HEART UK consensus statement on Lipoprotein(a): A call to action (2019)

Type of publication:
Journal article

Author(s):
Cegla J.; Neely R.D.G.; France M.; Ferns G.; Byrne C.D.; Halcox J.; Datta D.; *Capps N.; Shoulders C.; Qureshi N.; Rees A.; Main L.; Payne J.; Cramb R.; Viljoen A.; Soran H.

Citation:
Atherosclerosis; Dec 2019; vol. 291 ; p. 62-70

Abstract:
Lipoprotein(a), Lp(a), is a modified atherogenic low-density lipoprotein particle that contains apolipoprotein(a). Its levels are highly heritable and variable in the population. This consensus statement by HEART UK is based on the evidence that Lp(a) is an independent cardiovascular disease (CVD) risk factor, provides recommendations for its measurement in clinical practice and reviews current and emerging therapeutic strategies to reduce CVD risk. Ten statements summarise the most salient points for practitioners and patients with high Lp(a). HEART UK recommends that Lp(a) is measured in adults as follows: 1) those with a personal or family history of premature atherosclerotic CVD; 2) those with first-degree relatives who have Lp(a) levels >200 nmol/l; 3) patients with familial hypercholesterolemia; 4) patients with calcific aortic valve stenosis and 5) those with borderline (but <15%) 10-year risk of a cardiovascular event. The management of patients with raised Lp(a) levels should include: 1) reducing overall atherosclerotic risk; 2) controlling dyslipidemia with a desirable non-HDL-cholesterol level of <100 mg/dl (2.5 mmol/l) and 3) consideration of lipoprotein apheresis.

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Corrigendum: It has been brought to our attention that the wording of the German reimbursement criteria for apheresis is not clear in the above paper (Section 7. Management of patients with raised Lipoprotein(a), Subheading: Apheresis). This should read: “In Germany, Lp(a) levels exceeding 60 mg/dl and LDL-cholesterol in normal range along with progressive CVD has been approved as an indication for regular lipoprotein apheresis since 2008.”

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Current management of children and young people with heterozygous familial hypercholesterolaemia - HEART UK statement of care (2019)

Type of publication:
Journal article

Author(s):
Ramaswami U.; Humphries S.E.; Priestley-Barnham L.; Green P.; Wald D.S.; *Capps N.; Anderson M.; Dale P.; Morris A.A.

Citation:
Atherosclerosis; Nov 2019; vol. 290 ; p. 1-8 [epub ahead of print]

Abstract:
This consensus statement on the management of children and young people with heterozygous familial hypercholesterolaemia (FH) addresses management of paediatric FH in the UK, identified by cascade testing when a parent is diagnosed with FH and for those diagnosed following incidental lipid tests. Lifestyle and dietary advice appropriate for children with FH; suggested low density lipoprotein cholesterol (LDL-C) targets and the most appropriate lipid-lowering therapies to achieve these are discussed in this statement of care. Based on the population prevalence of FH as ~1/250 and the UK paediatric population, there are approximately 50,000 FH children under 18 years. Currently only about 550 of these children and young people have been identified and are under paediatric care.

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Targeting dyslipidaemia to prevent cardiovascular disease (2019)

Type of publication:
Journal article

Author(s):
Viljoen A.; Fuat A.; Takhar A.; Williams S.; *Capps N.

Citation:
Prescriber; Jul 2019; vol. 30 (no. 7); p. 23-26

Abstract:
Dyslipidaemia is a key risk factor for cardiovascular disease, and its identification and treatment is important for both primary and secondary prevention. This article discusses how to screen for dyslipidaemia and optimise lipid-lowering therapy to improve cardiovascular outcomes.

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Coronary heart disease mortality in severe and non-severe familial hyper-cholesterolaemia : data from the UK Simon Broome FH register (2019)

Type of publication:
Conference abstract

Author(s):
Humphries S.; Cooper J.; *Capps N.; Durrington P.; Jones B.; McDowell I.; Soran H.; Neil A.

