Supporting Aortic Dissection

Thanks, Dan. Thanks for inviting me today. You're right, I met Dan at the Ertic Master Class at the Royal Brompton about, it was the day of the London Bridge incident. Yeah. Yeah. But what struck me is you had this algorithm which I developed on the back of your car. And I thought, gosh, I need to meet these people. But I'll return to this in a few minutes' time. But sorry? No. No, he has to pay nature, I think. Because yeah, they own the copyright to this. Yeah. So switching gears a little. I will resonate a lot of the talks today, but I'm a clinical academic, which means, yes, I'm professor of medicine at University of Leicester. I'm also consultant cardiologist at Glenfield as well. Some of our patients are here today in the audience as well. Thanks for coming. So what I do is, as a clinical academic, I have a research program on aortic disease, not just the research, but also clinical services as well. We do a lot of just quickly basic research. We try to understand what causes aortic dissection. For that, you need to develop animal models. From there, you find mechanisms of this disease where you can develop new drugs and targets for this. I also do what are called biomarkers. I'll return to this later. I'm probably the guy that developed most of the ones that cited right now, but I've also done clinical research with international registries such as the International Register of Acute Aortic Dissection, IRAD, which I'll be talking about today, as well as I've chaired national registries such as those in Japan which I'm from a few years ago. So the title that I was given today, I was asked to talk about the aortic clinic which I started down at Leicester but before that I think well many of you probably do know where Leicester is but this is the geographical center of England to my understanding and where Glenfield is is well has a helipad and all that for its ECMO services as well and it's also known for its cardiovascular services including those for a coronary artery disease and heart failure and now hopefully we're trying to build this up for aortic disease as well we have a a very rich history in vascular surgery, as well as cardiac surgery, as well as vascular medicine through hypertension experts in the past. And I don't know why it glitches. It's not glitching here, but it's glitching there. But yes, I was brought in as the aortic and vascular medicine specialist. And so the Trust did have a press release on what I've been doing earlier this year in June, I think. It was mentioned a few talks ago on the bureaucracy of the NHS, and yes, it's very difficult to do something new, but yet an aortic cardiology service is something that we have not had there. Yes, it's difficult between the cardiac and vascular surgeons to get an integrated service because they're both off on different sites, but they are now integrated since last month. But I am basically the coordinator and the guy that offers everything else. So yes, right now, I am the gatekeeper clinic for most of our affiliated hospitals, ranging down from Northampton, Kettering, to the Seaboard, to Skegness, but I also have patients coming from London and I think somewhere from Cambridge next month as well. So this is based on a patient story, but basically we've been doing what's written here. I've been offering an aortic cardiology service, both outpatient and inpatient, where we are to promote and progress our integrated services at the hospital. Now I'm going to return to that from the medical standpoint, because basically what this means is, what does this mean? Now returning to some of the research I've been doing, Yes, there's something called the International Registry of Acute Aortic Dissection. It's been around for about 20 years now. I believe this is one of the most authoritative study groups on this disease now. We've put out about 80 papers into the world. I've been one of the original members of it. Sorry, this is an old slide, so it shows me as University of Tokyo. But as you can also see, it is not represented in the UK. It remains empty here. I'm trying to get our institution to be entered into IRAD so we can understand what the commonalities and differences are in practice between ourselves as well as others. But through our efforts in IRAD, we've been able to bring about what contemporary medicine is about, about aortic dissection and outcomes of the diseases. So myself, because I'm a cardiologist, I'm more interested in what type B dissections mean, those that are treated medically and how we should treat them, how their outcomes are. Some of the papers that we've been or I've been involved are what are factors which influence the outcomes of type B dissection. One of the ones that got published in one of the high impact journals was that we identified that something called it partial thrombotic false lumen is actually worse than a patent or even thrombose false lumen, which was something we never even thought about at the time. Probably has to do with hemodynamic issues, but it was still interesting. But one more thing is that I've been interested in how we should treat patients with drugs or medications. This has been published, and I'm just going to give you the quick overview on this because you are a patient group is yes. The data from IRAD suggests you should be on a beta blocker. Yes, as high as possible if you can tolerate it, but if not, the alternative to a beta blocker is a calcium channel blocker such as diltiazem, which is the second recommendation from the American Heart Association. It's not specifically directed in European guidelines. Diltiazem, what this one does, drops your heart blood pressure but also your heart rate. So it's important to drop your heart rate as well as your blood pressure. Some of my patients know I ask both, not just one. If you ask me which is more important, yes, heart, you know, blood pressure is important. So diltiazem, but not both. If you combine a to beat a blocker with diltiazem. Some assume that taking both will be better. It slows down the heart too much. It could cause your heart to stop beating even. So you need to be careful in what you do. Renin-angiotensin inhibitors, these are called ACE inhibitors or angiotensin receptor blockers. Those who are familiar with data on Marfan disease and congenital aortopathies, there is expectation and promise that these drugs might be beneficial in patients with Marfan syndrome. However, when you look at patients who don't have Marfan syndrome, who are the elderly patients with atherosclerotic aortas, in which they dissect more or less because of hypertension and mechanical stresses on the heart with degeneration in age, it's not so. Some of these patients, you know, you have an extensive aortic dissection, you get kidney damage. And the thing is, you don't want to be taking one of these drugs when you have possible kidney damage. So that's the difference between Marfan syndrome or congenital aortopathies and diseases in the adult. Sure, if you don't have anything else wrong with you, such as your kidney, the angiotensin receptor blockers or the ACE inhibitors, sure, they probably will be as beneficial or not as compared to a beta blocker. But