Cardiovascular Health 2016

SEPTEMBER 2016

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Professor Sir Nilesh Samani Find out how cardiovascular disease treatments are evolving from the medical director of the British Heart Foundation

INFOGRAPHIC

What are the 6 symptoms of heart failure? P7 JOINT INSIGHT Hear about

Sudden Cardiac Arrest (SCA) from an expert and a patient P8 PHOTO: BRITISH HEART FOUNDATION / JOHN ANGERSON

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IN THIS ISSUE

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Johanna Ralston How to tackle the world’s No1 killer: cardiovascular disease P4

Dr Kim Rajappan How wireless technology can get to the heart of the matter P8

Patient story Before having a subcutaneous defibrillator fitted, Steve Sturgiss did his own research. Watch the video online now

Cardiovascular health – building on a legacy of pioneering research When I suddenly lost my father to a heart attack in 1979, it was the day before his 58th birthday. That sudden loss had a profound effect on me as a young man. It has been a driving force for me at the British Heart Foundation, where I regularly see the dramatic progress made in fighting cardiovascular disease since my father’s heart attack

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ewer people than ever before are dying from cardiovascular conditions each year in the UK. Research has been at the heart of that improvement – whether it is from providing the evidence for better public health or developing new drugs and techniques to improve and save lives.

But this tremendous improvement should not cause Follow us

complacency. Heart disease is not beaten. It is still a sudden and devastating killer.

Coronary heart disease takes more lives in the UK than any other single disease and cardiovascular diseases are the biggest overall cause of death in Europe and an increasing problem in the developing world.

Improving treatments In the late 1970s, BHFfunded researchers were be-

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Simon Gillespie Chief executive, British Heart Foundation

@MediaplanetUK

ginning to convince the cardiovascular community that heart attacks were caused by blood clots blocking the coronary arteries. That evidence transformed heart attack treatment as researchers worked on ways to target the blood clot and restore blood supply to the heart.

In the coming decade we hope to see similar transformational developments in heart attack treatment. @MediaplanetUK

Research is underway now that offers promise of regenerative techniques to repair the currently irreparable damage caused by a heart attack. With continued support for research, cardiovascular treatments will become available that once seemed like science fiction – treatments that we hope will end the sudden devastation caused by heart disease Please recycle

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Statins – and their role in tackling heart disease Statins stake their claim as England’s most widely prescribed drug

By Ailsa Colquhoun

I

n preventing heart attacks or stroke, the statistics are absolutely clear: statin tablets are part of the strategy to be considered, says blood fats expert Dr Robert Cramb, director of pathology and consultant chemical pathologist, at the Queen Elizabeth Hospital, Birmingham.

Statins are a group of drugs prescribed in the UK to help prevent cardiovascular diseases (CVD) such as a heart attack or stroke.

Available in five forms – simvastatin, atorvastatin, fluvastatin, pravastatin and rosuvastatin - these drugs work by lowering the total amount of bad cholesterol in your blood by reducing the amount produced inside the liver. Left untreated, this cholesterol can build up in the arteries to affect blood flow to vital body organs such as the heart or brain.

CVD remains a major cause of British deaths. At the coalface of this problem are GPs, who are challenged to help manage this problem. But hindered by an increasingly inactive adult and child population, they have to

Dr Robert Cramb Director of pathology and consultant chemical pathologist, at the Queen Elizabeth Hospital, Birmingham

confront the fact that drugs may be the only method to help some individuals. A family history of heart attack or stroke, inherited high cholesterol, diabetes, and other risk factors (smoking, high blood pressure, excess weight commonly start the discussion to improve diet and lifestyle but may ultimately culminate in the need for statin prescription.

With almost 30 years’ experience in use around the world, statins can now be prescribed with confidence, Cramb believes.

GPs have a wide range of continually updated resources on which to support their decision to initiate statin therapy. This is usually life-long, as statins cannot cure CVD but instead help prevent it from getting worse or recurring.

Statins can also reduce the chance of CVD developing in people at risk.

