTERNS IN HEART FAILURE INCIDENCE: A POPULATION-BASED STUDY OF 4 MILLION INDIVIDUALS. THE LANCET, 391(10120), PP.572-580. AVAILABLE AT: HTTPS://WWW.THELANCET.COM/JOURNALS/LANCET/ARTICLE/PIIS0140-6736(17)32520-5/FULLTEXT 2. NATIONAL HEART FAILURE AUDIT

COR18-C010 Sept 2018

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Heart failure nurses improve lives and save money Nick Hartshorne-Evans CEO, Founder, and Patient Advocate, Pumping Marvellous Foundation Charity

We know specialist nurses improve the lives of people with heart failure and save the NHS money, but we need to preserve and expand their services. Heart failure patients value these specialist nurses, but we may have to fight to keep them.

here are 920,000 people living with heart failure in the UK. Specialist nurses who make a vital difference to the lives of heart failure patients are under threat. “We speak to thousands of heart failure patients annually and they say that the one person they cannot do without is their Heart Failure Specialist Nurse,” says Nick Hartshorne-Evans, patient advocate and founder of the Pumping Marvellous Foundation, the UK’s patient-led heart failure charity. A diagnosis of heart failure – where the heart fails to pump efficiently, depriving the body of oxygen and nutrients – means learning a new way of life. Specialist nurses coach patients and their families to live with the condition as well as they possibly can.

Between 30% – 40% of people diagnosed with heart failure die within a year, but swift diagnosis and referral to a specialist nurse may improve the prognosis for individual patients As well as helping patients manage the condition, the nurses can make referrals to other members of the medical team and signpost to external organisations such as Citizens’ Advice. “Symptoms include breathlessness, extreme fatigue and ﬂuid overload, which can mean some patients lose their jobs and homes. Nurses can help,” says Hartshorne-Evans. Specialist nursing care also prevents hospital admissions Heart failure is the leading cause of hospitalisation in over-65s in the UK. With an average hospital stay of ten days, heart failure is responsible for more bed days than any other condition. On average, in-patients cost £400 a day. Hartshorne-Evans says, “Heart failure nurses who are able to prescribe can adjust levels of medications to suit changes in the patient’s symptoms. These specialist nurses can also give early warning of problems, so fewer patients may require hospitalisation.” However, Hartshorne-Evans says, “It is becoming apparent that Heart Failure Specialist Nursing is at risk. There are examples of where areas are losing services and nurses are not being replaced.” Moreover, the availability of heart failure nurses – especially those with the power to prescribe – is patchy. Some areas have no community heart failure nurses at all, including one city of 700,000 people. “We need to see equity in provisioning and an increase in the availability of community services, where nurses work out of local clinics and can visit patients’ homes. Heart failure nurses are the ﬁrst port of call for their patients. Without them, doctors’ surgeries would be overrun, and expensive hospital stays would soar.” “More specialist nurses, with the capacity to prescribe, would improve patients’ lives and save the NHS money. You wouldn’t deny services to a person with cancer; nor should you with heart failure.” Linda Whitney Read more at healthawareness.co.uk

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CARDIAC COLLAGEN SOURCE: BHF SITE, DR NEIL DUFTON, IMPERIAL COLLEGE LONDON

Fainting could be a sign of a fatal condition Fainting or palpitations may be signs of an underlying heart rhythm disorder that could potentially prove fatal. Here’s how to check whether you are at risk. Trudie C A Lobban MBE FRCP Edin – Founder & CEO, STARS / Arrhythmia Alliance and AF Association

