The first Joint Guidelines on myocardial revascularization

Cardiologists and surgeons have joined forces to write recommendations for coronary artery disease, where cases are becoming increasingly complex and both PCI and CABG are viable options

The Joint, European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines on Myocardial Revascularization are the first guidelines that bring together both disciplines involved in coronary revascularization.

Recommendations on revascularization have been embedded in other ESC guidelines on stable angina, non-ST-segment elevation myocardial infarction (STEMI), and STEMI but never before have cardiologists and cardiovascular surgeons joined forces to write common guidelines.

Their work has been accomplished through the ESC/EACTS Task Force, chaired by Dr. William Wijns, MD, PhD, FESC, co-director of the Cardiovascular Centre in Aalst, Belgium, and Professor Philippe Kolh, MD, PhD, FESC, cardiovascular surgeon at the University Hospital of Liège and professor of physiology at the University of Liège, Belgium.

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William Wijns

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Philippe Kolh

The Task Force comprises equal numbers of surgeons, interventional cardiologists, and non-interventional cardiologists, and the costs of producing the Guidelines have been shared between the ESC and EACTS.

It was felt that a joint approach was needed because in many cases of coronary artery disease (CAD), both percutaneous coronary intervention (PCI) angioplasty and stenting, and coronary artery bypass graft are possible and can be justified. There are chapters in the Guidelines dealing with technical issues of these procedures, but what's novel is that the guidelines emphasize a multidisciplinary approach for deciding which procedure should be used.

That means bringing together the surgeons and interventional cardiologists who perform the procedures with general cardiologists, clinical cardiologists, and experts in prevention to look at the data and address the question of what's best for the patient ‘instead of having a turf battle type discussion’, says Wijns.

In particular, the Guidelines recommend setting up a ‘Heart Team’ made up of the surgeon, interventional cardiologist, and non-interventional (clinical) cardiologist, to discuss specific cases. Comparative trials between surgery and PCI that have been performed with both parties around the table have shown that the approach is not only feasible but adds value to the decision process and improves patient outcomes.

An increasing proportion of CAD cases are complex and it is here that the multidisciplinary dialogue helps with decision-making.

Another novelty is a chapter on risk stratification of patients according to whether a procedure is likely to confer survival benefit or reduce the risk of MI in the long term. The SYNTAX score is used to help guide decisions for complex PCI, with clear thresholds set for recommending surgery or PCI. For example, if PCI gets too complex with a large number of stents then surgery is suggested. New data are included which suggest that PCI may be considered in some left main coronary artery cases, although caution is needed because long-term data are not yet available.

The Guidelines also discuss indications for PCI or surgery in stable angina, non-STEMI, and STEMI. The recommendations for non-STEMI and STEMI are in line with previous guidelines and reemphasize the importance of revascularization in patients with acute CAD.

In addition to the three big conditions, there are detailed suggestions for patients with co-morbidity, such as CAD and peripheral vascular disease, CAD and carotid stenosis, or CAD and arrhythmias.

There is also a chapter with strong recommendations on optimizing medical management of patients with revascularization. ‘There's sometimes this erroneous belief that if you fix the conduit, be it with a stent or with a bypass, the patient is cured’, says Wijns. ‘That is wrong, and the teams who perform revascularization should be absolute specialists in secondary prevention’.

Also new is a chapter on the process of decision-making for patients which outlines what to explain to the patient, how to do it, and when. They advocate giving patients appropriate information so that they can be active participants in the decision over which procedure to select.

Patients also need time to consider the information. ‘When you are half asleep in a cath lab with a catheter in the groin is not the best time to make a judgement’, says Kolh. ‘It doesn't mean that you cannot do ad hoc PCI, but in more complex [elective] situations we advise having at least one day for the discussion’.

Taken together, the Heart Team, risk stratification, and patient information are designed to identify the best strategy for the patient at that point in time.

Guideline timetable 2010

  • August 29—First released at the ESC Congress in Stockholm. Published on the ESC website.

  • September 12—Presented at the EACTS annual meeting in Geneva.

  • Autumn—Printed version published in the European Heart Journal and the European Journal of Cardio-Thoracic Surgery.