Citation:
Atherosclerosis; Aug 2019; vol. 287

Abstract:
Background and Aims: Background: In 2016 the International Atherosclerosis Society (IAS) proposed that patients with "severe" FH (SFH) should be identified since they might warrant early and more aggressive cholesterol-lowering treatment such as with PCSK9 inhibitors. SFH is diagnosed if LDL-cholesterol (LDLC) >10 mmol/L, or LDLC >8.0 mmol/L plus one high-risk feature, or LDLC >5 mmol/L plus two high-risk features. Here we compare CHD mortality in SFH and non-SFH patients in the UK Simon Broome Register since 1991, when
statin use became routine.
Method(s): 2929 Definite or Possible patients (51% women) aged 20-79 years recruited from 21 UK lipid clinics were followed between 1992-2016. The excess CHD standardised mortality ratio (SMR) compared to the population in England and Wales was calculated (95% Confidence intervals).
Result(s): (67.7%) patients met the SFH definition. Post 1991, the SMR for CHD mortality was significantly (p=0.007) higher for SFH (220(184-261) (34,134 person years, 129 deaths observed, vs 59 expected) compared to non-SFH of 144(98-203) (15,432 person years, 32 observed vs 22 expected). After adjustment for traditional risk factors, the Hazard Ratio for CHD mortality in SFH vs non-SFH was 122 (80-187) p=0.36. Applying UK guidelines for the use of PCSK9i agents, overall ~24% of those in the register are likely to be eligible, but if this were restricted to those with SFH, overall ~16% would qualify.
Conclusion(s): CHD mortality remains elevated in treated FH, especially for SFH, emphasising the importance of optimal lipid-lowering, including the use of novel agents, and management of other risk factors

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Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis (2019)

Type of publication:
Systematic Review

Author(s):
*Padmanabhan, Hari; Siau, Keith; *Curtis, Jason; Ng, Alex; Menon, Shyam; Luckraz, Heyman; Brookes, Matthew J

Citation:
The Annals of Thoracic Surgery. Dec 2019; vol. 108 (no. 6); p. 1840-1848

Abstract:
BACKGROUND Pre-operative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes following cardiac surgery.METHODS A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and non-anemic patients. RESULTS Out of 1103 studies screened, 22 met the inclusion criteria. A total of 23624 (20.6%) out of 114277 patients were anemic. Anemia was associated with increased mortality (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.32-3.24; I2=69.6%; p<0?001), AKI (OR 3.13, 95% CI 2.37-4.12; I2=71.1%; p<0?001), stroke (OR 1.46, 95% CI 1.24-1.72; I2=21.6%; p<0?001), and infection (OR 2.65, 95% CI 1.98-3.55; I2=46.7%; p<0?001). More anemic patients were transfused than non-anemic (33.3 versus 11.9%). No statistically significant association was found between mortality and blood transfusion (OR 1.35, 95% CI 0.92-1.98; I2=83.7%; p=0.12) but we were not able to compare mortality with or without transfusion in those who were or were not anemic. CONCLUSIONS Preoperative anemia is associated with adverse outcomes following cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models, and as a target for risk modification.

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Coronary heart disease mortality in severe vs. non-severe familial hypercholesterolaemia in the Simon Broome Register (2019)

Type of publication:
Journal article

Author(s):
Humphries, Steve E; Cooper, Jackie A; *Capps, Nigel; Durrington, Paul N; Jones, Ben; McDowell, Ian F W; Soran, Handrean; Neil, Andrew H W; Simon Broome Familial Hyperlipidaemia Register Group

Citation:
Atherosclerosis. 2019 Feb;281:207-212

Abstract:
BACKGROUND AND AIMS The International Atherosclerosis Society (IAS) has proposed that patients with "severe" FH (SFH) would warrant early and more aggressive cholesterol-lowering treatment such as with PCSK9 inhibitors. SFH is diagnosed if LDL-cholesterol (LDLC)>10mmol/L, or LDLC >8.0mmol/L plus one highrisk feature, or LDLC >5mmol/L plus two high-risk features. Here we compare CHD mortality in SFH and nonSFH (NSFH) patients in the UK prospective Simon Broome Register since 1991, when statin use became routine.METHODS 2929 definite or possible PFH patients (51% women) aged 20-79 years were recruited from 21 UK lipid clinics and followed prospectively between 1992 and 2016. The excess CHD standardised mortality ratio (SMR) compared to the England and Wales population was calculated (with 95% confidence intervals).RESULTS1982 (67.7%) patients met the SFH definition. Compared to the non-SFH, significantly (p < 0.001) more SFH patients had diagnosed CHD at baseline (24.6% vs. 17.5%), were current smokers (21.9% vs 10.2%) and had a BMI>30kg/m2 (14.9% vs. 7.8%). The SMR for CHD mortality was significantly (p=0.007) higher for SFH (220 (184-261) (34,134 person years, 129 deaths observed, vs. 59 expected) compared to NSFH of 144 (98-203) (15,432 person years, 32 observed vs. 22 expected). After adjustment for traditional risk factors, the Hazard Ratio for CHD mortality in SFH vs. NSFH was 1.22 (0.80-1.87) p=0.36, indicating that the excess risk was largely accounted for by these factors.CONCLUSIONS CHD mortality remains elevated in treated FH, especially for SFH, emphasising the importance of optimal lipid-lowering and management of other risk factors.

