If you had a heart problem in 1948, the chances are, your doctor was blissfully ignorant.
Although X-ray had been around for 50 years, this technology had limited use for cardiology, as it can’t pick up the detail of the heart muscle.
MRI scans - which use magnetic fields and radio waves to produce detailed pictures of the heart – didn’t exist yet, neither did echocardiograms, which utilise high-frequency sound waves to do the same thing. These tools weren’t available on the NHS until the 70s.
Without imaging it was very difficult to make a diagnosis. This was a problem – after all, the starting point for any treatment is always a diagnosis.
When diagnoses were made in the ‘40s and before, it was due to incredibly skilled clinicians, using little more than a stethoscope.
The NHS has come a long way in this respect.
We’ve evolved from stethoscopes to having equipment which costs many millions; coupled with this, our medical teams have built up their knowledge and expertise of the emerging technology, which is envied the world over.
Innovation and change in my career
In terms of my own career, which began when I trained at Charing Cross hospital in the mid-80s, I have witnessed big leaps, and huge improvements in care. People were dying young in their 40s and 50s; I’m pleased to say for many patients, this has really changed.
Life expectancy has become markedly better for certain conditions – if in isolation, you have single vessel coronary disease, which is where one artery narrows, you might well have died 20 years ago. Now you should have a normal life expectancy.
In the early to mid-80s, the treatment for heart attacks in some centres was to sedate people and put them in bed for two weeks. Patients simply weren’t actively treated.
By the late 80s, clot-busting drugs (thrombolysis) such as streptokinase, marked a step-change in care for people who had suffered heart attacks. This treatment used medication to break down blood clots formed in blood vessels, helping treat myocardial infarction (heart attacks).
It wasn’t perfect – after all, we knew the artery could become blocked again for a significant number of patients.
So we needed another solution.
A revolution for treating heart attacks
Around the same sort of time as the advent of clot-busting drugs, coronary angioplasty – where a balloon mechanism is used to keep the artery open – was being developed.
Cardiologists soon realised that angioplasty provided better outcomes for those suffering heart attacks compared with treatment using drugs – provided that it can be delivered quickly.
However, this brought up another problem: knowledge had been developed faster than it could be delivered on a national scale.
Hospitals had just introduced the clot-busting drugs – and now there was something new to take on board.
The solution was to roll out a pilot scheme: The National Infarct Angioplasty Project.
Royal Brompton & Harefield NHS Foundation Trust was one of a handful of centres involved in this ground-breaking scheme along with the London Ambulance Service, and in April 2004, the primary angioplasty service was pioneered at Harefield for those who had suffered a heart attack.
The purpose of the project was to establish the feasibility of rolling out a primary angioplasty service within England, the barriers to such a development and the likely costs that would be encountered.
It has been thanks to this innovative approach that we have been able to get a national angioplasty service running in a way that other countries simply haven’t been able to do.
Harefield – at the time one of five London hospitals and only seven nationally – was at the forefront of making angioplasty a viable treatment for the NHS.
As early adopters, we provided a model to other centres. We are still a leading example of what is possible when it comes to angioplasty: speed is critical to survival and our ‘arrival-to-treatment’ time of just 28 minutes remains one of the fastest in Europe. Following the procedure, patients are usually out of hospital within two to three days.
The introduction of angioplasty has been one of the major changes for cardiac patients within during my career.
Improving quality of life for cardiac patients
In terms of treatments and innovations which truly help improve quality of life, I would nominate coronary stenting, which is where a tube-shaped device is placed in the coronary arteries that supply blood to the heart. This results in improved blood flow helps with symptoms such as angina and shortness of breath.
Patients often report immediate benefits. As stenting is carried out using a catheter, a thin tube, rather than surgery, it’s much less invasive than conventional bypass surgery and patients the recovery time is shorter.
