Modern treatment of heart disease: Can we do better?

0:02 okay good evening ladies and gentlemen um for those of you who don't know me I I'm Trevor McMillan and I have the the privilege of being the vice Chancellor here at Keel University um it's it's a very great pleasure to welcome you to the inaugural lecture to be given very soon by by Jim Nolan um I feel like the opening script for these anogra lectures gets a little bit repetitive for those that you that come uh quite often but it is genuinely true that these universities these lectures are a very very important part of university life and and indeed at Keel here we are one of a relatively small number of universities that have maintained the tradition a lot of other

0:49 universities have either done away with inaugural lectures or or turned them into a sort of mini Symposium rather than uh an individual event but I think for us it's a very good opport to highlight some of the worldclass research that goes on in our institution um and in on this particular occasion a very good opportunity for us to emphasize the very close collaborative relationship we have with some of our partners in particular within the NHS it's also though clearly indeed all about the individual uh in this case Jim Nolan we were discussing already um these are not easy lectures to put together uh I don't don't know many of you in the audience but I suspect we will have uh some people in the audience

1:35 who will know every word about what Jim is about to talk about and who will be able to critique it in every detail and there will be some of us who actually do not know very much of the background and so to be quite honest he could almost say anything he likes and we would absolutely implicitly believe it so that's quite a fine uh line to tread um but all in all the key thing to be honest is that that he will keep us entertained for the next 50 minutes or so and I'm sure he'll do that now at this time in the in the proceedings it's it's normal um that I try to summarize the curriculum V of the new professor who's about to talk to you on this particular occasion Jim CV I have to say

2:21 is one of those that I just genuinely cannot give Justice to in the short time that I have available so I'm actually going to bottle it I'm going to wimp out and I'm going to give a very very uh quick overview of of his history and then hand over to Jim so that he can talk about it uh himself so Jim qualified from leads in 1983 uh he trained in cardiology at the Royal free in London the Royal infirmary in Edinburgh then in Amsterdam and then back to the leads before taking up his current post as a consultant Interventional cardiologist in 1998 during his appointment in Amsterdam he was trained in novel techniques that facilitate safer coronary intervention

3:07 procedures he's had a major role in research Education and Training into these new techniques and as a result of his academic and education in initiatives UK practice has evolved into a new model of coronary intervention he carried out Research into chronic heart failure and was awarded his MD from Leeds University in 199 six despite being a full-time NHS clinician with no academic sessions Jim has an enviable research record his principal research interests relate to heart failure and the use of trans radial access for coron for coronary intervention and he has established an internationally renowned cardiac research program and has published a large number of peer-reviewed papers

3:54 including highly cited pivotal studies for those of you who think about such things as the H index which is a measure of how many times other researchers cite his his work that number is 25 which I can assure you might be a meaningless number to many of you but 25 is the sort of number that even full-time researchers would be very very proud to have Jim has contributed to many uh textbooks and there's a regular lecture at National and international conferences he served on the editorial Boards of major cardiac journalist and is a member of the Govern in Council of the British cardiovascular Interventional Society his work has genuinely stimulated a major change in UK practice

4:39 with most centers Now using radial access for Interventional procedures and that has led to very important benefits for patients Jim has a very very important place in the regional and National clinical community and indeed in the work of this University tonight he's going to talk about identifying patients at risk of early death um from heart failure which at a personal level is of great interest having just lost one of my closest friends to a sudden heart attack just 6 weeks ago at the age of 62 and he's also going to talk about the role of access site for coronary intervention so can I therefore formly welcome Jim Nolan professor of Interventional Cardiology uh to the stage and invite him to present his

5:25 inaugural lecture modern treatment of heart disease can we do it better [Applause] thank so it's a very serious world we live in now doctors are under intense scrutiny we're always uh made to declare any possible conflict of interest we have at the beginning of a lecture so here's mine Stoke City supporters or everon supporters won't recognize this trophy it's the 2005 Champions League trophy of course won so memorably in Istanbul I can hardly believe it was 11 years ago in some ways it's ruined my football

6:11 supporting life because nothing can ever be that good again so when I was looking uh back through the things I'd been up to over the years I I was struck by how everybody's research career does start somewhere and when I was uh A cardiology regist at the Royal free we had a vet working in the department with us he'd come to try and learn how to do some uh some of the techniques and uh he told me one day he had a little dog that kept falling over whenever it tried to run um because it had complete heart block and we had a couple of pacemakers line around that we had to explant from people so we kind of run one under the tap washed it down sterilized it went up to the veteranary hospital popped it into the dog and uh we were up and running reported the case so I spent a

6:56 bit of time doing these pace make procedures in dogs before I kind of realized that there probably wasn't a long-term career in that for me in uh clinical Cardiology and practice in people so when you think about uh what people die from two-thirds of the people in this room will die from cardiovascular disease commonly from es schic heart disease um es schic heart disease being narrowing of the coronary arteries and the things that kill them are blockages of the chary arteries they cause symptoms they can olude um they can cause heart attacks with all their complications or patients can survive with damage to the heart and they have to live with chronic heart failure when I went up to Edinburgh to do my research