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Patient experience within the adult congenital heart disease outreach network: A questionnaire-based study (2018)

Type of publication:
Journal article

Author(s):

Georgina Ooues, Paul Clift, Sarah Bowater, Sayqa Arif, Andrew Epstein, Neeraj Prasad, Dawn Adamson, Mandy Cummings, Charles Spencer, Paul Woodmansey, Jenny Borley, *Thomas Ingram, Adrian Morley-Davies, William Roberts, Najmi Qureshi, Susan Hawkesford, Nichola Pope, James Anthony, Thomas Gaffey, Sara Thorne, Lucy Hudsmith and On behalf of The West Midlands ACHD Network, UK

Citation:
Journal of Congenital Cardiology; Sep 2018; vol. 2 (no. 1)

Abstract:
Background: Specialist multi-disciplinary care improves outcomes of Adult Congenital Heart Disease (ACHD) patients. Following the NHS England Congenital Heart Disease standards review, the aim is to deliver high quality, patient-centred, care closer to patients' homes. Cardiac investigations performed on the same day of outpatient appointments reduce the non-attendance rates. This young cohort of patients, benefits from comprehensive multi-disciplinary management. We developed a Patient Questionnaire across our West Midlands ACHD network to measure patient experience. Methods: Patient questionnaires were distributed to patients attending outpatient clinics in all 8 Outreach Centres and the Level 1 ACHD Centre (University Hospitals Birmingham). Results: 71 males (55%) and 59 females (45%), median age range 25-34years old (range between 16 and 75years old), returned the questionnaires (n=130). Most patients travelled less than one hour to hospital (93%, n=120) and less than 20miles (86%, n=99). The mean travel distance was 14+/-12.3miles (range 1 to 160miles), with Level 1 ACHD Centre patients travelling a significantly longer distance (mean 29.6+/-44miles) compared to the local Outreach Centres (mean 11.3+/-9miles, p=0.0037). There was a wide variability in the provision of parking, although most patients found the appointment time and location convenient (91%, n=117 and 95%, n=121 respectively). There was also marked variation in the number of electrocardiograms (19-100%) and echocardiograms (0-60%) performed on the same day as their clinic appointment. Most patients felt they were given enough information regarding their condition (85%, n=98), with no significant differences between the centres (p=0.24). Conclusion: To our knowledge, this is the first questionnaire-based study assessing patient experience within the NHS ACHD Outreach network with significantly reduced travel times and maintained high patient satisfaction. There was a wide variation ininvestigations performed and patient information leaflets provided. Standardisation of services is required at allcentres to ensure equity of care, with Specialist Nurses' input and more availability of tests on the day of clinicappointments in all centres.

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Assessment of chronic obstructive airways disease in heart failure : An analysis of current practice (2018)

