Speaker abstracts: 7th December 2017 Health policy symposium

Controlling Hypertension
Professor Bernard Cheung, University of Hong Kong

Editor, Postgraduate Medical Journal

The biggest news in the world of hypertension at the moment is the publication of the latest American guidelines (ACC/AHA) on the prevention, detection, evaluation and management of high blood pressure. The most controversial change is in the definition of hypertension, which now includes a systolic blood pressure of 130-139 mmHg or a diastolic blood pressure of 80-89 mmHg. This change will, at a stroke, make a sizeable proportion of the general population hypertensive. This is fine in a society in which a disease label entitles people to be reimbursed for medical treatment, but for most of Europe and Australasia, where healthcare is provided by the government, this may be less welcome. The characteristics of people with ‘Stage 1 Hypertension’ are interesting; most are overweight but few have any cardiovascular complications yet. This highlights the fact that obesity is the precursor of hypertension in many of the patients. Management of Stage 1 Hypertension must rely heavily on lifestyle changes. Fortunately, hypertension at this early stage is easy to control and potentially reversible. New concepts arising from the PATHWAY trials initiated by the British and Irish Hypertension Society should help blood pressure control. These include combination therapy and the use of amiloride and spironolactone. In 2018, using drugs to bring the blood pressure down to a certain level is seen as too simplistic. Cardiovascular risk assessment and promoting a healthy lifestyle are now part of the equation, and rightly so.

Prof Bernard Cheung(1)

Professor Cheung MB BChir, BA, MA, PhD (Cantab), MRCP(UK), FRCP (London), FRCP (Edin), FCP, FHKCP, FHKAM (Medicine) is the Sun Chieh Yeh Heart Foundation Professor in Cardiovascular Therapeutics and heads the Division of Clinical Pharmacology and Therapeutics in the Department of Medicine of the University of Hong Kong. Professor Cheung is an Honorary Consultant Physician of Queen Mary Hospital and the Medical Director of the Phase 1 Clinical Trials Centre. He is also the Director of the Institute of

Cardiovascular Science and Medicine, and the President of the Hong Kong Pharmacology Society. Professor Cheung has wide experience in senior roles of editing national and international journals. His main research interest is in cardiovascular diseases and risk factors, such as hypertension and the metabolic syndrome. He is a principal investigator of the Hong Kong Cardiovascular Risk Factor Prevalence Study. He is ranked among the top 1% of researchers in his field. Professor Cheung read Medicine at Magdalene College, Cambridge. He was a British Heart Foundation Junior Research Fellow at Cambridge before taking up lectureships at the University of Sheffield and the University of Hong Kong. In 2007 – 2009, he held the chair in Clinical Pharmacology and Therapeutics at the University of Birmingham, England.

Cardiovascular heart disease prevention in everyday clinical practice – can we do better?
Professor Kornelia Kotseva, Imperial College, London

Cardiovascular disease (CVD) is a leading cause of mortality accounting for 17.5 million deaths every year globally and 4.3 million deaths every year in Europe. The proportion of all deaths attributable to CVD is greater among women (49%) than in men (40%), with large geographic inequalities between countries.

The aim of the Joint European Societies Guidelines on CVD prevention is to improve the practice of preventive cardiology through development of national guidelines and their implementation in everyday clinical practice. Guideline implementation in Europe has been evaluated with five EUROASPIRE surveys starting in mid 1990s. The results showed poor lifestyle and risk factor management in patients with coronary heart disease (CHD) and in people at high risk of developing CVD. A comparison across the recent three surveys showed adverse lifestyle trends and a substantial increase in obesity, central obesity and diabetes. Despite significant improvement of blood pressure and lipid control many patients were not reaching the risk factor goals and there was no change in glucose control. Comparing the most recent two surveys, there were no major differences in lifestyle and risk factor management in people at high risk of developing CVD.

