Dutch guidelines for interventional cardiology: institutional and operator competence and requirements for training

Interventional cardiology is an expanding field within cardiovascular medicine and today it is generally accepted that cardiologists require specific training, knowledge and skills. Hospitals where coronary interventions are performed must be properly equipped and able to provide specialised care. Percutaneous coronary interventions are frequently used for coronary revascularisation. The public should have confidence in the uniformity of high quality care. Therefore, such quality of care should be maintained by certification of the individual operators, general guidelines for institutional requirements and formal audits. The Netherlands Society of Cardiology (NVVC) will be implementing a new registration system for cardiologists with a subspecialisation that will include registration for interventional cardiology. The NVVC asked the Working Group of Interventional Cardiology (WIC) to update the 1994 Dutch guidelines on operator and institutional competence, and requirements for training in interventional cardiology in order to incorporate them into the official directives. The present guidelines represent the expert opinion of the Dutch interventional cardiology community and are in accordance with international regulations.After two rounds of discussion, the NVVC approved the guidelines in November 2004 during the autumn meeting.     

Continuing medical education in Europe: NVVC,CVOI, ESC,UEMS and EBAC

The European Board for Accreditation in Cardiology (EBAC) is a joint initiative of the European Society of Cardiology (ESC) and the Cardiology Section of the Union of European Medical Specialists or Union Européenne des Médecins Spécialistes (UEMS). EBAC operates independently from these parent organisations. The ESC is the highest cardiovascular scientific authority in Europe and the most important provider of Continuing Medical Education (CME) in cardiology. The UEMS officially represents the European medical specialists at the European Union (EU). The UEMS consists of different mono-specialist sections, among which the Cardiology Section. The recognition of the importance of CME and the need for quality standards and quality control led the UEMS to establish the European Accreditation Council for CME (EACCME) in January 2000. CME activities that seek European accreditation have to comply with the regulations of this council. As a consequence of the establishment of EACCME, the mono-specialist sections of the UEMS together with the different European scientific societies started to create accreditation boards with the aim to assess international CME activities in accordance with the regulations of UEMS and EACCME. EBAC was founded in 2000. EBAC accreditation is complimentary to national CME accreditation. The Netherlands Society of Cardiology (Nederlandse Vereniging voor Cardiologie, NVVC) and its Institute for CME, the Netherlands Institute for Continuing Cardiovascular Education (Cardio-Vasculair Onderwijs Instituut, CVOI) formally recognise EBAC accreditation and Attendance Certificates.     

Recurrent and founder mutations in inherited cardiac diseases in the Netherlands

Since the start of joint outpatient clinics with both cardiologists and clinical geneticists, in 1996, both the number of patients and the research activities in this field have tremendously grown. In 2001, around 600 patients were evaluated for a cardiological disorder in all Dutch departments of clinical genetics, being nearly 5% of all patients evaluated at a department of clinical genetics at that time. These figures rose to 2500 and 10%, respectively, in 2007. This growth can be attributed to several factors such as the expanding possibilities of DNA testing in potentially inherited cardiac disorders, highly motivated people working hard in the joint cardiogenetics outpatient clinics that are now available at all university medical centres and some secondary hospitals, and last but not least growing awareness of cardiologists that part of their daily clinical practice actually deals with families instead of individual patients.     

2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation: Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups

Recently, the European Society of Cardiology (ESC) has updated its guidelines for the management of patients with acute coronary syndrome (ACS) without ST-segment elevation. The current consensus document of the Dutch ACS working group and the Working Group of Interventional Cardiology of the Netherlands Society of Cardiology aims to put the 2020 ESC Guidelines into the Dutch perspective and to provide practical recommendations for Dutch cardiologists, focusing on antiplatelet therapy, risk assessment and criteria for invasive strategy.     