Jennifer Taylor, MPhil.

Editorial board meeting of the European Heart Journal at ESC Congress in Stockholm on 31 August 2010

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The editorial board as well as the reviewers are crucial for the quality of the scientific content of journals including the European Heart Journal. To acknowledge the support and work of editors and editorial board members, each year the European Heart Journal organizes three editorial board meetings, at the European Society of Cardiology's Annual Congress, the Scientific Sessions of the American Heart Association, and, at the meeting of American College of Cardiology. The meetings are also essential for editors to obtain feedback from scientists and clinicians working for the European Heart Journal to further improve the process of manuscript transfer, publication and especially, the selection of papers for publication.

This year's meeting was particularly important as it marked the 30th anniversary of the European Heart Journal, outlined in an editorial recently published.1 The Editor-in-Chief Prof. Thomas F. Lüscher reported on the impressive history of the European Heart Journal from its inception by its first editor Desmond Julian, to its remarkable reputation today. Indeed, the submission of manuscripts has grown from a few hundred to more than 3600 manuscripts expected this year. Most of the manuscripts still come from Europe but authors from the United States and Australasia are also significantly contributing, which reflects the global nature of today's European Heart Journal. The manuscripts are handled by the Editor-in-Chief and/or deputy editors and also in many cases by associate editors. Papers are sent for review and a decision is made only after at least two or three reviews have been obtained. Thanks to an efficient editorial office and the commitment of our reviewers turnaround time has been reduced to 24 days, in spite of transferring some manuscripts to ESC subspecialty journals, a new feature introduced last year. Indeed, more than 600 manuscripts had been transferred and eventually about one third were accepted. We anticipate that more manuscripts will be transferred to the ESC subspecialty journals in the future, since the acceptance rate of the main journal dropped to 12–15% this year. This allows even stricter selection for high quality manuscripts to be published in the European Heart Journal.

Without the impressive commitment of reviewers from all over the world, the European Heart Journal could not be published. Therefore, the editor-in-chief acknowledged the Elite Reviewers: scientists and clinicians that have reviewed more than 20 papers within the last 12 months, during the editorial board meeting.

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Elite Reviewers at Stockholm with Lüscher, left to right, Alec Vahanian, Luigi Biasucci, Walter Riesen, Jeroen Bax, Ron van Domburg

This year for the first time, a ‘Reviewer of the Year’ Award has been introduced. The recipient was Prof. Giuseppe Biasucci, Professor of Cardiology at the Catholic University in Rome, whose main areas of interest are Acute Coronary Syndromes, Atherosclerosis, Stem Cell Therapy, Thrombosis & Platelets.

Prof. Biasucci reviewed an impressive 43 manuscripts within the last 12 months. The editors were particularly impressed by his balanced judgement and extensive analysis of the papers he reviewed.

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T.F. Lüscher left, G Biasucci, Reviewer of the Year right

The next editorial board meeting of the European Heart Journal will take place during the scientific sessions of the American Heart Association, November 2010 in Chicago, USA.

T.F. Lüscher, A. Tofield

References

1
Lüscher
T.F.
Brugada
J.
Gersh
B.J.
Landmesser
U.
Serruys
P.W.
Murphy
S.
Dedecke
S.
Rogers
S.
Ruschitzka
F.
Happy birthday European Heart Journal: in 30 years from Cinderella to centre stage
Eur. Heart J
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2010
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31
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The EACPR is working to incorporate cardiovascular prevention into the usual cardiac care

One of the youngest European Society of Cardiology Associations, Jen Taylor reports

The European Association for Cardiovascular Prevention and Rehabilitation (EACPR) is a young association. It originated in 2004/2005 after the lengthy merger of several European Society of Cardiology (ESC) working groups on exercise physiology, cardiac rehabilitation, epidemiology and public health, sports cardiology, and basic science and translational research.

Originally, the EACPR had six to eight sections that were defined by the original working groups, but now the merging process has been completed and there are four sections: Cardiac Rehabilitation; Exercise, Basic & Translational Research; Prevention, Epidemiology & Population Science; and Sports Cardiology.

