Just been to the women in cardiology session…bit disappointed to see so few girlies !!! Where are you all!!!?

Anyway..great presentation from a current EP SpR about a career in EP and decision made in your absence to help promote women in cardiology, provide more career advice (from those already established in careers in the subspecialties).  So, please approach any of us.

We will webcast the presentation on the website but please comment here if you would like me to put you in touch with a female in cardiology for a chat about anything!

Miles Dalby from Harefield presented an interesting case of NSTEMI opening up the debate of when to take to the cath lab…when hot or not? By not having a cooling off period with time for the antiplatelet therapy to take effect there are less risks eg of ischaemia (from embolisation), dissection etc. Not much data out there to guide us. Suggestion of benefit in troponin postives (not surprising…but then you have to wait for the 12 hour troponin so by definition not piping hot!!!) but Miles has set up a randomised study to look into timing (called DANCE…not with the wolves..or maybe?!!)….see session report on the website for more info. Also see the recent NICE guidelines on treatment unstable angine (comments please!!)….

What do you think about timing…should NSTEMI be the new PPCI?

For the purposes of the exercise, we’ll take two patients, Mr. Thurgood Powell, a highly successful 57 year-old businessman making $250,000 (£166,128) per year with his company PoshPosh Entertainment, and Mortimer T. Schnerd, a pleasant 43 year old man who is unemployed but working part-time in the local K-mart, earning $17,400 (£11,562) per year. Both men will experience heart attacks, both men will present to Emergency Rooms in both countries,  and require 4-day ICD or HDU stay, require surgery, the implantation of an automatic defibrillator and follow-up for the first year after the heart attack. We are going to put both patients through the US and UK healthcare systems to compare what happens in a generalised manner…..The US perspective is on Wes’ site

This is the UK perspective. NHS versus private healthcare:

The UK Case of Mr. Thurgood Powell (a native Englishman) who has private health insurance

The red phone in HDU rings and the ambulance crew advise the nurse that they have a 57 year old man with a 45 minute history of chest pain and ECG changes of an anterior ST segment elevation. ECG performed and interpreted on scene by paramedic crew. ETA 50 minutes. Loading dose of aspirin 300mg and clopidogrel 600mg given by crew on scene.
The nurse contacts the hospital switchboard to activate the PPCI team to attend the cath lab. The SpR (registrar) and SHO (senior house officer) attend the front door to await arrival of the ambulance and transfer the patient directly to the cath lab.

Patient arrives. Looks poorly, but no contraindication to proceeding directly to cath lab. Angio performed and shows culprit 95% LAD stenosis. Other significant 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities and as LAD lesion, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring a DC shock, the patient tolerates the remarkably well. Patient is transferred to the high dependency unit,  HDU- a 4 bedded dedicated unit.

In an emergency situation Mr Powell is treated as an NHS patient so all appropriate care will be provided and there is no need to worry him about money. In the UK most insurance companies operate a 6 week rule. If treatment can be offered by the NHS within 6 weeks then patients are usually not covered by their insurance. Elective treatment not available for > 6 weeks on NHS is usually covered by medical insurance.

Patient is started on bisoprolol 2.5mg daily, Ramipril, Aspirin, Clopidogrel, and atorvastatin, although the local PCT has advised that simvastatin should be prescribed due to costs (as they will pay for the ongoing treatment in the community after discharge) – but the doctor uses his/her discretion.

Patient develops signs of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on day 3.

He leaves HDU on day 4 for a bed on the NHS ward. He could pay £80/day for a private room if he wishes. As no infection control issues he may be in a 4- bedded single sex bay, or a side room, if available. He may have a TV in the side room but there is unlikely to be one in the 4-bedded bay. However, a sitting room on the ward will have a TV for all to view if well enough. His food is ordered form a menu sheet collected by the housekeeper.

He spends two more days on the ward and then is discharged to be followed-up in an outpatient clinic at his local hospital, hopefully in one month. Clinics are very busy but the local DGH should prioritise his appointment.  He may request to see a private cardiologist earlier if covered by medical insurance if he wishes to self fund. He will also be referred to the rehabilitation team at his local hospital who should be in contact within a week to commence his rehab programme. He will have had Phase 1 whilst on the ward. This is provided by the NHS.

The patient is discharged home. There is no bill to pay.  The hospital claims an emergency tariff charge from the Primary Care Trust (hold the budget and commission services locally) which will equate to the most expensive procedure during his stay ie the PCI (costs to follow-sc)

Despite his treatment, Mr. Powell continues to have ongoing exertional angina and as he has private medical insurance (which he has taken out himself) and this is an elective appointment he seeks a referral from his primary care physician (General practitioner or GP) for a private consultation with a cardiologist of his choice. He may have an excess to pay depending on his policy but Mr Powell is fully covered for outpatient and inpatient treatment in this instance.