ainting or palpitations may be nothing to worry about, but they can also be early warnings of a potentially fatal condition. Both commonly occur in people with cardiac arrhythmias - the medical term for an irregular heart rhythm. Heart rhythm disorders are Britain’s biggest killer. There are four main types of arrhythmias. They are common, potentially serious, and often unsuspected. Fainting (syncope) resulting from an insufficient blood supply to the brain, can be a symptom of the most common arrhythmia - atrial ﬁbrillation (AF), an irregular and/or too-rapid heart rhythm. This is means blood does not ﬂow through the body properly, which may result in blood clots. If a clot forms in the heart and travels to the brain it can cause a potentially fatal AFrelated stroke. “AF causes 12,000 debilitating and fatal AFrelated strokes in the UK each year. These are more debilitating and more likely to be fatal than most other strokes. Many could be avoided if AF is diagnosed and appropriate anticoagulation therapy prescribed,” says Trudie C A Lobban MBE FRCP Edin, Founder and Chief Executive of the charities STARS, Arrhythmia Alliance and AF Association. “AF affects one in four of us over the age of 40, and the symptoms are often palpitations or a faint, which are all too often overlooked,” she adds. “Anyone of any age experiencing a faint could have an underlying arrhythmia, which could result in an AF-related stroke.”

Aspirin proven ineffective in preventing AF-related strokes Anticoagulants, which help prevent clots forming therefore, reducing the risk of an AF-related stroke, have long been used to treat AF, but many people have AF unknowingly, and so suffer strokes that may have been avoided. Lobban points out that aspirin, commonly taken as a stroke-preventative, has been proven ineffective in preventing AF-related strokes. The good news is that a simple pulse check will indicate the possibility of AF before it results in a potentially fatal AF-related stroke. However, the UK

currently has no national screening programme of pulse checks or heart rhythm screening, so you need to know how to do it yourself. Lobban says, “Checking your pulse will indicate your heart rhythm as well as your heart rate - how often the heart beats - but also the regularity of the rhythm, which is important in diagnosing AF.”

How to take your own pulse To get your baseline pulse and normal heart rhythm, take your resting pulse when you wake in the morning and before bed, for seven days. To assess your resting pulse rate in your wrist, sit down for five minutes beforehand. Remember that any stimulants (such as caffeine or nicotine) taken before the reading will affect the rate. You will need a watch or clock with a second hand. Hold your left or right hand out with your palm facing up and your elbow slightly bent. With your other hand, place your index and middle fingers on your wrist, at the base of your thumb. Your fingers should sit between the bone on the edge of your wrist and the stringy tendon attached to your thumb. You may need to move your fingers around to find the pulse. Keep firm pressure on your wrist with your fingers in order to feel your pulse. Count for 30 seconds, and multiply by two to get your heart rate in beats per minute. If your heart rhythm is irregular, count for one minute and do not multiply. Record the results. A heart rate of 60 to 100 beats a minute is normal, but also pay attention to the rhythm. If it is irregular - anything other than a steady boom, boom, boom - consult your doctor. Everyone is different, so regular pulse checks will help you understand what is normal for you, and detect changes warranting investigation. Linda Whitney

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New technology gives hope to people with heart valve disease Dr Dougie Muir Consultant Cardiologist, James Cook University Hospital

New developments in Transcatheter Aortic Valve Implantation (TAVI) have revolutionised the treatment of heart valve disease, saving more lives and reducing NHS costs.

here are people with heart valve disease who travel hundreds of miles to speak with Consultant Interventional Cardiologist, Dr Douglas Muir. That’s because Dr Muir and his hospital, the James Cook Hospital in Middlesbrough, are specialists in a procedure called Transcatheter Aortic Valve Implantation (TAVI). In the procedure, people with a damaged heart valve receive a replacement valve, which is put in place using a tube the size of your little ﬁnger. The tube, with a collapsible ‘crimped’ replacement valve inside, is usually inserted under local anaesthetic into an artery running from the groin. Dr Muir explains: “A bit like putting a ship in a bottle”. Some patients notice a difference immediately People receiving the procedure transform from being so breathless that they can’t even walk across the room to planning coast-to-coast walks. Dr Muir says he’s had patients who say they feel completely different as soon as they sit up in bed. AS can kill in under two years Aortic Stenosis (AS) is one of the most common heart conditions affecting older people. Considered age-related ‘wear and tear’, the condition affects around one in ten 80-year-olds and is characterised by a narrowing of the heart valve. Left untreated, severe AS can kill within one to two years. TAVI was introduced at the James Cook Hospital in 2009 and today, around one in ﬁve people with AS will be offered the procedure. Traditionally only those with the most severely damaged valves and at such high-risk as to be inoperable were given TAVI. However, as understanding of the procedure, and the technology, have improved, people who are lower surgical risk also now receive TAVI, compared to the past where only inoperable patients were eligible. It’s seen as a much less risky alternative to open heart surgery, which requires the chest to be cut open, full anaesthetic and the support of a surgical team and expensive stand-by equipment. Hospital stay reduced from a week to a day TAVI has also reduced the average post-operative hospital stay from a week to one day. “The local anaesthetic makes the big difference to recovery,” Dr Muir says. Within two to three hours the patient can be up in bed, and around 70% go home the next day. Complications and post-operative pain are also much improved. Compared to traditional surgical approaches to this condition, TAVI has a higher up-front cost, but this is offset when you take into consideration the patient’s length of stay in hospital and use of resources, Dr Muir believes. He describes TAVI as “a win-win solution for everyone.” Read more at healthawareness.co.uk

