OUP user menu

CardioPulse ArticlesProgress and challenges in the fight against smoking and cardiovascular diseaseDevelopment and delivery of a high-quality European Cardiovascular Magnetic Resonance ExaminationThe Glasgow Cardiovascular Research Centre of the British Heart FoundationCountry of the month: Ireland 2014Automated external defibrillators should be mandatory on board all commercial airliners

DOI: http://dx.doi.org/10.1093/eurheartj/ehu186 1625-1633 First published online: 1 July 2014

Progress and challenges in the fight against smoking and cardiovascular disease

A global review 50 years after the US Surgeon General's report warning Americans that smoking is dangerous

In January 2014, public health organizations celebrated the 50th anniversary of the US Surgeon General's report that warned Americans about the dangers of smoking, linking it to lung cancer, low birth weight, and an increased risk of death overall. It did not establish a definitive link between smoking and cardiovascular diseases, however. Since then, the evidence base tying smoking to cardiovascular disease and a range of health problems has grown enormously, making it all the more troubling to see that the number of male smokers continues to rise along with population growth (Figure 1) and that smoking prevalence remains high in many countries around the world.

Figure 1

Total number of smokers worldwide, males and females, 1980–2012. Shading around the solid lines represents uncertainty intervals. To access the live visualization tool, visit http://ihmeuw.org/1ch7.

The Institute for Health Metrics and Evaluation (IHME) at the University of Washington monitors fatal and non-fatal health outcomes globally, as well as potentially preventable risk factors that affect these outcomes. A recent IHME study of smoking around the world found that, despite the fact that smoking prevalence declined among males and females in high-income countries (Figure 2) and developing countries (Figure 3) over the last three decades, some of the highest smoking levels in the world are found in Western, Central, and Eastern Europe (Figure 4). In 2012, prevalence of smoking was 38, 36, and 37%, respectively, in Greece, Bulgaria, and Macedonia. Smoking prevalence also surpassed 30% in countries such as France, Austria, Latvia, and Russia.

Figure 2

Smoking prevalence in males and females in high-income countries, 1980–2012. Shading around the solid lines represents uncertainty intervals. To access the live visualization tool, visit http://ihmeuw.org/15wf.

Figure 3

Smoking prevalence in males and females in developing countries, 1980–2012. To access the live visualization tool, visit http://ihmeuw.org/16p5.

Figure 4

Smoking prevalence, both sexes, 2012. To access the live visualization tool, visit http://ihmeuw.org/15wg.

Progress in cardiovascular disease differed among countries. For example, according to the IHME-led Global Burden of Disease 2010 study, developed countries reduced premature death and disability from ischaemic heart disease, as measured in disability-adjusted life years (DALYs), by 5% between 1990 and 2010 (Figure 5). It remained the top cause of DALYs in both years, however. These countries also cut DALYs from stroke by 11% during this period (Figure 5), but it remained the second-ranking cause of DALYs both years.

Figure 5

Leading causes of disability-adjusted life years in 1990 and 2010 and percentage change, developed countries. To access the live visualization tool, visit http://ihmeuw.org/348.

In contrast, DALYs from ischaemic heart disease rose by 60% in developing countries (Figure 6), shifting from the 10th largest cause of health loss in 1990 to the third leading cause in 2010. Stroke also increased from the sixth to the fifth leading cause of DALYs between 1990 and 2010 and grew by 35%.

Figure 6

Leading causes of disability-adjusted life years in 1990 and 2010 and percentage change, developing countries. To access the live visualization tool, visit http://ihmeuw.org/24m.

A large percentage of the burden of ischaemic heart disease and stroke can be traced to smoking. In developed countries in 2010, 29% of DALYs from ischaemic heart disease and 25% from stroke were attributable to smoking. In developing countries, smoking contributed to 32 and 29% of DALYs from ischaemic heart disease and stroke, respectively.

In 2010, the countries with the highest percentage of total DALYs from ischaemic heart disease included Ukraine, Belarus, and Georgia (Figure 7). In Ukraine and Belarus, nearly 30% of the health loss from ischaemic heart disease was attributable to smoking, and in Georgia the fraction was 31%. Globally, Macedonia, Bulgaria, and Romania had the largest percentage of total DALYs from stroke. In Macedonia, smoking contributed to 31% of DALYs from this cause. Nearly, in Bulgaria and Romania, 23% of stroke DALYs were attributable to smoking.

