Cardiovascular disease remains the most common cause of death in the UK and across the world, so in this issue of BioScience Today, Ellen Rossiter speaks to Dr Vijay Kunadian, Senior Lecturer and Honorary Consultant Interventional Cardiologist at Newcastle University and Freeman Hospital Newcastle upon Tyne, about the progress that’s been made and the challenge that remains.
“The way we treat people with heart disease has been transformed in recent years. We used to treat patients with drugs, but now for anyone in our region experiencing chest pain, that’s a population of over 2 million, they are given an ECG in the ambulance, then transferred directly to the Freeman Hospital for treatment when they experience a full blown heart attack.
“In fact today, we often capture patients before they even experience damages to the heart following heart attack, identifying and treating the emerging problem quickly, often within 15 minutes. Just 10 years ago patients who’d had heart procedures would stay in hospital for about a week, now within about 10 minutes of a procedure, it is as if a miracle has happened and people are wanting to go home straight away. Sometimes we have to remind them that they’ve experienced a life-threatening event and keep them in for a night or two.
“So much progress has been made, and cardiovascular deaths have been reduced, but cardiovascular disease remains the leading cause of death and we want to know why that is, especially given we’ve made so much progress.”
Newcastle University and neighbouring Freeman Hospital are together paving the way in the realm of cardiovascular research, you might have seen the latter’s cardiothoracic surgeons at work in a recent BBC documentary, Vijay’s research interests, however, lie in a different area of cardiac care.
“I’m more of a plumbing cardiologist” explains Vijay, “I fix blocked heart arteries. Few women do my job, but I did it because my supervisors/mentors were very supportive. I didn’t realise I had this potential, but I made the most of the opportunities that came my way and I was surprised to find that I was able to do this.”
“Science always fascinated me, even when I was in school, especially the human body and in particular the heart. At the same time, I started scoring high marks in science and that stimulated my interest. I was encouraged to be a doctor by my parents, and from day one when you are studying medicine you learn about anatomy and you dissect organs – and the heart really caught my attention.
“My very first job was at the Freeman Hospital here in Newcastle in the cardiothoracic section, where I was preparing for my surgical exams. I was working in the lung area, rather than the cardio section and it just didn’t feel right, even though I had wanted to be a heart surgeon since Medical School.
“I went on to work in Gateshead and Darlington as a junior doctor training in general medicine, at the time, however, the biggest interventional heart centre in the region was in Middlesbrough, so one of the defining points of my career was being invited to take up a research position at the James Cook Hospital in the cardiology department.
“Another crucial moment came a few years later when I was studying for my doctorate of medicine at Newcastle University and I took it upon myself to email a Harvard-based researcher, whose work I almost always quoted in my papers, saying I’d love to work with your team for a year and to my surprise, I had a reply within a couple of minutes saying ‘yes, we’d love to have you, but you’ll have to find your own grant’.
“I successfully applied to the training programme and I was awarded a grant by the South Cleveland Heart Fund, which made joining the research team in Boston MA USA possible, with some support also forthcoming from the Brigham and Women’s Hospital at Harvard Medical School.
“Going to Boston to work with the most prestigious cardiovascular researchers in the world, including Braunwald, the father of cardiology who actually defined heart attacks, and Professor Mike Gibson who was my mentor, was an inspiration.
“I was asked to stay in Boston where there are a lot of opportunities, but I wanted to come back to here to finish my clinical interventional cardiology training and to give something back to the region which provided me with such excellent training. Once back in Newcastle, however, I was torn between my clinical work and research interests, I applied for a clinical post but was disappointed not to get it and I was encouraged to take up academic posts. I was invited to take up a clinical Consultant post in Edinburgh but followed my instinct to take up the academic post in Newcastle University instead.
“In the end, you have to go with what you feel comfortable with, deep down you know your abilities, it was a risk as the academic posts were usually short term (2 year) contracts, whilst clinical posts were permanent, but looking back it was the right decision for me. I worked hard to generate grants and publish in journals, working from a building in which there was no other academic cardiologist.
“The University has been highly supportive, with me now holding a tenured post, which is 50% clinical and 50% research based – which is ideal for my research interests which are patient centred.
“The Freeman Hospital, where I am based on my clinical days, is rated outstanding by the care quality commission, I am so happy to work in an organisation that is so patient centred, the hospital is one of the main reasons I stay in the North East, being patient centred is what we do, it is not just a logo.
“There are very few centres in the country that offer cardiac care as advanced as you’ll find here at the Freeman, from babies right through to patients of 100 years plus. The team here that perform heart transplants are so inspiring.
“In terms specifically of the clinical provision for treating patients with coronary heart disease, we are also one of the largest centres in the country, with regards to the volume, complexity and diversity of the cases that we treat. We see everything here and I never know who is coming through the door next, as my entire list is an urgent or emergency list.
“One thing I noticed during my first day back in Newcastle working as a Consultant, having been in Boston, was that the demographics of my patients had changed dramatically in just 12 months.
“Almost all of my patients were now in their 80’s or 90’s, where previously older patients had not been referred by doctors for advanced care and were sent home, this was no longer the case and we had the opportunity to treat them.