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“Why I’d recommend listening to the hearts of older people” After the usually active Brenda Walker began experiencing breathing problems, she was diagnosed with heart valve disease — a condition that was simply corrected with a TAVI procedure.

x-head teacher, ex-senior lecturer and publisher Brenda Walker, 84, has been extremely active all her life. “I always have to be doing something,” she admits. A keen gardener and lover of the arts, she still teaches English occasionally and loves visiting her children, grandchildren and greatgrandchildren who live in various places around the world, including Canada, Norway and France. When she was 75 – an age when most people are taking things easy – Brenda started a doctorate on the new dynamics of ageing. “I’d been working on my PhD for a while when I suddenly found it difficult to breathe, climb stairs or walk any distance,” remembers Brenda. “My ankles were swollen, too.” Alarmed, she visited her GP, but was told her symptoms didn’t indicate a heart problem. Taking the less-invasive TAVI option Not content with this, and with her breathing worsening, Brenda went to a consultant who diagnosed her with aortic stenosis, or heart valve disease — a condition that affects the ﬂow of blood through the heart and is potentially fatal. “The consultant listened to my heart with a stethoscope — whereas the GP hadn’t,” says Brenda. “That made all the difference and I was immediately sent to hospital for various tests. “I was told that I was a high-risk patient and would be a candidate for

a newer procedure called TAVI., short for Transcatheter aortic valve implantation. When they explained how the procedure worked and that is was less-invasive and would lead to a quicker recovery, I was happy to agree to it.” With this procedure, an artificial replacement valve Brenda Walker is inserted into the Patient heart using a balloon catheter, either via the main artery in the groin or via a small incision on the side says Brenda, who finished her of the chest. Brenda was also advised PhD five years ago, has since taken that if she did nothing, she could correspondence courses with a only expect to live for another two- local horticultural college, joined a and-a-half years. swimming club and recently taught “I didn’t really want surgery,” a wellbeing movement class with 14 says Brenda. “So I in a way I was people in the local village hall. She’s glad that I had the opportunity to also been working on the design of have TAVI, which the surgical team her garden and is looking forward carefully explained to me with the to a trip to Prague. “I still think it’s use of diagrams. I was desperate amazing that I can almost run up to finish my PhD and knew that steps now,” she says. “My partner, the big benefit would be shorter David, who is 85, says: ‘She used to recovery time.” Brenda, now based in trail behind me. Now look at her!’” Somerset, had the procedure under Brenda’s advice to anyone general anaesthetic at Glenfield experiencing the same symptoms is Hospital in Leicester six weeks after to insist that their GP listens to their her initial diagnosis. heart with a stethoscope. “I thought my problems were just down to Fast recovery time and no ageing,” she says. “So I’d recommend symptoms getting advice from a specialist. And The results were miraculous, she says. don’t delay, because you never know. Her breathing problems stopped, she It might be the sign of a serious didn’t need medication of any kind problem that can be easily solved.” and her recovery time was almost Tony Greenway instantaneous.In fact,Brenda only spent two-and-a-half days in hospital — and a day after she arrived home, she took her children shopping. “I’ve had the valve for seven years, and I’m still very energetic,”

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A new health crisis is looming Simon Gillespie Chief Executive of the British Heart Foundation

Through research, we’ve made incredible progress in transforming survival rates for heart attack and stroke. But this progress means people’s experiences of living with heart and circulatory diseases today are very different to those cared for in the earliest days of the NHS.

hen the NHS was established in 1948, half of all deaths in the UK were caused by heart and circulatory diseases. Today, it’s reduced to a quarter – a testament to the power of research. However, we’ve seen the opposite trend in the number of patients visiting GP surgeries and hospitals suffering from multiple, long-term diseases. Vast improvements in treatments for heart and circulatory diseases mean people are living longer with a range of complex conditions, which current methods of care and treatment are struggling to deal with. This is, or should be, of grave concern.