Figure 7

Ischaemic heart disease DALYs as a percentage of total DALYs, both sexes, 2010. To access the live visualization tool, visit http://ihmeuw.org/196l.

Although smoking prevalence is declining in both developed and developing countries, prevalence remains particularly high in certain regions, especially Europe. And despite declining prevalence, the number of male smokers has risen worldwide due to population growth. Even 50 years after the US Surgeon General's report on smoking and health was published, a substantial amount of the burden of ischaemic heart disease and stroke worldwide could potentially be averted by eliminating smoking. In developing countries, the rapid increases in premature death and disability from ischaemic heart disease and stroke underscore the urgency of combatting tobacco use.

In the USA specifically, efforts to fight tobacco since the launch of the Surgeon General's report have spurred progress. Figure 8 shows how, even as the US population grew, the number of male and female smokers declined from 1980 to 2012. Smoking prevalence in both sexes combined dropped from 31% in 1980 to 16% in 2012. Countries still struggling with high smoking prevalence and increasing numbers of smokers could benefit from emulating the most effective anti-smoking initiatives and regulations instituted in the USA.

Figure 8

Total number of smokers in the USA, males and females, 1980–2012. Shading around the solid lines represents uncertainty intervals. To access the live visualization tool, visit http://ihmeuw.org/1e9d.

To inform decision-making, IHME and its collaborators will continue to update the Global Burden of Disease study annually, including estimates for smoking and the attributable health loss from smoking. We hope the comprehensive, timely, and freely accessible findings from this study will guide health policy in the years to come.

Embedded Image

Embedded Image

Development and delivery of a high-quality European Cardiovascular Magnetic Resonance Examination

Drs Steffen E. Petersen and Sven Plein on behalf of the European Cardiovascular Magnetic Resonance Examination Board discuss this academic examination, a part of the European Cardiovascular Magnetic Resonance certification process

Embedded Image

Steffen E. Petersen

Embedded Image

Sven Plein

The European Cardiovascular Magnetic Resonance (CMR) Exam has been offered since 2005, but over the past 2 years has been fundamentally transformed to meet the quality requirements of a high-stakes exam. The European CMR exam now forms an integral part of the European CMR certification process, which has been offered by the ESC Working Group on CMR and subsequently the European Association for Cardiovascular Imaging—CMR Section since 2013. As European CMR certification is a new process, for an interim period ending 31 December 2014, a grandfathering scheme is available for experienced CMR practitioners.

European Cardiovascular Magnetic Resonance Exam Board

In 2011, a European CMR Exam Board was formed with the aim of developing the existing CMR exam into a high-stakes exam. All members of the exam board were trained in good practice of question writing and agreed to strict confidentiality regulations. A CMR exam syllabus was developed by the European CMR Exam Board and made publicly available http://www.escardio.org/communities/EACVI/education/Pages/core-syllabus-cmr.aspx.

QR code to link to the Cardiovascular Magnetic Resonance syllabus

Embedded Image

All exam questions map to the CMR exam syllabus. A blueprint describes the proportion of questions in each exam that maps to topics in the CMR exam syllabus. This blueprint is publicly available and was set by the European CMR Exam board and validated in a survey among the global CMR community.

Recurring tasks of the exam board members include the drafting of questions, the peer review of questions, assessment of questions for difficulty level (which is used to determine the pass mark), putting together and reviewing of the proposed exam for matching the agreed blueprint, overseeing the exam delivery, and interpreting the psychometric data for the overall exam.

European Cardiovascular Magnetic Resonance exam delivery

The European CMR exam currently takes place after the annual EuroCMR Congresses. The exam setting and delivery is fully computer-based and consists of 100 multiple-choice questions with a single best answer. 2.5 h is allowed to answer the questions. Multiple-choice questions may contain CMR images or CMR movies. The risk of deception is minimized through the presence of invigilators, random order delivery of the questions, and the five answer choices per question. The pass mark for each exam is determined by the modified Angoff standard-setting method, which avoids dependence of this pass mark on the exam group performance. Psychometric analysis of each question and the overall exam allow insights into the difficulty of the question and into how much each question allows the separation of the more knowledgeable from the less knowledgeable exam candidates. Cronbach′s alpha is a measure of reliability of the entire exam.

