First published online: 14 June 2011
The new European Society of Cardiology declaration of interest procedure: a step towards improved transparency in relations between professionals and industry partners
The ESC has launched a new declaration of interest form and review process to increase transparency. Prof Michel Komajda ESC President, speaks to Helen Jaques about the new process
For doctors and the public to have confidence that guidelines and other outputs from professional healthcare organizations are free from bias, it is important for such organizations to have thorough and transparent disclosure of any financial relationships with pharmaceutical companies.
‘There were some scandals in the past that made the public a bit wary about how doctors are influenced or influence their patients based on their own interests’, says Professor Michel Komajda, president of the European Society of Cardiology (ESC). ‘We believe that a highly influential expert organization like the ESC should take the lead in this matter, to meet the demands of the public that there is full transparency regarding such relationships’.
Taking the lead is what the society has done by issuing a new, detailed declaration of interests form to all volunteer members and staff holding positions within or speaking on behalf of the society, and to all invited speakers, chairpersons, and presenters at ESC, Working Group, and Association congresses. Since January 2011, a total of 1976 declarations of interest have been sent to 998 people.
‘Relationships between professionals or professional organizations and industry are normal and important for medical progress, but the provision to this is that we need to know very transparently who is doing what and who has any kind of contracts or relationships with whom’, says Prof. Komajda. ‘It is important that the messages we convey when speaking for or acting on behalf of the ESC are perceived as crystal clear and free of any risk of bias due to vested interests'.
The toughened new declaration of interest form not only asks individuals to declare any financial rewards or interests they might have with industry, but also whether their institution or their first-degree relatives have any such relationships.
Speaker's fees, honoraria, consultant fees, and advisory fees are included on the form, as are receipt of royalties for intellectual property, such as a device or a diagnostic tool, and any departmental, institutional, or personal research funding.
Holding shares or stock options in a company that might have an interest in the healthcare area also needs to be declared on the form. Finally, any relationships with companies or institutions whose activities are in opposition to the society's mission to reduce the burden of cardiovascular disease in Europe need to be declared.
‘Let's imagine that you're a major stockholder in a tobacco company’, suggests Prof Komajda. ‘We believe that this would not be compatible with speaking on behalf of the ESC because it would be a major breach of our aim to protect people from cardiovascular disease’.
People who speak or work on behalf of the ESC will be required to fill in the declaration of interest form on the society's website via the ‘My ESC’ password-protected section. The level of any financial interests—from EUR1 all the way up to EUR100 000 or more—and the nature of the potential conflict need to be declared in some detail.
Forms will then be assessed for any potential conflicts of interest via a sophisticated peer review procedure. ‘We have established a sort of ladder system’, says Prof. Komajda. ‘When you are a member of a committee your declaration of interest goes to the chairperson of the committee. If he or she has any concerns or questions they can refer to the presidential trio, which is the current, past, and next president of the ESC, then if they can't reach a conclusion it goes to the full board of the ESC’.
Individuals will be prompted by email every December to review and update their form to reflect any changes in circumstances. If someone does not fill in their form after several reminders they will be suspended from their position.
The information in these forms, in terms of the nature of the potential conflict of interest and the name of the company involved, will be made public whenever the individual speaks at an ESC event, and a presentation slide summarizing these disclosures is mandatory in any ESC congress.
This information will also be published together with the guidelines for people who work on ESC writing committees. ‘I think the new form is particularly sens because they define how one patient should be treated or managed, it is very important that what is written is perceived as scientifically neutral’, says Prof. Komajda. ‘Producing guidelines is also one of the most visible activities of ESC’.
Any member of the writing group who has declared a financial interest that might have some bearing on part of the guideline will be asked to abstain while the respective paragraph is being written. ‘Let's say somebody has a major activity in a device company, the taskforce might consider asking this person to leave the room so they can make their own assessment on how to express their views without the presence of this person’, says Prof. Komajda.
By pioneering such a stringent and sophisticated declaration of interest process, the ESC hopes to act as an example of best practice and help set a new standard of transparency across Europe and internationally.
Helen Jaques, freelance medical writer and editor
Cardiovascular medicine and the Israel Heart Society
A review of cardiology in Israel by Prof. Gad Keren
I consider myself as belonging to the third generation of cardiologists in Israel. The first generation practised after the foundation of the country in 1948 as part of internal medicine. That generation founded the Israel Heart Society (IHS) in 1953 which belongs to the Israel Medical Association thereby stating that cardiology is an independent subspecialty. The second generation consisted of our mentors who laid the solid basis for modern cardiac care, cardiology training, academic careers, and research. The third generation, to which I belong, grew up during the years when innovative diagnostic and therapeutic modalities were introduced and made the enormous changes in the outcome of cardiac patients worldwide and in Israel.