The working groups were joined because there was some overlap in their activities and interests. ‘The main reason from the ESC's point of view was to streamline the common message of several working groups’, says EACPR president Pantaleo Giannuzzi, MD, FESC, Chief of the Department of Cardiac Rehabilitation and Director of the Scientific Institute for Clinical Care and Research of Veruno, Salvatore Maugeri Foundation—IRCCS. ‘All these original working groups had as a major objective prevention and rehabilitation’.

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P. Giannuzzi

Sports cardiology is one area that could be considered too specialized, but it is linked to the prevention of sudden death in sporting activities, and also to physical activity for prevention.

The association has expanded by 160 members per year over the last 4 years, reaching 1700 in 2009. The countries most represented are Belgium, Germany, Greece, Italy, and the UK, and the top five non-EU countries are Israel, Norway, the Russian Federation, Switzerland, and the USA.

The EACPR's mission is to promote excellence in research, practice, education, and policy in cardiovascular prevention and rehabilitation in Europe. Over the last few years, it has created a strategic plan with two main principles: first, to bring together the expertise of the four sections in board committees responsible for flagship projects and, secondly, to support all aspects of the ESC prevention policy agenda.

Giannuzzi explains: ‘The ESC has given to our association the responsibility to cover all the agenda of prevention and rehabilitation from the scientific point of view and from the political point of view’.

One of the EACPR's major activities is the EuroPRevent annual congress, which has been particularly attractive to young researchers. Some 90% of attendees of the congress are <40 years of age and come from different hospitals and institutions from around Europe and beyond. They are involved in all fields of prevention—epidemiology, basic science, education, and intervention—and are active in identifying and promoting new interventions for primary and secondary prevention.

The main goal for the next EuroPRevent, which will be held in Geneva in April 2011, is to establish good relationships with sporting associations, particularly the Olympic committee based in Switzerland. ‘We want to use all national and international associations for sports as a partner for prevention’, says Giannuzzi.

Through these partnerships and the media, they want to spread the message that sport is not just a professional activity but can also be a leisure activity, and that people should exercise more in order to reduce their risk of cardiovascular disease.

Another major asset is The European Journal of Cardiovascular Prevention and Rehabilitation (EJCPR), which covers all aspects of cardiovascular prevention, epidemiology, rehabilitation, exercise physiology, exercise training application, and basic and translational research. It is a very young journal but achieved an impact factor of 2.5 in 2009 and the expectation is that this will increase to 3 for 2010.

EACPR members contribute scientifically to ESC policy on prevention by being on guideline task forces related to cardiovascular prevention. They also contribute to guidelines in other fields of cardiology. The association provides input into the content of scientific sessions at the ESC Congress.

To execute its role of leading prevention implementation for the ESC, the EACPR has been given a mandate from the ESC to influence the national policy on cardiovascular disease prevention.

The association wants to add value to national efforts by demonstrating that prevention and rehabilitation are both clinically and cost-effective in different health economies. To facilitate cooperation with the national societies, the EACPR has created a network of national coordinators who work together around the theme of prevention.

The EACPR has a number of projects on prevention implementation. One of these is a benchmarking project that is analysing how the guidelines for prevention are used.

Another project is looking at health economics. It aims to model the clinical- and cost-effectiveness for cardiovascular prevention based on the results of the EUROASPIRE surveys on the status of cardiovascular prevention in Europe.

The surveys have demonstrated disappointing results from cardiovascular disease prevention efforts in Europe despite the increased use of drugs for prevention. Improvements in lifestyle are needed to address the problems of obesity, diet, physical activity, smoking, and so on.

Going forward, the organization and structure of the EACPR will be streamlined around key projects that are ongoing and new ones that have yet to be identified.

Giannuzzi's ambition is to establish a more advanced model and standards for cardiac care that is more effectively oriented to cardiovascular prevention. Although important progress has been made in acute care for cardiac patients in hospital, elements of prevention need to be added to their care package. That would see patients admitted to hospital for acute coronary syndrome or heart failure also receiving interventions that have a prevention aim.