Insights from the 2013 European Cardiovascular Magnetic Resonance Exam

Sixty-five candidates sat the 2013 European CMR exam, held in Florence after the EuroCMR Congress. Across three computer rooms at the University of Florence seven invigilators supervised the exam supported by six IT staff. The mean exam duration was 144 min (range 71–150 min). 95% of candidates were 30–50 years of age, the majority (n = 52) were non-native English speakers and 95% sat the exam for the first time. We found that being a native English speaker did not significantly improve the chances of success. The majority of exam takers were Europeans (n = 60), but there were also three Asians, one North American, and one candidate from Australia/New Zealand. There was variation of self-reported CMR experience among the exam candidates ranging from none (n = 1), to <1 year (n = 16), to 1 to 2 years (n = 19), to 2 to 3 years (n = 11), to >3 years (n = 17) with one candidate not providing an answer. Interestingly, the likelihood of passing the exam was statistically not related to the length of CMR experience. This may suggest that a test of CMR knowledge cannot be compensated for entirely by experience. Although an organ of the European Society of Cardiology offers the exam, not only Cardiologists (n = 58) take the exam. Among the candidates were four radiologists, two labelled as ‘other’ (likely MR physicists), and one candidate did not provide an answer. In the 2013 exam, the pass mark based on the modified Angoff score was 64% and 53 candidates (81.5%) passed the exam. The average exam score was 73.4 ± 9.1% (range 51.0–91.8%). There was some small variation in average scores among the different topics listed in the syllabus and blueprint. Congenital heart disease and physics were among the topics with slightly worse average scores, but there were no outliers in either direction. Written feedback from exam candidates collected immediately after the exam was generally very positive.

In conclusion, the EACVI Section CMR offers an annual high-quality, high-stakes European CMR exam that forms part of the European CMR certification process. The dedication and expertise in subject matter and exam theory of all CMR exam board members has made this possible. This high-quality exam has set an international standard for CMR and imaging exams for others to rise to.

Steffen E. Petersen, MD DPhil FESC, s.e.petersen{at}qmul.ac.uk

Sven Plein, MD PhD, s.plein{at}leeds.ac.uk

The Glasgow Cardiovascular Research Centre of the British Heart Foundation

One of the six UK Research Centres of Excellence that opened in 2006; it will soon be linked to a new clinical research facility under construction at South Glasgow Hospitals Campus, which will be the largest hospital in Western Europe

‘People make Glasgow …’ is the marketing slogan of Scotland's largest city which is home to The British Heart Foundation (BHF) Glasgow Cardiovascular Research Centre (BHF GCRC).

It was the people of Glasgow who provided £7 million in addition to £5 million awarded by the BHF, to build the facility; scientists who make the Centre home to some of the world's best cardiovascular researchers; and patients whose samples and data make new medical advances possible.

Embedded Image

However, one person in particular was responsible for getting the whole thing off the ground: Prof. Anna Dominiczak. Appointed BHF Professor of Cardiovascular Medicine in 1997, she was instrumental in securing funding for the new Centre and attracting high-calibre staff, such as Prof. Andrew Baker and Prof. John McMurray, a world-renowned expert in heart failure, who was recently named one of the most-influential biomedical researchers in the world in a study by Stanford University.

When the BHF GCRC opened in April 2006, Prof. Dominiczak—who by then had received an OBE from The Queen—was named the Centre's first Director. Now Head of the College of Veterinary, Medical and Life Sciences and a vice-principal, she says: ‘The BHF GCRC is leading the way in cardiovascular research in Scotland with our scientists providing outstanding insights into the development and treatment of heart disease’.

‘Our expertise in stratified medicine is being recognised with millions of pounds of investment which will see us benefit from a new clinical research facility currently under construction at South Glasgow Hospitals Campus – which will be the biggest hospital in western Europe’.

Historically, the pioneering work begun by Drs Tony Lever, Jehoyda Brown, and Ian Robertson in the 1960s, who established the MRC Blood Pressure Unit, set the stage early on for Glasgow as an internationally renowned hub of excellence in hypertension and cardiovascular science.

