Simplified atrial fibrillation ablation saves lifes and money without sacrificing quality

News from the World of Cardiovascular Research

Publisher: EHRA 2019 in Lisbon, Portugal

A catheter ablation protocol for atrial fibrillation (AFib) including only “the bare essentials” of the procedure delivered similar outcomes as a more involved strategy featuring pulmonary vein mapping, according to research presented at EHRA 2019 in Lisbon, Portugal.

According to a press release, 30 percent more patients could be treated with this simplified protocol for the same cost, offering hope of shrinking wait times for these procedures.

“Catheter ablation started in 1998. There has been little improvement in clinical outcomes in the last 10 years despite costlier technologies and a more complicated procedure requiring highly skilled staff,” principal investigator Prapa Kanagaratnam, PhD, of Imperial College London, said in the release. “In this trial, we stripped the procedure back to the bare essentials to see if it achieved the same outcomes.”

Kanagaratnam et al. randomized 321 symptomatic AFib patients to one of three treatments: cryoballoon ablation with same-day discharge; conventional cryoballoon ablation with pulmonary vein mapping and overnight hospitalization; or antiarrhythmic drugs. All patients spent 12 weeks getting their procedures and/or optimizing drug treatment before the one-year follow-up period began.

During follow-up, 21 percent of patients with the simpler ablation approach required rehospitalization, compared to 18 percent of those in the conventional ablation arm who underwent pulmonary vein mapping. This difference wasn’t statistically significant, but both ablation groups fared much better than patients treated with drug therapy alone—76 percent of them ended up back in the hospital to relieve symptoms.

“It is possible that more patients will now choose catheter ablation outright, rather than trying drugs first,” Kanagaratnam said. “The findings also question the value of drug therapy, and whether catheter ablation should be the first line treatment for atrial fibrillation patients with symptoms.”

And, given the statistically insignificant difference in hospitalizations among the ablation groups, Kanagaratnam said returning to a basic ablation approach might provide cost-effective and efficient care to more patients. This is of particular importance considering AFib is the most common heart rhythm disorder and causes between 20 and 30 percent of all strokes, the release stated.

“Some of the more technical parts of the procedure can be omitted, making it easier, cheaper and quicker, without sacrificing results,” Kanagaratnam said. “In the U.K., patients with atrial fibrillation have to wait months for catheter ablation. The simpler protocol could shorten waiting lists within the same budget.”

If you have any heart concerns or symptoms and would like to be reviewed, please contact the Dorset Heart Clinic to be seen by one of our expert cardiologists. We will always provide an appointment within a few days of being contacted.

There’s no such thing as ‘too fit’

News from the World of Cardiovascular Research:

Publisher: Journal of the American Medical Association (JAMA)

Having reduced cardiorespiratory fitness (CRF) is as harmful to survival as coronary artery disease, smoking cigarettes or diabetes, suggests a retrospective study published Oct. 19 in JAMA Network Open.

Researchers analyzed data from 122,007 patients who underwent exercise treadmill testing, and stratified those individuals into five CRF groups based on how they stacked up against the average person of their age and sex: low (below 25th percentile), below average (25th-49th percentile), above average (50th-74th percentile), high (75th-97.6th percentile) and elite (97.7th percentile or higher).

Elite performers were 80 percent less likely to die than low performers over the median follow-up of 8.4 years. They were even 23 percent more likely to survive than high performers, an important finding considering recent evidence has suggested extreme amounts of exercise might actually be harmful. In this study, there appeared to be no upper limit for the benefit of increased CRF.

“Potentially adverse cardiovascular findings in highly active cohorts, including an increased incidence of atrial fibrillation, coronary artery calcification, myocardial fibrosis, and aortic dilation, have raised concern for potential cardiovascular risk above a certain exercise or training threshold,” wrote lead author Kyle Mandsager, MD, of the Cleveland Clinic Foundation, and colleagues. “It remains unclear whether these associations are signals of true pathologic findings or rather benign features of cardiovascular adaptation. The present study is the first, to our knowledge, to specifically evaluate the association between extremely high CRF and long-term mortality.”