Life expectancy in Israel has significantly increased over the years largely attributable to a reduction in cardiovascular mortality. Improvements in acute cardiac care, reperfusion and revascularization therapies, primary percutaneous coronary intervention (PCI), effective control of risk factors, and adherence to guideline-based therapies have all contributed to the fundamental change in patient outcomes. The IHS via its working groups, educational activities, and participation in major national forums has played a significant role and impacted on cardiovascular medicine in Israel.
The population of Israel is covered by a National Health insurance programme. Medical care is provided by four main ‘sick funds'. Every hospital in the country has an independent cardiology department and all departments have an intensive coronary care unit (ICCU) and non-invasive services. A unique feature of Israeli cardiology is that all centres, except for two, have catheterization laboratories. Many centres have advanced electrophysiology and heart failure programmes and a few have basic research laboratories.
The fact that ICCUs are an integral part of the departments of cardiology allows rapid implementation of evidence-based treatments. The widespread availability of catheterization laboratories, along with the country's small size, allowed for almost universal application of primary PCI for STEMI. In 2010, 94% of patients who received reperfusion therapy had primary PCI with a mean door to balloon time of only 68 min.
The resources for cardiac surgery are also quite well developed with 10 departments and relatively short waiting lists for most procedures. There is a small segment of private service and a few relatively small private hospitals where elective cardiac care is practised.
The IHS has 640 members and is headed by an elected Board, Secretary, and President. The society has 11 working groups that are very active in holding scientific meetings, advocacy, writing position papers, and educating fellows, other health professionals, and the public. Information on activities, innovations, meetings, and lectures by experts is presented on our website (). The society is proud to be an ESC member and many of our members hold key position in ESC associations, working groups, and committees. The IHS endorses the ESC Guidelines with local adaptation as necessary.
ESC-Israel Heart Society joint session
The IHS has its annual conference in the spring and is pleased to invite ESC members to its 58th Annual Conference, 4–5 May 2011 (). In addition, the society holds smaller scientific meetings and endorses established international meetings in Israel in the fields of interventional cardiology, acute cardiac care, and electrophysiology. During the national meeting, achievement awards and research grants are given to those who excelled in their research or educational activities.
The IHS is responsible for the syllabus of the fellowship and the board exams and holds an annual board review course for fellows. A physician who intends to become a cardiologist is initially trained and board certified in Internal Medicine for 3.5 years including 6 months of research. Training in cardiology lasts 3 years during which a fellow rotates and is exposed to all relevant fields including intensive care, cardiac catheterization, echocardiography, electrophysiology, paediatric cardiology, etc., preparing him/her to become an independent cardiologist in the community or in the hospital. If a fellow wants to pursue an academic career he/she is expected to participate in research activity and publish scientific papers. The journey is long and difficult and demands dedication.
The IHS has been conducting a bi-annual survey of all AMI patients admitted to all ICCUs in the country since 1990. This ACSIS survey, in addition to yielding many important publications, has been an invaluable tool for quality control and benchmarking, allowing individual departments to compare their performance with that of the whole country. This effort has contributed to the very high level of adherence to guidelines in contemporary practice. The use of all evidence-based therapies has been increasing steadily. In 2010, 97% of AMI patients in the country were discharged on aspirin, 96% received statins, and over 80% received beta-blockers and ACE inhibitors. Over the past 10 years,
30-day mortality from AMI has decreased from 8.5 to 4.2% (P&0.0001).
Israeli cardiology faces a number of challenges today. Israel is experiencing a shortage of physicians and this is apparent in cardiology as well. There is a growing need for cardiologists that is unlikely to be filled by current medical school graduates. Funding for research is another major challenge. Reimbursement for medications and procedures in Israel is determined by the government every year, and there is always some gap between the introduction of evidence-based therapies and reimbursement. The availability of heart transplantation in Israel is very limited due to religious considerations in large segments of the population.
I am confident that with the superb tradition of Israeli cardiology and the dedication of our young generation Israeli cardiology will remain at the forefront of medicine in Israel, maintaining and expanding its contribution to European and international cardiology.
