Onwards and upwards in cardiology

President of the Irish Cardiac Society Prof Jim Crowley spoke with Pat Kelly ahead of the Society’s upcoming Annual Scientific Meeting and AGM about the past, present and future of cardiac care in Ireland

The Irish Cardiac Society (ICS) Annual Scientific Meeting and AGM will see a range of distinguished speakers and marks the 70th anniversary of the ICS. From humble beginnings, the Society has grown to become highly influential nationally and internationally and has built important links with other cardiology groups worldwide, explained ICS President Prof Jim Crowley.

“When we were established in 1949, it was really just a small group of physicians with a special interest in cardiology,” Prof Crowley told the Medical Independent (MI). “Cardiology was hardly even recognised as a specialty at that time but it had goals for education, research and training right from the beginning, so it is interesting to see how it has grown — we are expecting around 400 delegates to the meeting in Galway, for example, so there has been a huge change in the landscape of cardiology during those 70 years.”

One result of that change in landscape has been a decline in cardiac mortalities, said Prof Crowley, which indicates that the development of the specialty in Ireland has been something of a success story. “Even in the past 20 years, there has been a drop of almost half in the number of people who die from heart disease,” he continued. “Longevity has also improved for both men and women and much of that is due to a reduction in cardiac mortalities. Part of that is also due to changes in Irish society itself and how cardiac care is delivered.”

Innovations

Practically all of the major advances in Irish cardiology have involved the ICS, in conjunction with decisions made by Government and other policy-makers. “We have been instrumental in encouraging and pushing Government to make certain decisions over the past 70 years and there are a lot of new procedures taking place, such as coronary angiography; we have programmes now that deal with patients’ treatment for emergency heart attacks and there is a lot of innovative equipment that we use for non-invasive imaging now, for example.”

This year, the conference will, for the first time, feature a session on medical innovations, which reflects the changes in the way cardiology is now delivered in Ireland. “Cardiology, in particular, is one of the specialties in which there has been very strong innovation over the years, with developments in new devices, new procedures, equipment that allows different measurements to assess patients’ outcomes, invasive and non-invasive monitors and devices that allow us to monitor when a patient’s condition deteriorates so we can intervene early,” Prof Crowley explained.

“Ireland has been a centre of those innovations in a lot of ways over the past 20 years, with large companies, as well as a lot of smaller indigenous start-up companies that have been developing these devices that have been moved on into industry,” he told MI. “There have also been close links between those companies and the universities and academia, so I think this medical innovations session helps to highlight the links between cardiology innovations in Ireland and universities, the ICS, clinicians and industry.”

He also highlighted the establishment of the multiplanar reconstruction committee, which will examine how hospitals can be equipped with devices and resources so that hospitals can better deal with cardiac patients over the next 10-to-15 years. “Along with that, we will need strategies to manage conditions like heart failure and a lot of that will need to be in the community,” explained Prof Crowley. “We will need strategies to enable patients to be assessed in the community. If we find that their heart failure is going to deteriorate, then we can intervene earlier and so reduce the need for hospital care. It has been well proven by studies in Ireland and abroad – if you can intervene at an earlier stage, hospitalisation rates can be dramatically reduced.”

Challenges

Prof Crowley also drew attention to the Primary PCI (percutaneous coronary intervention) programme, which allows patients who suffer certain forms of heart attack to be brought to cardiac cath labs across Ireland, regardless of where they live. “That is also driving down mortality rates,” he pointed out. “Phase 2 of that will focus on non-STEMI heart attacks. These patients do not need an angiogram as an emergency procedure, but they do require one during the course of their hospital stay and managing these patients logistically is going to be a challenge, because they outnumber the STEMI group by about four-to-one,” he explained.

Another area that will require change is risk management, said Prof Crowley. This is an area that has been subject to increased focus and will require management strategies, both in the community and hospital settings.

Attendees at the meeting will also receive a historical booklet providing an overview of the Society over the past 70 years, which will provide readers with perspective regarding how far the ICS has come. “It provides a flavour of how these changes have come about, reflected by presentations in the ICS over the past 70 years,” he said.

The meeting will hear a presentation from Prof Salim Yusef, a world-renowned cardiologist and past-President of the World Heart Federation, who will deliver this year’s Stokes Lecture. “It’s very exciting to have him as a speaker,” stated Prof Crowley. “He will speak about the various trials and innovations in advances in clinical cardiology in which he has been involved throughout his career. He has been involved in some of the major clinical trials in cardiology over the past 30 or 40 years, stretching back to the time when we began thrombolytic therapy, and also trials in large epidemiological studies that have defined the risks that are associated with heart disease, as well as some of the newer drug therapies for patients with peripheral vascular disease and coronary artery disease.

“It will be very exciting to hear his take on the history of cardiology over that time and where he thinks it will go from here.” Other speakers at the conference will include the President of the British Cardiovascular Society, the incoming President of the European Society of Cardiology (ESC) and two American College of Cardiology (ACC) past-Presidents and Prof Crowley was keen to emphasise the work that the ICS has put in to foster links with similar organisations in other jurisdictions. The importance of these relationships should not be underestimated, he pointed out. “We have very strong links with the ESC, British Cardiac Society and ACC in particular,” he told MI. “We invite members of those societies and they have come every year and there are a number of former Presidents of the ACC who attend every year. These are very influential, world-renowned cardiologists. We are also becoming increasingly integrated with the ESC and we encourage all of our trainees to go abroad to world-class training centres for the last two years of their training,” said Prof Crowley, who is joint national speciality director for the SpR training programme along with Prof Brendan McAdam.

‘Mega-centres’

“This means that all of our trainees gain exposure to the mega-centres of cardiology. We want them to see what can be done when you do have the resources so that when they come back, they can aspire to bringing change to their local centres in Ireland – we have relied on that over the last 30-to-40 years,” he continued. “When they come back, they bring new technologies and new approaches, and they also come back with new ideas on how centres can be developed in Ireland. We have relied on that to help bring change and cutting-edge treatments in Irish cardiology.”

He also addressed the issue of these doctors choosing not to return to Ireland, a concern that cardiology shares with many other specialties. “We conducted a survey recently which showed that from the time the programme was established in 1998, over a 10-year period, between 60 and 70 per cent of the trainees who go abroad eventually come back to Ireland. Of the ones who choose not to return, they provide important links for the new crop of trainees because these doctors become consultants in large centres across the world and provide links for the next crop of trainees,” he explained.

Prof Crowley also spoke briefly about the iAspire study, details of which will be presented at the meeting by Prof Bill McEvoy. “This study is part of the EuroAspire group of studies, which were designed to look at how well we are adhering to current guidelines for patients with acute coronary syndrome,” he said. “All of these patients need to be put on appropriate medical therapy and to have their risk factors treated aggressively — we need to get their cholesterol down to appropriate levels, get their blood pressure under control, manage their diabetes, get them to stop smoking, and so on. The EuroAspire study looks at how well we are dealing with these, the highest-risk group of patients. The iAspire study looks in depth at how well we are doing this in Ireland.”

Prof Crowley concluded by stating: “From my point of view, it is important that in the future, we start looking at the Government review of hospital management [of cardiology treatment] and programmes that address the management of acute coronary syndrome. We also need to look at how to develop electrophysiology services further across Ireland, because the demand is much higher than our capacity to deliver at the moment, and we also need to look at developing community services and primary prevention.”