‘Adherence to long term lifestyle changes [and] adherence to long term cardioprotective drugs is one major concern in terms of preventing new admissions to the hospital and for controlling the global cardiovascular risk’, says Giannuzzi. ‘We need to do more while the patient is in the hospital and also in the community for prevention’.

The EACPR is working on a model and standards of care that incorporates cardiovascular prevention into the usual cardiac care, beginning in the hospital and continuing in the community. Elements of the model include education, rehabilitation, promoting effective lifestyle changes, and drug adherence for prevention.

The goal is to have a finalized document ready for next year's EuroPRevent in Geneva, and to publish it during the ESC Congress in Paris in 2011.

J. Taylor MPhil, medical journalist.

Implantable devices currently used in cardiology therapy

John Cleland and Daniel Gras discuss the increasing use of new devices that are available for cardiologists to treat cardiac disease.

Devices are being used more often and in diversified ways in cardiology. Along with drugs, they are part of the armamentarium for tackling diseases such as heart failure which are difficult to treat, says Professor John Cleland, MD, FRCP, FESC, Professor of Cardiology at the University of Hull, England.

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John Cleland

Cleland predominantly uses cardiac resynchronization therapy (CRT) and cardiac resynchronization therapy defibrillator (CRTD) for heart failure, and rarely implantable cardioverter-defibrillator (ICD). His research is focussed on exploring the boundaries of CRT indication. ‘We don't think that any of the criteria used to select patients are actually very robust’, he says. ‘So I wonder whether or not all patients with heart failure should perhaps have CRT’.

The indication for an ICD in the current guidelines is low ejection fraction, and they advise not to treat people whose heart failure is too severe (class 4). The UK's NICE guidelines also require some evidence of an increased risk of arrhythmias, but European guidelines do not stipulate this.

For CRT, there is an additional requirement for QRS width. But while QRS has become the traditional way for selecting patients, Cleland says the data to show that it is important do not exist. ‘If it's just a marker of ventricular dysfunction and patient adverse outcome, then we have much better markers than QRS’, he says.

He believes that CRT is underused. Fewer than 5% of heart failure patients currently get CRT, but on current knowledge it could be nearer to 20%. With further research on what CRT can achieve this could reach 50%.

The underuse is due in part to confusion about how it should be used. Some doctors will not go ahead with implantation unless they can convince themselves that the patient has ventricular dyssynchrony, even if all of the other criteria are met.

Every clinical trial of CRT has produced a benefit, but large trials have consistently excluded atrial fibrillation despite the fact that around one-third of patients with heart failure have atrial fibrillation. The result is a hesitancy to advise CRT in those patients.

In addition, there is a reluctance to suggest to patients that they should undergo a procedure that has a certain risk and morbidity of its own. And, patients themselves may be hesitant to be exposed to risk when success is not guaranteed.

The major risk with CRT is in the implantation of the small device itself.

It can take 2h, which is longer than the time to implant a pacemaker or a defibrillator. Lead displacement is another risk, but with new technologies this is decreasing. There is a small risk of coronary venous dissection, often harmless and only very rarely leads to a serious complication.

Infection rates are 1–3% for pacemakers, defibrillators, and CRT devices, and are more common in the latter because it is a longer procedure and there are more leads. When infection does occur, often, the whole device must be removed.

Defibrillator trials show that there is no mortality benefit over the first 12–18 months of device implantation, implying that there is some harm being done early on. The same is not true for CRT devices, suggesting that any harm from device implantation is swamped by the benefits.

Cardiac resynchronization therapy is thought to re-coordinate cardiac activity and make cardiac function more efficient. Unlike other successful interventions for heart failure, it is the only one that drives blood pressure up, which is helpful because low blood pressure often limits the use of drug therapy.

Cardiac resynchronization therapy alone, even without a defibrillator, reduces the rate of admissions for worsening heart failure, reduces death from worsening heart failure, and reduces sudden death. ‘CRT is going to benefit the large proportion of patients in whom it's implanted as opposed to the defibrillator, which I think benefits only a small proportion of patients who get implanted’, says Cleland.

He rarely uses ICD for heart failure because it is expensive (around €20 000), is associated with high morbidity rates, and offers little to the patient other than reducing the risk of sudden death by a rate of just 1–1.5% per year.