when you have multisystemic disease, complicated disease such as those that you get when you're an adult after you dissect, you have to think about what you use because some of those might be harmful when you think about the other organs that are impacted. That's just one thing we'd like you to keep in mind. So IRAC is going to be coming forward with a patient website called Living with Aortic Dissection. It's not released yet, but I'm just going to show you a preview of what it will be, if I could get this to start working. So it's going to be hosted out of our host institution in Michigan. So iRoute is based out of Michigan. It'll start off with this YouTube thing explaining what aortic dissection is. But what's more important is that there's going to be five sections here for four patients. The physical... What do I need to do? Okay, here. It'll have recommendations on physical activity and exercise, pain management. It'll also have information on medications, what your targets will be, how you should visit patients with surgery. other issues such as those that are not often discussed in the clinic, emotional issues, depression, anxiety, stress, relationship issues, and those on lifestyle, on how to return to daily life because in the end what we want is a patient with dissection to get back to what they used to be doing, and And that's what we're here to do. So this is what will be going online hopefully soon. There will be a patient feedback page where you can ask answers as well. I'm not too sure what will be in the final published version, but that's what we intend. And so that might be one form that you might be able to use moving forward from the US. Now moving back to what I do, so I've been a guy that's been developing all these biomarkers for dissection hoping that we can diagnose dissection increase awareness faster in the emergency department. So the 2014 ESC guidelines were kind enough to use one of the algorithms that I came up with which actually can use here but one thing that I need to mention to you here is as it's written here as well when heart is ruled out think aorta but when you look at the ESC guidelines this is the only thing I wanted you to see it says this is called ST elevated myocardial infarction it says it's already ruled out what I'm trying to say is these guidelines are not perfect Next, it starts off at the point where it's already filtered towards dissection. It doesn't say that this is a patient with chest pain. It says this patient already has myocardial infarction ruled out. Now you go down this pathway. Do you have dissection? This is already beyond the step of awareness, unfortunately. If you've already gotten to this point, you're already suspecting you're dissection, which Which is the ironic part. Having said all that, it does take the first step in saying, let's go the next step. Let's have an algorithm to diagnose this. And the EAC guidelines are based on, this is a paper that I had written a few years back with a lot of the members of the European community. What this is, the first part is a clinical risk score which was used in the 2010 American Guidelines which uses a three-tiered point system to say whether you have risk of aortic dissection. It's based on, one, pain features, two, as you can see here, also physical examination as well as your conditions, pre-existing conditions, such as Marfan syndrome. And when you're at high risk, then you use de-dimers, what we were saying at the time. And so the ESC guidelines basically published this, using this, and took the AHA guidelines, added on the de-dimer, the biomarker, and tried to go forward with it. So that's 2010. It's not perfect. So last year, we came out and wrote another position paper for the European community. Now, when you look at this, it starts with chest pain. But it also says troponin and D-dimer. What I'm trying to say is we're saying here is we need to think both generally about coronary disease as well as dissection at the same time and get a protocol-based algorithm to rule in or rule out diseases of the heart and chest, which is basically what is shown here in illustrated form. But we're still far from this. It's not been implemented into medicine yet. To be honest, I was contacted about six years ago when I was still in Japan by one of the leading vascular surgeons here at Dr. Paul Bonser at Birmingham who wanted to take forward my biomarkers here. He and John Pepper reached out to me at the time, but unfortunately as you might know, Paul Bonser passed away after that. And then I guess someone knew and they asked me to come to Glenfield and Leicester about three or four years ago and so I came. And John Pepper and myself been trying to get an implementation trial to see how these algorithms actually work in the public health system in England because we need to prove that this is working, how well it works, so that we can put a poster up in the emergency departments. To increase awareness, it's not just the patient groups, we need the junior doctors, we need the emergency departments to know what kind of flow there is, flow chart, or what kind of diagnostic algorithm there is. There are things available for heart failure like this, but there are not for chest pain. Well, there are for myocardial infarction, but not for chest pain in general, which includes aortic dissection. Now, we have been working on a trial that we would wish to go forward with that includes not just ourselves in Leicester but the Royal Brompton Liverpool here as well as Southampton Manchester which would be throughout England to try to test how D-dimer and troponin together in an emergency setting would help to filter aortic dissection help to increase its awareness. Unfortunately some of the funding sources such as NIHR have not been willing to go forward because probably dissection is not rare enough, but also not common enough. It's not myocardial infarction. It's not aneurysm either. Which brings me to the point, I mean, we need the patients to help us. I mean, this is probably the most important thing that we can do to bring awareness to the clinical setting. Not my fault. But we need a poster in the emergency department. I resonate that. But we need that to also show how well it works. That is how you need to convince the medical doctors, the next generation, on why and how we use this. And that's probably my mission for the next three to five years, is to get this to work and get this out to the medical community. not just for ourselves, but for the next generation. Because this is what's important. Yes, aortic dissection is still, I'm not going to say misdiagnosed. I'm going to say under-recognized. But that means that if we're able to recognize it more, that there is a possibility we will be able to get patients to the hospital earlier. The faster, earlier they come, the better the outcome is likely. So with your support, I mean, I don't know if you know, but I've traveled half the world to get here today. But this is what is necessary for the UK. This is the bottom line. I mean, I wish all of you the best, and I support you 100%. But to get this into the clinic is probably something you and me both need to work on together. Thanks. Thank you.