Valve replacements and the innovative percutaneous (catheter-based) valve interventions, such as the TAVI (Transcatheter aortic valve implantation) and the MitraClip, (a medical device used to treat mitral valve regurgitation) are also making a real difference to patients.
We’re at the forefront of delivering these to patients as part of Commissioning through Evaluation for Mitraclip (one of only three UK centres), and delivering TAVI to over 100 patients per year on each of our two sites. Our experts are working closely with the medical industry companies to develop the next generation of such technologies.
While it’s still not clear whether they increase life expectancy, they are certainly often transforming quality of life for such patients, and keeping many of them out of hospital.
Technology and cardiology
Increasingly, innovation is driven by the med-tech industry, with NHS clinicians working in partnership. Developing new technology is simply too expensive to do on our own.
Take pacemakers, small electrical devices fitted in the chest or abdomen, which are used to treat abnormal heart rhythms. The latest devices are smaller than a penny and can be inserted directly into the heart, rather than buried under the skin on top of the chest.
That’s a major leap forward and decreases the chances of complications. Having a pacemaker with up to three wires, sometimes five or six leading from the shoulder into the heart, gives more potential to form scar tissue, which can cause problems.
Another example is a device called CardioMEMS™ HF System, an implantable pulmonary artery pressure monitor to treat heart failure. It works by monitoring changes in the pressure of blood through the pulmonary artery which can indicate worsening heart failure. It sends information wirelessly to medical staff who can use the information to adjust medications and treatment, if needed.
We had one patient who’d gone from needing to be admitted for their heart failure seven times in one year to not being admitted at all the following year, thanks of one of these devices.
They help us know when patients’ conditions change, often acting as an ‘early warning’ signal, and giving us enough time to intervene and prevent problems occurring.
It’s not the finished article. But it’s a really good sign of where we can go with chronic disease management.
Heart health in the cloud
As a Trust, we are heavily involved with researching and pioneering pacing and cardiac resynchronisation therapy. This is where three wires (leads) connect to the device monitoring the heart rate to detect heart rate irregularities and emit tiny pulses of electricity to correct them. In effect, it is “resynchronising” the heart.
Being able to monitor patients with chronic disease remotely, without them needing to come into hospital for an appointment, is going to be a massive opportunity for us.
Professor Martin Cowie, another consultant cardiologist, has been instrumental in research into home monitoring for our patients with heart failure. Home monitoring for patients with implantable cardioverter defibrillators (these are devices implantable inside the body, able to perform controlled shocks and pacing for the heart), however, is now the standard of care for our patients.
We check the device every three months, but instead of having to travel here, they have a box which they take home and plug into the mains. On any given day there are cardiac-physiologists watching and monitoring the devices.
We can remotely check if there’s a problem with their heart or the device. The device alerts our monitoring team if there’s a problem, or when they have an appointed time with us to check. It’s completely wireless: patients just need to be within two metres of the home monitor. Their defibrillator talks to the monitor, which immediately sends all the information to our team.
Sometimes a patient contacts us and says, ‘I think my defibrillator has just gone off, and we say ‘OK, stand next to your monitor and download the information.’ We can tell them immediately all is fine.
When our monitoring team check the data they might spot the defibrillator was activated, perhaps in the middle of the night. They will give the patient a call in the morning and ask what was going on at 2.51am – when the defibrillator gave a shock.
Sometimes the patient will have noticed something – but thought it was a bad dream. The defibrillator did its job, and the patient is well.
Funding innovation
This technology is not cheap; the reality is it’s challenging for the NHS to fund all of these innovations.
At Royal Brompton & Harefield NHS Foundation Trust, we believe in making the very latest technology available to the patients it will benefit. We try extremely hard to allocate resources effectively, so that we can do this. I know I have support at the highest level to deliver the best care to our patients.
For that reason, I love my job, and I’m looking forward to making sure patients can access to the next raft of innovations in cardiac care.
Dr Mark Mason is a consultant cardiologist and director of the Heart Division at Harefield Hospital.