Risk stratification for sudden cardiac death in hypertrophic cardiomyopathy: Dutch cardiologists and the care of mutation carriers

Background. Patients with hypertrophic cardiomyopathy (HCM) and HCM mutation carriers are at risk of sudden cardiac death (SCD). Both groups should therefore be subject to regular cardiological testing – including risk stratification for SCD – according to international guidelines. We evaluated Dutch cardiologists' knowledge of and adherence to international guidelines on risk stratification and prevention of SCD in mutation carriers with and without manifest HCM. Methods. A questionnaire was sent to 1109 Dutch cardiologists (in training) containing case-based questions. Results. The response rate was 21%. Own general knowledge on HCM care was rated as insufficient by 63% of cardiologists. The percentage of correct answers (i.e. in agreement with international guidelines), on the case-based questions ranged from 37 to 96%, being lowest in cases with an unknown number of risk factors for SCD. A substantial portion of correct answers was based on the correct answer ‘ask an expert opinion’. Significantly more correct answers were provided in cases with manifest HCM. There was little difference between the answers of cardiologists with different self-reported levels of knowledge, with different numbers of HCM patients in their practice or with different numbers of carriers without manifest HCM. Conclusion. Knowledge on risk stratification and preventive therapy was mediocre, and knowledge gaps exist, especially on HCM mutation carriers without manifest disease. Fortunately, experts are frequently asked for their opinion which might bring patient care to an adequate level. Hopefully, our results will stimulate cardiologists to follow developments in this field, thereby increasing quality of care for HCM patients and mutation carriers. (Neth Heart J 2009:17:464–9.).     

Two-compartment model for rabbit skin organ culture

Summary A new method was developed for rabbit skin organ culture. In a two-compartment model, skin discs were cultured on a Millicell-HA insert unit with a microporous membrane which allows transport of culture medium via the dermis into the epidermis, whereas the epidermal side remains free of direct contact with culture medium. In this relatively simple two-compartment organ culture model, rabbit skin could be cultured for 7 d in RPMI 1640 medium supplemented with fetal bovine serum, or for 2 d in RPMI 1640 medium supplemented with cofactors. The histomorphology and ultrastructure of 7-d cultured rabbit skin discs was essentially similar to that of freshly isolated rabbit skin. Keratinocytes in the stratum basale continued to divide during organ culture. The terminal differentiation of the epidermis continued in vitro as was found by the presence of keratohyalin granules, the intact stratum corneum, and keratin expression. Furthermore, glucose consumption continued until culture Day 7, but thereafter it declined rapidly. Concomitantly, degenerative changes were found. At the end of the 7-d culture period the distance between single dermal collagen fibrils had increased as compared to noncultured skin. This model of skin organ cultures can be used to study biological processes, dermal toxicity, and penetration and metabolism of xenobiotics in intact skin. Furthermore, within certain limits, processes responsible for repair and regeneration of damaged skin can also be studied in this model because the rabbit skin can be cultured for 7 d. The present study was financially supported by grants of Duphar B. V. (Weesp, Netherlands), the European Community, and the Dutch animal welfare organizations Samenwerkingsverband van de Nederlandse Vereniging tot Bescherming van Dieren en de Nederlandse Bond tot Bestrijding van de Vivisectie, Anti-Vivisectie Stichting en Stichting Schoonheid Zonder Wreedheid.     

Ten greatest discoveries of the 20th century in cardiovascular medicine

The Netherlands Society of Cardiology (NVVC) was founded 70 years ago on 28 April 1934. When looking back at the history of our Society on its 70th anniversary, it might be a nice opportunity to mention ten great discoveries in cardiology in the 20th century.     

Monogene kardiale Ionenkanalerkrankungen

Monogenic forms of heart diseases are often associated with high cardiovascular risk in the youth and require careful clinical and genetic assessment. These diseases are generally associated with ion channel gene mutations which are genetically heterogeneous and have varying sensitivity with respect to mutation detection. Analogous with other ion channel disorders, cardiac channelopathies are often episodic and can be triggered by environmental factors (generally with increased heart frequency during physical exertion and/or mental stress). Early diagnostics and interdisciplinary care by cardiologists, pediatric cardiologists, and human geneticists (and if needed psychologists) is recommended. Recently, preliminary expert recommendations for genotyping in familial forms of arrhythmias have been published to facilitate directed genetic investigations in the light of pathophysiologic heterogeneity.     