With ICD, patients get inappropriate and unnecessary shocks at four or four times the rate of the life-saving shocks. Some patients appear oblivious to the shocks, while for others it is a nightmare experience to the extent that they want the device turned off.

Implantable cardioverter-defibrillator also leads to an increased risk of hospitalization for heart failure, and for sick patients the evidence that ICDs alter outcome is dubious.

The type of patients who would benefit from a defibrillator is ill-defined. Cleland says the best way of selecting patients for ICD is to identify patients who should not have them, rather than trying to identify patients at higher risk of arrhythmias—a strategy which has by and large failed.

‘I think that we're looking at identifying patients who are at risk of arrhythmias but are at risk of dying of other things and excluding those patients from implantation’, he says.

Other devices are available for heart failure, including left ventricular assist devices (LVADs), which are booster pumps that can be implanted and take over some of the heart's function.

Their use is generally limited to transplant centres, where they are used as a bridge to transplant or an alternative to transplant. Worldwide several thousand patients have received these devices and many hundreds have been maintained on them for months if not years. The longest survival was 7 years. But LVADs are expensive and associated with risks of stroke and infection.

Contractility modulation devices are being used experimentally. They are a bit like CRT but deliver quite a high-energy pulse at a time in the heart cycle when they do not cause the heart to contract. That seems to change the intracellular calcium concentration and cause the subsequent heart beat to be stronger than it otherwise would be. The results of clinical trials have been controversial, with some believing that they were neutral and others that they showed some evidence of benefit.

Other devices which are used to stimulate the carotid baroreceptors and the vagus are being studied. These could be designed to improve cardiovascular function and cardiac contractility, and perhaps bradycardia. It is too early to say how effective they will be.

New implantable devices are needed to help cardiologists learn more about the natural course of disease in heart failure and atrial fibrillation, says Dr Daniel Gras, a cardiologist at Nouvelles Cliniques Nantaises in Nantes, France.

In heart failure, the aim is to learn whether the disease will aggravate itself or remain stable. If deterioration of heart function can be anticipated, then preventive therapy could be initiated.

In atrial fibrillation, information from the device would help cardiologists decide whether to initiate anticoagulant therapy to avoid the development of stroke.

Implantable devices now exist that can monitor pulmonary pressure in heart failure patients over the long term. Gras does not use the device because it is not reimbursed. He adds that if the technology is proved to be reliable and of benefit for the patient, then he would prefer to use a more sophisticated device that is capable of not only providing new information but also delivering a therapy.

He is working with engineers to try to design such a device and so far their experimental studies look very promising.

Gras uses an implantable Holter monitor to diagnose bradycardia or tachycardia in patients presenting with episodes of recurrent syncope without an explanation, or episodes of palpitation and a negative EP study.

The device carries few risks because it requires a very small incision of 1 cm. It is inserted subcutaneously in the chest, in front of the heart, and provides the equivalent of a permanent electrocardiogram, which is stored in the memory of the device. It has produced no major difference in mortality, but results in a lower hospitalization rate and a better quality of life for patients. But, the main interest in the device is in avoiding unnecessary pacemaker implantation. Just 5–6 years ago, before the device existed, the only option was to implant a pacemaker or do nothing. It was a tough decision and meant that sometimes pacemakers were implanted in patients in whom there was no real indication, and sometimes pacemakers were not implanted in patients who could have benefited.

Use of this device is limited, because it is not uniformly reimbursed—a strange situation, given that pacemakers are more expensive than the diagnostic device. Gras says: ‘In some European countries, if the device is not reimbursed they would prefer to directly implant a pacemaker despite [the fact that] they are not 100% sure that there is a real need to do it’.

Last December CardioPulse reviewed Development of the Artificial Pacemaker, Eur Heart J 2009;31:2957–2959.

J. Taylor M Phil.

Personal experiences of émigré cardiologists: Sven Plein, MD, PhD

When Sven Plein arrived in the UK from Germany as a newly qualified doctor, the plan was to spend 18 months as a postgraduate before returning home. Almost 15 years later, he is working as a consultant cardiologist and senior lecturer in Leeds, England.