The researchers noted their study is also different from many previous reports because it uses an objective measure of physical fitness rather than self-reported activity levels. Also, genetic factors and other lifestyle habits may contribute to both aerobic fitness and improved survival, they wrote.

Upon multivariable adjustment, Mandsager et al. found participants with below-average CRF versus above-average CRF had 41 percent decreased odds of survival—a risk on par with smoking or diabetes, and even greater than coronary artery disease (29 percent increased risk of all-cause mortality). And the survival odds were even greater for people with CRFs categorized as high or elite for their age and sex.

“These findings not only reinforce the large collective body of evidence correlating aerobic fitness with numerous health benefits but also illustrate the importance of aerobic fitness as a powerful, modifiable indicator of long-term mortality,” the authors wrote. “Healthcare professionals should encourage patients to achieve and maintain high levels of fitness.”

If you have any heart concerns or symptoms and would like to be reviewed, please contact the Dorset Heart Clinic to be seen by one of our expert cardiologists. We will always provide an appointment within a few days of being contacted.

Clot-busting drugs prevent 4,000 strokes each year

News from the World of Cardiovascular Research:

Publisher: European Heart Journal

Half a million people in the UK are living with the undiagnosed heart rhythm disorder — Atrial Fibrillation — unaware they are at greater risk of having a stroke.

Increased use of anticoagulant drugs in patients who have a common heart rhythm disorder prevented four thousand strokes in England between 2015 and 2016.

The analysis — part-funded by us and published today in the European Heart Journal (EHJ) is re-assuring for patients who suffer from the condition known as atrial fibrillation, and a major success story for stroke prevention.

Atrial fibrillation (AF) affects around 1.2 million people in the UK, with 500,000 people believed to be living undiagnosed and unaware that they are at a 5-fold higher risk of stroke compared to those unaffected.

The findings highlight the urgent need for better screening and diagnosis of AF to ensure patients receive the clot-busting treatment which could prevent a devastating stroke.

Professor Chris Gale, Honorary Consultant Cardiologist at the University of Leeds commented on net next steps:

“Sudden strokes in people who have AF are unnecessarily common. Treatments which prevent AF-related strokes are saving lives, but there are still many thousands of people in the UK living with undiagnosed AF who are missing out.

The BHF-funded team from the University of Leeds used national data to analyse the known patients with AF, people seeing a consultant for stroke, new AF diagnoses and the use of anticoagulants amongst high risk patients between 2006 and 2016.

They found that, since 2009, the number of people with AF who are being treated with anticoagulants has more than doubled.

The researchers estimate that, had the uptake of anticoagulants stayed at 2009 levels, there would have been around 4,000 more strokes in patients with AF in England in the 2015/16 financial year.

Stroke is the fourth biggest killer in the UK and the leading cause of disability and in 2016, killed almost twice as many women as breast cancer.

Source: Fraser Macrae, University of Leeds.

Atrial fibrillation is the most common type of irregular heartbeat; it causes the heart’s chambers to beat in an uncoordinated, irregular manner. AF can cause blood to pool in the heart, which can form into a blood clot. It this clot travels to the brain it can block the blood supply, leading to a stroke.

AF contributes to between 20–30 per cent of all strokes, and treating these patients with anticoagulants — drugs which slow the formation of blood clots — can cut patients’ risk of stroke by two thirds.

Professor Sir Nilesh Samani, our Medical director points out the importance of spotting AF:

“Spotting AF is surprisingly easy; all it takes is a simple pulse check. A normal heart beat will feel regular, but if you find yours is irregular or random, go and see your GP. It could save your life,”

So why have things improved? The researchers say the reason more people are taking anticoagulant drugs is likely thanks to efforts across the health service to educate patients and doctors about the benefits of anticoagulation. It also comes down to changes to guidelines in the UK and Europe, and the development of new types of anticoagulants which provide a safer and more convenient alternative to warfarin.