Type of publication:
Conference abstract

Author(s):
*Muthusami R.; *Mahmoud M.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.S.; *Moudgil H.; *Candassamy N.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) are global epidemics incurring significant morbidity and mortality with overlapping symptoms & risk factors. Whereas with other coexisting co-morbidities such as with Diabetes Mellitus and Ischaemic Heart Disease, much work has been done to concurrently improve outcomes from both pathologies, whether anything is uniformly undertaken in practice to firstly recognize and secondly improve outcomes from HF and COPD is less understood. The objective here was to establish our current pattern of assessment to identify potential areas of improvement that would enable us to better manage the modern multi-morbid patient. METHODS Electronic medical records of all patients admitted to our District General Hospital (serving fairly static population 250,000) over a 6 month period to end December 2016 and referred internally to our Heart Failure Specialist Team were assessed. Data for all admitted cases were cross-referenced to Electrocardiography (ECHO) and Pulmonary Function Lab Databases. RESULTS 116 patients (63% male) with mean (SD, range) age 74.9 (11.7, 32-100) years had been admitted and of these 37% had died over the subsequent 12 months follow up period. Of the total, 113 (97%) had prior transthoracic cardiac ECHO (updated within a two year window); Mean estimated Left Ventricular Ejection Fraction (LVEF) was 41%. Comparatively, only 31 (27%) patients had undergone Spirometry testing at our centre over the preceding 10 year period and of these approximately half (51%) had shown obstructive spirometry. Collectively, 44 (38%) were known to have any Obstructive Airways Disease with 32 (28%) being COPD but a slightly higher figure at 50 (43%) were on inhaler treatment. . Sub-analysing, the 59 (51%) specifically with Ischaemic Heart Disease as opposed to other causes for Heart Failure (Valvular Heart Disease, Cardiomyopathy etc.) had a higher 12 month mortality rate (49%) as well as higher prevalence of known COPD (32%), higher proportion of patients with obstructive spirometry (65%) and patients on inhaler therapy (45%). Only 2 of the 7 patients on Amiodarone had Spirometry. CONCLUSION The basic provision of spirometry to Heart Failure patients, and in particular those with Ischaemic Heart Disease, needs to be improved with our findings probably consistent with others providing the same models of diagnosis driven care. Our findings are in a population with established Heart Failure and potentially in their final years of life but there may be improved quality of life and care planning, if assessing those presenting earlier.

Iron deficiency in heart failure: A retrospective review of current practice and patient outcomes in a district general hospital (2018)

Type of publication:
Conference abstract

Author(s):
*Chatrath N.; *Kundu S.; *Makan J.

Citation:
Heart; Jun 2018; vol. 104, Supp 6

Abstract:
Iron deficiency (ID) affects up to 50% of patients with heart failure (HF) with higher rates in decompensated, hospitalised patients.1 ID is associated with poor functional capacity and recurrent hospital admissions. The 2016 European Society of Cardiology (ESC) guidelines for management of HF advocate measurement of ferritin and Transferrin Saturations (TSAT) in all HF patients. ID is defined by serum ferritin <100 mg/L or 100-299 mg/ L and TSAT <20%0.2 Intravenous Iron therapy is recommended for any patient meeting these parameters. This retrospective study looked at the diagnosis and management of ID in HF patients in a district general hospital. All 111 (n=111) inpatients with a diagnosis of HF with reduced ejection fraction (HFrEF), admitted between April-October 2016 were included. The mean age of the population was 75 (30100), 37% female and 63% male. 64% (n=71) were anaemic (Male n=46, Female n=25) as defined by our laboratory haemoglobin reference ranges for gender. Only 51% (n=57) of all patients had Ferritin checked during admission or within 3 months of discharge with an average Ferritin of 161 mg/L (11-1432). 30.6% (n=34) of all patients had absolute iron deficiency (Ferritin <100 mg/L) and 14.4% (n=11) had ferritin in the range 100300 mg/L, in which further TSAT testing to confirm functional iron deficiency is recommended but is not performed locally unless specifically requested by the clinician. Only 4.5% (n=5) of all patients had further investigations looking into causes of ID, including gastro-intestinal work-up. 47.8% (n=53) died in the 1 year follow-up period with 9% (n=10) not surviving past the initial admission. Of the 101 patients surviving the initial admission, there was a total of 135 hospital admissions within the follow-up period, 58% (n=78) of which were directly related to HF. 11.7% of all patients (n=13) were prescribed oral iron therapy on discharge and only 2 out of all patients had intravenous iron therapy during admission or within 6 months of discharge. This study highlights the high readmission and mortality rates of hospitalised HF patients and that ID is an underdiagnosed comorbidity in this population. A new protocol has been proposed which involves mandatory testing of ferritin, and TSAT if required, at the time of diagnosis and during regular follow-up. Local research is underway to further evaluate the benefits of iron replacement in HF and the effects of the proposed protocol on this population.

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