7:42 degree I was interested in looking at heart rate Behavior as a way of examining cardiovascular health as you sit there running along with a heart rate of about 60 beats a minute or so you might think that that is a Rocksteady thing that your heart rate doesn't change but in fact here you can see one human individual's heart rate fluctuating quite uh widely over the course of three or 4 minutes your heart rate is constantly changing you know you stand up you sit down you watch the football West Ham score a winner in the last minute of extra time whatever it may be the misses tells you off for not washing the dishes quick enough you're constantly varying your heart rate and there's a complex neurological system that controls uh regulation of heart rate here up here is the cardiovascular control center in the brain Stone it's

8:28 what uh Sports scientists would call the monkey brain it's buried deep within the the brain at the base of the brain you've got no real conscious control over what's happening here but a complex set of nerves run to and from this and control your heart rate and they're influenced by temperature um standing up sitting down all sorts of things really and if you can measure this change in heart rate you can get an idea of the functioning of the autonomic nervous system and the health of the cardiovascular system in that individual so when I went to Edinburgh we developed a way of counting the amount of variability that occurred over a 24-hour period from a a little tape recorder and the first thing we did was to study some normal people and people with various diseases to see if we could have if we

9:14 had a reproducible technique so if you did the measurement on a Tuesday and then on the following Wednesday did you get the same results and if that's so the results will be clustered closely along this line and you can see that we had a very reproducible technique there there are various numerical ways of analyzing that in more detail but uh after publishing this paper we were pretty confident that we had a good way of analyzing heart rate variability and assessing autonomic function the next thing we did was we looked at patients with severe chary artery disease but who who had never had a heart attack whose heart was functioning well and these two parallel lines are the normal range and the dots of the patients that we studied and most of them are well within the normal range there's always a few outliers so we knew that if you had chary artery disease on

10:00 its own you didn't have abnormal cardiac regulation then we looked at a group of patients with chronic heart failure this is the normal range again the two parallel lines and you can see here about 60 to 70% of the patients fell well below the normal range so they had reduced heart rate variability and this was probably an index of the severity of their General condition the patients with the lowest heart rate variability were the patients with the lowest ejection fraction so if your heart was fun functioning poorly you were down here if your heart was functioning quite well you were up here and your variability was preserved the next thing uh I mean that that series of studies along with some others made up my MD thesis and when I left edmir and I went to leads I wanted to do another study to see if we could

10:45 link this to outcome and prognosis in heart failure and you know for any of the medical students it's quite an interesting story I I went along to the senior academic cardiologist and asked them if they would wanted to work with me and help me to do this study and the answer was uh no um I asked if I could borrow a couple of ambulator ECG monitors to do the study and the answer again was no so I waited till the uh Professor went away in his holidays and I borrowed the two ambulatory ECG machines from the cupboard we got a 75,000 Grant to buy a couple more and I uh contacted the these are my friends really I got on the phone to my friends in Nottingham up in Edinburgh another guy in Doncaster and we recruited about 500 patients with chronic heart failure measured their heart rate variability we

11:31 followed them up for a couple of years and the patients down here who had very abnormal heart rate variability didn't do very well at all and after 18 months to two years 70% of them were dead and the patients up here who had preserved heart rate variability in contrast did pretty well and weren't far off an AG matched population who had normal cardiac function it's an interesting paper you know the background to it about it being done for £75,000 with without any involvement of the local academic people the journal it was published in circulation the average number of citations for patients for for papers published in that journal would be 15 in a year and this Pat this paper has been cited over a thousand times so it's a it's a significant pivotal and

12:17 fundamental piece of heart failure research of course you know knowing about it is one thing can you do anything about it we we studied a group of patients before and after putting them on an Ace inhibitor captopril and we showed that we could improve the heart rate variability of the patients by putting them onto captopril so we did have a a therapeutic tool that we could use for these people so at the end of that group of heart failure studies we knew that autonomic control of heart rate is deranged in heart failure and you can investigate it reliably by heart rate variability an analysis the magnitude of derangement is related to the severity of the condition and it can be modified by drug therapy and it's strongly predictive of survival and it can be used to guide treatment decisions after

13:05 that we've done a whole series of other things that are are ongoing right up to now 14 subsequent peer-reviewed Publications we looked at the different ways people die different prognostic factors we followed them up for a long time we looked at different heart rate variability analytical techniques and it's kind of interesting really the first thing that we did was uh I I went up to drove up to Edinburgh collected all the tapes they were on Cass C ET so there's nearly 500 cassettes I drove down to London and I met the uh professor of Cardiology from Virginia who flew over handed over the tapes to him he bundled them all up took them on a flight back to America the next day drove them down to uh a NASA laboratory in Miami and they ran the tapes through a supercomputer it took months to do a

13:53 complex analysis looking at chaotic Behavior we and we were able to show that uh that analysis was even better than the heart rate variability technique that we' done through working with NASA in a kind of British way this data was this paper was published just last year we then thought well could we do it quite easily could we look at any other things and we thought we might look at heart rate range so the difference between Peak heart rates and minimum heart rate and we thought that if that was wide that it would represent preserved autonomic function and if it was narrow it was probably abnormal autonomic function and we correlated the two measurements together heart rate variability here and heart rate range here and you can see there is a relationship between the two and then we looked at whether this related to prognosis in the same way as