He is admitted at a date to suit him (2 days time say) for another angiogram performed by the cardiologist. The angiogram is unchanged. The stent is fine. Mr Powell stays in a private ward which is part of the NHS hospital and covered by the NHS medical team. He has a single en-suite room, tastefully decorated and with his own TV.  Food is prepared by a chef on the ward, served on tasteful china and a tray. He has his own phone in his room.

It is decided that because of his young age, pain refractory to medical therapy and his complex anatomy not amenable to PCI, that he will be referred for a bypass. He checks he is covered by his insurance company for the procedure. He is seen by the surgeon on the ward the same day and elective surgery scheduled on a mutually convenient date (say a couple of weeks time). He has a pre-operative echocardiogram which shows LV impairment with EF at 35%. He is discharged home and the insurance company receive the bill from the hospital for the angiogram and echocardiogram. The cardiologist and surgeon (consult) submit their fees to the insurance company independently. Mr Powell will pay an excess direct to hospital or doctor (usually £500-£1000/yr).

Approximately 6 weeks after surgery (which is billed directly to the insurance company), patient notes palpitations and light headedness. He returns Accident and Emergency where his is found to be in sustained monomorphic ventricular tachycardia. He is admitted to hospital again as an NHS patient (as this is deemed emergency treatment) and another angiogram is performed to check the grafts. Vessels unchanged. An ICD is scheduled for next few days (patient had atrial fibrillation in the past, after all). Patient returns home. There is no bill to pay by the patient for emergent treatment. The hospital charges tariff price for ICD and inpatient emergency tariff for most expensive procedure…likely to be ICD- costs to follow sc). If quota of commissioned ICDs has been met at the Trust, the Trust can seek payment from the PCT by ‘payment by results’. Only after negotiation and in exceptional circumstances would the PCT not pay. They would want to see national guidance is being followed.

Patient is amazed by the state-of-the art technology installed.

Follows up will be with cardiac physiologist in ICD clinic (NHS), surgeon at 6 weeks post op (privately- surgeon bills insurance company directly) and with his cardiologist (privately- cardiologist bills insurance company directly) at a mutually agreeable time.

SUMMARY: Mr Powell has received all his emergency medical care on the NHS irrespective of whether he has private insurance or not. He elected to use his medical insurance for the elective care but he could have had this equally on the NHS. His choice. His premium may go up next year. In addition his tax bill will go up next year to 60% as he is in the high income bracket. He may reconsider his options! The only difference with elective private medical care is that he can choose his physician, he will receive treatment more quickly and at a convenient date compared to the NHS. He has a more comfortable stay in a private ensuite room in the private wing of the hospital.

The U.K. Case of Mortimer T. Schnerd (a native Englishman) with no medical insurance

The red phone in HDU rings and the ambulance crew advise the nurse that they have a 43 year old man with a 45 minute history of chest pain and ECG changes of an anterior ST segment elevation. ETA 50 minutes. ECG undertaken on scene by paramedic crew. Loading dose of aspirin 300mg and clopidogrel 600mg given by crew.
The nurse contacts the hospital switchboard to activate the PPCI team to attend the cath lab. The SpR (registrar) and SHO (senior house officer) attend the front door to await arrival of the ambulance and transfer the patient directly to the cath lab.

Patient arrives. Looks poorly, but no contraindication to proceeding directly to cath lab. Angio performed and culprit 95% LAD stenosis and other significant 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities and as LAD lesion, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring a DC shock, the patient tolerates remarkably well. Patient is transferred to HDU. He is in the next bed to Mr Powell.

Mr Schnerd is an NHS patient so all appropriate care will be provided and there is no need to worry him about money.

Patient is started on bisoprolol 2.5mg daily, Ramipril, Aspirin, Clopidogrel, and atorvastatin, although the local PCT has advised that simvastatin should be provided due to costs (and they will pay for the ongoing treatment in the community after discharge) – but the doctor uses his/her discretion.

Patient develops signs of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on day 3.

He leaves HDU on day 4 for a bed on the NHS ward. As no infection control issues he may be in a 4- bedded single sex bay, or a side room, if available. He may have a TV in the side room but there is unlikely to be one in the 4-bedded bay. However, a sitting room on the ward will have a TV for all to view if well enough. His food is ordered form a menu sheet collected by the housekeeper.

