Undergraduate Journal Cardiovascular Medicine 2012

The Undergraduate Journal of

Cardiovascular Medicine1st edition, november 2012

www.heartsoc.co.uk

The future ofcardiovascular

medicine?cardiac regeneration medicine: synthetic

cardiac grafts

National Undergraduate Cardiovascular Conference 2012

Approved by the British Cardiovascular Society, the fi rst ever National Undergraduate Cardiovascular Conference will be held at Southampton General Hospital on Saturday, 3rd November 2012. Targeted at undergraduates and junior doctors, this conference aims to: •Provide an insight into career options and the diff erences between the various cardiovascular specialties.

•Highlight important and interesting recent research fi ndings that relate to each specialty.

•Provide an opportunity for students involved in cardiovascular research to present their work either orally or as a poster to an audience of interested students and a jury of clinicians and researchers.

•Provide a networking opportunity, aiming to increase collaboration between students from diff erent universities with a view to creating a national cardiovascular community for undergraduates and a circuit of educational, skill building and career development events across the country.

We expect wide participation in this exciting event from many students at universities around the UK and abroad.

The organising committee would like to thank the British Cardiovascular Society and the Cardiology Department at Southampton General Hospital for their help and support during the organisation of this conference. We would also like to thank the following sponsors for making this event possible:

3

foreword

The Undergraduate Journal of Cardiovascular Medicine: 1st edition, November 2012.

Cardiology remains one of the most exciting and rapidly evolving specialties in the whole of medicine and, as a result, always tends to attract high quality trainees. This is fortunate as cardiovascular disease accounts for a large proportion of the patients seen both in hospital and in primary care and remains one of the biggest killers in modern Western society.

It was as a 3rd year medical student that I first became attracted to Cardiology as a specialty and I hope this national undergraduate cardiovascular conference will serve as a catalyst for many of you to pursue a similar path. Cardiology has always been a fascinating and rewarding specialty. The clinical and research developments in cardiology have been massive and eclipsed most other specialties. There is no indication that this rapid pace of development in cardiology is likely to slow down over the duration of your own careers in medicine. I must congratulate the organisers of the National Undergraduate Cardiovascular Conference 2012 for putting together such an excellent programme spanning both research and a spectrum of clinical specialties in modern cardiovascular care. It will give you a valuable insight into why cardiovascular medicine remains one of the most innovative, challenging and, above all, rewarding areas of modern medicine. I am sure you will have a fantastic day.

Iain A Simpson MD FRCP FACC FESC Consultant Cardiologist and President, British Cardiovascular Society

4

the committeePresident

Alexander Bush

Speakers & Seminars

Hwai Jing Hiew

Speakers & Seminars

Qian Yue Tan

Treasurer & Sponsorships

Michael Stephanou

Research Presentation

Hamed Hajiesmaeili

Research Presentation

Stelios Iacovides

Publications & Media

Ka Ho Oscar Chiu

Committee Support

Aman

Chungh

Stephanie

Kwok

Luke

Michael

Claire

McAleer

Avinash Segaran


5

contents

Programme 6 Speakers Biographies 8 Abstracts:

• The Panel 12

• Oral Presentations 14

• Poster Presentations 16 Delegate Information 24


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programme

08:00 – 09:00 Registration

09:00 – 09:15 Welcome

09:15 – 10:00 Keynote Address: Cardiac Regenerative Medicine – Synthetic Coronary Grafts

-Professor Alexandar Seifalian

10:00 – 10:45 Electrophysiology -Dr. Arthur Yue

10:45 – 11:15 Coffee/Poster Presentations

11:15 – 12:00 Percutaneous Coronary Intervention (PCI) -Dr. Andrew Whittaker

12:00 – 12:45 Heart Failure, Basic Pacing and Devices -Dr. Andrew Flett

12.45 – 13:45 Lunch/Poster Presentations

13:45 – 14:30 Oral Presentations

14:30 – 15:15 Non-invasive Cardiac Imaging -Dr. Dhrubo Rakhit

15:15 – 16:00 Adult Congenital Heart Disease -Dr. Aisling Carroll

16:00 – 16:15 Coffee/Poster Presentations

16:15 – 17:00 Cardiothoracic Surgery -Mr. Nicola Viola

17:00 – 17:30 How to get there? Tips on CV writing and getting the job -Dr. Abdul-Majeed Salmasi

17:30 – 18:00 Closing and Prize Presentations


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the speakersKeynote Speaker: Professor Alexander Seifalian

Dr. Alex Seifalian is a Professor of Nanotechnology and Regenerative Medicine at the Division of Surgery & Interventional Science, University College of London, UK. His breakthrough work in bypass grafts for cardiovascular treatment saw the Professor awarded the 2007 'Winner of The Overall Cardiovascular Innovation Award' by the prestigious Medical Futures Innovation Awards panel, while his work on harnessing nanotechnology for implanted

devices has resulted in the development of 'NASA style' nanotechnology coatings for bypass grafts used in heart and blood vessel surgery.

His research interests include development of nanomaterials, development of cardiovascular implants, development of nanofluorescence particle including quantum dots for localization and treatment of cancer, stem cells for development of organs using tissue engineering, development of organs using biodegradation nanomaterials and stem cells, including liver and intestine, hepatic microcirculation and oxygenation using an optical technique, ischemia repercussion injury and preconditioning. In fact, the team lead by Dr. Seifalian patented a nanocomposite material that was used to create the first ever completely synthetic windpipe.

Dr. Arthur Yue

Dr. Yue is currently a consultant cardiologist and electrophysiologist at University Hospital Southampton. Having trained in Oxford University, he completed his specialty cardiology training at Southampton University Hospital and Oxford John Radcliffe Hospital. His sub‑specialty interest involves the diagnosis and management of all forms of heart rhythm disorders and conditions associated with sudden cardiac death. He is fully trained in the implantation and follow-up of pacemakers for treatment of bradyarrhythmias, defibrillators (ICD) for prevention of sudden death, and cardiac resynchronization therapy (CRT) devices for treatment of heart failure. For catheter ablations, he utilizes both conventional techniques and three‑dimensional mapping technologies to investigate and target complex arrhythmic substrates.

(Adapted from: http://www.uhs.nhs.uk/ContactUs/Directoryofconsultants/DirectoryofconsultantsY/YueDrArthur.aspx)


the speakers

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Dr. Andrew Whittaker Dr. Whittaker is currently a 4th year Cardiology Specialty Registrar training in Interventional Cardiology. From January 2013 he will be the Interventional Cardiology Fellow at Wessex Cardiothoracic Centre. He qualified from University of Leicester Medical School in 2000 and completed his PRHO and SHO training in Leicester. After gaining MRCP he undertook a 3-year period of research in cardiovascular medicine for which he was awarded a Doctorate in Medicine. His research project was titled The Role of Endothelial Progenitor Cells in the Aetiology and Pathogenesis of Coronary Artery Disease. He subsequently entered Specialist Registrar

training in Cardiology and is currently enjoying his training in the Wessex Deanery. His sub-specialty interest is Interventional Cardiology (percutaneous coronary and valvular interventions). Dr. Whittaker maintains an interest in clinical research with special interest in coronary artery disease pathophysiology, endothelial dysfunction and repair, cardiovascular genetics, and cellular reparative mechanisms in cardiovascular disease.

Dr. Andrew Flett Dr. Flett is a recently appointed consultant in heart failure and devices commencing February 2013 at University Hospital Southampton. He trained in advanced heart failure management at the heart hospital in London and recently set-up the second ultrafiltration service in the country.

His research interests are in cardiovascular magnetic resonance having developed a pioneering method to quantify the myocardial extracellular space as British Heart Foundation clinical research fellow. He is also the Vice chairman of the Society for Cardiovascular Magnetic Resonance web committee. He has developed an online CMR academy and authored several book chapters. He has presented his work at national and international meetings and won 2 young investigator awards.