Cost-effective NHS pricing has also determined the leading status of one statin in particular simvastatin – which has held the title of England’s most commonly prescribed drug for at least five years. Thanks to recent price cuts

in statin stablemate drug atorvastatin, GPs now have a number of cost effective statin choices and between 2014-15 atorvastatin became NHS England’s fastest growing drug. Cramb says: “Economically, it is hard to argue against recommending a treatment with drug costs of around £30 a year, when compared to the costs of having a cardiovascular event, affecting an individual’s quality of life and ability to work.”

But importantly, Cramb notes, that doctors should only prescribe a statin once they have carefully considered an individual’s risk of a CVD event and then only after discussion with the patient so that they understand the benefits of statin use balanced against the needs of life-long prescription and the low risks of statin side-effects. He says: “This should result in a properly informed decision and not one made on the basis of scientific research taken out of context.”

Read more on health awareness.co.uk

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Cardiovascular disease treatments ‘save lives’

By Tony Greenway

Sabine Ernst Consultant cardiologist and lead for electrophysiology research at Royal Brompton & Harefield NHS Foundation Trust

New technology trial gives hope to heart patients

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pecialists aim to show that pioneering cardiac imaging technology will save lives A trial of an innovative technique to cure a potentially fatal heart condition is yielding promising results, says consultant electrophysiologist Dr Sabine Ernst from Royal Brompton & Harefield NHS Foundation Trust.

In a world-first, around 20 patients with atrial fibrillation (AF) are trialling new imaging technology, which will allow heart specialists to more accurately pinpoint the causes of the condition, and improve treatment success rates.

The new cardiac imaging system is known as D-SPECT, and the trial hopes to show that more people with AF can make a full recovery, without the need to repeat the procedure, or suffer unpleasant symptoms such as recurrent palpitations.

The D-SPECT system allows specialists to target and treat the nerve endings that are thought to cause AF, which produces an irregular and often abnormally fast heart rate. This can lead to low blood pressure and blood clots that may cause fatal heart failure or a stroke.

The trial will help establish the best way to carry out this technique, says Ernst.

Read more on health awareness.co.uk

Treatments for cardiovascular disease are constantly evolving says Professor Sir Nilesh Samani, Medical Director of the British Heart Foundation.

What is cardiovascular disease?

It’s a term for conditions which affect the heart and coronary circulation.The most common form is coronary heart disease, and its key causes are high blood pressure, high cholesterol, smoking, diabetes and lack of physical activity. Having some of these risk factors is not uncommon so I would recommend that those in middle age have a health check from their GP because it’s a simple thing to do and it can help identify those who need advice and potentially preventative treatments.

What have been the main treatment breakthroughs in recent years?

This is an area that is always

Professor Sir Nilesh Samani Medical director, British Heart Foundation

evolving. Statin treatments for high cholesterol and high blood pressure medications have been successful in reducing the burden of coronary heart disease. Then there are pacemakers which can be used to treat advanced heart failure. These have come to the fore in the last 10 years — and have saved lives.

What about new treatments?

class of drug called PCSK9 Inhibitors, which look very promising. In terms of developments in the next decade, regenerative medicine is an exciting area and could help hearts pump properly again after a heart attack by harnessing stem cells to create new heart muscle, or improve existing muscle. Plus, genetic medicine will help us better understand the causes of cardiovascular disease and should lead to new treatments.

What’s the key to finding better treatments in the future?

New treatments made possible by, for example, harnessing the potential of stem cells and genetics requires more research funding — which is the highest priority for the British Heart Foundation.

With further research, new treatments to improve and save lives will follow.

An alternative to statins is a new

Fuel your heart, power your life

By Tree Elven

World Heart Federation calls on governments to increase efforts to better prevent, treat and control cardiovascular disease, the world’s No 1 killer.

World Heart Day on September 29th is the day when people across the globe gather on and offline to raise awareness of cardiovascular disease (CVD), which causes a staggering 17.5 million deaths a year, and the simple individual steps we can take to prevent it.

“If you look after your heart, you look after your whole health,” says Johanna Ralston, CEO of the World Heart Federation (WHF), which organises the worldwide event. “And it’s simple (even if it is not always necessarily easy)! Stopping smoking, cutting down on alcohol, exercising, and eating more healthily can measurably improve your heart health and general well-being.”

It’s a simple, vital message – 80 per cent of premature

Johanna Ralston CEO, World Heart Federation

(under the age of 70) deaths from CVD are preventable.