He spends two more days on the ward and then is discharged to be followed-up in an outpatient clinic at his local hospital, hopefully in one month. Clinics are very busy but the local DGH should prioritise his appointment. He will also be referred to the rehabilitation team at his local hospital who should be in contact within a week to commence his rehab programme. He will have had Phase 1 whilst on the ward. This is provided by the NHS.

The patient is discharged home. There is no bill to pay.  The hospital claims an emergency tariff charge from the primary care trust which will equate to the most expensive procedure during his stay ie the PCI (costs to follow-sc)

Despite his treatment, Mr. Schnerd continues to have ongoing exertional angina and mentions this at his outpatient appointment He is placed on the waiting list for an angiogram (the target on the NHS pathway is for referral to treatment to be completed in 18 weeks- 18 week RTT time) performed by one of the cardiologists team, which is unchanged. The stent is fine.

Mr Schnerd stays on the day ward. He is in a 4 bedded single sexed bay. There is no TV (which is in the day room) or telephone (again in the day room). Food is ordered from a card. Lunch will be sandwiches. Hot meal in the evening as required.  

It is decided that because of his young age, pain refractory to medical therapy and his complex anatomy not amenable to PCI, that he will be referred for a bypass. The cardiologist writes a letter to a surgeon and he will be seen as soon as possible in the surgeons clinic (he is still on the 18 week RTT pathway). He is referred for an out-patient  pre-operative echocardiogram which shows LV impairment with EF at 35%. He is discharged home The hospital bill the PCT (Primary Care Trust who hold the budget and commission services) for a daycase angiogram tariff- a standard fee across the UK with some weighting in certain situations eg in London.

Approximately 6 weeks after surgery, patient notes palpitations and light headedness. He returns Accident and Emergency where his is found to be in sustained monomorphic ventricular tachycardia. He is admitted to hospital again as an NHS patient and another angiogram is performed to check the grafts. Vessels unchanged.

An ICD is scheduled for next few days (patient had atrial fibrillation in the past, after all). Patient returns home. There is no bill to pay by the patient for emergent treatment. The hospital charges tariff price to PCT for ICD and inpatient emergency tariff for most expensive procedure…likely to be ICD- costs to follow sc). If quota of commissioned ICDs has been met at the Trust, the Trust can seek payment from the PCT by ‘payment by results’. Only after negotiation and in exceptional circumstances would the PCT not pay. They would want to see national guidance is being followed.

Patient is amazed by the state-of-the art technology installed.

Follows up will be with cardiac physiologist in ICD clinic (NHS), surgeon at 6 weeks post op (NHS) and with his cardiologist at a mutually agreeable time.

SUMMARY: Mr Schnerd has paid nothing for all his treatment…all on the NHS.

So visit the USA blog by Wes Fisher to see the story from the other side of the pond and tell us what you think!!! Is the NHS so bad, can we learn from the US system? Are both systems in need of reform…a Congress bill coming up in the US, an election in the UK..your chance to have your say! Fire away!!!!

Sarah

PS please note that these are fictional characters and scenarios and statements are those of author, generalised and not exhaustive. It is recognised that other scenarios may be different but the cases are for general illustration and comparison only ie dont shoot me!!

Firstly a bit of information about my fellow (far more experienced blogger and high speed tweeter..how he has not got RSI, I dont know!)…Wes.

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem, Evanston, IL and is a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005!!  He also brands tee-shirts (all for charity, I might add..what a star!) and you HAVE to see his website for this.

His experience of the UK is rather typical (sorry Wes!)….he says, and I quote…

‘ touring quaint countryside villages with ladies who ride to market on their bicycles in flowered dresses (sc- driving around in open top sports cars!?), or strolling the streets of Oxford and the shores of the River Thames, stopping to have a cup of tea with bisucits and clotted cream (sc- I think he means scones and he forgot the jam!) whilst growing my LAD lesion there!’

What about the pubs Wes??

Anyway, back to the case scenario and I must credit Wes with the fictional names. I could not have done better!

For the purposes of the exercise, we’ll take two patients, Mr. Thurgood Powell, a highly successful 57 year-old businessman making $250,000 (£166,128) per year with his company PoshPosh Entertainment, and Mortimer T. Schnerd, a pleasant 43 year old man who is unemployed but working part-time in the local K-mart, earning $17,400 (£11,562) per year. Both men will experience heart attacks, both men will present to Emergency Rooms in both countries, and both men with require 4-day ICD stays and require the implantation of an automatic defibrillator and follow-up for the first year after the heart attack. Beyond that, heck, who knows. But that will at least give us a starting point to discuss the good, the bad, and the ugly of both health care systems and to compare and contrast the two systems. We will purposely refrain from political commentary in our posts (that’s for you to do in the comments section!). We only ask that the commentary discussion be respectful and civil.