Dr. Dhrubo Rakhit Dr. Rakhit graduated from Charing Cross and Westminster Medical School in 1993 and trained as a Cardiologist in London. He is a specialist in all types of echocardiography, including 3D echo, tissue Doppler, stress and contrast echo, transoesophageal echocardiography (TOE) and optimisation echo for patients with pacing devices. He has presented his work

at a number of prestigious national and international meetings and completed his PhD titled 'The Use of Echocardiography to Screen High-Risk Patients for Subclinical Cardiac Disease in 2006. Dr. Rakhit has also developed the 3D TOE and stress echo services within the trust and established the digital archiving system for echo.

(Adapted from: http://www.uhs.nhs.uk/ContactUs/Directoryofconsultants/DirectoryofconsultantsR/RakhitDrDhrubo.aspx)


the speakers


Dr. Aisling Carroll

Dr. Carroll is a consultant cardiologist specialising in adult congenital heart disease at Southampton General Hospital. She graduated from National University of Ireland, Galway and completed her sub-specialty Cardiology Fellowships in adult congenital heart disease, heart failure and cardiac transplantation at Mayo Clinic, Minnesota, USA. She is a prominent speaker having given many talks in various cardiology and congenital heart disease conferences.

Mr. Nicola Viola

At University Hospital Southampton, he is the surgical lead and certified specialist for the extracorporeal life support (ECLS) program.

He has contributed to a number of peer-reviewed articles and several chapters in surgical textbooks and is author of the award-winning textbook “Key Questions in Cardiac Surgery”, now included in the surgical curriculum of the American Association of Directors of Cardiothoracic Surgery Programs.

He has presented at national and international meetings on congenital cardiac surgery and quality control.

(Adapted from: http://www.uhs.nhs.uk/ContactUs/Directoryofconsultants/DirectoryofconsultantsV/ViolaMrNicola.aspx)

Dr. Abdul-Majeed Salmasi Dr. Salmasi is a Senior Research Fellow at the National Heart and Lung Institute, Imperial College London and a Consultant Cardiologist. He is the Director of Cardiovascular Teaching and Training at NHS Brent.

He obtained his PhD in Medicine from St. Mary's Hospital medical school (currently Imperial College London) and continued his training in cardiology at St. Mary's Hospital, London. He has edited four postgraduate textbooks in Cardiology and till now published 50 original articles in the cardiovascular filed.

He is a fellow of the European Society of Cardiology, Fellow of the American College of Cardiology and a Fellow of the Faculty of Public Health at the Royal College of Physicians of London. His main research interest is left ventricular hypertrophy and the relation between hypertension and glucose intolerance, atrial fibrillation and cardiovascular changes in autoimmune diseases.

(Adapted from: http://www1.imperial.ac.uk/medicine/people/a.salmasi/)

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Second Second Second eeeditionditiondition

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abstracts


The core around which this conference is based is the cardiovascular research being conducted by undergraduates around the country. This year, four students will be presenting their research during an oral plenary session. Up to 20 more students will be presenting their work as a poster. This represents a fantastic opportunity for undergraduates involved in cardiovascular research to present their work to a national audience of interested students, and to our faculty of leading cardiovascular researchers.

The Panel Dr. Simon Corbett Dr Corbett is a consultant cardiologist at University Hospital Southampton. He is fully trained in all aspects of coronary intervention including formative experience with renowned pioneer and innovator, Dr Antonio Colombo in Milan. Principal clinical interests are the use of angioplasty to treat heart attacks and the use of intra-vascular ultrasound and pressure wires to assess and guide treatment of coronary artery narrowings. My main research interests are participation in multi-centre, randomised clinical trials and local research projects evaluating the coronary pressure wire and measurement of platelet reactivity.

Professor Nick Curzen Prof Curzen is a consultant cardiologist and Professor of interventional cardiology at University Hospital Southampton. He specialises in percutaneous coronary and aortic valve intervention. He is the co-editor of three cardiology textbooks including the Oxford Textbook of Interventional Cardiology as well as authors of 21 book chapters and 120 peer-reviewed papers. He has won numerous research prizes including the John Hart Research Prize. He was the expert adviser on treatment of heart attack to Prime Ministers Directive Unit in 2004 and he is currently the honorary secretary of the British Cardiovascular Intervention Society. Professor Huon Gray Professor Gray is a consultant cardiologist with interests in interventional cardiology. Trained as a registrar in Brompton and St. George’s Hospital London, Prof Gray has been working as a consultant in University Hospital Southampton since 1989. He has over 100 publications in various aspects of cardiology and has won the ACCEA Gold Award in 2005. He has held a number of important posts including the president of the British Cardiac Society between 2003 and 2005.

12

13

abstracts


Dr. Paul Roberts Dr Roberts is a consultant cardiologist at University Hospital Southampton specialising in cardiac rhythm management. He is an experienced interventional electrophysiologist with particular expertise in device implantation (pacemakers, ICDs, and cardiac resynchronization devices) and catheter ablation. He was appointed to European Heart Rhythm Association Electrophysiology Accredidation Committee in 2008 and is an active participant in clinical research with over 130 published abstracts, 50 peer-reviewed publications and has edited 2 books for the Royal College of Physicians and written 6 book chapters.

Dr. Michael Griksaitis Michael completed his undergraduate training at Newcastle University, and went on to complete his Paediatric Membership in the Northern Deanery. He then took up a position in Paediatric Cardiology at Southampton and then subsequently Paediatric Intensive Care, to become a paediatric cardiac intensivist. His research interests and publications include trauma physiology, specifically monitoring cardiac function and cardiac output during haemorrhage and medical education. He has recently published a textbook on Paediatric Cardiology, designed to combine the basic sciences with clinical skills for junior doctors on PICU and Cardiology. Outside of work, Michael enjoys underwater photography and surfing.

Dr. James Rosengarten James is currently the Research Fellow in Cardiac Rhythm Management, based at University Hospital Southampton. Under the supervision of Prof. Morgan and Prof. Hanson at the University of Southampton, he is utilising engineering techniques to discover novel biomarkers of sudden cardiac death risk. He is a Wessex specialist registrar in cardiology, specialising in electrophysiology and devices. He has a strong interest in education and training, from examining students at the University of Southampton, through to representing Wessex trainees at a national level.