“As it was a recent phenomenon, there was so little supporting evidence to show how best to treat our older patients with heart disease – should they be treated the same as a 50-year-old for example or not?
“Everything we do is evidence based, typically based on research involving 20,000 patients, yet here there was little evidence on how best to treat the clinical problem. We’ve made great progress in the treatment of many diseases, and people are surviving things that they would not have done previously, but ultimately their heart catches up with them.”
Newcastle University, is a world leader in research into ageing, its causes, and consequences, having been awarded funding from the National Institute for Health Research (NIHR) to form a Biomedical Research Centre (BRC) in partnership with the Newcastle upon Tyne Hospitals NHS Foundation Trust, one of only 20 BRCs in the country and the sole one researching aging.
So Vijay’s interest in how best to treat her older patients with heart disease fit in perfectly, her work in this area has been supported by both the BRC and the British Heart Foundation (BHF). Vijay is quick to highlight how supportive the BHF has been of her research and her career – even helping her to find a new mentor. “I wouldn’t be here without the BHF – I wasn’t too sure that I could survive academia back then, but they did and they supported me all the way.”
The biggest trial in which Vijay is involved, has been facilitated by an incredible £1.7m grant from the BHF, the biggest research grant in clinical cardiology research ever brought into Newcastle University, involving over 40 hospitals and 2,000 patients – which is examining the benefit and risk of coronary revascularisation versus conservative management in high-risk older patients who have had minor heart attacks.
In addition, Vijay is working on a project to see if medications such as Aspirin and Ticagrelor, which are used to prevent clots forming, might also prevent heart attacks in COPD patients. Patients with COPD are at a higher risk of suffering heart disease and heart attacks – yet she found only 2% of COPD patients were on heart medication. Now with a $1.2m grant awarded by Astra Zeneca, work is afoot to see if existing drugs could help tackle the problem and reduce the risk.
Vijay also hopes to examine the link between heart attacks and brain function, as an estimated 50% of patients who suffer a heart attack also experience a decline in brain function, so one of her priorities is to see if there is anything that can be done to prevent that decline.
One can’t help wondering how Vijay does it all, in a role which she describes as “300% everything: 100% clinical, 100% research, 100% teaching.” Co-Chair of the European Society of Cardiology ESC/European Association of Percutaneous Cardiovascular Interventions EAPCI Scientific Documents and Initiatives Committee; with editorial responsibilities for a number of journals and sitting on several steering committees, it is no wonder Vijay’s is the Winner of the Sunday Times ‘We Are The City Rising Star Award 2018’.
“Balancing my clinical and research work can be a challenge, but the team here are very supportive, flexible and understanding – an absolutely brilliant team with whom to work.”
NHS burnout is a hot topic of conversation, and her advice on how best to avoid it is “look after yourself, have early nights and there are certain things you have to say no to. I always make sure I have plenty of rest before I am on call,” explains Vijay.
“For me, time management, self-discipline and prioritisation are key. On Sunday afternoon I plan the week ahead and that helps me to keep on top of things. When people entrust you with so much, you want to give your all.
“I looked up to my mentors and watched how they handled their responsibilities and learnt a lot from them, they taught me to stop sitting there worrying and to just get on with things. Challenges make you stronger, make you better, they are opportunities. My mentors played a major role in my career and now, in turn, I’m teaching students and nurturing the next generation. Being a doctor is an amazing thing. Importantly my entire family have always been very supportive and encouraging in everything I do.
“Newcastle itself inspires me, the people in the North East are amazing, and I take great inspiration from my patients, they keep me motivated as I want to make a difference in their lives. I’ve received my training in the North East and I want to give something back. Sometimes the cases we deal with are horrendous, but we don’t give up on them, we keep going and we are able to make a difference. We give everything to save someone’s life.
“You have to take the abilities you have and do the best that you can in the job that you do. Everything in life is about striving to go over and above with the abilities that you have, and doing that can lead on to so many things. You have to get your head down, do your everyday job and then everything else follows,” observes Vijay.
As a publication based in Newcastle, the team at BioScience Today, were disappointed to learn that cardiovascular disease is still such a problem in the North East, in fact where people living in Kensington and Chelsea have an average life expectancy of 83.1 years, in some parts of the North East, like Teesside it is much lower. Statistics suggest that life expectancy is 16.6 years lower for men and 12.2 years lower for women in the most deprived areas of Stockton-on-Tees than in the least deprived areas.
There are a number of factors involved, as Vijay explains, from deprivation to risk factors such as smoking, a poor diet, diabetes, hypertension, and family history. “It is the genetic aspect of heart that hasn’t yet been conquered, yes the gene that has been linked with heart disease has been identified, but there is still so much more to know.”
Vijay’s best advice for us? “Life is precious, look after yourself, be physically active, walk wherever possible, pack in smoking and watch what you eat – particularly if you have a family history of cardiovascular disease; and keep an eye on your cholesterol. Even small changes can make a major difference.”
What would be your dream we ask Vijay? “To see cardiovascular disease eradicated,” she says without a pause. “We have made huge progress in treating some diseases, some of which have been more or less eradicated, and although we have transformed our understanding and treatment of cardiovascular disease in recent years, we are a long way from eradication.”
For Vijay, it is clear, combatting cardiovascular disease is the driving force that propels her work.