Born in Frankfurt, Germany, in 1968, Dr Plein attended a medical school in the town of Marburg, graduating in 1995. German medical graduates at that time began their working life with an 18-month low-paid period of clinical work in a role equivalent to junior house officer.

Having spent some time as a student working at the Queen Elizabeth Hospital in Gateshead, England, Dr Plein and his partner found the prospect of a year or so working in the UK more appealing. At that time, there was an acute shortage of junior doctors in England and the National Health Service (NHS) was actively recruiting in Germany. ‘First the salary was about 3 times what we would have had at home. It also meant I would be able to get a job at the same hospital as my partner, which would have been very difficult in Germany’.

‘At that time, you could actually take a job on the spot and we were offered a job over the phone by the clinical director of Liverpool Teaching Hospitals NHS Trust who said ‘you can start on the 3rd of August’. There were a number of benefits such as free accommodation and an induction as well as the chance to take advantage of good clinical training'. It seemed too good to be true, although Plein admits experiencing culture shock on arriving in Liverpool from a small, rural German town and having to settle into a high-rise flat in the inner city. Work wise; however, there were very few problems. Many other junior doctors were from Germany and a series of organized inductions helped smooth the way.

Plein found the hospital jargon and widespread use of abbreviations baffling at first, but it was easy to settle in to the daily routine. ‘What I particularly liked was the team hierarchy in the hospital of a junior house officer, a senior house officer, registrar, and a consultant. You could always ask someone if you were not sure of something. The culture of friendliness and openness in the NHS made integration easy. In the German system, things are a lot more rigid. You would be wary of asking a consultant something, but I found a willingness to share knowledge and help train junior doctors embedded in the system in England’. Having help on hand also eased the potentially nerve-wracking experience of being on call and facing patients for the first time.

When Plein's 18-month period as a junior house officer in Liverpool ended, his partner was keen to qualify as a general practitioner (GP) and wanted to gain experience in England, so they decided to stay a little longer. Plein had decided to pursue cardiology as a speciality and was set to return home. However, when he applied for posts in German University hospitals, he was advised to seek further academic experience first. He found a research fellowship at the Cardiac MRI Centre in Leeds and was quick to make the most of the opportunities there. ‘They had a brand new scanner and very few people to use it, so I was able to get involved with that and it developed into an association with the research group that has continued to this day’

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Research group day's excursion in Yorkshire Dales 2010.

By 2002, Plein had been offered a registrar training post in cardiology at Leeds General Infirmary and his wife was enjoying her work as a GP. Although there was still a possibility of returning to Germany, it was becoming more remote and a period working on research collaboration in Switzerland in 2006 convinced Plein that he had more to lose and less to gain from a career perspective back home. Having a family unit in the UK was the key to establishing a successful career. Plein's wife has also been able to realize her career ambitions and the couple now have two children aged 4 and 6. ‘There was always a lot of ambiguity in our minds about where they should grow up but the bi-lingual environment has been good for them so far’.

From his own point of view, Plein feels that he has been able to develop his own skills and career in the UK with a freer hand than he would have had back home. ‘In Germany many departments are dominated by the Professor of Cardiology who must not be questioned. In the UK, the system is much flatter and individual consultants enjoy a much more autonomous existence leading their own team of junior doctors and being able to choose their own career path set their own agenda’.

His 15 years in the NHS have given Plein the opportunity to see the strengths and weaknesses of the system. He says: ‘The NHS in England still isn't as efficient as the German health system, partly because it is less profit driven. That can also be strength however, as in Germany; a lot of effort appears to go into maximising profit for a department, sometimes by performing procedures solely because they bring in money. Here, I only prescribe a test or treatment because I think it is clinically indicated’.

The creeping over-regimentation of the NHS is also a source of frustration with too much time wasted in directives such as ensuring everyone is trained to the same standard on issues such as hand washing or arbitrary centrally set targets for patient care. ‘We often say that England is now much more Prussian than the Prussians ever were and has adopted every rule and regulation going. Similarly, the ethics and other administrative procedures for research are now so time-consuming with the paper work almost exceeding the time required to do the study itself’.