What do cardiologists know about the effects of cardiovascular agents on sexual function? A survey among Dutch cardiologists. Part I

Introduction

Several cardiovascular agents, such as diuretics and β-blockers, can negatively affect sexual function, leading to noncompliance with therapy. Others such as angiotensin II receptor blockers (ARBs) can improve patients’ sexual function.

Aims

We aimed to gain insight into cardiologists’ knowledge about the effects of cardiovascular drugs on sexual function and whether they take this knowledge into account when prescribing drugs.

Methods

An anonymous questionnaire was mailed to 980 members of the Netherlands Society of Cardiologists (cardiologists and residents in training).

Results

Almost 54 % of Dutch cardiologists responded; 414 questionnaires were analysed. Forty-five percent of cardiologists were aware that diuretics can negatively affect sexual function, 93.1 % knew about the negative effects β-blockers can have, but only 9.2 % were aware that ARBs can have positive effects on sexual health. Almost half of respondents (48.2 %) stated they change medication regularly in an attempt to improve sexual function. Experienced cardiologists said they do this significantly more often than less experienced ones.

Conclusions

Cardiologists’ knowledge about the effects of cardiovascular drugs on sexual health appears to be insufficient. Sexual dysfunction is not routinely taken into account when cardiologists prescribe drugs.     

Einthoven Dissertation Prizes 2008

For the 19th time in a row, the Netherlands Society of Cardiology (NVVC), the Interuniversity Cardiology Institute of the Netherlands (ICIN), and the sponsor, Sanofi-Aventis have supported the competition for the best three PhD theses on a cardiovascular subject published last year. The prize carries the name of one of the great Dutchmen in the history of cardiology: Willem Einthoven (1860-1927), the pioneer of the human ECG and winner of the Nobel Prize in 1924. The jury reviewed a total of 20 dissertations. The jury members were impressed and pleased by the scientific quality of the work of the young doctors. As always, it was not easy to decide which ones to nominate for the final round. Three nominees, Gabe Bleeker, Niels Riksen and Joanne Schuijf, presented their work at the spring meeting of the NVVC, which was held in Amsterdam on 18 April 2008.     

Genetic counselling for hypertrophic cardiomyopathy: are we ready for it?

Hypertrophic cardiomyopathy (HCM) is a dominant genetic disorder of the myocardium associated with dysfunctional contractile proteins. The major risk of HCM is sudden cardiac death, which may occur even in asymptomatic carriers. Causes are highly heterogeneous. Over 140 different mutations in nine sarcomeric genes have been described to date. The majority of cases (80% or more) may eventually be traced to one of these genes. Although genetic counselling is suggested even if mutations are not known, molecular diagnosis implies new options such as carrier identification or - theoretically - preclinical risk stratification. A scheme according to which cardiologists and clinical and molecular geneticists could cooperate in counselling patients and managing HCM clinically is proposed.     

Einthoven Dissertation Prize 2010

For the 21st time in a row, the Netherlands Society of Cardiology (NVVC), the Interuniversity Cardiology Institute of the Netherlands (ICIN), and the sponsor, Sanofi-Aventis, have supported the competition for the best three PhD theses on a cardiovascular subject published last year. The prize carries the name of one of the great Dutchmen in the history of cardiology: Willem Einthoven (1860-1927), the pioneer of the human ECG and winner of the Nobel Prize in 1924.     

Syndromale Formen geistiger Behinderung

Mental retardation of varying degree is a major component of genetic syndromes. Affected individuals with the same disorder may show different degrees of mental retardation. Making a diagnosis is a great challenge for clinical geneticists, especially because of the wide clinical variability. Besides carefully evaluating the family history and conducting a clinical examination, consideration of guiding clinical signs – including obesity, macrosomy, microcephaly, prenatal or/and postnatal growth restriction, and multiple congenital anomalies – is very helpful in establishing the correct clinical diagnosis. Modern cytogenetic and molecular cytogenetic techniques help clarify the etiology and define new disease nosologies.     