abstracts


14

Oral Presentations Is there a difference in self-reported quality of life between affected and unaffected paediatric cardiac patients? Name: Revati Kumar University/ Trust/ Department: University College London, United Kingdom Project Type: Clinical Project Field: Paediatric Cardiology Authors: Revati Kumar, Dr. Sara O'Curry, Ms. Holly Clisby, Dr Juan Pablo Kaski Abstract Background: A well-documented effect of suffering from a chronic condition is the impact on the patient’s health-related quality of life. However, for paediatric conditions, literature is currently divided. The relative rarity of the conditions means that there is a scarcity of information. Aim: The purpose of this study was to evaluate whether affected children self-reported a difference in quality of life when compared to unaffected children. Methods: 83 children between the ages of 8 and 18 presenting to the heart function, hypertrophic cardiomyopathy and inherited arrhythmia clinics at Great Ormond Street Hospital formed the study population. The tools used to measure quality of life were the PedsQL Generic Core Scales 4.0 and the PedsQL Cardiac Module 3.0, well-established and validated questionnaires. In addition, a subgroup analysis within the affected cohort sought to investigate whether the severity of the condition affected quality of life. Results: Results indicated that affected children experience a lower quality of life than unaffected children in terms of their physical capabilities (p=0.035). No difference was demonstrated between the cohorts in terms of psychosocial functioning (p=0.071). The subgroup analysis indicated no difference in quality of life between the groups; further research with larger sample sizes may be necessitated in order to validate these findings. Conclusions: The findings indicate that although affected children have significantly lower physical abilities than unaffected children, they are currently receiving excellent psychological support to help them cope with their illness, and this should be maintained. Effect of remote ischaemic conditioning (RIC) on myocardial infarct size in STEMI patients undergoing primary PCI Name: Fiona Chan University/ Trust/ Department: University College London, United Kingdom Project Type: Clinical Project Field: Cardiovascular Clinical Trial Authors: Fiona Chan, Steven White, Derek M Yellon, Derek J Hausenloy Abstract Background: Despite optimal therapy, patients with a ST-elevation myocardial infarction (STEMI) still experience significant morbidity and mortality. Remote ischaemic conditioning (RIC) may be a novel therapeutic strategy for improving outcomes in STEMI patients. In RIC, cardioprotection is elicited by serially inflating and deflating a blood pressure cuff on the upper arm to induce cycles of non-lethal ischaemia and reperfusion. In ERIC-STEMI, we investigate whether RIC could reduce MI size in patients undergoing primary percutaneous coronary intervention (PPCI). Methods: The ERIC-STEMI is an ongoing single-centre, single-blinded randomised controlled clinical trial that investigates whether RIC reduces MI size and improves myocardial salvage in STEMI patients undergoing PPCI. Patients with suspected STEMI are recruited on arrival at the PPCI centre, then randomised to receive either RIC or control. In the RIC protocol, a blood pressure cuff is inflated to 200mmHg for 5 min then deflated for 5 min, a cycle repeated 4 times. Control patients have a deflated cuff for 40 minutes. Blood samples are taken for measurement of serum Troponin-T at the time of PPCI and 6, 12, 24 and 48 hrs following PPCI. A 48hr area under the curve (AUC) was calculated as a measure of MI size. Patients also have cardiac MRI at discharge and at 6 months to assess MI size, myocardial salvage, cardiac remodelling and function. Results: As of August 2012, 180 patients have been recruited. An interim analysis of the blood results for 114 patients (n=54 RIC; n=60 control) revealed that RIC resulted in 23% reduction in 48hr AUC TroponinT (71,518 ng/L (±7,616) with RIC versus 93,669 ng/L (±7,969) with control; p=0.047). Conclusions: In this interim analysis of 114 patients of the ERIC-STEMI study, it appears that STEMI patients randomised to receive RIC prior to PPCI had a 23% smaller MI size when compared to control patients.

15

abstracts


The role of circulating endothelial precursor cells in the development of arteriovenous fistulae used in haemodialysis Name: Sonul Gajree University/ Trust/ Department: University of Glasgow, United Kingdom Project Type: Laboratory Project Field: Renal Transplantation & Haemodialysis Authors: Vesey A, Gajree S, Glen J, Aitken E, Clancy M Abstract Background: Circulating endothelial precursor cells (CEPC) are central to vasculogenesis. Maturation of an autologous arteriovenous fistula (AVF) requires a large expansion of blood vessels and may depend on vasculogenesis. We aimed to evaluate the role of CEPCs in AVF maturation. Methods: Patients with end-stage renal failure about to undergo creation of an AVF were recruited. Whole blood was sampled immediately pre-op, 2 days post-op and 4 weeks post-op. CEPC quantification was performed using a commercially available kit. Clinical and duplex ultrasound assessment was undertaken immediately pre-op and 4 weeks post-op. CEPC titres were correlated with clinical and ultrasonographic outcome data. Results: Interim data are summarised (n=15). There was a trend to lower baseline CEPC titres in subjects compared to healthy controls. Smoking was significantly associated with lower baseline CEPC levels (p<0.0005). Day 2 post-op levels of CEPC were significantly higher than pre-op levels (p=0.028). At the time of writing, 5 patients had completed 4 week follow-up with 100% primary patency. Fistula diameter was positively associated with immediate post-op rise in CEPC levels (p=0.015) but not with baseline CEPC levels. Conclusion: Although these are early results, it has been demonstrated that a greater immediate post-op rise in CEPC count is associated with a larger fistula diameter at 4 weeks. It is hoped that these results will be confirmed and translate to clinical outcomes as more patients are recruited. A targeted pharmacological intervention designed to increase CPEC levels (e.g. erythropoetin) and potentially improve AVF patency could then be tested.

What is the angiographic significance of ‘reciprocal’ ST segment depression in ST elevation myocardial infarction? Name: Charles Johnson University/ Trust/ Department: University of Sheffield, United Kingdom Project Type: Clinical Project Field: Acute STEMI Authors: C Johnson, S Brown, S Turton, A Sultan, R Orme, C Jackson, D Tayler, A Morton, J Gunn Abstract Background: ST elevation myocardial infarction (STEMI) is frequently associated with ‘reciprocal’ electrocardiographic ST segment depression. For 30 years there has been debate about the significance and origin of this finding. The advent of primary angioplasty for STEMI allows us to re-examine the question. Method: We analyzed the ECGs and angiograms of patients presenting to the primary angioplasty service of our hospital with STEMI between June and December 2009. STEMI was defined as characteristic chest pain with ST elevation (STE) ≥1mm in ≥2 limb leads or ≥2mm in ≥2 contiguous chest leads, and reciprocal change as ≥1mm ST depression in the inferior leads for anterior STEMI, and in the anterior leads for inferior STEMI. We measured the aggregate magnitude of STE in each territory. We determined the extent of angiographic disease, both ‘culprit’ (ipsilateral) and ‘bystander’ (contralateral), in terms of the number of coronary arteries and segments affected, the SYNTAX scores, and vessel dominance. Results: Of 188 patients, 70% were male, the mean age was 63.4 years, 95 had anterior and 93 inferior STEMI. Reciprocal change was seen in 39% of anterior and 46% of inferior STEMIs. The magnitude of STE for inferior STEMIs was 81% greater for cases with reciprocal change than for those without (p<0.001); and for anterior STEMIs it was 27% greater (p=0.05). There was a correlation between ipsilateral maximum STE and contralateral maximum ST depression for inferior, but not anterior, STEMI. There was no relationship between reciprocal change and contralateral coronary artery disease (vessels, segments or SYNTAX score) for either anterior or inferior STEMIs. Conclusion: The magnitude of reciprocal ST segment depression in STEMI is related to the magnitude of STE in the culprit territory, and is unrelated to the presence or extent of non-culprit disease. Reciprocal change probably reflects the size of the index STEMI itself.