Richard, a 47-year-old father of two from Dorset, was diagnosed with atrial fibrillation four years ago. After a Saturday morning coffee, he had sensations of butterflies in his chest. When it didn’t go away after a few hours, and he started to feel abnormally tired, he took himself to A&E.

“I had a heart attack when I was 36, so I knew I needed to get things checked. It was a complete shock when the doctors told me my heart was beating at between 170 and 200bpm. I could barely tell.

If you have any heart concerns or symptoms and would like to be reviewed, please contact the Dorset Heart Clinic to be seen by one of our expert cardiologists. We will always provide an appointment within a few days of being contacted.

Genetic tool to predict adult heart attack risk in childhood

News from the World of Cardiovascular Research:

Publisher: Journal of the American College of Cardiology

People at high risk of a heart attack in adulthood could be spotted much earlier in life with a one-off DNA test, according to new research which we part-funded, published today in the Journal of the American College of Cardiology.

An international team led by researchers from the University of Leicester, University of Cambridge and the Baker Heart and Diabetes Institute in Australia used UK Biobank data to develop and test a powerful scoring system, called a Genomic Risk Score (GRS) which can identify people who are at risk of developing coronary heart disease prematurely because of their genetics.

People who are at high risk could be encouraged to make important lifestyle changes from an early age and be offered lifesaving medicines on a case to case basis, should they be necessary.

Genetic factors have long been known to be major contributors of someone’s risk of developing coronary heart disease – the leading cause of heart attacks. In today’s health system, doctors identify those at risk doctors use scores based on lifestyle and clinical conditions associated with coronary heart disease such as cholesterol level, blood pressure, diabetes and smoking. But these scores are imprecise, age-dependent and miss a large proportion of people who appear ‘healthy’, but will still develop the disease.

1.7 million genetic variants in a person’s DNA

The ‘big-data’ GRS technique takes into account 1.7 million genetic variants in a person’s DNA to calculate their underlying genetic risk for coronary heart disease.

The team analysed genomic data of nearly half a million people from the UK Biobank research project aged between 40-69 years. This included over 22,000 people who had coronary heart disease.

A powerful tool

The GRS was better at predicting someone’s risk of developing heart disease than each of the classic risk factors for coronary heart disease alone. The ability of the GRS to predict coronary heart disease was also largely independent of these known risk factors. This showed that the genes which increase the risk of coronary heart disease don’t simply work by elevating blood pressure or cholesterol, for example.

People with a genomic risk score in the top 20 per cent of the population were over four-times more likely to develop coronary heart disease than someone with a genomic risk score in the bottom 20 per cent.

In fact, men who appeared healthy by current NHS health check standards but had a high GRS were just as likely to develop coronary heart disease as someone with a low GRS and two conventional risk factors like high cholesterol or high blood pressure.

These findings help to explain why people with healthy lifestyles and no conventional risk factors can still be struck by a devastating heart attack.

Crucially, the GRS can be measured at any age including childhood as your DNA does not change. This means that those at high risk can be identified much earlier than is possible through current methods and can be targeted for prevention with lifestyle changes and, where necessary, medicines. The GRS is also a one-time test and with the cost of genotyping to calculate the GRS now less than £40 GBP ($50 USD) it is within the capability of many health services to provide.

Our medical director, Professor Sir Nilesh Samani, Professor of Cardiology at the University of Leicester was a senior author of the study and gave his thoughts:

“At the moment we assess people for their risk of coronary heart disease in their 40’s through NHS health checks. But we know this is imprecise and also that coronary heart disease starts much earlier, several decades before symptoms develop. Therefore if we are going to do true prevention, we need to identify those at increased risk much earlier.

“This study shows that the GRS can now identify such individuals. Applying it could provide a most cost effective way of preventing the enormous burden of coronary heart disease, by helping doctors select patients who would most benefit from interventions and avoiding unnecessary screening and treatments for those unlikely to benefit.”