Passive dissemination of guidelines in isolation is generally ineffective and results in only small changes in practice. The challenge is to motivate and support more physicians to routinely practice CVD prevention. A new more comprehensive and professional approach is needed, integrating primary and secondary prevention into a modern preventive cardiology programme. All high CVD risk patients require multidisciplinary programme, adapted to medical and cultural settings in each country, combining a lifestyle intervention with effective risk factor management to achieve better risk factor control and adherence with cardioprotective medications, and to reduce the risk of future cardiovascular events

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Professor Kornelia Kotseva MD, PhD, FESC is a Senior Clinical Research Fellow at the Department of Cardiovascular Medicine, National Heart and Lung Institute, Imperial College London and holds positions as Consultant Cardiologist at the Imperial College Healthcare NHS Trust and as Visiting Professor of Cardiovascular Epidemiology and Prevention at the Department of Public Health, University of Ghent, Belgium. Her main research interests are in lipids, blood pressure, diabetes, and prevention of cardiovascular disease. She is a Chair of the Scientific Steering Committee of the European Society of Cardiology EUROASPIRE IV and V surveys in 27 European countries, aiming to describe the lifestyle and risk factor management in patients with coronary heart disease and in people at high risk of developing cardiovascular disease. Furthermore, she was a Principal Investigator of the EUROASPIRE III Health Economics study and a medical coordinator of the European Society of Cardiology EUROASPIRE III survey, the British Cardiovascular Society ASPIRE-2-PREVENT and ASPIRE-2-PREVENT survey and the European Society of Cardiology EUROACTION and EUROACTION PLUS studies. Professor Kotseva has won numerous prestigious awards and has authored more than 160 publications in peer reviewed journals, two textbooks and chapters for a further eight textbooks. She is a member of the International Editorial Board of the European Journal of Preventive Cardiology, a past member of the Nucleus of the former European Society of Cardiology Working Group on Epidemiology and Prevention and a Member of the Research Council of the Foundation for Circulatory Health (FFCH), International Centre for Circulatory Health, NHLI, Imperial College London. She teaches at the Master’s Certificate of Advanced and Short Course programme in ‘Preventive Cardiology – Cardiovascular Health and Disease Prevention’ at Imperial College London and leads the module on Cardiovascular Risk Estimation for the Imperial College MSc in Preventive Cardiology.

Mediterranean Diet to prevent heart disease
Professor Ramon Estruch, University of Barcelona, Spain

ramon-estruchProfessor Ramon Estruch is Senior Consultant at the Internal Medicine Department of the Hospital Clinic (Barcelona) since 2002. He is also Associate Professor at the Barcelona University since 1996, Member of the Board of Directors of the CIBER Obesity and Nutrition, Institute of Health “Carlos III”, Government of Spain, since 2006 and Member of the Advisory Board of the ERAB (European Foundation for Alcohol Research) from European Union since 2010. The main research lines developed are the following: 1) Cardiovascular effects of Mediterranean diet 2) Mechanisms of the effects of moderate wine and beer intake: Effects on the expression and function of cellular and endothelial adhesion molecules related to development of atherosclerosis; 3) Effects of chronic alcohol consumption on heart, liver and brain; 4) Effects of different alcoholic beverages on immune system; 5) Effects of olive oil, nuts and cocoa in lipid profile and inflammatory biomarkers related to atherosclerosis. In the last years, his group has received grants from the European Commission, National Institute of Health (NIH and NIAAA) from USA, CICYT, Instituto Nacional de Investigación Agroalimentaria (INIA) del Ministerio de Educación y Ciencia, Fondo de Investigación Sanitaria (FIS) and Instituto de Salud Carlos III (ISCIII). In addition, Prof. Estruch is the leader of the Thematic Network “Mediterranean Diet and Cardiovascular Disease” from the ISCIII.

How fit for purpose is UK Party policy on preventing heart and circulatory disease?
Professor Donald Singer, Fellowship of Postgraduate Medicine, London

Disorders of the heart, brain and circulation are the commonest cause of death and disease in adults in developed countries. Much of the burden of premature disabling and fatal disorders of the heart and circulation in the UK is preventable. However several key contributors to these diseases are epidemic in the UK, including obesity, diabetes and related cardiovascular risk factors. Political leaders and their parties have a major role to play in shaping public policy on measures to promote the health of the nation.  General elections were held in the UK in 2015 and again in 2017. These provided opportunities for major political parties to declare their major policies to be continued or developed, including on health matters. Heart health-related aspects of the general election manifesto for 2015 and 2017 for each of the 7 major UK political parties were assessed. This talk will consider the extent to which these important policy documents feature the public health measures needed to address as far as possible the major preventable risk factors for preventable heart and vascular disease in the UK.