Prof. Dominiczak's own research group developed internationally recognized research programmes in genetics and genomics of hypertension and stroke, with publications in Nature Genetics, Nature, and other top journals as well as multimillion research grants from the BHF, MRC, Wellcome Trust, and EU.

The Centre is now part of the Institute of Cardiovascular Medicine (ICAMS) at the University of Glasgow both of which are led by Prof. Rhian Touyz, who joined from Canada in 2011.

The BHF GCRC boasts a staff of over 160 and >200 students, with an annual research income of over £30 million. Its facilities include a 3 T MRI suite, state-of-the-art imaging, high-throughput genotyping equipment, and a fully staffed clinical research facility jointly run with NHS Greater Glasgow and Clyde. Recently, the BHF awarded it a further £3 m to become a Centre of Excellence —one of just six in the UK.

Embedded Image

Prof. Rhian Touyz said: ‘Heart research at the BHF GCRC incorporates basic biology, integrative physiology, and translational and clinical research and its Principal Investigators are internationally-recognised for their work on the mechanisms of disease, including arrhythmias, congenital heart disease, coronary heart disease, heart failure and public health and also in pulmonary hypertension.

The output of the Centre has been informing cardiovascular research and practice worldwide. Our focus going forward is on stratified medicine and the new development at the South Glasgow Hospitals Campus: the Stratified Medicine Scotland Innovation Centre and the Clinical Research Facility which will give us unrivalled infrastructure and equipment’.

Every year, ICAMS produces >350 research papers and its students benefit from the expertise of world leaders in their field, across the whole range of cardiovascular medicine from cardiology and diabetes to hypertension and genomics.

Embedded Image

Prof. Jeremy Pearson, Associate Medical Director for Research at the BHF, said: ‘The BHF recently awarded a Research Excellence grant to the Glasgow Centre, recognising its internationally competitive research and the presence of a critical mass of integrated basic and clinical science allied to a strong training programme for younger researchers’.

‘This award is in addition to a wide portfolio of current investment for specific projects totalling over £15 million at Glasgow. One highlight includes on-going grant support for BHF Professor Andrew Baker's ground-breaking translation of years of preclinical research into a clinical trial using gene therapy to reduce restenosis’.

‘We also support several aspects of Glasgow's innovative programme of clinical research to improve therapeutic options and patient outcome after myocardial infarction. These include evaluating the clinical and economic benefits of measuring cardiac fractional flow reserve; stratifying post-MI risk by using MRI to quantify myocardial haemorrhage; and a pilot study to understand whether a larger trial is warranted to compare conservative medical management of ACS patients who have had previous bypass surgery with invasive management’.

2014 is a big year for cardiovascular research in Glasgow: the city is hosting the Cardiovascular and Interventional Radiological Society European Congress in September, while both Profs. Dominiczak and Touyz will serve as presidents of the European Hypertension Society and the International Society of Hypertension, respectively.

Embedded Image

Country of the month: Ireland 2014

Report by Dr Angie Brown and Dr Siobhan Jennings, National Cardiovascular Disease Prevention Coordinators for Ireland

Embedded Image

Angie Brown, MD, FRCPI, MRCP, BSc, MB, BChir, Consultant Cardiologist and Medical Director of the Irish Heart Foundation, abrown{at}irishheart.ie

Embedded Image

Embedded Image

Siobhan Jennings, MB, DCH, MPH, FFPHMI, Consultant Public Health Medicine, siobhan.jennings{at}hse.ie

Health care

Ireland has a multi-tiered health system that is undergoing major reform. Key elements of the reforms include the introduction of Universal Health Insurance and a focus on keeping people well and preventing ill health (Healthy Ireland). The Health Service Executive provides all of Ireland's public health services. Approximately 80% of health funding is provided though the taxation system and private health insurance provides an additional source of funding.

Forty per cent of citizens are eligible for medical cards allowing access to a range of health services free of charge with the remainder having limited eligibility to free services. Further, 45.8% of citizens obtain private health insurance.

Ireland has 48 acute publicly funded hospitals, 28 have facilities for acute cardiac care, 9 of which are major cardiac centres with catheterization suites. A further seven private hospitals have cardiology services.

Reference: catheterization suites (seven centres are designated 24/7 primary percutaneous coronary intervention) centres).

