CARDIOLOGY
significantly. Patients were very pleased with the new service and felt involved; their needs were fully met and their concerns were addressed.
l The levels of medicines optimisation post MI were improved significantly. For example, the optimisation of ACE inhibitors dosing was improved from 16% to 74% and Beta blocker dosing from 6% to 46% only after one visit. Multiple barriers to adherence were identified and addressed.
l The levels of adherence to secondary prevention medicines as measured at 3-6 months post attending clinic improved significantly.
l The new service created capacity within the cardiology outpatient clinics leading to reducing the waiting time to be seen post discharge by over 50%.
l The ACS readmission rate after introducing the service was reduced by around 50% compared to standard care before introducing the project.
l Persistence on optimal secondary prevention medicines at 10-12 months post discharge was significantly improved compared to standard care (70% vs. 30% respectively).
l The patients loved the MYMEDS questionnaire and found it very useful to help them to think about all medicines related issues in advance. This made the consultation more structured and relevant to patients.
Another successful project has focused on improving lipid management, providing patients with better access to innovative medicines – such as PCSK9 inhibitors,
through a collaborative MDT approach. The plan was for a clinic to be led by a consultant pharmacist and supported by a cardiology nurse. After the service was established an advanced pharmacist was recruited to support the bulk of the service. The service runs two clinics per week and includes additional time for follow ups with phone calls, supply and monitoring. Suitable patients are invited to attend the clinic and offered the medicines as per guidelines. Appropriate blood tests are carried out at baseline. Patients who agree to try the medicine are provided with full education about the medicines and how to administer the injectable drug, how to dispose of it, and how to store it safely. One dose is administered in clinic and a second is given to the patient to administer two weeks after. Patients are followed up by two phone calls to discuss experience and decide if they want to continue. Only then additional injections are supplied. At three months, the response to PCSK9i is evaluated. Therapy is continued in patients with good response and adherence. The reported results,3
described in full on
the NICE Shared Learning website, included: l Those on PCSK9i + statin had a greater reduction in LDL-C vs those on PCSK9i monotherapy (69% vs 51% reduction, respectively).
l Two patients on PCSK9i monotherapy (9%) had <35% reduction in LDL-C and the addition of Ezetimibe provided a further 15% reduction in LDL-C.
l Due to possible adverse drug reactions (ADR), two patients were switched from Evolocumab to Alirocumab 75mg (with
Innovations in the treatment of heart failure
The conference also provided an insight into innovation, including developments in the area of pulmonary artery pressure monitoring. Significant progress has been made by the NHS to adopt and access innovative technology, pharmaceuticals, devices and diagnostics. Jane Roxburgh, regional director, electrophysiology & heart failure, EMEA North, Abbott, explained how the Accelerated Access Collaborative is now firmly established in improving the spread of these key innovations. Two innovations from the company have already been supported by that work: l Flash Glucose Monitoring (Freestyle Libre) is available on the NHS to a specific group of patients with type 1 diabetes. The technology eliminates the need for patients to perform finger-prick testing to monitor their glucose levels. l High Sensitivity Troponin testing is
also an aide in the early rule out of myocardial infarction.
The MedTech funding mandate also aims to support getting innovative medical devices, diagnostics and digital products to patients faster. This will commit to accelerating selected NICE-approved devices that are effective, deliver material savings to the NHS, and are cost-saving and affordable. “If we look at heart failure specifically, this is a costly disease. It’s a significant and growing burden on the NHS and it accounts for around about 5% of all hospital admissions. Looking at the evolution of healthcare in heart failure, with new treatments being introduced, this enables patients to live longer. Therefore, the number of patients that any heart failure heath service manages will increase year on year, so it increases the burden. One key question is how industry
40 l
WWW.CLINICALSERVICESJOURNAL.COM
can support the NHS to reduce hospital admissions and ultimately improve outcomes for patients,” commented Roxburgh.
She offered an insight into CardioMEMS – a pulmonary artery pressure monitor that communicates a sensor inserted into the pulmonary artery. The technology provides the clinician with a daily update on the patient’s status allowing them to make a decision on treatment.
In the CHAMPION trial, significant reductions in admissions to hospital for heart failure were seen after six months of pulmonary artery pressure guided management compared with usual care. Over the randomised access period, rates of admissions to hospital for heart failure were reduced in the treatment group by 33% (hazard ratio [HR] 0·67 [95% CI 0·55-0·80]; p<0·0001) compared with the control group.4
AUGUST 2020
good outcome). Four (17%) stopped treatment altogether due to assumed ADR and non-adherence.
l At 12 months, mean TC was 4.2 (46% reduction) and LDL-C was 1.9 (64% reduction).
“This is just a glimpse of what we do. We are also working with the University of Leeds, to look at how we can integrate artificial intelligence into our consultations to make them more patient centric. We also use several virtual clinics to support our heart failure nurses, our cardiac rehab teams, and primary care healthcare professionals to better optimise cardiovascular medicines at different time points in the healthcare continuum. Ultimately, to deliver improvement, it is important to think outside the box, about patient centricity and MDT working,” concluded Dr. Khatib. Dr. Riyaz Patel, consultant cardiologist and clinical lead for cardiovascular disease prevention, Barts Health NHS Trust, continued the discussion from a secondary care perspective, highlighting the need to cross traditional healthcare boundaries to have a real impact on patient outcomes “In 2015, we opened up a fantastic new
heart centre, the Bart’s Heart Centre – the largest in the country and one of the largest in Europe. It is a magnificent centre and if you haven’t visited, you should drop by. It has incredible volumes of patients coming through it, but it sits at the doorstep of East London, covering some of the most deprived areas with the highest premature cardiovascular mortality rates in the country. How could we sit there in all good
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