Cardiac recovery by stem and progenitor cells

For the 20th time in a row, the Netherlands Society of Cardiology (NVVC), the Interuniversity Cardiology Institute of the Netherlands (ICIN), and the sponsor, Sanofi-Aventis, have supported the competition for the best three PhD theses on a cardiovascular subject published last year. The prize carries the name of one of the great Dutchmen in the history of cardiology: Willem Einthoven (1860–1927), the pioneer of the human ECG and winner of the Nobel Prize in 1924.     

The NVVC: here, there and everywhere

When I started my cardiology training, back in 1976, cardiology in the Netherlands was highly dependent on internal medicine. Coronary care and intensive care units were led by internal medicine physicians in most hospitals in the Netherlands whereas in the US (where I had worked for a while) cardiology was a discipline in its own right, at least in university centres. In our country, this changed rapidly in the ensuing years and the Netherlands Society of Cardiology (NVVC) played a key role in this process.     

Einthoven dissertation prizes 2014

For the 26th time in a row the Interuniversity Cardiology Institute of the Netherlands (ICIN-Netherlands Heart Institute) and the Netherlands Society of Cardiology (NVVC) have supported the competition for the best three cardiovascular PhD theses, published in the year 2014 [1–3]. The dissertation prize carries the name of one of the greatest Dutchmen in the history of cardiovascular medicine, Willem Einthoven, who in 1902 for the first time recorded the human ECG, for which he received the Nobel Prize in 1924 [4].This time the jury received a total of 28 PhD dissertations published in 2014. The jury members were very much impressed by the high scientific quality of the PhD fellows. The ultimate selection was based on a combination of several parameters: the curriculum vitae of the candidate, the scientific originality of the PhD thesis and its relevance for the cardiovascular field. In addition, several objective bibliometric parameters were used: (1) the number of articles in first-rate journals both in PubMed and the Web of Science (WOS), (2) the number of citations in WOS, (3) the Hirsch index and (4) the contribution as a first author (or shared first author).Based on a combination of these results, the jury finally selected three nominees: K.Y. van Spaendonck-Zwarts (University Medical Centre Groningen), N.M. van Mieghem (Erasmus Medical Centre, Rotterdam) and W.J. Dewilde (Sint Antonius Hospital, Nieuwegein).The members of the jury were: J.W. Deckers (Director CVOI), S. Heymans (ICIN professor), A. Mosterd (Chairman WCN), M.J. Schalij (Chairman Concilium NVVC) and V.A. Umans (President NVVC).The three candidates presented their Ph.D. theses at the annual spring meeting of the NVVC, held at the Congress Centre “De Leeuwenhorst” in Noordwijkerhout, 9–10 April 2015. Based on the quality of the presentation, the audience determined the ranking of the laureates. Mrs. dr. K.Y. van Speandonck-Zwarts received the third prize, dr. N.M. van Mieghem the second prize, and dr. W.J. Dewilde the first prize. We like to congratulate the three winners with their excellent PhD Theses. Summaries of the three nominated PhD theses are given below.     

Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study

Introduction

Detection of atrial fibrillation (AF) is important given the risk of complications, such as stroke and heart failure, and the need for preventive measures. Detection is complicated because AF can be silent or paroxysmal. Describing current practice may give clues to improve AF detection. The aim of this study was to describe how cardiologists currently detect AF.

Methods

Between December 2014 and May 2015, we sent Dutch cardiologists an online questionnaire. Firstly, we asked which tools for detection of AF their department has. Secondly, we presented six case vignettes related to AF, in which they could choose a diagnostic tool. Thirdly, we compared the results with current guidelines.