14:40 heart rate variability this is mortality here patients with a narrow heart rate range were dying fairly frequently and patients with a broad heart rate range survived very well so at the end of that the conclusion was that you don't really need to do the complex superc computer analysis with NASA you can just do a 24-hour tape and look at the difference between the maximum and the minimum heart ratees it's a bit like when the Americans started sending astronauts into space and they spend billions of dollars developing a brro that can write in weightless environments and the Russians gave their cosmonauts a pencil so you can do it pretty simply we did some other things with uh various other groups quite a number of patients in chronic uh patient of papers in

15:26 chronic liver disease last year published some working looking at different types of exercise training chronic respiratory disease my cardial infarction tropical diseases it was quite interesting we studied a group of squaddies who'd been to Biz who came back with a horrible worm infection of their skin and we thought that the uh the treatment was a bit cardiotoxic um so we did study them and we found that there was a bit of cardiotoxicity uh in what we were doing to them with the the treatment for the worms but if you don't treat it the worms spread through your body and they eventually get into your eyes and they start to swim around inside your eyes you can see them swimming backwards and forwards in front of your eyes so personally I'd take the toxic treatment rather than have some worms swiming around inside my eyes for the next few

16:13 years so that's the heart failure work in in brief I wanted to talk uh in more detail about the treatment of coronary disease through stent implantation now this is an anagram of one of my patients this is a catheter that it's inserted into the vascular system and it's positioned at the osteum of the the origin of this cor artery and the black stuff is dy running down the artery you can see here a very narrow segment of the artery and we can treat this by a technique called coroplastic we can thread a a wire it's 14,000 of an inch in diameter up the artery we can position a balloon into the narrowed section if we blow it up we leave this little metal coil behind push the narrow segments of the artery outwards and relieve the Narin you can

17:00 see here the balloon inflated across the narrow section of the artery and bingo it's gone so it's a very effective uh treatment for coronary artery narrowings one of the problems is how do you get the catheters Into the Heart traditionally the catheters have been introduced into this artery in the groin the femoral artery it's a huge artery 6 8 millimet in diameter but there are problems if you puncture this artery it's the only arterial supply to the leg and if you block it or damage it the patient's got no blood supply to their leg it's next to a very big vein it's next to an important nerve it can be very difficult to compress these are some pictures of patients who've had cets put up their

17:47 Emeral Aries I collected these pictures in two weeks at North staffs inside those big bruised things are things like this it's like kind of jelly if this gets infected it's a disaster this is an infected um hematoma this was a fatal complication other things that can happen are you can get bleeding uncontrolled bleeding from these punctures and if it happens into the abdomen this is a CT scan of a patient who came to our catheter lab walked in had a catheter put into the femoral artery in an anoplasty perform and had a blood pressure of 70 at the end of the procedure went straight to CT scanning this gray stuff here is is 60% of the patient circulating blood volume Within the abdomen from a femoral puncture the bladder squashed and pushed out the way

18:32 this is the bowel pushed out into only half of the abdomen you can see how this can be not a very good thing now when I was in leads we had these problems all the time I spent most of my life down on the itu or pressing on femoral arteries or trying to deal with the complications that we were causing to our patients who were walking in for procedures the femoral complication rate was somewhere between 10 and 20% so one in 10 one in five of the patients that we were supposed to be helping were having horrible femoral complications if you have one of these femoral complications these are the patients who had a a bleed in femoral complication these are the ones who didn't have them you're much more likely to die 10 times more likely to die they're not things that you want to have it's not a benign

19:20 phenomena the first thing that we did was look at whether we could do the procedures from the arm this is the braal artery in the arm it's quite a big artery in order to do the procedure you do have to cut down to this artery make a hole in it and sew it up afterwards it's it's not necessarily easy to do but we did do a study where we compared complications for femorals with complications for brachials in anti-coagulated patients and we were able to significantly reduce the rate of access side complications by going to the brachial artery the problem is it is hard to do you look at this picture and you've got an artery colored red a vein colored blue and a nerve colored yellow well I can tell you when you look down there everything is exactly the same color you know you pull this artery out you know you're looking at it and you're

20:06 thinking is that the artery or is it the vein is it the nerve you know it's quite difficult to do the procedure vascular surgeons would be hor horrified at the thought of a cardiologist doing this so we could do it in leads the guy I was working with was very good at doing it but in order to do brachial procedures well you've got to do thousands of them if you don't do many you're looking at an 8 to 10% incidence of complications from the brachial cut down never mind the the the risk of the femoral procedure when you get down here and you've done a thousand or so it's okay but it's just too hard to do and it takes too long this is a picture of a patient who uh who's had a a braal cutdown procedure here you can see and the only anatomical difference between a man and a monkey is that the man can oppose his finger and