Making a global difference This year, the WHF is ramping up World Heart Day to a whole new level with the launch of a global policy call to governments to implement reliable and fit for purpose surveillance and monitoring systems for CVD. The policy call is being supported by: a policy brief, which looks at how countries and regions collect data on cardiovascular disease with a focus on premature mortality caused

by CVD; and the launch of the CVD World Monitor, an online data visualisation tool that tracks 150+ countries’ progress against the World Health Organization Global Action Plan Targets, which are aimed at achieving the overall goal of a 25 per cent global reduction in premature mortality from CVD by 2025.

“This year, we’re very ambitious for World Heart Day,” explains Ralston. “World Heart Day is vital for raising awareness among the general public, but now we’re also using this platform to push for change at policy and advocacy level. We’re calling on governments to strengthen monitoring and surveillance of CVD and suggesting the priority actions they need to take.”

“Join in on World Heart Day – there are thousands of events online and in communities, and it does make a difference. If we act together now, we can reduce premature deaths from CVD, and help people everywhere to live longer, better, heart-healthy lives.”

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Professor Martin R Cowie MD MSc FRCP FRCP (Ed) FESC Professor of Cardiology, Imperial College London

Heart failure – the Cinderella of heart disease

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eart failure affect almost a million people in the UK: the heart does not pump strongly and normal activities cause breathlessness. Rapid diagnosis and modern treatment (with drugs and special pacemakers) can make a huge difference to quality and length of life. NICE gives clear guidance as to what good care is but the All Party Parliamentary Group for Cardiac Disease at Westminster has recently highlighted unacceptable variation across the country.

A simple blood test, BNP, can help a GP identify heart failure but this is available only in a minority of areas. Seeing a specialist to ensure a correct diagnosis and a good treatment plan is essential. Specialist nurses are also key to success. Pumping Marvellous, the patient group, has highlighted the need for this service to be available to all patients in the UK - not just the lucky few.

My pacemaker gave me my life back Grandfather of three Peter Jenkins is enjoying a new lease of life thanks to cardiac resynchronisation therapy

By Ailsa Colquhoun

Nick Hartshorne-Evans Chief Executive (Founder) Pumping Marvellous Foundation

Being SMART about heart failure

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eceiving a diagnosis of Heart Failure at 39 with no previous medical condition was a tough “gig”. Not knowing what was going to happen and having owned and run my own businesses over the past 13 years my mind changed to helping people with Heart Failure.

Reflecting on the 7 years since diagnosis, I already seem to be a statistical winner. A lot still needs to change with expectations being managed around the “New NHS”; the patient’s team needs to think differently. Thinking SMART about patient care. Innovation is being squeezed, not everybody has a heart failure nurse and the equity of care seems to be widening.

Focussing on being SMART, creative, doing what we knows works best and ensuring new therapies become available quicker would have a significant impact.

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ife has changed beyond comparison for Peter Jenkins, who was fitted with a cardiac resynchronisation therapy device (CRT) in 2012, following a heart attack.

Mr Jenkins, 80, of Locks Heath, Hampshire, says: “It’s as if someone has switched something on in me.

I’ve got my whole life back, and it’s changed incredibly for the better.”

CRT plus defibrillator therapy (CRT-D) works by resynchronising the heart’s two chambers, improving its efficiency. For Mr Jenkins, the difference made by the device was immediate and extraordinary.

“Before it was fitted I thought I was a goner. I just couldn’t breathe, and this meant I couldn’t do

anything. I couldn’t sleep at night and I could barely get up to sit in a chair. I really felt that I wasn’t going to last.”

Learning about Mr Jenkins’ breathing difficulties, Dr Flett and the team of cardiologists at University Hospital S outhampton decided to upgrade Mr Jenkins’ pacemaker to the CRTD. Afterwards, even before he left hospital, Mr Jenkins says his breathing had improved beyond comparison, and now he is home he’s able to enjoy some quality time with his three grandchildren aged between 5-9 years. He is teaching them to sail model yachts, and he is actively able to pursue his interest in veteran aircraft. “My whole life has changed.

My heart is now working really well,” he says.

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6 symptoms of heart failure

Depression

Swollen ankles

Shortness of breath

Loss of appetite

Fatigue

Exercise intolerance

Since the first implantable pacemaker was developed in 1958, millions have benefited from pacemaker therapy, and Mr Jenkins says he would urge anyone recommended this procedure to have it. “I can’t thank the hospital team enough for their help.”