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Professor Donald Singer is a clinical pharmacologist interested in drug discovery, prevention and treatment of cardiovascular disease, and improving safety and effectiveness in use of medicines. He is also interested in promoting better public understanding of the benefits and risks of medicines. He trained in Medicine in Aberdeen, at the Hammersmith Hospital, at Charing Cross and Westminster Medical School and then at St Georges Hospital Medical School and at Heart Science Centre of the Imperial College. He was foundation holder of the Chair of Clinical Pharmacology and Therapeutics at Warwick University and has since worked on the faculty of Yale University and as a clinical pharmacologist on the Human Resources for Health Programme for Rwanda advising on systems for pharmacovigilance. He is President of the Fellowship of Postgraduate Medicine and a member of the Healthcare Professionals’ Working Party of the European Medicines Agency. He was formerly a member for of the Council of the British Pharmacological Society. He is a member of the Executive Committee of the Europe an Association of Clinical Pharmacology and Therapeutics, which supports scientific and educational exchange for over 4000 clinical pharmacologists from 32 countries.

Personalising heart medicines to improve cardiovascular health: is precision medicine always cost-effective versus one-size- fits-all medicine?
Professor Ken Redekop, Erasmus University, The Netherlands

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Precision medicine (PM) refers to the separation of patients into more homogeneous subgroups, with the rationale being that patients who will benefit from a treatment should receive the treatment while patients who will not benefit should not. Recent developments in areas like genomics have led to sky- high expectations about PM and the vision of a world where “the right patient receives the right treatment at the right time”. But is PM always better than the alternatives? One recent example of PM in cardiovascular health relates to antiplatelet therapy after acute coronary syndrome. While one can opt to give all patients the same drug (e.g., clopidogrel, ticagrelor or prasugrel), one can also apply a precision medicine strategy where patients undergo testing to determine which drug is best for a particular patient. However, the cost-effectiveness of this strategy depends on different factors, including costs (of the test and the treatment), the effectiveness of the different drugs and life expectancy. As a result, precision medicine may not necessarily be cost-effective versus the alternative of giving all patients the same drug. A valid and comprehensive assessment is required to help healthcare professionals and policymakers decide which treatment strategy is the best one in a particular situation. When all factors (including cost-effectiveness) are considered, a precision medicine strategy may or may not be the best one in the effort to improve cardiovascular health, and health outcomes in general.

Heart surgery in developing countries
Mr Wade Dimitri, University of Warwick

Today open heart surgery (OHS) is barely 65 years old and is regarded as one of the major medical and technological advances of the 20th century, performed effortlessly on all patients of all ages from neonates to octogenarians with advanced cardiac pathologies. It is estimated that more than 4000 procedures are performed daily worldwide with a mortality of less than 2% in the majority of patients undergoing OHS in developed countries. This talk will consider efforts and challenges in aiming to make effective heart surgery available in developing countries. Cardiovascular disease accounts for over a quarter of deaths in the UK and most other western countries and is the most common cause of death in the developed world. It also accounts for an a surprisingly burden of disease in less developed countries (LDCs), although accurate statistics are hard to obtain; its true incidence and impact on the individual and the healthcare system in LDCs are largely unknown. Since its beginnings, Cardiothoracic surgery in the UK has led the development and refinement of many techniques and health technologies and has resulted in significant reduction in cardiovascular mortality and morbidity. Such progress and improvements have not followed in the developing world where mortality and morbidity remain high, approaching 60% in certain countries. The reasons are multifactorial and include concomitant diseases, lack of access to medical care leading to advanced disease at presentation, as well as lack of effective pre-operative preparation and post-operative care.

Urgent efforts are needed to reverse this trend and improve outcomes of adults and children with heart disease undergoing heart surgery. Numerous concerted efforts have evolved over time: the most effective have been widespread sustainable programmes delivered as a collaboration between recipient LDC centres twinning with well-established centres offering technical, educational and financial support. These collaborative programs in cardiothoracic surgery in developing countries should take into consideration social, political as well as economic factors.