20:52 thumb the opposable thumb is the only anatomical difference between us and a monkey so this person came to the cath lab had a braak your cut down procedure and had a complication and afterwards the the do the doctor damaged the median nerve pulled it out damaged it thought it was the artery and he's afterwards he's asked to oppose his finger and he can't do it anymore because of the damage to the nerve so this is a person who's gone for Cony anagram and his cardiologist has turned him from a man into a monkey I can tell you that patients don't like that so brachial access is not the answer we gave up on that one and while I was there these guys in Amsterdam at the olvg hospital published this data so at the same time we were

21:37 having this 10 to 20% rate of major fov vascular complications these guys were doing the same procedures in exactly the same way with the same antithrombotic regime and their rate of vascular complications was 0% and when I saw this I was amazed really I wanted to know how whether it was real I went to a course that they were running their patients came into the cathlab they had the procedure they put a little bit of compression on and they walked out of the cathlab I I was really impressed by what they could do and I was fortunate at the time that there was more money in the NHS and I was able to go over to Amsterdam for six months to try and learn how to do the radial procedures and that the reason they're safer is because of simple Anatomy this is the radial artery it's very superficial so it's easy to puncture it's a bit small

22:24 uh it's about half the size of the femoral artery if you puncture it and you get get bleeding you'll see it because it comes out it can't disappear into a body cavity very easily it Lies Over The Bone if you feel where your pulse is you can easily compress it because it's overlying a bone and the other thing uh about it is that the hand has a double blood supply this is the radial artery but there is aner artery on the other side the two arteries have a complex uh intersecting uh vascular system so if you do block the radial artery it's very rare that it would have any significant es schic complications so I spent 6 months in Amsterdam and at the end of it I'd learned how to do the procedures I mean I did learn that uh Amsterdam had uh a variety of uh different architectural and cultural

23:10 things going on here's some examples I didn't go to any of these places I got these pictures off the internet I did notice that uh on a Friday and a Saturday night 99% of the British males in Amsterdam were dressed like this it's it's some kind of bizarre marriage ritual in 2016 practiced by male British people I came back and uh in 1998 end of 98 we started doing the procedures at North staffs and it took a few years to uh to collect the data but this is the data that we published in 2003 on the first thousand cases that we did so in a thousand cases remember that we were running a complication rate then that was very high we had only three complications one patient got a a little

23:57 pseudo aneuris I'll show you a picture of that later and two patients got what we thought were infections they were in fact reactions to the sheaths so no. 3% so that was uh a market Improvement on what I was used to when I was uh senior registro leads and the procedures didn't really take any longer 26 minutes as opposed to 22 minutes for the radials and femals um angioplasties were identical procedural duration and kind of at that time when we were doing lots of femorals the department 85 90% of the procedures are radial now uh but at that time when we were doing lots of femals we had a kind of two-tier Society going on in the recovery area this is time to mobilization to so when the patients are up and about and walking around so the radial patients it was 20 minutes 20 minutes after you've finished you're

24:43 walking around and the femoral patients have to lie flat in the back for four to six hours so these guys are you know lying down trying to drink coffee out of one of those baby cups with a little spout covered in Crumbs from some terrible NHS sandwich they're trying to eat while they're lying flat these people are wandering around switching the TV TV over watching homes under the hammer switching it over to test match special whatever they want really occasionally helping to squeeze a blood bag while one of these gets taken down to CT scanning doing a bit of light portering duties I thought that uh my colleagues in the greater Cardiology Community would be pleased and they would think that this was a good thing for patients and they would all will take it up but

25:29 that really wasn't what happened and there was a lot of opposition uh to what we were doing at north staff's um people didn't like it it was a challenge to them they couldn't do it um they didn't want to do it really so they had a variety of things they said they said we're not convinced you only did easy patients so if you did any more complicated patients you wouldn't get those good results so we published this a couple of years later Ted collected this data we did 104 patients who had rescue anoplasty so at the time this was before primary anoplasty and we used to treat heart attack patients with blood thinners potent blood thinners and if they didn't work and the blood flow didn't return in the artery would take them into the cath lab and uh do an anoplasty to unblock the artery and these patients have a 50 to 60% rate of

26:15 those femoral complications that I showed you earlier but the radial uh vascular complication rate in this high-risk population was 0% so we were able to do them without Jeopardy some patients are quite difficult to do this is a patient with a very high body mass index who has two mechanical heart valves two metal valves they're on wering you can't stop the wering and they need to have a right and left heart catheter and traditionally we would have put the catheters in from the femoral approach but here we've got a Ral puncture and we've punctured an arm vein we haven't stopped the anticoagulation we studied a group of these patients small group um and we found that we could do the procedures successfully 96% success rate they took us a bit longer they don't take us longer anymore this was right at the beginning before we'd learn how to do

27:01 the Venus punctures well and that the radiation uh doses were uh the same as the femoral group um and we had 0% vascular complications in this group of very high-risk patients more recently we've looked at uh patients with cardiogenic shock having radial in red or femoral angioplasty and there was seven or 8,000 patients in this study um and what we found was we could do the patients uh with cardiogenic these are the the sickest patients we look after they're in the middle of having a very big heart attack they're so sick that blood pressure can be 50 or 60 you know they're not well people um if we can unblock their blocked arteries we can make them better this is the survival rate for the patients done rally with shock and this is the survival rate for the patients done femally with shock so

