It’s conference time again, and I’m lucky enough to be in Barcelona at the European Society of Cardiology Heart Failure annual meeting. Much as I love cardiology, having a conference that starts at 08:00 on a Saturday isn’t necessarily my cup of tea. Why these conferences are always organised on a weekend is beyond me! Barcelona is a beautiful city, but alas I have had precious little time to see it (although I have had some fantastic food). Hopefully I’ll get some time later, and Barcelona are playing Real Madrid tonight so there should be a great buzz in the city! Tomorrow I’m excited and somewhat nervous to be giving a talk myself at the conference. It is on the ‘first in human’ trial I was involved with of an implantable sensor to remotely monitor heart failure patients. Wish me luck!
Speaking of talks, I have been asked by the hospital trust to give a talk to the public, and I have attached the flyer . It would be great to see you there if you are free and can make it.
One thing I love about conferences is learning about novel and breakthrough science; the cutting edge of medicine. Last September at the main European Society of Cardiology I discovered the utility of polygenic risk scores for heart attacks. I have written about these before so won’t go into detail you can read more here but in brief, these are saliva tests on a person’s DNA, which tell doctors an assessment of their genetic risk of a heart attack. This can be very useful to guide discussions and treatment recommendations. In recent weeks I have started seeing the first patients back in clinic who have had the test, and thought it would be interesting to discuss a couple of cases.
Let’s call the first person Mark (obviously not his name!). Mark is middle-aged, and has had historically high-ish cholesterol. Not so high that his GP has been really worried, but high enough to suggest he be on statins, in part as he has a family history of heart disease. I won’t go into details, but he had possible side effects, and so had since tried other cholesterol lowering drugs. Unfortunately these also caused side effects. He was fully expecting his genetic test to show a high risk (as was I to be honest) but actually his risk came out as rather low.
It’s important to state a genetic risk isn’t a crystal ball, and no-one can predict the future with certainty. It’s also important to realise that lifestyle will absolutely modify outcomes – 2 identical twins with the same DNA can have very different risks of a heart attack if one lives a healthy lifestyle and the other smokes, is overweight, has high blood pressure and so on.
Mark leads a healthy lifestyle, so for now at least, we are more confident to adopt a watch and wait approach rather than persist with medications that he clearly finds difficult to tolerate.
Tom (also not his real name) is younger, in fact several years younger than me. He also has a family history of heart issues, and a cholesterol that was modestly elevated. He took the DNA test to get a clearer understanding of his heart attack risk. Standard primary care assessment (called a Q risk) of his risk would put him in a low risk group, but this algorithm is terrible at estimating risk in young people. If one uses it in a 50 year old sat on the coronary care unit having just had a heart attack, it will get it wrong 50% of the time. It is ok at assessing the risk of a population, but tells you precious little about the individual sat in front of you.
In medicine, as in life in general, we all like to give (and receive!) good news. Delivering not so good, or bad news, is hard. Some of my worst moments in life have been giving bad news to patients or their relatives, it’s one of the hardest, but most important, parts of the job. In Tom’s case, I was delivering both good and bad news (I don’t know about you, but I always like to hear the bad news first when given a choice!) His bad news was that his genetic risk of a heart disease was actually pretty high. There is good evidence that in this circumstance (modest cholesterol result but high genetic risk), one should look to treat the person as if they have very high cholesterol – ie the actual number should be thought to be higher.
However I was keen to point out the good news, which is that at his young age, now we have this information, we can absolutely treat him and minimise risk for the future. He already leads a healthy lifestyle, and this will mean medication, but he now won’t be blindly walking into many years of elevated risk. He will be able to be in control. When framed like that, he was much happier. Prevention is better than cure, cliche but true.