A key benefit of CRT-D technology is that it can be monitored remotely by the hospital. Using a transmitter device called Merlin at Home, which synchs with the CRT-D to communicate critical information, the hospital team can see immediately how the device is working. Mr Jenkins is delighted to receive such care and attention. He says: It’s like having a really nice Big Brother watching you. They ring me up if something seems wrong – they know about problems even before I do.”

Cardiologist at University Hospital Southampton Dr Andrew Flett says:

Peter Jenkins Patient

Read more on health awareness.co.uk

“It is very satisfying when a patient does well using CRT-D technology, as many patients do. For these people, the change Dr Andrew Flett to their life is often transformative.”

Guidelines used by clinicians are pretty clear about the evidence supporting CRT-D use in people with heart failure, he says, and as device technology improves, the odds of a patient benefiting from this treatment have risen from two in three up to nine in ten in some patients.

There are also benefits to the NHS, believes Dr Flett, as these devices can additionally deliver organisational cost savings resulting from the prevention of emergency (acute) admissions for heart failure. According to research, acute admission rates relating to heart failure can be reduced by around 50 per cent as a result of using CRT-D technology. According to Dr Flett, Merlin at Home can play a role in this, as it helps the cardiology team to identify problems with the device before they become detrimental to the patient’s health.

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Steve Sturgiss Heart failure patient

“My biggest concern about receiving the ICD was: what happens if it goes wrong? I did quite a lot of research online about the two different types of ICD, subcutaneous and intravenous, but got information from the cardiac team as well.

I chose the subcutaneous defibrillator because it is much less invasive. If there are any problems it’s much easier to remove, so there is a smaller chance of any serious complications. There’s no problem now: I can do everything I did beforehand; I can stretch the same as I could before too.

Generally, it’s just there and you don’t notice it.”

Wireless technology gets to the heart of the matter In today’s NHS, patients at risk of sudden cardiac arrest (SCA) now have real choices about their treatment

By Ailsa Colquhoun

Trudie C A Lobban MBE FRCP (Edin), Founder & Trustee, Arrhythmia Alliance

“If you or someone you love has been told that you are at risk of sudden cardiac arrest (SCA) due to an irregular heart rhythm (arrhythmia), treatment options may seem overwhelming. At Arrhythmia Alliance we offer patients an ICD factsheet to help explain the differences between the traditional ICD and the latest alternative, the subcutaneous ICD. It’s important to be fully aware of the latest technological advancements, and to discuss with your doctor about the options.”

Read more on healthawareness.co.uk

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ver the past five years, new technology has become available to cardiologists specialising in the prevention of SCA – an emergency condition dubbed the ‘silent killer’ as the heart simply stops beating without warning. Around nine in ten people suffering an SCA will die before they reach hospital.

Until recently, treatment to prevent an SCA has centred on the insertion of a transvenous implantable cardioverter defibrillator (TVICD) - a device that attaches to the heart wall using leads passed through the veins. When this device detects a dangerous-

ly fast heart rhythm, it sends an electrical pulse to the heart to restore a normal beat.

However, thanks to technological advance heart specialists have the alternative of a device that does not attach to the heart subcutaneous ICD technology (SICD).

At the John Radcliffe Hospital, Oxford, consultant cardiologist Dr Kim Rajappan and his electrophysiologist consultant colleagues are among the most experienced implanters of ICDs in the UK. An international hospital trial, involving the John Radcliffe hospital, centres on exploring mainstream use of SICD technology – something Rajappan believes is being en-

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Transvenous ICD

Arrhythmia

The transvenous defibrillator is implanted near the collarbone. One or two leads are fed through a vein into the heart. The leads are attached to the heart wall for sensing of arrhythmias and therapy delivery.

An irregular heart rhythm, some can be life-threatening.

UK #s

250 people per day die from SCD in the UK

AED

An Automatic External Defibrillator is a portable electronic device that automatically diagnoses a life-threatening arrhythmia, and is able to treat the patient through defibrillation.

Subcutaneous ICD

Defibrillation

A controlled electric shock, to stop a lethal arrhythmia and restore the normal rhythm of the heart.

couraged “by a desire for devices that don’t sit in the vascular space.” The trial is due to conclude in 2019.