abstracts


16

Poster Presentations Prevention of stroke following a transient ischaemic attack Name: Zenab Sher University/ Trust/ Department: King’s College London, United Kingdom Project Type: Audit Project Field: Vascular Medicine Authors: Zenab A Sher Abstract Introduction: In the UK, stroke accounts for 11% of deaths. A Transient Ischaemic Attack (TIA) is a neurological emergency, caused by risk factors for stroke. Its clinical presentation includes unilateral hemiplegia, hemiparesis, coordination problems and speech and visual disturbances, depending on the location of the lesion. The patient usually recovers from these symptoms within a day, unlike a stroke which may lead to permanent disablement. The risk of developing stroke after a TIA is greatest in the first 48 hours following onset of symptoms. Intervention and treatment after a TIA can help reduce this from 10% to much lower in the highest risk patients. Based on the ABCD2 scoring system, a high risk patient is someone with a score of >4. Aim: To see if NICE guidelines are met appropriately – are all high risk patients seen by a specialist within 24 hours of symptom onset? Methods: Retrospective data analysis of consultation outcomes and delay to treatment for TIA patients at the stoke unit, in April - July in 2010. Results: 37 patients were seen in the TIA clinic, 46% of which were diagnosed as TIA. The remaining 54% presented with stroke-like symptoms which were other causes. 88% of the TIA patients were treated with Aspirin, whilst the remainder 12% were already on warfarin. Of the TIA patients, 47% were classified as ‘high risk’ of stroke as they had an ABCD2 score of 4 or more. From the high risk patients, 87.5% were seen in clinic within 24 hours of symptom onset. Conclusion: A considerably high number of patients were seen by a specialist within the recommended time frame based on NICE Guidelines, however not all patients are referred within the 24 hours. Telephone triaging, referrer education and raising public awareness of stroke symptoms can help improve this. The use of atrial fibrillation cycle length as a predictor of ablation success Name: Alexandra Hanlon University/ Trust/ Department: King's College London, United Kingdom Project Type: Article Project Field: Atrial fibrillation ablation Authors: Alexandra Hanlon Abstract The current policy to ablate only those patients with paroxysmal AF (duration <7 days) is too excluding, and the use of AF cycle length (AFCL) is proposed as the method of patient selection. Longer AFCL is known to reflect reduced AF complexity, and the current study shows that a surface ECG recorded intra-f wave duration of >142ms has a specificity of 92.9% and sensitivity of 69.7% in predicting successful termination of persistent (>7 days) AF at ablation, with success being defined as maintenance of sinus rhythm without pharmacological antiarrhythmic treatment for more than 12 months. Furthermore, an AFCL of >142ms in conjunction with an AF duration of <21 months has a 100% specificity in predicting procedural termination of AF. Longer AF cycle length also correlates with better response to antiarrythmic therapy and DC cardioversion. Therefore, it is proposed that surface ECG AFCL should be the method of patient selection for ablation, in order to include those patients with long AF duration, but who may still undergo successful ablation. A comprehensive approach to the reduction of device-related infection in a cardiology department Name: Kirsty Bromage University/ Trust/ Department: University of Bristol, United Kingdom Project Type: Audit Project Field: Implantable Cardiac Devices Authors: Richard Bond, Daniel Augustine, Kirsty Bromage, Lara Howells, Richard Kilbey, Stuart Walker, Mark Dayer Abstract Introduction: Infection is a serious complication of cardiac device implantation (CDI). Few large-scale clinical audits have been carried out, meaning estimations of risk may not reflect current practice. Aims: To quantify infection rates of CDI procedures carried out in a district general hospital before and after the instigation of a comprehensive infection control policy. Methods: Retrospective analysis of outcomes for all CDIs from January 2007 to May 2012. Following a spike in infection rates, a series of changes were introduced during June 2011 and beyond in an effort to reduce device-related infections. These comprised: Chloroprep instead of povidone-iodine/chlorhexidine, a pre-pacemaker shower, routine venograms stopped, Vicryl Plus in place of Vicryl, any instruments with rust removed from use, Flucloxacillin for 48h, MSSA screening for high risk cases (September 2011) and all cases (May 2012), theatre air filters and flows replaced/reviewed, Chlorhexidine nail brushes. Results: Prior to the review of practice, 1948 CDIs were carried out, 35 of which resulted in device-related infections (1.8%). We identified two spikes in infection rates that were significantly higher than our long-term infection rates: April-July 2010 (4.8%, Fisher’s exact test p=0.019) and February-June 2011 (3.8%, Fisher’s exact test p=0.043). Since the comprehensive review of practice was implemented, there has only been 1 infection within 3 months of device implantation out of the 318 cases performed between July 1st 2011 and 25th May 2012 (to allow for 3 months of follow-up): a rate of 0.3%. Although this value is not significantly lower than our long-term rates (Fisher’s exact test, p=0.0511), it is significantly lower than the rate between February and June 2011 (Fisher’s exact test, p=0.004). Conclusion: A thorough review of practice had the impact of reducing device-related infection. Whether this will result in a durable and significant reduction in device-related infection remains to be seen.

17

abstracts


Coronary artery bypass grafting with Y-type saphenous vein: a case report highlighting the associated intra-operative benefits Name: Iheukwumere Duru University/ Trust/ Department: Manchester Medical School - University Hospital South Manchester, United Kingdom Project Type: Case Report Project Field: Coronary Artery Bypass Graft Authors: I Duru, B Krishnamoorthy, WR Critchley, JE Fildes, N Yonan Abstract The long saphenous vein (LSV) is the predominant conduit utilised in coronary artery bypass graft (CABG) surgery, and can be retrieved via endoscopic vein harvesting (EVH). Whilst EVH is associated with significantly greater recovery, wound healing and cosmetic appearance than the traditional open vein harvesting technique, the long-term outcome has been questioned. Retrieval of the LSV has been associated with elevated risk of bleeding in the tunnel during harvesting. This complication is even more distinct when a branch of the Y-type, anatomical variant of the LSV is dissected and cauterised, due to the size of the vessel being cut. However, we demonstrate a case in which the Y-type variant of the LSV was instead harvested and successfully utilised as a conduit. We therefore present the benefits associated with our approach. The postoperative results of this case were compared to the outcome of 5 other patients, in whom the same anatomical variant of the LSV was dissected and cut by diathermy. Our findings indicate that harvesting, rather than cauterising the Y-type vessel, resulted in fewer complications, including intraoperative bleeding. This further reduced the operating time and did not necessitate the conversion to either open or bridging techniques in order to extract the vessel. Renal function after mitral valve surgery performed with minimally invasive vs. conventional sternotomy approach Name: Aleksandra Szczap University/ Trust/ Department: University of Bristol, United Kingdom Project Type: Audit Project Field: Cardiac surgery Authors: A Szczap, F Ciulli, G Asimakopoulos Abstract Background: Patients undergoing mitral valve surgery frequently sustain renal injury. Using plasma creatinine and the Cockroft-Gault formula to estimate creatinine clearance (eCrCl), this study examines the hypothesis that minimally invasive mitral valve repair (MIMVR) is associated with lesser degree of renal injury as compared with mitral valve repair (MVR) through sternotomy. Methods: This study evaluates data from all isolated MVRs performed by two surgeons at our institution over a 3-year period. Data were collected using our prospective computerised database. In total, there were 27 patients undergoing MIMVR and 170 patients undergoing MVR via sternotomy. Pre- and postoperative renal function at day 1, 4 and 7 was measured in the two groups. A secondary analysis with the populations divided into normal (eCrCl>50mL/min) and compromised pre-operative renal function (eCrCl<50mL/min) was performed. Results: The two groups were similar with regards to age, gender, BMI, EuroSCORE, angina and dyspnoea status, heart rhythm, left ventricular function, previous MIs, previous PCIs, diabetes, hypertension, smoking, pulmonary disease, post-operative hospitalization, in-hospital death, post-operative heamofiltration and re-operation. (P>0.05). Renal function improved significantly in both groups between pre-operatively and day 4 (P<0.05). There was no significant difference between groups at any time point in terms of plasma creatinine levels pre- and post-operatively (values for MIMVR vs. MVR: 104.0 vs.105.5, 103.8 vs.104.0, 97.6 vs.100.0 and 103.4 vs100.0 umol/Lpre-operatively, on day 1, 4 and 7 respectively. P>0.05 for all) and creatinine clearance values (values for MIMVR vs. MVR: 62.7 vs. 64.5, 65.9 vs. 65.9, 70.5 vs. 70.4 and 61.3 vs. 69.0 ml/min pre-operatively, on day 1, 4 and 7 respectively. P>0.05 for all). The above observation weres also valid for patients with reduced renal function pre-operatively. Conclusion: Overall, MVR does not result in singificant renal dysfunction. There is no difference in renal function between patients undergoing MIMVR and MVR through sternotomy. Is it possible to transmit sounds through the arterial system as a means of measuring blood pressure? Name: Aisha Ali University/ Trust/ Department: University of Manchester, United Kingdom Project Type: Clinical Project Field: Cardiology Authors: Aisha Ali, Ewan Glassey, Sabeera Hussain Abstract Background: We aim to study how vibrations propagate along the arterial system and whether a new non invasive auscultative method of measuring blood pressure in patients with arrhythmias is achievable. Method: 59 participants were included in the study, 18 had a normal BMI, 5 were underweight and 31 were considered moderately obese. Measurements with a Doppler ultrasound were made at the brachial and radial arteries. A sensitive microphone was mounted within the acoustic pathway of a stethoscope. Artificial sounds were produced at the subclavian artery and detected by the three probes. Recordings were made on the left arm at three positions and two time intervals (cuff deflated and inflated.) The difference of the amplitude of sound waves during cuff deflation and inflation (VD1-VI1) and the difference of the frequency (FI1-FD1) was calculated. Results: A significant attenuation of sound was caused by the restriction of blood flow through the brachial and radial artery. The microphone (VD1-VI1) was on average 66.45mV (95% CI 23.9-52.9.) The (FI1-FD1) recorded by the microphone during the two time intervals was 5.03Hz (95% Cl 7.6- 2.45.) Indicating that frequency of sound waves rises with cuff pressure. Conclusion: The attenuation of artificial sounds during cuff inflation demonstrates that sound waves conduct through the arterial blood supply. This often coincides in time with the Korotkoff sounds. These observations suggest that the production of regular rhythmic vibrations may be used in addition to Korotkoff sounds as an audible criterion for recognising systolic pressure in patients with AF.