Lead author Dr Michael Inouye, of the Baker Heart and Diabetes Institute and University of Cambridge also commented on the findings:

“The completion of the first human genome was only 15 years ago. Today, the combination of data science and massive-scale genomic cohorts has now greatly expanded the potential of healthcare.

“While genetics is not destiny for coronary heart disease, advances in genomic prediction have brought the long history of heart disease risk screening to a critical juncture, where we may now be able to predict, plan for, and possibly avoid a disease with substantial morbidity and mortality.”

Today, we are just beginning to harness the enormous potential of genomic medicine. Within the next decade scientists anticipate to see this kind of technology bringing countless benefits to the lives of patients.

If you have any heart concerns or symptoms and would like to be reviewed, please contact the Dorset Heart Clinic to be seen by one of our expert cardiologists. We will always provide an appointment within a few days of being contacted.

British Heart Foundation scientists develop tool for spotting deadly sepsis in people who have heart failure

News from the World of Cardiovascular Research:

Publisher: Journal of the American College of Cardiology

Nearly one in four deaths in people with heart failure are caused by sepsis, according to new research published today in the Journal of the American Heart Association.

Researchers we fund have developed a way to identify patients who are most at risk, often years before they become ill.

The team hope the tool will help doctors determine which patients may benefit from closer monitoring and help to ensure they receive rapid treatment when they fall ill. Sepsis is a very serious complication of an infection. Without treatment it can lead to multiple organ failure and death. Catching cases early could save thousands of lives every year.

1 in 4 deaths

Professor Richard Cubbon, from the University of Leeds who led the study said, “We have created a simple way to identify people with heart failure who are at greatest risk of dying from sepsis. It could be part of a routine check which is already performed when they visit their doctors.”

With our risk profile, we hope people at high risk of sepsis will receive better monitoring, and infections which could lead to sepsis are treated early.”

550,000 people in the UK have been diagnosed with heart failure, but estimates suggest there may be many more cases.

Heart failure occurs when the heart is not pumping blood around the body as well as it should, most commonly when the heart muscle has been damaged – for example, after a heart attack. Around 550,000 people have been diagnosed with heart failure in the UK, but estimates suggest that in reality this figure is much higher. The debilitating condition causes breathlessness, fatigue and premature death. People who have heart failure are also more vulnerable to potentially deadly infections.

Researchers from the University of Leeds tracked 1,802 patients with chronic heart failure from 2006 to 2014 for an average of four years. The scientists collected information about each patient at the beginning of the study. During the study, 737 patients died, with 173 (23.5 per cent) deaths caused by sepsis.

The team analysed this data and found several distinct markers which flagged higher risk of death from sepsis specifically, rather than progressively worsening heart failure or sudden cardiac arrest.

Blood samples from high-risk patients contained lower levels of vitamin D and higher counts of platelets – cells which help blood clot. Those at high risk were also older, more likely to have chronic lung disease (chronic obstructive pulmonary disease) and more likely to be male.

The researchers used this data to create a ‘risk profile’ which could be used in future to flag patients at highest risk of dying from sepsis. These patients could receive counselling, closer monitoring by their GP and vaccines to prevent respiratory infections – the root cause of 70 per cent of sepsis cases in the study.

Sepsis, sometimes called blood poisoning, occurs when the immune system goes into overdrive in response to an infection and starts attacking the body’s own cells, causing damage to vital organs. It can take hold quickly and, without rapid treatment, can lead to multiple organ failure and death.

Our medical director Professor Sir Nilesh Samani, Medical Director at the British Heart Foundation also commented on the study.

“This observational study re-emphasises that, despite modern treatments, people with heart failure have a prognosis that is worse than many cancers with 2 out of 5 people dying within 4 years.

“The new finding here is that sepsis is an important cause of death in these patients accounting for almost 1 in 4 deaths. We also now know that particular characteristics of the patients, some of which may be correctable, makes them more prone to developing sepsis.

“Further research is necessary but this study highlights potentially important ways in which we may be able to improve the outlook of patients with heart failure.”