27:47 in the very sickest patients we could do the procedures and we got better results than the femoral operators the next thing they uh opponents said to us was that radial procedures are too difficult to do and they can be difficult the artery can be small you know it can be 2 millim in diameter could be smaller than the caliber or some of the catheters this is a a radial artery with a long segment of intense spasm and so radial spasm was a problem at the beginning of our experience um this is some data that uh Ted low um collected early on we did ultrasounds of the right radial artery the left radial artery and the two arteries and in blue is the the diameter before we started the procedure and in red is the radial diameter after we've given some sublingual gtn and we

28:34 consistently got a 15 to 20% increase in radial artery diameter more recently we've looked at whether that's beneficial or not in a large uh analysis of nearly 9,000 patients this was the rate of radial spasm for the placebo treated patients this is for the rate for Loos nitrate and this is the rate for high do nitrate so if you give gtn you make the artery bigger and you don't get SP 2% makes it easier to do once we' sorted out what to do with radial spasm we still experienced some difficulty in passing caths up the arm in some patients and we didn't originally know why that was so we started to take anagrams of the arms this is a normal arm anagram this is the radial artery this is the olar artery this is the brachial artery keep away

29:20 from there and this is uh quite a normal patient and once we started looking at Patients we found there were other things going on you can see this radial artery runs right up here before it joins the brachial artery so this is a very unusual High bicationic uh of both radial arteries on both sides this is a big 360 degree Loop of the radial artery you can see that it being difficult to navigate equipment around there to do your cor anoplasty once we'd uh kind of noticed this we started to collect data and we studied about 1500 patients published the the data in uh five or six years ago and what we found when we systematically

30:06 collected the data on these 1500 patients was that 86% had normal Anatomy 14% had something abnormal commonly it was a high bicationic and we know that those anatomical variations do have different implications the failure rate for radial procedures with normal uh Anatomy was less than 1% if you have a loop at that time even for experienced operators the failure rate was 40% we're much better at dealing with them now but so what we do after collecting this data is we shoot an arm anagram in everyone if you see a big 360 Loop you've got the option of bailing out and doing a femal

30:53 puncture or puncturing the other side the next uh obstacle that was put in our way was you get too much radiation from radial procedures now radiation you know it can be an issue this is an early x-ray machine there's there's some electrical gobbins in this big wooden thing here uh that generates the x-rays and they come out of here pass through this man's hand and through this uh here this kind of viewing thing this guy's looking down he sees the x-rays down here after they pass through here they pass into this man's head where they Bounce Around randomly for a while before exiting in uh God knows where they go this is the very first x-ray that was ever taken Mrs ronen's hand 1895 these are the hands of one of the early x-ray Pioneers you can see what

31:39 happens if you put your hand in the main x-ray Beam for a while so you can kind of understand why Mr ronen said to Mrs ronen stick your hand in their love for a minute it'll be fine Mar curri I think had an arm amputated before dying of a hematological malignancy and it was very common for the radiation Pioneers to do that it's important not to get too paranoid about radiation it's all around us really this is a a raid on map a Raad on gas map of the UK you can the dark areas are places where there's lots of raid on gas which contains a lot of radiation so in these mountainous areas the Lake District North Wales or coastal areas where there's lots of Rocky outcrops you get a lot of raid on gas if you live down here the council will pay to have a a sucker machine to extract

32:25 the gas from your house I don't think so not for me altitude is another Factor this is uh this is the back of my head heading to the summit of a 4,000 meter peak in the Alps took two days to get to this point when I looked along this Ridge I kind of regretted spending that two days getting to that point because if you fall off here if you slip down one side or your friend does you've got to jump off the other side to stop the uh the whole process from happening so if you move from New York to Denver which is at 8,000 ft you get about 30% more radiation every year and of course proportionately as you go up higher because the atmosphere thins uh you get more radiation there are other environmental sources of radiation you get about 10 Micro seevers every day share a bed with

33:11 another person you get an extra 05% get more if they're eating a banana while they're in bed lifestyle factors can be important here you know perhaps uh if you're Hugh Hefner in the Playboy Mansion you got seven or eight people in there can be quite hazardous in terms of radiation exposure look at a computer monitor for 12 hours you get a micro seers for the ecoar Warriors amongst us if you're living within 50 mies of a nuclear PowerPoint for plow plant for 12 months you get an extra micro receivers unfortunately if you live near a Coal Power Point power plant you get three times that much not very important in the UK which is now A post-industrial Wasteland so compared to these things

33:56 radiation in the chlap can be quite hazardous so here is the amount of radiation you get from a chest x-ray 2 and a half days of extra background radiation and down here an anoplasty is 10 years worth of extra background radiation you can see if you have three or four angop plasties you have some diagnostic anagrams one of them is really complicated you can get a lot of radiation in the cast lab the patient can get a lot of radiation and that uh you know you saw that man's hands the early radiation Pioneer but this can happen in our patients injury to the skin here's another patient who had an anoplasty doctors didn't move the tube around enough it was a difficult procedure skin breaks down has to be grafted it's not a good thing to happen or to do to someone this is a patient's arm who was exposed to