He explains that using TVICDs requires more potentially harmful xrays, as well as introduces risks of blood borne infection and damage to the heart – even, potentially, death if the leads need to be removed. Other factors defining use include the patient’s medical history, as well as their physical status, notably, the pre-existing condition of their veins.

Increasingly, cosmetic acceptability is also an issue: the implanting process

Dr Kim Rajappan Consultant cardiologist, John Radcliffe Hospital, Oxford

The subcutaneous defibrillator is implanted on the left side of the chest next to the rib cage and one lead is implanted just under the skin above the breastbone. It sends a shock without the use of wires implanted in the heart.

of both devices leaves a scar. However, SICDs are implanted near the armpit, which may be less conspicuous. Device size can also be a concern, although this is reducing as technology advances.

Noting his hospital’s ongoing research into device use, Rajappan says: “My personal view is that the devices are interchangeable in large numbers of patients - perhaps, even the majority.” As a result patients’ preferences play a larger part in the choice of device used.

For these reasons, Rajappan feels it is important that patients understand

their options, and that the decision to treat those patients is tailored to the patient’s preferences. “Personally, I think the Internet can be helpful in this regard; patients are increasingly well informed and come ready to share their thoughts. Although some patients’ interpretation of their research may need further discussion, encouraging the interested patient is important. We have moved away from the days of a passively nodding patient. Doctors should no longer dictate: “This is what we are going to do to you today.”

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295 Sue Jardine

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Sue’s TAVI procedure and how it’s got her back on her feet

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ue, from Kent, was diagnosed with aortic stenosis in 2013. After a successful TAVI procedure she is now back to enjoying time with her grandchildren and gardening in her community.

One evening in 2013, Sue and her husband went out for a walk. She became so breathless that she felt it was too much to go on walking.

Realising this wasn’t normal she visited a heart specialist who, after conducting an echocardiogram and further investigations said that she would need her aortic valve replaced. Sue points out “I had already had open heart surgery several years earlier, so the doctors were reluctant to perform another openheart operation. I was told of an alternative, minimally invasive treatment called TAVI.” Sue had the procedure at the London Bridge Hospital.

“I was well enough to leave hospital within two days,” she recalls. “My recovery was just unbelievable; I felt so well so quickly. Every day I noticed I could breathe a bit more easily.

“I am a busy grandmother to six children so I was very grateful to be back to normal, playing football with them and enjoying this new lease of life.”

Mike Higginbottom, Chair of the Heart Valve Voice Patient Action Group, said ‘It’s great that Sue recognised her symptoms were not just the signs of ageing and did something about it.

“Heart valve disease is treatable if diagnosed early. At Heart Valve Voice we’re campaigning for the regular use of the stethoscope, equal access to imaging technologies and the best treatment for all patients.”

Read more on healthawareness.co.uk

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Number of TAVI procedures performed. BCIS data 2014, NICOR, Total=7,417

The more we listen the more lives we save: heart valve disease, a growing epidemic

By Will Woan and Chris Young

With an ageing population, we need to know more about heart valve disease.

Heart valve disease has been described as the “forgotten epidemic”1; and with good reason. The disease affects more than one million people aged over 65, and this figure is set to soar as this aging population could double to 19 million by 2050. Yet, awareness of this common, severe and ultimately curable condition remains dangerously low.

Heart valve disease is a condition caused by either wear, disease or damage to the heart’s valves, affecting the flow of blood through the heart and causing a range of symptoms.

Heart Valve Voice was established in 2013 with a vision to transform the diagnosis, referral and treatment of this life threatening disease. Yet, this task is not without challenges, as Mr Chris Young, its Chair and Consultant Cardiothoracic Surgeon at Guy’s and St Thomas’ Hospital, London, explains: “Many people think that the symptoms of breathlessness, chest pains,

dizziness and fainting are signs of ageing, so they don’t seek help. This is one of many reasons why we treat half as many people as France. We could do much better.”

A recent global population based study2 gives us clear evidence that the prevalence of undiagnosed and known heart valve disease in older people is a public health concern, with the number of patients set to double by 2046.