Risk factors

Coronary heart disease (CHD) mortality rates in Ireland fell by 68% in men and by 69% in women between 1985 and 2006. Approximately 40% (38% M; 45% F) of the CHD mortality decline could be attributed to improvements in treatment uptake. Approximately 48% (54% M; 37% F) was attributable to risk factor improvements.

Currently, smoking prevalence is estimated at 22%, three-quarters of the population have cholesterol levels above recommended and over half have hypertension (treated or untreated). At least 6 out of 10 Irish adults (61–64%) are overweight or obese and almost one in three Irish adults do not achieve a baseline level of recommended activity. Diabetes is increasing with prevalence estimated at 3.5% but projected to increase to 5.5%. Alcohol consumption is high at 11.9 L per person per year.

Embedded Image

CHD in Ireland 1985–20061

Main actors and prevention methods

The National Cardiovascular Health Policy 2010–19 identifies key players including

  • The Department of Health;

  • Health Service Executive;

  • Health Information and Quality Authority;

  • Irish Heart Foundation;

  • Irish Cardiac Society;

  • Irish Association for Cardiac Rehabilitation;

  • Irish College of General Practitioners; and

  • Royal College of Physicians of Ireland.

Prevention activities

Following earlier health promotion strategies specific initiatives addressing CVD in Ireland started in 1999 with ‘Building Healthier Hearts’, followed more recently by ‘Changing Cardiovascular Health: National Cardiovascular Health Policy 2010–19’. The latest Government framework for action ‘Healthy Ireland’, launched in 2013, identifies the main population goals and approaches needed to create a healthier Ireland and strongly recommends inter-governmental and inter-sectorial action. Following a number of tobacco control initiatives including the workplace smoking ban in 2004, the Irish government has now set a target for ‘A Tobacco Free Society by 2025’.

The Health Service Executive (HSE) funds all public sector health services including prevention campaigns such as the ‘QUIT campaign’, an integrated smoking cessation media campaign based on the statistic that one in two smokers will die of a tobacco-related disease, health promotion services based on the settings we live in, as well as contributing to policy development. Also, the HSE works in partnership with a number of agencies such as Safefood, an all-island body promoting awareness and knowledge of food safety and nutrition issues, which launched a Childhood Obesity Campaign in 2013.

There is a strong non-governmental sector (NGO) sector focused on CVD prevention. The Irish Heart Foundation has health promotion programmes in the workplace, community, and schools and has advocated on a number of issues including a tobacco-free society and restrictions of marketing of foods high in fat, sugar, and salt to children. CROí, based in the West of Ireland, has a number of programmes addressing high-risk individuals, e.g. ‘My Action’ as well as a Masters and Postgraduate Diploma in Preventive Cardiology.

Cardiac rehabilitation

Cardiac rehabilitation services in Ireland are provided in the cardiology departments of general hospitals. Virtually, all such departments offer a programme. They are supervised by cardiologists and secondary prevention and rehabilitation are closely related.

In-patient cardiac rehabilitation never developed in Ireland. All rehabilitation is out-patient based and is provided by a multi-disciplinary team comprising, ideally, a physician, a nurse specialist, physiotherapist, dietician, social worker, and in some cases, a clinical psychologist. Structured advice on exercise with graduated circuit training, behavioural change, lifestyle and risk factor management is provided, backed up by videos and reading materials that are tested for appropriateness to the literacy of participants. Family participation is strongly encouraged.

The conventional three phases of cardiac rehabilitation are provided over 8–12 weeks. Attendance rates are generally high and the programmes are regarded as being supportive and are popular. Development of phase IV programmes is more variable although some programmes have developed strong community links. Rehabilitation was pioneered in three Dublin hospitals; more recently, the ‘My Action’ programme in Galway in Western Ireland has been outstandingly successful.

The future

Ireland faces the challenge of an ageing population with predicted increase in hypertension, atrial fibrillation, and obesity. The Government's commitment to ‘increase the proportion of people who are healthy at all stages of life’ is set out in the ‘Healthy Ireland’ framework.

It is Government policy to be tobacco free by 2025 (smoking rate of >5%) and Ireland is set to become the first country in the EU to introduce standardized packaging of tobacco products.


Automated external defibrillators should be mandatory on board all commercial airliners

Two physicians in Denmark discuss the need for change in European regulations concerning the medical kit carried on commercial aircraft

A 32-year-old man was declared dead on arrival at Amsterdam Schiphol Airport.