abstracts


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Systolic arterial blood pressure is underestimated by auscultation compared with Doppler return-to-flow Name: Sabeera Hussain University/ Trust/ Department: University of Manchester, Blood Pressure & Heart Research Centre, Stockport NHS Foundation Trust, United Kingdom Project Type: Clinical Project Field: Blood Pressure and Heart Research Authors: S. Hussain, PS Lewis Abstract Introduction: Systolic blood pressure (SBP) is a key indicator of cardiovascular risk. It is therefore important to measure blood pressure accurately to aid diagnosis and research. Methods: We studied 24 females and 32 males aged between 18-85 years. With subjects in a sitting position with their left arm supported horizontal at level of shoulder, an A and D Medical UA 767 PC semi-automated blood pressure monitor was used to inflate and deflate an appropriately sized cuff placed on the upper arm. Three readings were taken at 1 minute intervals. SBP was assessed, during cuff deflation, by simultaneous auscultation of first Korotkoff sound (K1) heard over brachial artery with the bell of a Littmann stethoscope and by the point of return of arterial blood flow measured by flat-bed Doppler probes placed over the brachial and radial arteries. Results: SBP measurements differed significantly between methods. The pressure at which arterial blood flow returned at the brachial Doppler was 5.58mmHg higher than K1 (95% CI 1.85 to 9.32, p value= 0.004). The point of return of radial Doppler flow was 2.44mmHg higher than K1 (95% CI 0.66 to 4.21, p value = 0.008). Conclusion: The traditional auscultatory method of blood pressure measurement underestimates systolic blood pressure compared with Doppler return-to-flow whether measured at the brachial or radial arteries, leading to potential errors in assessing cardiovascular risk and monitoring patients' health.

Cardio renal arrhythmia study in haemodialysis patients using implantable loop recorders

Name: Sidharth Mohan University/ Trust/ Department: University of Southampton, United Kingdom Project Type: Clinical Project Field: Cardiology Authors: Paul R Roberts, Sidharth Mohan Abstract Background: End Stage Renal Disease (ESRD) occurs as the final stage of chronic kidney disease (CKD). It is at this stage that the kidneys cannot function for themselves and an intervention is needed. This is most often in the form of dialysis. The increasing incidence of contributing factors such as diabetes and hypertension has lead to an increase in the prevalence of ESRD. Existing research shows that these patients on dialysis have been shown to have extremely high sudden cardiac death (SCD) rates. It is thought that arrhythmias may be the cause of SCD in this population. Aims: This is an ongoing study that is being conducted to investigate the link between SCD and arrhythmias in patients with ESRD on dialysis, using implantable loop recorders. Methods: The observational study is being conducted on patients who suffer from ESRD and also one or more of the following; Poor left ventricular function as defined by an ejection fraction of less than 35% on echocardiography; Renal failure secondary to diabetes; Significant left ventricular hypertrophy. All patients that are part of the study must have an implantable loop recorder fitted (ILR-Reveal device). The ILR once implanted is set up to transmit information using the CareLink remote system. Transmitted information is displayed as an ECG rhythm strip on the CareLink website. Results: The study is still in its recruitment phase and so far 5 patients have been recruited for the study. The results so far have shown signs of atrial fibrillation for 20% of the participants. Conclusion: This study shows that it is possible to record the cardiac activity on a regular continuous basis for ESRD patients who are on dialysis. This is vital for gaining an insight into the role of arrhythmia and cardiac disease in mortality caused by dialysis.

The influence of a baseline heart rate on the final outcome in patients with acute myocardial infarction with ST-segment elevation (STEMI)

Name: Srdjan Milanov University/ Trust/ Department: Faculty of Medical Sciences, University of Kragujevac, Serbia Project Type: Clinical Project Field: Cardiology Authors: Srdjan Milanov, Dusica Ognjanovic, Goran Davidovic, Violeta Iric-Cupic Abstract Background: Acute myocardial infarction is a clinical form of the coronary heart disease characterized by permanent damage or loss of cardiac tissue. Heart rate is the most important determinant of myocardial oxygen demand and cardiac workload. Many prospective studies have shown association between baseline heart rate levels less than 80 beats per minute(bpm) and better outcome in patients with STEMI. Purpose was to investigate the influence of baseline heart rate levels on the final outcome in patients with STEMI. Methods: This largely prospective and partly retrospective, population-type study, included 167 patients with STEMI treated in Coronary Unit,C linical center Kragujevac form January to June 2011. Baseline heart rate was defined according to the first ECG on the admission. All data are stored in a specially designed database, and statistically analyzed in the SPSS for Windows with the methods of descriptive and analytical statistics. Results: In the observed group of 167 patients, 13(7,8%) patients died and 154(92,2%) patients survived. Of a total number of patients, 106(63,5%) had baseline heart rate levels less than 80 bpm (χ2-test;p=0,000). Among the survivors, 98(58,7%) patients had baseline heart rate levels less than 80 bpm and 56(33,5%) greater than 80 bpm; and in the group of patients with a fatal outcome 8(48%) patients had baseline heart rate levels less than 80 bpm and 5(3%) greater than 80 bpm. Mean baseline heart rate among the survivors was 79.27±21.59 (36-177) beats per minute. There was no statisticaly significant difference between males and females. Conclusions: In the observed group of patients with STEMI baseline heart rate less than 80 bpm was associated with a better outcome but a lot of patients who survived had heart rate greater than 80 bpm which indicates that heart rate had an important but not the major role in a surviving of these patients.