How are heart and circulatory diseases connected with wider conditions? Our latest ﬁgures reveal that nine out of ten people living with longterm heart and circulatory diseases suffer from at least one or more further conditions, including stroke, dementia and high blood pressure. These diseases are usually connected. When your heart isn’t beating properly and your blood ﬂow is disrupted it can have a devastating affect all over your body. This has huge consequences. People with more than one illness are at greater risk of succumbing to physical disability, premature death and will also have a poorer quality of life. This, in turn, places huge strain on family and social support teams. In many cases, supporting loved ones can take over the lives of families and carers. Most people who suffer from multiple conditions are not aware of how one condition can lead to another.

Personalised treatment is a challenge for the NHS But more people living with multiple conditions is also an alarming challenge for the NHS, which is already under unprecedented strain. Like many health systems around the world, the NHS is designed to treat individual illnesses rather than individual patients. Not enough research has been undertaken

to have a heart attack compared with the general population. A heart attack survivor is twice as likely to have a stroke, and one in three stroke survivors will develop dementia within ﬁve years. Yet these conditions are often treated separately. This means different medical appointments, different doctors and different medicines. We are not treating the individual. The result is more people being hospitalised, longer hospital stays, and ultimately worse outcomes for patients.

People with more than one illness are at greater risk of succumbing to physical disability and premature death into how to treat different illnesses together or how we can innovate to provide personalised approaches to unique combinations of conditions. Nowhere is this truer than in the treatment of heart and circulatory diseases. A person with type 2 diabetes is more than twice as likely

We need to radically change our approach To effect such profound change we urgently need more research. Research that will help us identify conditions that tend to group together, and why. We also need to work out why some people appear more likely to suffer multiple conditions than others. Once we have identiﬁed those at risk, we need innovative ways of treating conditions together in ways that are personal to the individual.

But the NHS needs to play its part too. It needs a bold ambition to give personalised care to every patient and be committed to translating research into innovative changes in how healthcare is delivered. Patients with diabetes should have easy and immediate access to heart disease services. Mental health services should be more closely linked to heart attack clinics and rehabilitation programmes to better support people’s physical and psychological health and wellbeing. We don’t have the answers yet, but research is underway. Just like they did when the NHS was born through a bold idea, it’s time for scientists and clinicians to come together to overcome the biggest challenge we face in improving NHS care in the coming decades.

Find more at healthawarness.co.uk

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This article was developed in collaboration with Actelion Pharmaceuticals UK who also provided funding. Contributors to this article did not receive payment for their involvement. IMAGE: GETTYIMAGES

Pulmonary arterial hypertension: a patient’s side of the story Julie Royle Patient

We need greater awareness of pulmonary arterial hypertension to improve patient support.

n her 53rd birthday, Julie Royle was told that she had stage three pulmonary arterial hypertension (PAH). The words might not mean much to most people – but Julie remembers, “I walked out of the hospital feeling like a bomb had gone off in my life. People talk about cancer and heart disease, but no one talks about PAH.” PAH is extremely rare and there is no cure, so a diagnosis has lifechanging consequences for the patient and their family. By the time Julie was diagnosed, she already had an advanced case of the condition, which causes a narrowing of the blood vessels that lead from the heart to the lungs. As a keen jogger and ﬁtness instructor – Julie was extremely healthy with no underlying health complaints to indicate that anything was wrong. When she started experiencing breathlessness, her GP initially prescribed an inhaler. This did little to help and Julie found that she was getting more exhausted at work, where she was a secondary school cookery teacher. After several more trips to the GP, she was eventually sent for an echocardiogram, which was the first step towards her diagnosis. “For every second of every minute and every hour of my day, I focus on my inability to breathe normally. It’s exhausting.” I started having blackouts In one sense, it was a relief to ﬁnally receive a diagnosis and start treatment, but there is little anyone can do to prepare for the reality of living with PAH. “I started treatment and immediately felt better, but then I started to have blackouts,” says Julie.