During a flight from Spain to Denmark in the summer of 2012, he suddenly lost consciousness and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was provided by passengers, but the medical kit on-board the aircraft lacked equipment needed for CPR and treatment of acute medical conditions in general. For example, there was no ventilation mask or bag, nor any medications used in the treatment of acute medical conditions, such as epinephrine or antihistamine. The only way to help this young man was by providing basic life support with manual chest compressions and mouth-to-mouth/nose ventilation. There was no automated external defibrillator (AED) on-board.

The aircraft made an emergency landing in Amsterdam, where an emergency medical team (EMT) was awaiting the arrival. At that time, CPR had been provided for >30 min. The EMT took over the treatment and started providing advanced life support. Repeated rhythm analysis showed asystole and the EMT finally decided to end resuscitation attempts.

Every day >300 000 flights are scheduled worldwide and ∼2.75 billion passengers are flying annually on commercial flights. A recently published paper in the New England Journal of Medicine describes the presence of medical in-flight emergencies in the USA recorded by medical communication centres.1 The study shows that cardiac arrest comprised 0.3% of all of medical emergencies and 82% of these passengers died, constituting 86% of all deaths in the entire study population.

Previous studies have shown that if public AEDs were available, patients would be defibrillated earlier and have a better chance of survival.2 The European Resuscitation Council (ERC) has declared the need for deployment of AEDs in both public and residential areas.3

Delivering high-quality chest compressions with minimal interruptions and early defibrillation are keystones in the attempt to restore spontaneous circulation. European Resuscitation Council guidelines describe that CPR and defibrillation within 3–5 min have shown survival rates up to 49–75% in out-of-hospital cardiac arrest with ventricular fibrillation. Furthermore, data have shown that each minute of delay before defibrillation during shockable rhythms reduces the chances of survival by 10–12%.3,4

There are no uniform international requirements for AEDs on aircraft. When reviewing the guidelines for contents of medical kits on-board aircrafts, we discovered differences between USA and European regulations, the most important difference being that in the USA, AEDs are mandatory on all aircraft with a maximal payload capacity of more than 7500 pounds.5

In contrast, the European operating rules do not require AEDs on aircraft, neither in regulations adopted in 2008 nor in the latest update of 2012.69

In Europe a basic First Aid Kit is required on all flights, whereas stethoscope, oropharyngeal airways, and medications, e.g. antihistamine, atropine, and epinephrine, are required only in Emergency Medical Kits (EMK). Automated external defibrillators are not a required part of EMKs, and moreover, EMKs are only required ‘if any point in the planned route is more than 60 minutes flying time (at normal cruising speed) from an aerodrome at which qualified medical assistance could be expected to be available’.6,7

Some European airlines have chosen to exceed these requirements and have deployed AEDs and EMKs in all aircraft, whereas others fulfil only the minimum requirements.

Airports with qualified medical assistance are scattered across the densely populated European continent, which means that almost any European aircraft would be able to make an emergency landing within the required 60 min, thus not requiring on-board EMKs and/or AEDs.

Brown et al.10 showed that AED use on flights resulted in 50% survival among victims with VT/VF and 14% overall survival in cardiac arrest in general. Considering the importance of early defibrillation, a delay to the first defibrillation may reduce survival significantly.

It would be beneficial for in-flight cardiac arrest victims if uniform international regulations required AEDs on all flights, as it may result in increased survival in this patient group. In fact, an aircraft cabin may be an ideal setting for deployment of AEDs with a short transport distance to the patient.

We, therefore, suggest that the ERC, the European Society of Cardiology, and other relevant organizations create public awareness on this issue and emphasize the importance of implementing requirements for AEDs on all commercial flights. Furthermore, it would be important to discuss the need for uniform international regulations concerning contents of EMKs in general, as some acute medical conditions such as anaphylactic reactions need prompt treatment to avoid deterioration in the patient's clinical condition. A ‘landing-within-60 minutes rule’ seems arbitrary and meaningless, especially in the case of cardiac arrest.

It would be preferable if EMKs including AEDs were mandatory in all commercial airliners, irrespective of the duration of the flight and distance to the nearest airport.

Embedded Image

Embedded Image


View Abstract