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“Obesity paradox” in patients with acute myocardial infarction Name: Stefan Simovic University/ Trust/ Department: Faculty of Medical Sciences, University of Kragujevac, Serbia Project Type: Clinical Project Field: Cardiology Authors: Stefan Simovic, Goran Davidovic, Violeta Iric-Cupic, Srdjan Milanov Abstract Introduction: Obese people live longer than their normal-weight counterparts. This phenomenon is called the “obesity paradox”. In obese patients there is increased sympathetic activity and is responsible for increasing heart rate. Purpose was to investigate what was the impact of BMI on the final outcome in patients with AMI and elevated heart rate, and whether there is the “obesity paradox” in these patients or not. Methods: This study included 140 patients with STEMI, treated in Coronary Unit, Clinical center Kragujevac in the period from January 2001-June 2006.Heart rate was calculated as the mean value of baseline and heart rate in the first 30 minutes after admission. BMI was calculated as the ratio of body weight in kilograms and body height in squared meters, and classified according to WHO.All data were stored in a specially designed database, and statistically analyzed in the SPSS using descriptive and analytical statistics. Results: In the observed group of patients, 40 (28,57%) patients died and 100 (71,43%) patients survived. In both groups there was more than 75% of obese patients (76% among survivors and 82,5% of patients who died). Compared to the mortality there was no statistically significant difference in the prevalence of obese patients (x2 test, p=403). The subgroup of patients with heart rate greater than 80 bpm also showed that obesity affects mortality rate in patients with acute myocardial infarction. In this subgroup there was 77,8% of obese patients among survivors and 81,1% among patients who died with no statistically significant difference (χ2-test; p=0,689). Conclusions: According to the mortality rate in this study there is a possibility that “obesity paradox” exists in patients with acute myocardial infarction. Heart rate – risk factor for morbidity and mortality in STEMI Name: Stefan Simovic University/ Trust/ Department: Faculty of Medical Sciences, University of Kragujevac, Serbia Project Type: Clinical Project Field: Cardiology Authors: Stefan Simovic, Goran Davidovic, Violeta Iric-Cupic, Srdjan Milanov Abstract Introduction: Heart rate is the most important determinant of myocardial oxygen consumption and metabolic demands of heart. Many studies have shown association between heart rate and increased cardiovascular morbidity and mortality, independently of other risk factors for atherosclerosis. Purpose was to investigate the heart rate in patients with STEMI and to determine the influence of heart rate on mortality in these patients. Methods: Study included 140 patients with STEMI, that were threated in Coronary Unit, Clinical center Kragujevac in the period from January 2001-June 2006. Study was partly prospective and partly retrospective. Heart rate was calculated as the mean value of baseline and heart rate in 30 minutes after admission. All data were stored in database, and statistically analyzed in the SPSS, using descriptive and analytical statistics. Results: In the observed group of patients with acute myocardial infarction, 40 (28,57%)patients died and 100 (71,43%)patients survived. Of a total number of patients, 109 (77,85%)had a heart rate levels greater than 80 bpm which was statistically significant (χ2-test; p=0,008).There was a significant difference in heart rate levels on admission between survivors and patients who died (Mann Whitney U test; p=0,000),with a greater levels in patients with fatal outcome (87,97±16,7 – survivors; 102,05±23,16 – fatal). There was no significant difference in heart rate levels according to age and gender of patients. Both univariate [expB (95%CI)-1,040 (1,017-1,063); p=0,000)] and multivariate regression analysis [expB (95%CI)-1,076 (1,006-1,151); p=0,033)] singled out heart rate greater than 80 bpm as independent mortality predictor in these patients. Conclusions: Heart rate greater than 80 bpm is a major risk factor for morbidity and mortality in patients with acute myocardial infarction, independent of other risk factors for acute coronary syndrome. Using FRET to characterise the actomyosin complex in cardiac muscle

Name: Lucia Chen University/ Trust/ Department: Imperial College London, United Kingdom Project Type: Laboratory Project Field: Molecular Medicine, Cardiology Authors: Lucia Chen, Valentina Caorsi, Chris Toepfer, Weihua Song, Steve Marston, Mike Ferenczi Abstract Introduction/Aims: Elucidating actomyosin interaction is key to understanding the molecular mechanisms of force generation in muscle. Although the swinging lever arm hypothesis is widely accepted, the precise myosin-actin interactions at different stages of the power stroke are still unclear and further studies of actomyosin complexes within functional muscle systems are required. Resolving these actomyosin interactions in cardiac muscle is needed to further understand muscle contraction in the heart. Methods: We use Förster resonance energy transfer (FRET) to measure nanometre distances between myosin and actin in functional cardiac muscle is described. In particular the interaction between the essential light chain (ELC)-AlexaFluor488 (labelled at a single cysteine in position 180 of a modified ELC, exchanged with the native one) and Actin-AlexaFluor594 Phalloidin is evaluated by the acceptor photobleaching method. In addition, we exploit FRET methods to measure the effect of cardiac disease mutations, such as E99K, an actin mutation in a transgenic mouse model which in humans leads to hypertrophic cardiomyopathy. Results: Our preliminary data suggests: i) E99K actin-mutation does not seem to affect the acto-myosin structures in terms of FRET efficiency evaluated; ii) in contrast to skeletal fibres, the ELC-Actin distance in rigor cardiac fibres is within the range for FRET, indicating that cardiac and skeletal muscle may possess differing cross-bridge conformations; iii) surprisingly, the ELC-Actin distance in relaxed cardiac fibres is approximately 1-2.5nm shorter than rigor-state distances. Conclusion: We successfully demonstrated that FRET has enough precision to detect nanometre-scale variations in the actomyosin structure in different muscle environments and that FRET may be a useful tool to determine the structural effects of disease-causing mutations at a molecular level.

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The role of dyskerin in cardiac hypertrophy Name: Divya Nagarajan University/ Trust/ Department: University of Manchester, United Kingdom Project Type: Laboratory Project Field: Heart Failure Authors: Divya Nagarajan, Delvac Oceandy Abstract Heart failure (HF) is a common cardiovascular disease affecting 2% of adults and carries a poor prognosis as 30-40% of people diagnosed with HF die within a year. Cardiac hypertrophy is an important stage in the development of HF and is characterised by an increase in the size of cardiomyocytes and interstitial fibrosis. Previous studies have shown that cardiac hypertrophy and cancer pathways share similarities and also HF is a metabolic disease and the metabolite pseudouridine is increased in the serum of patients with HF. By unifying these two strands to research the protein dyskerin was selected for study as a possible target for new HF treatment. The dyskeratosis congenita-1 (DKC1) gene encodes for dyskerin which functions as a pseudouridine synthase. Mutations in DKC1 gene leads to increased susceptibility to develop tumours. Pseudouridine is a modified nucleoside that is formed after post-transcriptional modification of uridine and is a key constituent for mature and stable RNAs. In this study, overexpression of DKC1 was compared against normal expression of DKC1 in neonatal rat cardiomyocytes to prove that elevated pseudouridine levels correspond to increased cardiac hypertrophy. This was performed using immunofluorescence staining techniques to measure cardiomyocyte size, luciferase assays to measure brain natriuretic peptide (BNP) expression and western blotting to measure protein levels. The results indicated that DKC1 overexpression and therefore increased levels of dyskerin causes hypertrophy of neonatal rat cardiomyocytes. In addition the results also suggest a novel finding that DKC1 might be involved in the upregulation of BNP in cardiomyocytes. In conclusion, this study has shown that the protein dyskerin is involved in the development of cardiac hypertrophy and possibly upregulation of BNP in neonatal rat cardiomyocytes. With further research, DKC1 gene regulation could be targeted as a possible new treatment option for HF. The effect of TGF-β1 and BMP-4 on bone marrow derived stem cell morphology on a novel bioabsorbable nanocomposite material for paediatric bypass graft application