Gad Keren, MD FESC FACC, Tel Aviv Medical Center, Tel Aviv, Israel and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Rediscovering the third coronary artery
A second right coronary artery is not at all unusual, as described here from Oxford, England
Introduction
Anatomy and functionality of the coronary circulation have been of interest to physicians ever since it emerged that mammalian hearts have their own blood supply. If asked how many coronary root vessels the normal human heart has, most medical students (and many practitioners) would answer ‘two’. Some might refer to a possible abnormal supernumerary left coronary artery, present in about 5% of patients. However, the frequent presence of two right coronary artery (RCA) roots is not generally well appreciated, even though it has been evident to anatomists and cardiac surgeons for centuries.
Reference to this can be traced back in the European medical literature to Giovanni Battista Morgagni's 1761 De Sedibus et causis morborum per anatomem indagatis (see ). Justus Halbertsma (1863), author of an early extensive case study in human coronary artery lay-outs, commented: ‘two coronaries are all but rare and multiplication of coronaries is so common that one is almost embarrassed and has to question whether what we established as normal above (two coronaries) really is the norm’. At about the same time, Richard Quain's seminal atlas of human vascular anatomy illustrated the presence of three coronary root vessels, one left and two right (Figure 1), as ‘the most frequent or standard conformation of the vessels’.
Figure 1. Lithographic drawings by the surgeon Joseph Maclise, showing the human aortic root with three coronary arteries: two right and one left. Left: Plate 1; right: Plate 48, Fig. 3; from Quain R. The Anatomy of the Arteries of the Human Body. 1st ed. London, England: Taylor and W 1844.
That very configuration continues to be illustrated in modern anatomy textbooks, such as Gray's, although now in a graphically less vivid fashion.
The second RCA-root arises from the right aortic sinus of Valsalva, most commonly ventral to the main RCA. In cases where there is no distinct additional RCA, it is usually replaced by the first branch of the main RCA. In either configuration, this vessel generally supplies the Conus venosus, and part of the upper septum. Occasionally, a supernumerary artery arises dorsally to the RCA, then usually feeding the sino-atrial node.
This anatomical insight is in contrast to how the coronary circulation is portrayed in modern ‘functional’ textbooks, which describe the presence of two coronary roots (left and right) as the physiological standard. This view filters through even to specialist communications on cardiovascular system function, diagnostics, or therapeutic interventions.
Three questions arise in this context:
What is the relative propensity of a second RCA?If cardiac surgeons and anatomists know that a second RCA is common—why do the rest of us not?Does this knowledge matter?
Second RCA propensity
In order to address the first question, it is helpful to recapitulate past observations and relate them to technologies used to study coronary artery configuration.
For the assessment of propensity, one should note that different names have been applied to the second RCA. Arturo Banchi (1904) called it the ‘adipose artery’, Georges Piquand (1910) referred to it as ‘l'artère graisseuse de Vieussens’, and Al Crainicianu (1922) used the term ‘arteria preinfundibularis’. Since the seminal work of Monroe Schlesinger et al. (1949), ‘conus artery’ has been preferred. However, the term has been used to refer to different vessel-origin configurations: a ‘true’ second RCA (with separate or shared aortic ostium, relative to the main RCA), or the first branch of the main RCA. Even if one allowed the term conus ‘artery’ for the latter configuration, rather than conal branch of the RCA, it should be applied only in the confirmed absence of a true second RCA. Such exclusion criterion is not generally applied.
Further confusion may arise from variations in second RCA ostium location, which may form an independent entity, or share access to the aortic blood pool with the main RCA, both originating from a small ‘bulge-like’ extension of the aortic wall. A clear distinction between two RCAs (both vessels connected in-parallel to an equally accessible aortic blood pool) and one RCA with a conal branch (where conal access to the aortic blood pool involves an in-series connection) may not always be possible, even if attempted. This may account for some of the variation in reported second RCA incidence. It may also contribute to an apparent age-related increase in propensity, reported by Brooks Edwards et al. (1981) and Motonobu Miyazaki and Morio Kato (1986), as aortic growth could integrate lateral bulges more smoothly into the aortic wall, making distinction of separate ostia easier.
With these limitations in mind, we conducted a meta-analysis of 35 case series (see ) involving 12 161 human hearts, revealing a mean prevalence of the second RCA of 23.8%.