A real plus of working as a health care professional in England is, Plein believes, the hospital culture of friendliness and camaraderie. ‘99.5% of people are friendly 99.5% of the time in the UK and I have had so few professional disagreements with colleagues over the years here’.

He is happy to be working in cardiac imaging, which he feels is keeping pace with developments in Europe. Another bonus for a clinical academic is the availability of research funding in the UK. The Welcome Trust currently funds Plein and his main research work is looking at the role of cardiac imaging on different types of heart disease—particularly ischaemic heart disease.

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His advice to medical graduates contemplating a move to the UK is: ‘Get your foot in the door any way you can, then work your way up the system. It's much more difficult now and the opportunities I had no longer exist, but once you're in the system, there are opportunities’.

For himself and his family, the experience of establishing a life and career in England has produced positive results. ‘We think England is offering us more than we could get elsewhere now, not just for work, but family, schooling, lifestyle and friends. If we went back now, I feel we would not only lose something professionally, particularly for my wife as a GP, but personally as well’.

Judy Ozkan BA, medical journalist.

Book review
Collateral circulation of the heart

Editor: Christian Seiler

ISBN: 978-1-84882-341-9

2009, XVI, 450 p. 321 illus., 120 in colour, Hardcover

Publisher: Springer-Verlag, London

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Besides epicardial vessels and the microcirculation, the coronary collateral circulation represents an important player in myocardial blood supply. Coronary collaterals are far more than fortuitously developed intercoronary connections, anatomic variants, or incidential angiographic findings. They provide important haemodynamic effects in several clinical settings. Furthermore, they do not function as simple rigid tubes, but are able to dilate and constrict under different physical or neurohumoral circumstances. Coronary collaterals are potentially myocardial salvaging in acute coronary syndromes and have obvious anti-ischaemic benefits in stable coronary artery disease. However, well-developed coronary collaterals may also elicit negative aspects, such as the risk of unwanted extension of myocardial infarction during alcohol septal ablation in hypertrophic obstructive cardiomyopathy, the occurrence of coronary steal during myocardial hyperaemia, and the risk of restenosis following percutaneous coronary intervention or early bypass occlusions due to competitive antegrade flow.

This book by Seiler provides a complete and concise overview of the current pathophysiological understanding, clinical implications, research efforts, and published data on coronary collateral circulation. The content covers a broad spectrum of different aspects, and therefore addresses several potential readers; the practicing (interventional) cardiologist will find concise discussions on important clinical scenarios with very well-illustrated case studies. For basic scientists, the book not only provides structured information on physical, cellular, neurohumoral, and genetic aspects of collateral flow, but also includes much inspiring data on angiogenesis and neovascularization. Detailed descriptions of non-invasive characterization, angiographic assessment, and quantitative investigation on coronary collaterals will stimulate the clinical researcher.

Collateral Circulation of the Heart’ is characterized by a very intuitive layout of the chapters. In the first part of the book, the relevance of coronary collaterals is discussed, followed by a chapter on their assessment. Prevalence, natural promotion, function, and artificial promotion complete the book to a successful state-of-the-art summary on this topic. Some redundancy in the content within the main chapters allows the reading of each chapter easy. Furthermore, the book impresses with a huge amount of well-illustrated figures, tables, diagrams, coloured photographs, haemodynamic tracings, and angiograms, on almost every page. Sections on historical background and interspecies differences are worth reading by all, not only by specialized experts. The extensive and complete literature citation index in each chapter makes it into a valuable scientific reference book.

Christophe Wyss

Department of Cardiology, University Hospital Zürich

People's corner

CardioPulse announces a new Series: The Personal Experiences of émigré cardiologists

CardioPulse is starting a new series about the personal experiences of cardiologists who have moved to practice in another country/culture. Their views and feelings on confronting another language, another healthcare system, different lifestyle habits, how their families cope, and adjust to the new environment.

Should you wish to contribute please contact Dr Andros Tofield at docandros@bluewin.ch

CardioPulse contact: Andros Tofield MD FRCS FACEP, Managing Editor CardioPulse, EHJ. Email: docandros@bluewin.ch

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