You have 2 blogs to comment on. The UK side  of the story here and the US side of the story on Wes’ blog.

Not sure if it will work but lets give it a go! So check back later today after we have a chance to confer over double expressos before we post our case scenarios. 

Enjoy the last day in Atlanta!

Sarah

Take a look! There are editorials, news, interactive programs and there is a rate and rhythm pocket guide you can download in pdf for free!

Also see reports of other AF trials (click in each for link to cardiosource and for slides too!):

CABANA

RACE II

Time to satisfy the non-EP docs today….off to other sessions!

This trial, in the NEJM March 15, 2010 attempts to answer this question.

2701 patients receiving DES in 2 trials (RAEL LATE and ZEST LATE) were randomised to DAT (clopidogrel and aspirin) vs aspirin alone. They had been free major CV events and bleeding in preceeding 12 months. End point MI or death (cardiac). The 2 trials were merged.

Essentially the cumulative risk of the primary outcome was 1.8% in DAT group vs 1.2% in the aspirin alone  group ie no significant difference. There was a trend towards harm for the composite endpoint of death, MI, stroke in the DAT group.

Warning!….this was 2 separate trials merged into one (due to slow recruitment). The enrollment criteria were slightly different and despite the merger the trial was still underpowered to detect differences in clinical outcomes between the 2 trials. The trial was in Asian patients (? results applicable in non-Asians as response to clopidogrel can vary in different ethnic groups) and used first generation DES.

So, a larger randomised trial in a more diverse population is now required…..Are we any further forwards in answering the question..probably not!

Over 90 sessions covered, together with slides, full motion video and audio recorded live!

It does come at a cost, but if you are at the meeting you can get a special deal! And, if you are not at the conference you can buy at half price for the next couple of weeks!

Cardiosource is also a useful resource…free access for members of BCS!!

No conflict of interest.

Health Care reform is a contentious issue here and the reconciliation bill is likely to be voted upon at anytime by Congress!

The problem with both the US system and the NHS is the escalating costs and funding. There is inequity in the US system which does not apply in the NHS (although there are some services which are restricted..before you all start!!!). Wes Fisher, my co-blogger, and I will pull together an article comparing the US system and NHS to help inform you all further…watch this space!!

In the US Medicaid provides for the indigent population, Medicare for the over 65’s and the other insurance companies provide for the rest… but this is optional, resulting in a significant proportion of the population without insurance cover. Costs are also not fixed…CABG can cost from $47k to $100k! Importantly there are no quality measures and there is no patient choice. The US spends more than TWO TRILLION DOLLARS on such health services.

Republican Paul Ryan criticised what would be a federally run system with no reward for innovation or quality. He advocates a more patient centred system. Chris Jennings, a former White House advisor and co-Director of the Leaders Project on the State of American Heath Care denied it was a government take-over. Both agreed that things had to change for the better.

The ACC was acknowledged as having an important role in the health care debate by providing guidelines and defining quality and outcomes.

Will get back to you with more on this Debate as I think we have lessons to learn on both sides of the Atlantic.

Results show that at 5 years there were similar rates of death, Q wave MI and stroke but more revascularisations in the PCI group compared to the CABG group. Stent type did not significantly affect outcomes.

We await longer term data from SYNTAX but this registry reassures further that unprotected LMS stenting is safe in selected cases.

Click here for access to summary and slides from the session

Not allowed to subject you to interventional device sessions (conflict of interest-ACC) and want to appeal to the wider cardiology community to get blogging!

This session (room is packed….about 300 folk!)  is focussing on the medical treatment of AF as opposed to the interventional treatment, describing the indication for the various  anti-arrhythmics including new agents.

Messages (for treating AF and maintaining SR incl after DC version):
1. Amiodarone is not approved by FDA for use in treatment of AF!
2. Dronedarone should not be given where heart failure.
3. Flecainide should only be given with normal heart.
4. Dofetilde can be given in heart failure
5. First line for AF- flecainide, propafenone, sotalol, or dronedarone
Second line-amiodarone, dofetilide or ablate
6. AF where also HT(LVH)- amiodarone and ablate
7. First line for AF where also CAD- dofetilide, sotalol, dronedarone
Second line- amiodarone and ablate
8. AF and heart failure- amiodarone or dofetilide and ablate

Based on recent guidelines (2009)……will get the link! Could not read author from back of room!!

Comments my EP friends?

We apparently need to look out for vernakalant…on the horizon but iv. Why can we pick easy names to spell let alone remember!!