Reported incidence appears related to the method used for vessel identification. Based on in-situ imaging, mean prevalence of a second RCA was 14.5% ( 4787 prevalence 2.4–40.9%). In contrast, ex-situ inspection revealed a second RCA in 29.8% (29 7374 prevalence 7.6–93.8%). This method dependence may be explained by the second RCA-size:proximal vessel diameter is ~1 mm in adult human, which is at the limit of spatial resolution for non-invasive imaging (one needs three voxels indicating wall/lumen/wall to discern a vessel, yet few routine in-vivo imaging techniques have voxel sizes &0.5 mm). In addition, techniques requiring contrast agent injection may fail to discover a second RCA (see below). This suggests that the lower apparent incidence observed in situ may result from false-negative detection errors, so that true prevalence of a second RCA in humans is likely to be closer to ex-vivo observations.
Thus, while we are not able to offer a firm value in response to question (i), a second RCA in humans clearly is far from unusual, with prevalence apparently exceeding one-third.
A knowledge gap?
If RCA propensity is indeed that high, why is this fact not much more widely appreciated? One possible explanation is that the predominance of non-invasive imaging, in particular in functional cardiovascular investigations, has helped us to be accustomed with the picture of coronary root-vessel configuration that these methods offer. In addition, classical anatomical training has been de-emphasized in modern medical curricula (e.g. see Stanley Monkhouse, 1992); so that a ‘functional imaging-compatible’ view of anatomy may appear both opportune and convenient, perhaps answering the second question.
If second RCA occurrence is indeed more common than generally assumed by non-anatomists/non-cardiac surgeons, the final question regarding relevance of the second RCA is even more important.
Second RCA relevance
In 1981, David Levin et al. analysed the frequency of failure to visualize any conus artery during coronary angiography of 508 patients. They reported that in patients with a separate conus artery ostium, it was visualized only if there was reflux of contrast medium from the main RCA injection site into the right aortic sinus. Such inadvertent filling of the second RCA was described in ~30% of cases. They speculated that another ~20% of patients, in whom noconus artery was visualized at all, also had a second RCA. Similar occurrences of ‘missing vessel’ in myocardial tissue with normal contractility prompted Javier Escaned et al. (1992) to suggest searching for a second RCA, using narrow-gauge catheters to facilitate engagement with small ostia, to resolve apparent discrepancies between coronary anatomy, clinical history, and ventricular function. However, indiscriminate injection of contrast medium into the right aortic sinus has been associated with arrhythmogenesis, including ventricular fibrillation. Therefore, without an awareness-driven approach to RCA angiography, the presence of (and abnormalities in) the flow-bed of a second RCA may go undetected.
The functional relevance of second RCA blood supply has been illustrated in several case reports, but has not been investigated systematically. Ray Matthews and Stephen Oesterle (1989) found that occlusion of the conus artery during angiography can result in ST-segment elevation. Jonas Eichh?fer and Nicholas Curzen (2005) reported similar results during angioplasty, as well as chest pain and evidence of myocardial infarction. Matthews and Oesterle also highlighted the importance of a second RCA as a source of collateral supply during chronic occlusion of the main coronary arteries, potentially with the ability of maintaining adequate myocardial perfusion even in severe coronary artery disease. This was also demonstrated by Abdul Rathoret al. (1970), Gregory Mishkel et al. (1991), Escaned et al. (1992), Tuvia Ben-Gal et al. (1997), and José de Agustín et al. (2010).
In addition, undiagnosed disease of conus arteries with separate ostia could represent a cause for unexplained cardiac pathologies, including ‘idiopathic'RVOT arrhythmias. Therefore, in answer to question (iii): it would seem that knowledge of the second RCA may indeed matter.
It would appear that there is a chasm between anatomical insight and its functional application regarding coronary artery root configuration. Ongoing improvements in non-invasive imaging may help to swing the pendulum back to a more anatomically grounded view, and promote re-evaluation of the true prevalence of different coronary artery root layouts in different patient cohorts in vivo. Awareness of the fact that the right aortic sinus can contain multiple coronary ostia, and that these give rise to a second RCA that feeds the RVOT in a third of patients (possibly more), would seem to be relevant to heart research, diagnostics, and treatment.
Supplementary material
T.A.Q. holds a Postdoctoral Fellowship from the Engineering and Physical Sciences Research Council of the United Kingdom (EP/F042868); and P.K. is a Senior Fellow of the British Heart Foundation.
References
The list of references is available as .