34:42 too much radiation during an EP procedure six months down the line this was still the situation so radiation can be pretty bad for you this was published a few years ago in heart these are hairless legs you know the the hair is dropping out of this cardiologist legs most of the radiation comes out on the table if you don't wear shin pads the hair drops out your legs underneath that uh hairless area of the legs is bone marrow and if you get a sizable dose of radiation you run a risk of getting cancer so if you're young when you get uh a dose of 100 m and you you can't get that much from cardiological procedures then you've got a 1 to 2% chance of dying from a radiation can cancer most of our patients are down here and the risks are much less but the operators the people working in the cath lab are in this own and they need to be much

35:28 more careful with radiation than habitually there have been over the years this is a report from Euro intervention of 30 Interventional cardiologists who died from brain tumors all of them were left-sided it's the the left side of the brain is the part of your head that's closest to the X-ray source so it's clear that there's possibly an important relationship there this was a study looking at lens opacities in normal people who don't work in the cath lab not many less than you know nine here 9% and here uh in cath lab nurses and Interventional cardiologists half of them had lens opacities that were directly related to radiation exposure so the early access site radiation literature said reported and observed increase in radiation measurements in the radial groups but there studies were really badly

36:14 performed they were observational poorly controlled there were major differences in the patients and the procedural groups and it's important to remember that statistical Association is not the same as causation so if you look at 100 ra Ral patients compared them to 100 femoral patients and the BMI is higher in the radial group as it commonly was then you will find more radiation in that group generated just by patient characteristics so we set out to uh to study radiation exposure in a well-controlled way and we wanted to minimize patient related variations so we only studied F studied firsttime diagnostic anagrams we want to minimize the influence of radiation generation protection protocol so we used fix the same radiation protocol for every patients and we matched the operators's expertise so we had some experts who'd

37:01 done a lot and uh intermediate people who' done a medium amount this is what we T what we found fluoroscopy time and access site the radial groups red the femoral groups yellow there was no difference in the amount of time that the doctors had their foot on the pedal this is the operator radiation exposure there was no difference for the radial or femoral group The traine of course got more radiation generated more radiation than the the experts but there's no surprise in that um and the patient radiation doses for either access site were identical again the trainee had a a higher uh uh uh measure of course if you took uh the expert femoral operator and and compared his measurements with the inexpert radial operator you'd find a difference that that's what was going on with the rest of the literature the the groups weren't

37:46 well matched so we we published really the first um uh paper that showed no difference in radiation exposure and that was diagnostic angiography he can see for single and multivessel uh anoplasty the fluoroscopy times were the same and here the radiation dose um for radial and femoral angop plasties uh were also the same in red and blue so we could find no difference in radiation exposure John Davis down there is one of these operators this is from uh 2003 th000 2003 2004 when we had five anoplasty operators and these are their personal Doses and I'm operator C and these two operators A and B were femoral operators and we're getting considerably more radiation than

38:33 me more recently we've looked at the entire world literature on radiation exposure this is a plot of how it's changed over time you can see that the early studies perhaps showed some increases but our study is down here and in fact the most recent studies show that the radial is probably better than the femal so the idea that radial uh access increased your radiation exposure was uh a myth nonsensical myth there's ways you can reduce your radiation exposure and we're looking at some of these in the Cath Lab at the moment this is a a simple little thing that sticks up between the patient and the operator and it screens out some of the radiation you can see it drops the dose by about 20% this is uh a a lead Shield draped over the abdomen and pelvis of the

39:18 patient it stops the radiation scattering back from the patient and hitting the operator and here you can see you get about a 50% reduction in um radi exposure with this measure and my personal radiation exposure is less than every year is less than if I move from New York to Denver it's negligible because I'm quite careful with it and I'm good at radiation protection nothing to do with the access site the next thing that the femal operators thought was an obstacle was that you get more Strokes now they had no data about Strokes they just said you get more Strokes it was their idea they they manufactured this idea in their heads as a reason not to do radial procedures they said it was because when introduce the catheter from the radial artery you have to go down this brachio falic artery and you cross these two arteries that do Supply the blood supply

40:05 to the right side of the brain and when you come from the femoral route you don't do that and that's true you do Traverse those vessels and there's potentially an embolic risk what they uh neglected to uh take into account was the fact that in the ascending aorta the only part of the aort that's Traverse by a radial operator's catheter there is no atheroma but in the arch and the descending aorta there's 40 to 60% incidents of complex atheroma which is a major source of emilii now if you take patients who have this and you ciz them in this early study from 1996 from the leg 17% incidents of emili catheterized them from the arm it was braal cutdowns there 0% so it's likely that those two set of factors traversing the head and neck vessels or traversing the aom say or to

40:51 counteract each other or or or play each other off we set out to studi this by looking at the British cardiovascular intervention Society database and bis uh has run for many years it collects data on every single anoplasty performed in the UK 130 different uh parameters and records every stroke that happens it's linked to mortality using the patient's NHS uh number through a central register it's a legal requirement for every death to be recorded So we looked at almost 350,000 angop plastic procedures and we documented the instance of stroke for radials and femorals and this is what we found the incidence of stroke after angop plasties is rising but it's not different for Ral in blue or femal in red in fact you know in the most recent