Results

We approached 90 cardiology departments and 48 (53%) completed the questionnaire. In asymptomatic patients with risk factors according to CHA₂DS₂-VASc, 40% of the cardiologists would screen for AF. In patients with signs or symptoms of AF, all but one cardiologist would start a diagnostic process. In both vignettes describing patients with non-frequent symptoms, 46% and 54% of the responders would use short-term (i.?e. 24- or 48-hour) electrocardiographic monitoring, 48% and 27% would use long-term (i.?e. 7 day, 14 day or one month) monitoring. In both cases describing patients with frequent symptoms, 85% of the responders would use short-term and 15% and 4% long-term monitoring.

Conclusion

Dutch cardiologists have access to a wide variety of ambulatory arrhythmia monitoring tools. Nearly half of the cardiologists would perform opportunistic screening. In cases with non-frequent symptoms, monitoring duration was shorter than recommended by NICE.

     

Polish Lebensraum: the colonial ambition to expand on racial terms

Lebensraum – the space a state believes is required for its natural expansion – has a pivotal role in the global expansion projects. Whenever this concept is discussed, it is almost exclusively reduced to the Imperial Russia’s domination of less-stately countries in Central and Eastern Europe; the British exploration and colonization of territories in Africa and Asia; the French settlements in parts of the Caribbean Islands and Africa; the German experimentation in South-West Africa, and the Dutch seaborne competing with the Spanish and Portuguese’s expansionism. Study related to Poland’s attempted acquisition of colonial territories outside Europe is rarely discussed. Drawing on the activities of the Polish Colonial Society, this article contends that the building blocks of colonization were not confined solely to European imperial powers. As colonization forged ahead in the twentieth century, Poland seemed to be the country where colonialism played a significant role in both national and transnational politics.     

Guidelines for heart transplantation

Based on the changes in the field of heart transplantation and the treatment and prognosis of patients with heart failure, these updated guidelines were composed by a committee under the supervision of both the Netherlands Society of Cardiology and the Netherlands Association for Cardiothoracic surgery (NVVC and NVT). The indication for heart transplantation is defined as: ‘End-stage heart disease not remediable by more conservative measures’. Contraindications are: irreversible pulmonary hypertension/elevated pulmonary vascular resistance; active systemic infection; active malignancy or history of malignancy with probability of recurrence; inability to comply with complex medical regimen; severe peripheral or cerebrovascular disease and irreversible dysfunction of another organ, including diseases that may limit prognosis after heart transplantation. Considering the difficulties in defining end-stage heart failure, estimating prognosis in the individual patient and the continuing evolution of available therapies, the present criteria are broadly defined. The final acceptance is done by the transplant team which has extensive knowledge of the treatment of patients with advanced heart failure on the one hand and thorough experience with heart transplantation and mechanical circulatory support on the other hand. (Neth Heart J 2008;16:79-87.)     

Cardiologist and cardiac surgeon view on decision-making in prosthetic aortic valve selection: does profession matter?

Aims

Assess and compare among Dutch cardiothoracic surgeons and cardiologists: opinion on (1) patient involvement, (2) conveying risk in aortic valve selection, and (3) aortic valve preferences.

Methods and results

A survey among 117 cardiothoracic surgeons and cardiologists was conducted. Group responses were compared using the Mann–Whitney U test. Most respondents agreed that patients should be involved in decision-making, with surgeons leaning more toward patient involvement (always: 83 % versus 50 % respectively; p?<?0.01) than cardiologists. Most respondents found that ideally doctors and patients should decide together, with cardiologists leaning more toward taking the lead compared with surgeons (p?<?0.01). Major risks of the therapeutic options were usually discussed with patients, and less common complications to a lesser extent. A wide variation in valve preference was noted with cardiologists leaning more toward mechanical prostheses, while surgeons more often preferred bioprostheses (p?<?0.05).

Conclusion

Patient involvement and conveying risk in aortic valve selection is considered important by cardiologists and cardiothoracic surgeons. The medical profession influences attitude with regard to aortic valve selection and patient involvement, and preference for a valve substitute. The variation in valve preference suggests that in most patients both valve types are suitable and aortic valve selection may benefit from evidence-based informed shared decision-making.