DATE OF PREP: SEPTEMBER 2018 JOB BAG: NOP 18/0423E

Medical staff had no knowledge of my condition The horror of her ﬁrst blackout was further compounded by the fact that the medical staff treating Julie at her local accident and emergency unit had no knowledge of PAH at all. Julie felt vulnerable and isolated. “The specialist centres are just amazing and the support from the charity, PHA UK has been a lifeline, but the problem is that even people within the medical profession don’t know about it. I have to carry information around with me all the time,” continues Julie. Getting out of bed and walking is exhausting While Julie may not look physically unwell, her condition has transformed her life beyond recognition. She is unable to work and ﬁnds that simply getting out of bed and walking around the house can be as exhausting as a workout. Many patients require an intravenous line to be permanently attached to them, which delivers vital therapy on a 24-hour basis. This requires the constant attention of a PAH specialist nurse. Julie feels fortunate that, while she did have an IV line for three years, and could need one again, she has now been transferred onto a different therapy, which does not require one. I’m staying positive and I hope for a cure Julie is grateful to her specialist centre and team at Sheffield Royal Hallamshire for getting her to where she is now. “They are an extraordinary NHS team who treat us all like family,” says Julie. Julie is hopeful that one day there may be a cure, but in the meantime she is focused on living positively. “Living with PAH is a 24-hour, mental and physical challenge and my only advice to others is to listen to your body, to take all the advice and support from the specialist centres and from PHA UK and to try and stay positive,” she concludes. Kate Sharma

Patients with PAH need earlier diagnosis and access to medicines

Dr Luke Howard Consultant Pulmonologist, Imperial College Healthcare NHS Trust

Patients living with pulmonary arterial hypertension (PAH) need access to the full range of advanced treatments along with earlier recognition of symptoms and diagnosis.

round 6,500 people in the UK are affected by pulmonary hypertension, of which, approximately half live with pulmonary arterial hypertension (PAH), which is caused by a narrowing of the blood vessels that lead from the heart to the lungs. As the heart is put under strain it can cause not only breathlessness, but blackouts and heart failure. “If untreated, the life expectancy of someone with PAH could be as little as three years. With treatment we can double or even triple the survival rates,” says Dr Luke Howard, Consultant Pulmonologist at Imperial College Healthcare NHS Trust. “The problem is, the symptoms for PAH are very generic. Breathlessness, dizziness and swollen ankles are common to many conditions and we often ﬁnd that GPs and patients themselves think the symptoms are a result of asthma, natural ageing or being unfit rather than a lifethreatening cardiac illness.” Directing patients with breathlessness to secondary care could identify PAH Most people who are diagnosed with

PAH are in their 50s and 60s and the condition affects more women than men. Around 10% of cases are genetic, but it can also be associated with other conditions including scleroderma or lupus, and people who have been born with a heart defect may also develop the disease. “Ideally, I’d like better secondary care services, whereby patients with undiagnosed breathlessness have easy access to people who are thinking about the different reasons for breathlessness and can raise the suspicion of pulmonary hypertension early,” continues Howard. There are currently six specialist centres in England, one in Scotland and one in the Republic of Ireland, where patients suspected of having PAH are referred to receive a conﬁrmation of whether or not they have the condition. It’s relatively easy to suspect PAH via an echocardiogram, followed by the insertion of a catheter in an expert centre, to measure the blood pressure in the right side of the heart and lungs, but the challenge is getting patients referred quickly. PAH is not curable, but it is treatable While the condition is not curable, it is treatable. There is a range of PAH drugs available that relax the muscle walls and dilate the vessels to allow blood to ﬂow more freely. Relatively lowgrade cases can be treated with simple tablets, and more severe cases might require a catheter to be positioned underneath the skin to release