41:38 years it looks as if the radial instance is lower so there was no uh excess of stroke once we looked carefully and you know more data has emerged from randomized trials if randomized trials are your thing this is the Rival trial 7,000 patients incidence of stroke .2% very similar to what we found in our in the UK database and identical for radials and for fals the next thing was okay well maybe you don't get more radiation maybe you don't get this maybe but it's not worth all the effort I can't you know it's not worth it I'm not doing it it's not worth the efforts so we looked at all of the randomized trials of radial or femoral access for primary anoplasty in patients having a heart attack anything that lies to the left of this line favors radial

42:25 access anything that lies to the right of this line favors femoral access and this is what we found overall in the radial group there was a 50% reduction in mortality so you were twice as likely to die if you had your anoplasty performed femally so we published this there was a whole host of hostile letters and reactions sent in one of which was uh that uh this wasn't very relevant because it was only a small number of patients in highly selected populations we went back to the abis database we looked at nearly 50,000 patients this is survival for femoral primaries survival for radial primaries 30% mortality reduction in 50,000 on selected patients if you ask any patients do they want to

43:11 live longer they're only going to give you one answer and that's going to be can you please do it radially doctor don't don't punch that arteria leg it's not good for me we uh We've looked outside the primary anoplasty population Kim um uh my research fellow analyzed this data it's nearly 450,000 anoplasty procedures blood transfusion less common for the radials vascular complications less common for the radials and mortality was reduced and when you look at the different patient groups if you look here these three dots these three bars lying to the left of the line indicate reduced mortality for radial procedures over femoral procedures for stable patients for patients with small heart attacks and for patients with big heart attacks and the same pattern for other

43:57 vascular for other complications for bleeding and for access site complications so in nearly half a million people with a variety of uh simple and complex angop plasties we were able to show that radial access was still beneficial there's a way of closing the puncture hole that you've made in the femal Ary with an expensive and complicated device it it implants a small amount of uh um uh material which is derived from a cow's bottom into your femoral artery where it will stimulate coagulation and close the artery and so the femer operators then said well you know we can we can do better now we've got these closure devices that we can put in and uh that will be great and we don't need to do those radial procedures but this also was a myth um transfemoral

44:43 access with closure devices in our our large half nearly half million pound half million patient cohort the radial group in red okay 30 to Day Day mortality much better for the radials compared to the closure devices other uh major cardiac complications much better bleeding halfed access site complications much less frequent so the closure devices are definitely not the answer the last and maybe latest thing that they came up with was that you have to stop doing all these radial procedures or you won't be able to do femoral procedures anymore you'll get useless at doing femoral procedures the idea that you know someone like me or all the other radial operators who can work in that Diddy little artery and overcome all those problems won't be able to anym PP a a huge great femoral

45:29 artery it's laughable really this is what we found when we looked across the database this is femoral procedures done in radial hospitals in red and femoral procedures done in uh femoral hospitals in blue okay mortality was lower in the radial hospitals mace rates were lower vascular complications were the same bleeding was the same so the radial guys can do the femoral procedures just as well if not better than the dedicated Fem operators so it was quite a journey to collect all that data and present it and uh at the same time we were involved in a lot of Education and Training in the department um Julie stubs down there has been helping me and Jenny uh all along we ran a lot of courses here's a few of them we ended up uh last year running

46:15 the big uh international meeting which we ran up in Liverpool just because it was uh logistically easier to do that but all all the time over that period of time since 2008 at the beginning for the first first five or six years we had other doctors other consultants in the lab with us sometimes two or three times a month trying to teach them how to do the procedures I mean I learned a lot really I I realized when I came back after a while I realized that I could do them but I couldn't really tell other people how to do them I had to learn what it was that I was doing that that I could uh help uh pass that information on to other people so we ran a lot of courses we wrote um uh a lot of things in textbooks we published these important review articles the State ofthe art article that told people how to do them we argued here with my colleague Marshall hamom from France

47:02 about uh that everyone should have a radial procedure and here we ended up I ended up working with the European Society of Cardiology and published this position paper that recommended that everyone should have radial procedures and how they should be done and you know you do Wonder after all of that because it was hard work was it worth all the effort and this is what's happened to arterial access side practice in the UK so the first 5 years it took 5 years to get from me on me own down here doing all the procedures to 10% of the procedures being done radially and here we are in 2014 76% of all the anoplasty in the UK is performed radly the rates still going up I don't know where it will stop 85 90 95 there are people in the UK who do 99%

47:47 of all their angioplasties radially it wasn't completely homogeneous were here the darker colors represent sent areas where radial procedures are frequent and the lighter colors less frequent this was how the map of the UK looked in 2005 you can see the red color spreading out from us conquered Wales there the north of England 2009 starting to look good and here we are in 2012 there's still a couple of uh London and the southeast don't go down there have a heart attack if you do get in a train come back up here some bits of Yorkshire strangely it's it's kind of interesting to look at what's Driven the changes is it the data I don't think it is really um this is