A fourfold increase in less invasive procedures such as Transcatheter Aortic Valve Implantation (TAVI) is to be expected. Due to the aging population, TAVI is a preferred method for patients at increased risk as it enables heart valve replacements with a minimally invasive procedure, reducing both operation and recovery times.

The growing number of patients demonstrates the important role that charities like Heart Valve Voice can play in ensuring a clear and effective treatment pathway across the NHS. Evidence suggests the existence of gaps in treatment of heart valve disease across the UK displaying a varied level in quality of care.

CEO of Heart Valve Voice Will Woan highlights: “We know that advanced imaging technologies have dramatically improved our ability to detect and treat heart valve disease at an early stage. Having access to these types of technology also allows us to do less invasive procedures and improve patient outcomes.”

Chris Young, Will Woan and their supporters are developing their new Vision Report, which offers practical solutions to the challenges. They plan to present the report to parliament in November to raise awareness of the disease and gain support. “We believe that there is a political ambition to support the needs of our ageing population,” Young comments. “With partnership, we can go a long way to ensuring that patients receive the best treatment at the right time, to improve their quality of life.”

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Br J Cardiol 2011;18:118

2

The OxVALVE Population Cohort Study (European Heart Journal June 2016)

COMMERCIAL FEATURE

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The smart way to better health

By Ailsa Colquhoun

Smart health technology can help make positive changes to patients’ behaviour and so hold the key to healthier living. Dr Mark Aloia, associate professor of medicine at National Jewish Health in Denver, Colorado, and global lead for behaviour change for Philips health technology, explains how.

How do you change behaviour?

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Dr Mark Aloia Associate Professor of Medicine, National Jewish Health in Denver, Colorado

and patients emerging, healthcare institutions have more reasons than ever to incorporate technology into the delivery of their healthcare services now, and in the future.

What are the roadblocks to healthier lifestyle success?

Behavioural change leading to a

healthier lifestyle takes time and effort; people do not fit into one mould and require personalised support.

An average 8-10 minute appointment with a healthcare professional may not provide the optimum environment to truly engage with and define the challenges, so technology also has a role in bringing as much background information to the table as possible within a time-limited consultation. Success depends on the construction of all five ‘pillars’ of change, offering people targeted support: we need to understand that it’s time to move from sitting across the table and telling people what to do, to sitting alongside people and finding out what they actually need.

Technological advances provide the platform to easily share and compare results, so we can better empower patients to meaningfully move toward a healthier lifestyle.

New heart scanning technology shines a light on faster patient recovery

By Ailsa Colquhoun

Patients having complex heart procedures can now return home from hospital within a day, thanks to breakthroughs in medical imaging technology.

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oday, patients with heart disease routinely receive treatments that, a decade ago, were unimaginable.

Heart disease, a top UK killer, is a leading cause of urgent and elective hospital admissions. In the past, open-heart surgery patients required a seven to 10 day recovery period; but now they can return home in as little as 24 hours, even after complex procedures.

Professor Mark Monaghan,

director of non-invasive cardiology at King’s College Hospital, London, believes that new medical imaging technologies play a key role in patient care advances. “Technology offers tremendous benefits for the cardiologist and the surgeon, as well as the patient,” he says. “Cardiologists and surgeons can diagnose more precisely, plan more accurately, use minimally invasive procedures, and have better information for aftercare; while patients will experience less pain and faster recovery.”

Industry partnerships, combined with all-important research funding - often from charities such as the British Heart Foundation - are instrumental in the widespread adoption of technologies such as EchoNavigator

Find out more: www.philips.co.uk/transformingcardiology

Professor Mark Monaghan Director of Non-Invasive Cardiology and Associate Medical Director, King’s College Hospital

fusion imaging from Philips. “This system combines ultrasound and xray imaging to give a complete picture of the heart’s soft tissue structures

and gives full and real time information to inform a much more predictable, safer and quicker procedure,” explains Professor Monaghan.

Another new system in use is Philips’ HeartModel, an ultrasound imaging technology that provides automated 3D heart scans. “This innovative tool means that we can reduce the opportunities for human error while ensuring that all changes in the heart function – no matter how small – can be detected and acted on accordingly,” explains Professor Monaghan.

“Ultimately, new technology such as this and other imaging innovations helps us provide increasingly better standards of care to our patients.”