a 24-hour infusion of a drug into the veins. For patients at the later stages of PAH there is now also an oral medicine, which is available in Northern Ireland, Scotland and Wales but not in England. Howard says “access to the full range of available treatments is essential when dealing with a life-threatening condition like PAH. At the moment inequality of access exists in the UK, which is largely determined by which devolved nation you live in and what treatments have been made available there”. As the search for a cure continues, new treatments are being discovered all the time. “Research has exploded in the last 10–15 years. We are seeing the repurposing of drugs and we are developing drugs from scratch,” says Howard. “We also have more targeted research where you look at the mechanism of the disease, such as genetic reasons, to develop more targeted therapies.” Howard remains positive about the outlook for patients with PAH and believes to achieve the best possible health outcomes for those living with the condition, access to the full range of available treatments is essential, coupled with a swift and timely diagnosis. Kate Sharma Find more at healthawareness.co.uk

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Q&A with cardiovascular expert: How overcoming heart failure is a team game Heart failure bestows a large burden on the UK NHS and any effective treatment needs to extend beyond just the remit of specialists. To see positive outcomes for heart failure patients, we need a more multi-disciplinary approach to care. Paul Forsyth Lead Pharmacist, Clinical Cardiology, NHS Greater Glasgow and Clyde

Paul Forsyth, Lead Pharmacist for Clinical Cardiology in Primary Care for NHS Greater Glasgow and Clyde, shares his views on why a multidisciplinary approach is essential to effectively treat patients with heart failure.

Q: Why is heart failure such a big concern? Heart failure is the most malignant form of heart disease and it affects around 1.5% of the population. It’s not only extremely prevalent, but when you look at how long people with the condition live, then the outcomes are comparable with forms of common cancer. However, the awareness about the severity of heart failure isn’t always there.

Q: Who leads care for heart failure patients? In the ﬁrst instance, a patient will be seen by a cardiologist and a heart failure nurse. These are the key roles within the specialist team and are not only vital to planning treatment, but also to exploring the root causes of the condition and whether there are any more complications

that need to be taken into consideration. By ensuring any treatment plans are put into place and implemented, the role of the heart failure nurse has been proven to be vital in reducing hospitalisation and improving mortality rates.

Q: Why is a multi-disciplinary approach needed to treat heart failure? While large aspects of care should be managed within the specialist team, heart failure is one of the top 10 reasons that people are admitted to hospital, so this is a condition that has implications for many different facets of healthcare. Specialists are there to be the drivers of treatment and care coordination, but without all the generalists backing us up, we are never going to win.

Q: What other specialists are involved? We also have dieticians and physiotherapists because we know that giving patients access to information about diet and exercise can help them in the long term. Heart failure and mental health problems often go hand-in-

hand as patients struggle through this journey, so a clinical psychologist may be involved too. Pharmacists can be involved in dispensing medicine but may also sit within the specialist team, ensuring that medicines are optimised according to individual patient need.

Q: What role do primary healthcare providers play? On a day-to-day basis, the GP is the primary caregiver, so it’s vital they know what the treatment plan is and can access the advice of the specialist team. However, there are also other professionals that a patient will see, including pharmacists in the community and general practice nurses. While they may not come up with the next steps of a treatment plan, these professionals are critical because they see the patients regularly and can pick up on any signiﬁcant changes in their health.

Q: How can patients help themselves? There is lots of self-management a patient can learn to take on to help themselves – and not just with regard to their diet and exercise. For example, one of the main symptoms of heart

failure is oedema, where a patient retains extra ﬂuid. We can educate patients that if they start to see their weight going up over a few days then they should get in touch with their specialist team.

Q: What can be done to encourage a team approach? At a UK level, there is a willingness to have a multi-disciplinary approach to treat not only heart failure, but other conditions. Everybody understands that with multi-morbidity and an ageing population, it’s important to have good knowledge of what every discipline brings to the table, so we can pick up the phone and talk to each other. In Scotland, we now have shared IT platforms for clinicians from different sectors to access. GPs need to be updated as they are the person that patients go to ﬁrst, but we also need to make sure that things like blood test results, discharge letters and the anticipatory care plans are on a shared platform where all key stakeholders can access them.

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