48:34 when we started to publish the big papers this was the first thousand patient paper that we published this is the big uh the the big data sets that we've been working with on uh and here the randomized data but when you look at when we started to run all the courses um down here and to start we we we we organized a fellowship in the hospital where I'd worked in Amsterdam so we sent other UK training over for 6 months at a time probably the Education and Training initiatives had a big impact on what happened to access site practice in the UK so I'll end up with a few pictures I know you all like pictures you can have problems with radial cases this is one we reported early on we we used to uh um olude the radial artery with a toric that was completely occlusive it stopped

49:19 Venus flow and this patient had a deep Venus thrombosis in the arm because we'd stopped the flow we don't use the toric anymore we've got unilateral compression devices this is two of the three complications from that first thousand patients a pseudo aneurysm um and uh what we thought was a skin infection it was in fact a reaction to the coating of the sheets that we were using at the time this is kind of interesting because the vascular surgeons came and looked at this they took the patient to the uh the operating theater there's a little you can see a little skin incision here and they just made a little incision and tied the radial artery off and the pseudoaneurysm disappeared they weren't bothered because of course there's a dual blood supply there this is an ultrasound of the pseudo aneurism you can see this big uh this is the radial artery this is the pseudo aneurysm it's a it's a big collection of Gunk with

50:06 blood flow into it this is a CT reconstruction of a pseudo aneurism Le you can see there's a little neck that leaks blood into this big circular sack this is an AV fistular this is the radial artery and this is a vein and there's a communication between I've I've only seen one of these in the whole time I've been doing the procedures nearly 20 years now um and uh the patient he is a patient of mine he doesn't want anything doing about he's not really bothered by it might be quite useful to him in the future if he gets renal failure this is a used to be a problem a radial perforation if we perforated the artery in the forarm if you can't stop the bleeding the forearm can swell up and if you get too much blood in there the pressure in the arm can rise and cause major problems with the vascular

50:52 and neurological supply of the arm now we we see these not uncommonly nowadays we deal with them much better by putting a sheath up or a catheter up we don't stop the procedure and if you leave the catheter up there for a while the perforation seals itself off one way of dealing with a big forearm hematoma is uh leech treatment you might think it's odd that a hospital in 2016's got leeches but every Hospital's got them somewhere the vascular surgeons uh and sometimes the plastic surgeons will use them so they stick them on your arm they stick The Blood Out drop the pressure if that doesn't work you can do this I've never seen one of these um if the pressure gets too high you have to inze the arm let the pressure drop this is a radial artery that a strong cardiologist has pulled out of a

51:39 patient probably best to avoid this cardiologist if you can't get the sheath out don't pull it too hard would be my answer you know there are ways of getting them out rather than pulling them because that's what happens you can pull the whole artery out this is a bleed into the chest from a subclavian puncture so you can get these complications they're usually easier to deal with and when you get them this is just one uh series 3,369 consecutive patients nor 0.06% instance of complications and they were all minor and they were all dealt with without vascular surgical intervention so I'm going to kind of stop you can always do better in clinical practice I think it's uh clear that you can risk stratify heart failure patients by analysis of heart rate

52:26 changes you don't even need to do the complicated stuff that I started out doing you can just look at the heart rate range the equivalent of a pencil radial access is the optimal way to do anoplasty but you know it's quite clear that people don't like change the establishment if I can call them that don't like change and they don't like challenges and so here in North staffs we were outliers really out Riders we were the first people to set up a big program but I do think we've had a big impact on National and international practice the unit has a reputation worldwide going forward we've got bigger plans Prof mamus my colleague down the front here has joined us from Manchester we're setting up an expanded cardiovascular research group to uh really work uh you know in a much more organized way going forward so I'll end

53:14 up with a few thanks to the staff at the uh the hospital particularly Julie stubs and Jenny pickle down there the only two members of the cath lab team are still here from when I started Rachel my secretary has been fantastic over the years to all my consultant colleagues and to John where is he down there driven up from Plymouth uh which is really nice and was a fantastic mentor to me in the first five 10 years I was here um to Tony berad the north staff's he committee who gave us the money to buy the equipment to do a lot of the research uh and has funded all many components of the clinical and research program in the hospital over the years and to Ted and Kim my two research fellows who collected a lot of this data and did a lot of the work in setting up the cardiovascular research unit I really should say thanks

54:00 to the management team at the hospital you know Hospital managers sometimes get a bad press but they're not all bad guys they're often trying to do the same thing as us Mark hackit the chief executive is a fantastic guy and has helped us along with Andy Garner from Keel in setting up the cardiovascular research unit and recruiting Mammoth and of course to all the family some of them are here tonight got a big extended family in Liverpool and North Wales it's a fantastic thing to have these are the two most important ones this is the Miss and the little boy this was his first day at school in September at about 8:15 in the morning this was at 4:30 that afternoon and you know in that kind of circular way of lectures and life one of my roles in his life is to make sure he

54:46 supports the the football team he's got this in his bedroom thank you [Applause]