Name: Hammad Lakhani University/ Trust/ Department: University College London - Division of Surgery and Interventional Science, United Kingdom Project Type: Laboratory Project Field: Cardiovascular Authors: Hammad Lakhnani, Achala de Mel, Alexander Seifalian Abstract Introduction: The incidence of congenital heart disease is 1.5 million worldwide, and often bypass grafts are needed as a treatment. In children, it is essential that the graft can grow and so there has been a shift from prosthetic grafts towards developing completely tissue engineered blood vessels. This study looks at using a bioabsorbable nanocomposite (POSS-PCL) polymer as scaffold in developing such a graft. The effects of the smooth muscle cell inducing growth factors, TGF-β1 and BMP-4 on bone marrow derived stem cells (BMSCs) were analysed on POSS PCL scaffolds. Methods: A new nanocomposite of POSS (polyhedral oligomeric silsesquioxane and PCL (poly(caprolactone-urea)urethane) was synthesized using a solvent coagulation technique. 40 µm sodium bicarbonate particles were added to the polymer to produce a porous surface and BMSCs were seeded onto the polymer by use of a micropipette. Alamar blue assays were used to assess growth of the cells on the polymer statically at serial time points. Cell morphology was assessed using optical, confocal and scanning electron microscopy. Differentiation of cells to the smooth muscle cell lineage was induced by the use of growth factors TGF-β1 and BMP-4. The phenotype of the cells was assessed using immunohistochemistry. Results: It was found that growth factor induction led to a decrease in cell growth on POSS PCL as compared to the tissue culture plate control surface and confocal microscopy analysis showed less cytoskeleton reorganization of these cells. After immunohistochemistry analysis, the BMSCs showed no differentiation to smooth muscle cells. Conclusion: Growth factor induction on the static scaffold discs led to a change in morphology, with less spreading of the cells, a lower proliferation rate and no differentiation into SMCs. These findings can be attributed to the POSS PCL being manufactured by a coagulation technique, resulting in a structure with low stiffness. Endothelial microparticles, inflammation and coagulation Name: Joanna Hack University/ Trust/ Department: University of Southampton, United Kingdom Project Type: Laboratory Project Field: Endocrinology and Metabolism Authors: Joanna Hack, Nicola Englyst Abstract Background: Endothelial microparticles (EMP’s) are formed as a result of endothelial damage, which is the precursor to the majority of cardiovascular disease (CVD), and can be initiated, by a variety of factors including inflammatory mediators and cardiovascular risk factors such as smoking and hypercholesterolaemia. EMP’s have been shown to have detrimental pro-inflammatory and coagulative effects that promote CVD; however, recent evidence suggests they also exert cytoprotective and anti-coagulant effects, via activated protein C (aPC). Aims: To optimise thrombin generation and aPC generation assays. To use a variety of factors to stimulate human umbilical vein endothelial cells (HUVECs) to produce EMPs. To compare aPC and thrombin generation on EMPs produced by different stimulation factors. Methods: HUVEC’s were grown to confluence in vitro and then stimulated for 24 hours with either TNF-α (4ng/ml), IL-6 (80ng/ml), Thrombin (1 U/ml), serum starved medium, Glucose (5mM) or Glucose (25mM). Preliminary experiments were also carried out using microvascular endothelial cells. EMP’s were then isolated and washed via a centrifugation process. Thrombin and aPC generation assays were then performed on each of the EMP populations. EMP counts and protein assays were also carried out as preliminary experiments. Results: Results show that EMP’s can generate both aPC and thrombin. The stimulus for EMP release did not produce a statistically significant difference in this ability, however TNF-α appeared to reduce EMP aPC production. This is supported by previous research on endothelial cells. EMP counts and protein assays provide interesting preliminary results. Further research with EMP counts and expression of membrane proteins may help clarify these results and increase our understanding of EMP function. Conclusions: The ability of EMPs to activate PC and thrombin, suggests they may play an important role in the development of CVD, but may also as previously reported have beneficial cytoprotective effects.

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The effect of neutrophil-derived microparticles on coronary artery endothelial cell activation Name: Robert Sandler University/ Trust/ Department: University of Sheffield, United Kingdom Project Type: Laboratory Project Field: Acute Coronary Syndrome Authors: RD Sandler, A Burnett, AC Morton, VC Ridger Abstract Background: Neutrophils are involved in the development and rupture of atherosclerotic plaques, which can lead to myocardial infarction. Administration of anti-neutrophil antiserum reduces leukocyte rolling over plaques in vivo and an increased number of circulating neutrophils exacerbates plaques. Furthermore, a complete depletion of neutrophils from the circulation reducing lesion area and macrophage content of plaques. Leukocyte-derived microparticles have been found in plaques and are elevated in symptomatic cardiac patients. We investigated the role of specifically neutrophil-derived microparticles (NDMP). Hypothesis: Neutrophil-derived microparticles (NDMP) from STEMI patients activate coronary artery endothelial cells (CAEC) to a greater extent that NDMP from healthy volunteers (HV) in vitro. Methods: Neutrophils were isolated from blood samples of STEMI patients (pre-treatment) and HV. They were stimulated with fMLP to produce microparticles, which were then isolated and cultured with CAEC. Levels of inflammatory cytokines IL-6, IL-8 and MCP-1 were analysed by cytometric bead array at 30min, 2h, 4h & 24h. Electron microscopy was also carried out to image NDMP. Results: STEMI patients have a higher circulating neutrophil count than HV (p<0.05) and NDMP from these patients appear to induce partial activation of CAEC in comparison (p=ns). Transport of blood on ice, prior to neutrophil isolation, reduces microparticle production in response to fMLP-stimulation (p<0.01). Conclusion: Pre-analytical variables, such as transport of blood on ice, have an effect on microparticle producton. Neutrophils are increased in STEMI and this may relate to increased activation of CAEC. A population of NDMP are not homogenous and show variation in size and shape (<1µm). Role of AMP-activated protein kinase (AMPK) in vascular endothelial protection Name: Aamir Shamsi University/ Trust/ Department: Imperial College London, United Kingdom Project Type: Laboratory Project Field: Vascular Sciences - Atherosclerosis Authors: Aamir Shamsi Abstract Background: Adenosine monophosphate-activated protein kinase (AMPK), although known for its role in regulating cellular metabolism, has recently emerged as an important kinase involved in vascular endothelial protection. We therefore investigated the hypothesis that AMPK activity is important for the induction of the endothelial cytoprotective genes hem oxygenase-1 (HO-1), manganese superoxide dismutase (MnSOD) and decay-accelerating factor (DAF). Methods: Human umbilical vein endothelial cells were exposed to factors known to alter AMPK activity including shear stress, AICAR (an AMPK activator), a constitutively active form of AMPK delivered by adenovirus (Ad CA-AMPK), or the combination of atorvastatin and rapamycin for 2 hours. EC were analysed by and either immunoblotting or flow cytometry. Transcription factor CREB was silenced using siRNA. Results: In this study we showed that atherosclerosis prone patterns of oscillatory shear stress may be responsible for down-regulating levels of active phospho-AMPK and HO-1. Cells treated with for 24 hours with AICAR had a significant increase in MnSOD, HO-1 and DAF protein expression (p<0.05). Ad CA-AMPK was shown to deliver active forms of AMPK into the cells and this led to the induction of MnSOD, HO-1 and DAF protein (p<0.05). We subsequently showed that increased AMPK activity leads to the activation and phosphorylation of CREB. Moreover, we found that depletion of CREB with siRNA reduces MnSOD protein induction by Ad CA-AMPK. Finally, we found that this pathway could be activated by a combination of atorvastatin and rapamycin which phosphorylated AMPK and induced DAF. Conclusion: We have shown that increased AMPK activity in the endothelium induces the cytoprotective genes MnSOD, HO-1 and DAF. We have also suggested that CREB may be involved in this pathway for AMPK-mediated induction of vasculoprotective genes and propose that AMPK and/or CREB represent potential therapeutic targets. Questionnaire-based study into non-genetic factors of influence in hereditary haemorrhagic telangiectasia Name: Budhi Maneesha Silva University/ Trust/ Department: Imperial College London, United Kingdom Project Type: Clinical Project Field: Vascular Sciences Authors: Buddhi Maneesha Silva Abstract Introduction: Epistaxis is the principal clinical presentation in 95% of hereditary haemorrhagic telangiectasia (HHT) cases. Nosebleed frequency and severity are highly variable and not explained by gene mutation alone. Treatment of these patients remains challenging, with modalities ranging from conservative therapies to invasive surgical procedures, whilst clinically significant reports of the influence of conservative therapies and lifestyle variables on epistaxis remain largely anecdotal and poorly studied. This study aims to identify extraneous variables associated with HHT-related epistaxis as reported by 649 HHT participants suffering from epistaxis. Methods: An online questionnaire-based study was carried out in which participants were asked about previous specialist invasive treatments for their nosebleeds, various commonly used medical therapies in the HHT population, other conservative treatments used for any purpose which influenced their nosebleeds and lastly lifestyle variables of influence. Patients were asked to score treatments and variables, their responses converted into numerical format and statistical comparisons performed where appropriate using GraphPad Prism. Results: The majority of participants reported the use of laser treatment and cautery, with mean scores of 0.98 and 0.42 respectively. Of the medical treatments specifically asked about, hormone and anti-hormone treatments displayed the greatest mean scores of 0.22 and 0.53 respectively. The greatest positive/negative mean scores for self-reported treatments were for room humidification, saline treatments and the Chinese herb Yunnan Baiyao (all 1.50) and acetylated salicylates (-1.79), anti-inflammatory drugs (-1.56) and omega-3 acids (-1.20). 54 participants reported a provocative effect of foods high in salicylates on their nosebleeds. Conclusion: This study supports existing evidence for the use of laser, cautery, hormones and anti-hormones and may provide evidence to suggest a preference for laser over cautery and anti-hormones over hormones. HHT patients may be advised that the use of room humidification and nasal lubrication and avoidance of foods high in salicylates is likely to improve nosebleeds