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Wade R Dimitri FRCS is a cardiac surgeon. Since retiring from active clinical work, he has increased his involvement with overseas training, teaching cardiac surgeons as well as operating. He is a Tutor at Warwick Medical School where he is a member of the Panel of Examiners. His main areas of interest are Beating Heart (Off Pump) Coronary Artery Bypass Grafting, Minimally Invasive Cardiac Valvular Surgery and developments in Cardiopulmonary Bypass Technologies. He went to a De La Salle school in Alexandria, Egypt and later graduated from Alexandria University Medical School in 1969 with Honours degree. His entire postgraduate training was acquired in the UK. This included several rotational posts in Cardiac surgery in major London teaching Hospitals leading to his appointment as Senior Lecturer and Honorary Consultant in Glasgow then NHS Consultant at the University Hospital in Coventry. He is a member of several Cardiac Surgical Societies including The Society for Cardiothoracic Surgery in Great Britain and Ireland, The Society of Thoracic Surgeons (USA), Scottish Cardiac Society, The Egyptian Society Of Cardiovascular and Thoracic Surgery and an Honorary fellow of The Indian Society of Cardiovascular and Thoracic Surgeon. He is a Council Member of the Fellowship of Postgraduate Medicine and a member of the RSM. He is a reviewer for The European Journal Of Cardiovascular and Thoracic Surgery as well as Injury.

Carotid artery disease and Stroke Prevention
Alison Halliday, Professor of Vascular Surgical Sciences, Nuffield Department of Surgical Sciences, University of Oxford

Stroke causes many thousands of deaths in the UK every year and is the country’s leading cause of disability. Billions of pounds are spent on treating the causes and the results of stroke – hypertension, heart disease, diabetes, smoking, but the greatest risk factor is age, and, despite attention to known modifiable risk factors, the numbers of new and recurrent strokes have not fallen significantly in recent years. A small proportion can be treated by acute thrombectomy and resources and effort are now being poured into this area; effectiveness of thrombectomy is, however, limited by the need to present to an acute unit within the first 4-6 hours of stroke, and by the availability of specialist neuro-intervention. Ischaemic stroke is more often due to carotid artery disease, and this talk aims to outline the evidence for intervention, both after acute stroke and transient ischaemic events and as a primary prevention measure, where severe carotid artery disease has raised the risk of stroke, but stroke has not yet happened.

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Alison Halliday is a Consultant Vascular Surgeon whose main interest is in Carotid Surgery and Stroke Prevention. She is Principal Investigator in the Asymptomatic Carotid Surgery Trial (ACST-1), one of the world’s largest clinical

surgery trials, involving thousands of patients from 30 countries. The group reported that prophylactic surgery removing tight carotid artery narrowing (carotid endarterectomy) prevents future fatal & disabling strokes for at least 10 yrs; this finding has changed worldwide surgical and stroke practice (Lancet 2004, 2010). Her group instigated and reported (the UK Carotid Surgery Audit (2005-8), the largest National Audit of carotid surgery in the UK – this work highlighted shortcomings in the NHS process of referral and of carrying out prompt carotid artery surgery. Working with the National Stroke Strategy this has provided a driver for preventing Stroke by improving surgical services. Collaborative research includes government-funded work (NIHR), working with the University of Oxford Clinical Trial Service Unit (CTSU), evaluating 2 stroke prevention technologies in ACST-2, a large International Trial comparing Carotid Endarterectomy with Carotid Artery Stenting. This work enables surgeons, stroke physicians, neurologists, cardiologists and interventional radiologists from many countries to work together.

Chair: Professor Allister Vale, University of Birmingham

OLYMPUS DIGITAL CAMERAProfessor Allister Vale is consultant clinical pharmacologist and toxicologist and former Director of the National Poisons Information Service (Birmingham Unit) and the West Midlands Poisons Unit, City Hospital, Birmingham, UK. He holds a professorial appointment in the University of Birmingham. He has served as President of the British Toxicology Society, of the European Association of Poisons Centres and Clinical Toxicologists and of the Clinical and Translational Toxicology Specialty Section of the Society of Toxicology. He has also been a Trustee of the American Academy of Clinical Toxicology for six years and was awarded the Academy’s Lifetime Achievement Award in 2009, the only non-North American to be so honoured. He is a former Medical Director of the MRCP(UK) Examination and a Censor of the Royal College of Physicians.

Chair: Dr David Slovick, London