Rebecca A.B. Burton, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
T. Alexander Quinn, National Heart and Lung Institute, Imperial College London, Harefield Heart Science Centre, Middlesex, UB9 6JH Harefield, UK; Computing Laboratory, University of Oxford, Oxford, UK, Corresponding author. Tel: +44 , Fax: +44 , Email: t.quinn{at}imperial.ac.uk
Peter Kohl, National Heart and Lung Institute, Imperial College London, Harefield Heart Science Centre, Middlesex, UB9 6JH Harefield, UK; Computing Laboratory, University of Oxford, Oxford, UK
Cardiac centres of excellence‘Royal Brompton': the specialist centre in London that specialist centres consult
It may be diagnosing Thalassaemia with magnetic resonance, navigating catheters round tight corners with magnets, or treating Marfan's syndrome with the Brompton Sheath—but if it is state of the art and it works, the Royal Brompton & Harefield NHS Foundation Trust, London, will almost certainly have pioneered it, reports Barry Shurlock MA, PhD
‘We don't do things we are not good at, nor high volume routine procedures like simple angioplasty or angiography, which are done in every hospital [that treats heart disease]. We are a national tertiary referral centre—perhaps best termed as a quaternary one!—With referrals from the whole of the UK and internationally. We are a National Health Service facility, but we do t out of our annual turnover of ?270 million (321 million Euros) private patient business contributes around ?23 million.
We have a lot of people from outside the UK doing research here—more than 50% in my department—and we definitely try to take on new people with a good CV and funding. For very good people who might be having trouble with funding, we would help them to write grant applications locally [in their own country] and they then have a very good chance of coming here, provided they allow a year or two. The nightmare is someone who has published 3 papers in Nature and wants to start next Tuesday!'
Prof. Dudley Pennell courtesy of Siemens
These are the words of Prof. J. Dudley Pennell, MD, FRCP, FESC, Director of the Cardiovascular Magnetic Resonance Unit at the Royal Brompton Hospital, London. Like many hospitals in the British capital, the ‘Brompton', as it is often called, started as a charitable enterprise and has in recent decades been folded into larger structures built on the belief that ‘bigger is better'. It has long been partnered with the Harefield Hospital, Middlesex, where Sir Magdi Yacoub carried out pioneering cardiac surgery, and the two hospitals now form Royal Brompton & Harefield NHS Foundation Trust. It is also an academic partner of Imperial College School of Medicine, which, in addition to Royal Brompton and Harefield hospitals, now encompasses St Mary's Hospital, the Chelsea and Westminster Hospital, the National Heart and Lung Institute, and the Royal Postgraduate Medical School, situated on the Hammersmith Hospital campus, together with other research centres and liaison with 11 district general hospitals scattered around London.
The Royal Brompton is situated in the heart of the Chelsea quarter of London, which has one of the highest real-estate values in the world. It was founded in the 1840s as the Hospital for Consumption and Diseases of the Chest and from its earliest days has been championed by royalty and such luminaries as the English novelist Charles Dickens. In November 2010, it opened a new Biomedical Research Unit with funds of ?12.3 million (14.6 million Euros) from the UK National Institute of Health Research. With a directly employed scientific and technical staff of 25, it provides research resources for medical researchers from Royal Brompton & Harefield and other centres, who spend time there working on novel interventional procedures, cardiac imaging, genetics of inherited cardiac diseases, and developmental treatments of cardiovascular disease using stem cells and genes.
Much more far-reaching changes are in the pipeline for the hospital, with major building plans projected to start in 3 years' time, with a finish date of 2020 or thereabouts, according to Pennell. Meanwhile, the Brompton is pursuing closer cooperation with the Imperial NHS Trust, having formed an Academic Health Sciences System that will coordinate work at several hospitals, with a view to providing better cooperation in research, improving cardiac care across the whole of West London, and reducing costs.
These anticipated changes to fabric and governance are, of course, important for the future of the hospital, but doctors at the Royal Brompton have a long tradition of fulfilling clinical responsibilities at the same time as pioneering new treatments. In his own field of magnetic resonance (MR), Pennell and colleagues have revolutionized the diagnosis of the inherited disease Thalassaemia, and evaluated new treatments, by means of non-invasive iron scanning of the heart.