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Cardiac CT angiography – is it ready as a screening tool for coronary artery disease? Name: Joanna Melgies University/ Trust/ Department: University of Bristol Project Type: Critical Discussion Project Field: Coronary Artery Disease Authors: Joanna Melgies Abstract Coronary Artery Disease (CAD) is the most common heart disease in the UK, affecting approximately 2.6 million people, nearly 25% of whom do not experience symptoms. Currently, there are no screening programs for CAD. Cardiac CT Angiography (CCTA) has been suggested as a non-invasive and reliable method of atherosclerotic plaque assessment with a potential to use in screening programs. For this programme to be successful, CCTA should be able to clearly identify pre-clinical disease in an appropriate patient group with cardiovascular risk factors by determining the plaque activity and thus its vulnerability. Once these criteria are achieved, a significant, cost-effective reduction in cardiovascular mortality and morbidity needs to be proven. The project reveals current understanding of atherosclerotic plaque formation, explains the technological features of CCTA and critiques this method in light of three of the WHO criteria for devising a screening programme – its ability to detect early stages of the disease, the benefit versus risk balance and cost-effectiveness. Overall, it appears there is currently insufficient evidence to support use of CCTA in a screening programme for coronary heart disease, however, with continued technology advancement this view will evolve.

The cost-effectiveness of cardiac MRI in the diagnosis and management of heart failure

Name: Edward Middleton University/ Trust/ Department: Imperial College London, United Kingdom Project Type: Clinical Project Field: Health Economics Heart Failure Authors: E Middleton, S Prasad Abstract Introduction: Heart failure is a condition with a high morbidity and mortality, affecting around 0.9% of the UK population. Its prevalence is rising - due to an aging population and increased survival of acute coronary syndromes - and high costs are associated management. As a syndrome, heart failure management requires identification of the aetiology and a treatment plan tailored to that case. Under guideline practice, this entails an echocardiogram followed by subsequent follow-up tests. Through Gadolinium-based techniques and tissue characterisation, cardiac MRI can provide detailed, accurate images of the failing heart. This study aimed to assess the cost-effectiveness of CMR in the diagnosis and management of heart failure. Methods: This was done using a population of 25 patients with heart failure from the Royal Brompton Hospital, who had histories presented to a panel of expert cardiologists. They were asked to create a management plan, based on information presented, which was entered into a web program designed specifically for this study. Using NHS tariffs, the management plan costs were calculated and compared. Results: We found that patients diagnosed using CMR-based protocols had management plans costing £301 more than standard protocols, on average. We found that patients diagnosed with CMR had overall savings in the diagnosis phase, but increased costs in the treatment phase. These increased costs were as a result of a greater number of patients being referred for revascularisation therapy: 25% vs 16% of cases. We also found that CMR increased the proportion of these therapies that were PCI rather than CABG, from 14% to 47%. Conclusion: In conclusion, although the initial outlay may be more costly, CMR may be more cost-effective in the diagnosis of heart failure than current guideline protocols. Increased costs were seen in the management of patients, but this is due to a higher treatment rate among CMR-diagnosed patients.

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the MPS guide for

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MPs1344: 10/11

www.mps.org.ukthe Medical Protection Society

a company limited by guarantee. registered in england no. 36142 at 33 cavendish square, london W1G 0Ps

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What you need to know

MPS1344 Fitness to practise and student member guide_Cover.indd 1

13/10/2011 09:58


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Moving from f1 to f2

Inside this issue:

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www.mps.org.uk

Medical Protection SoProfessional

Preparing for your F1 postan MPS guide


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Inside this issue:



While you MPS Guide to EthicsA map for the moral maze

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

The Medical Protection SocietyA company limited by guarantee. Registered in England no. 36142 at 33 Cavendish Square, London W1G 0PSMPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.

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www.mps.org.uk

The Medical Protection Society

33 Cavendish Square, London W1G 0PS

Granary Wharf House, Leeds LS11 5PY

39 George Street, Edinburgh, EH2 2HN

www.mps.org.uk

General enquiries (UK)

Tel 0845 605 4000 Fax 0113 241 0500

Email [email protected]

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MPS Education and Risk Management is a dedicated division providing risk management education, training and consultancy.

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Please direct all comments, questions or suggestions about MPS service, policy and operations to:

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In the interests of confidentiality please do not include information in any email that would allow a patient to be identified.

MPS1228_EthicsGuide_Cover.indd 1 06/04/2011 08:24

MPS1374 F1 Renewal campaign advert UK A4.indd 1 18/07/2012 13:16

delegate information

Southampton General Hospital Southampton General Hospital is the home of the University of Southampton's Faculty of Medicine. University Hospitals Southampton NHS Foundation Trust is one of the largest acute trusts in England. The Wessex Cardiac Unit is a nationally and internationally renowned centre of excellence. The department boasts world-leading experts in many fields of cardiovascular medicine. Established in 1972, it serves a population of around 2.8 million, and is mainly based in the £60m state-of-the-art North Wing at Southampton General Hospital. The cardiac care services cater to more than three million people in central southern England and the Channel Islands.


24

23

delegate information

Transportation Train Southampton Central train station is well served by trains from most of the UK's major cities. Uni-link's U6H bus runs between Southampton Central Station and the General Hospital every 20 minutes. Coach National Express and Greyhound both operate coach services from Southampton. Coaches stop at either the Central coach station, or at the University. From the coach station it is a short walk to Southampton Central train station. Uni-link's U6H bus runs between Southampton Central Station and the General Hospital every 20 minutes. Car Paid parking is available at Southampton General Hospital, however free parking is available at the University's Highfield Campus. Uni-link's U6H bus runs between Highfield Interchange and the General Hospital every 20 minutes. Air Southampton Airport connects Southampton with many other UK and European cities.

Accommodation Several B&B's and hotels are located close to the hospital, or a short bus ride away in the city centre.


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Undergraduate Journal Cardiovascular Medicine 2012

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Transcript of Undergraduate Journal Cardiovascular Medicine 2012