He said: ‘This is now available in more than 50 countries. Before the use of T2* scanning of the heart, three-quarters of people with Thalassaemia were dying, but over the past decade in the UK alone we have reduced mortality by more than 70%. We were the first to do this here at Royal Brompton, although it is now carried out throughout Europe and the rest of the world. Thalassaemia is endemic in the Eastern Mediterranean—in Italy, Cyprus and Greece—where it is a consequence of malaria—one copy of the [Thalassaemia] gene protects against malaria, by ‘stressing' the red blood cells, but with two carriers [as parents] there is a 1 in 4 chance of offspring having the disease’. In a study with Prof. Renzo Galanello, from the University of Cagliari, near Cagliari, Italy, Pennell and his group demonstrated the efficacy of Chelation therapy in removing iron from the heart.
3T SKYRA MRI scanner
Cath lab scanner
Royal Brompton has one of the largest units in the world for the treatment of adult congenital heart disease and has pioneered many new surgical techniques. It is an area where par excellence the motto ‘bigger is better' works particularly well, Pennell believes, as surgeons and others benefit from large numbers of patients with a variety of complex abnormalities. Many young patients who would formerly have died young are now surviving into their 50s and require the specialist care that is provided at Royal Brompton by Michael Gatzoulis and colleagues.
Getting catheters into tight spaces is the purpose of the hospital's Magnetic Navigation Laboratory, which is run by Dr Sabine Ernst and is only one of two such facilities in the UK. The use of powerful magnets and navigation software enables interventionists to ‘get in and out of complex hearts' with the distal tip of a catheter, in procedures such as ablation therapy for atrial fibrillation, explained Pennell. It is anticipated that the technique will also prove to be crucial in experimental stem-cell therapy, where it is frequently necessary to inject stem cells into specific locations in the heart.
One surgical technique developed at the hospital as a conservative alternative to aortic root surgery is the so-called ‘Tailor of Gloucester' procedure, which uses an engineered jacket to support the distended aorta in Marfan's syndrome. Originally proposed in 1994 by Dr Francis Ribicsek (Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Charlotte, North Carolina), it was first realized 10 years later at the Brompton by Mr John Pepper and his colleagues, who named it after one of the earliest books by English children's writer Beatrix Potter. The Tailor of Gloucester jacket is made by using computer-aided design techniques fuelled with morphological data from MR (Lancet 2). In this way, the external support can be engineered to match exactly the shape of the aorta, including sinuses and origins of coronary arteries.
Royal Brompton has learned from the experience of Japanese interventional cardiologists how to treat coronary arteries that are completely occluded. Dr Carlo de Mario now enters the blocked artery from both ends, not only forward through the coronary artery, but also reaching the distal region of the blockage by means of a collateral vessel, in order to clear the blockage. Transcatheter aortic valve implantation, pioneered by Philipp Bonhoeffer, is also carried out and there are ongoing studies of catheter valve repair procedures, including the MitraClip(R) for mitral regurgitation, clipping together the leaflets of the valve as an alternative to open-heart surgery. These programmes are leading in terms of patient throughput in the UK.
Earmarked for the future is an ambitious programme of gene mapping. In June 2010, 10 years after completion of the US-funded Human Genome Project (HGP), Royal Brompton set up a next-generation gene analysis facility for sequencing all 22 000 genes in 13 h, compared with the 13 years it took HGP. It is only one of five such cardiac gene centres in the UK. Although Pennell accepts that much more research is needed before the hopes of genetic medicine can be translated into the clinic, he said the Royal Brompton team is determined to be at the forefront of advances and has already invested ?3 million (3.6 million Euros) in the project.
He said: ‘our aspiration is to [carry out] gene mapping for thousands of people over the coming years. Genetics is going to become mainstream for cardiovascular medicine and with advances in the speed of the process we can expect that within 5 years it will be possible to sequence the whole genome within an hour at an affordable price. In the future, we envisage our patients coming in, having their genome sequenced, and an MR scan, and then being offered personalised diagnosis and treatment. With dilated cardiomyopathy, for example, several new causative genes have been identified, which include some [credible] drug targets. So, groups of patients exist for whom no current treatment is available that might benefit from an intervention in a dysfunctional pathway. In broad terms, the [abnormal] heart can be described in terms of a few factors—is it big, thick, stiff or arrhythmic? There are likely to be hundreds, or more genes involved and improved understanding of causation will help with diagnosis, family screening and development of new treatments’.
CardioPulse contact: Andros Tofield, MD FRCS FACEP, Managing Editor CardioPulse, EHJ. Email: docandros{at}bluewin.ch
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European Heart Journal 32 (12) ; DOI: 10.1093/eurheartj/ehr159
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