Professor Vijay Kunadian, Clinical Professor of Interventional Cardiology at Newcastle University, is working on the world’s largest minor heart attack trial, SENIOR - RITA.
Professor Kunadian discusses how her ground-breaking research is helping improve heart health, globally, especially for the under-represented.
Our population is ageing rapidly. Globally, between 2015 and 2050, the proportion of over 60-year-olds is to nearly double - from 12% to 22%.
Ischaemic heart disease - or coronary artery disease - is the leading cause of death in the UK and worldwide, with older adults experiencing a higher mortality burden.
In the UK, 5.7 million people are over 75 years old. 61% of all deaths due to heart attacks occur in this age group, which has the highest rates of high blood pressure and other cardiovascular comorbidities.
Delving into the science behind heart attacks, is one of the best ways to save lives and help clinicians create personalised care plans for patients.
How is your research helping older heart attack patients?
Clinical characteristics of the older adult population are heterogeneous, with frailty, comorbidity, cognitive function, health-related quality of life and other factors playing important roles in guiding clinical care, in addition to the impact of chronological age as a predictor of adverse outcomes.
There is, however, a lack of specific evidence in this patient group presenting with heart attacks, as older patients with heart attacks were historically under-represented in clinical trials.
I have developed internationally recognised expertise in managing cardiovascular disease among under-served groups (older adults and women with heart disease). My research interest is primarily focussed on addressing the unmet needs of improving cardiovascular outcomes in this thus far neglected (in clinical trials, research and care) cohort of patients.
What has your research in this area shown?
The NIHR ICON1 study of which I am Chief Investigator and is led by Newcastle University and funded by Newcastle Biomedical Research Centre showed:
- The recruitment of older adults with heart attacks to clinical research is feasible.
- The complication rates are minimal following invasive procedures.
- Frailty is associated with adverse clinical outcomes, following invasive management of older patients with heart attacks.
- There is a high prevalence of undiagnosed cognitive impairment at baseline in these patients.
- Compared to robust patients, the pre-frail group had a significantly greater presence of high-risk lesions in their coronary arteries.
- Frail older adults with heart attacks have poor health related quality of life (HRQoL). One-year following invasive management, there are modest improvements in HRQoL most marked in frail and pre-frail patients, who received a proportionally larger benefit than robust patients.
- Frailty is associated with an increased risk of poor outcomes at 5-year follow-up.
- In these patients, the presence of multimorbidity is associated with an increased risk of long-term adverse cardiovascular events, driven by a higher risk of all-cause mortality.
These important novel findings enabled confidence in the clinical community in undertaking invasive procedures in older heart attack patients and, importantly, also enable a personalised care of older adults based on frailty and co-morbidity.
These findings are now included in the European Society of Cardiology heart attack clinical practice guidelines and the American Heart Association Scientific Statement on the management of heart attacks in older adults.
How will your research help older heart attack patients in the future?
The important pilot data gathered from ICON1 study laid the foundation for securing national funding from the British Heart Foundation for the ongoing SENIOR-RITA trial (£2 million).
SENIOR-RITA addresses the research question, does a routine invasive strategy in older patients with minor heart attacks reduce cardiovascular mortality and non-fatal myocardial infarction compared with a conservative treatment strategy?
Nationally (England & Scotland) all older frail patients presenting with minor heart attacks in recruiting sites are now randomised into conservative vs invasive care. More than 8,000 patients aged over 75 years old have been screened, around 1500 participants recruited making this the world’s largest trial, despite challenges posed by the pandemic.
SENIOR-RITA currently exceeds the total sample size of existing trials.
Given the significance of this trial to impact patient care, SENIOR-RITA is already highlighted in the 2020 European Society of Cardiology heart attack clinical practice. This will be the first study worldwide to determine the best treatment strategy for the management of older patients presenting with minor heart attacks evaluating frailty and multi-morbidity.
Our study will have significant impact on the health and well-being of older patients presenting with minor heart attacks. SENIOR-RITA will help inform national (National Institute for Health and Clinical Excellence) and international guidelines (American College of Cardiology, American Heart Association, European Society of Cardiology Guidelines).
What is next for your research?
Having contributed to advancing the care of older adults with heart disease, I wish to focus my next major research on advancing the care of women with heart disease.
Cardiovascular disease, in particular coronary artery disease, is the leading cause of death in women in the UK and worldwide. Women are under diagnosed, under treated, and under-represented in cardiovascular research.
I have undertaken several pilot projects so far to address this important problem.
A collaborative project that I undertook using British Cardiovascular Intervention Society database and Swedish angiography databases of around half a million patients showed that women versus men experience more complications and mortality following angioplasty procedures. This led to a number of initiatives nationally and internationally to address the disparity in care received by women with heart disease including the Lancet Commission to reduce the global burden of cardiovascular disease in women by 2030, where I am the UK Commissioner.
Non-obstructive coronary disease is twice more common in women than men. Such patients have spontaneous coronary artery dissection, coronary macro/micro vascular spasm and coronary microvascular dysfunction. These conditions are often missed in routine clinical practice and thus patients are not treated correctly. The European Association of Percutaneous Cardiovascular Interventions Consensus document that I chaired raised the awareness of this condition worldwide.
Importantly, there is an increase in heart attacks in young women globally. In addition, psychosocial and socioeconomic factors, appear to contribute to the global burden of cardiovascular disease in women. Women living in the most deprived areas have highest burden of cardiovascular morbidity and mortality.
Optimal care of women with heart disease, in particular, those presenting with minor heart attacks is not clear or unknown. The 2020 European Society of Cardiology heart attack guidelines has recognised a gap in the evidence on the best treatment strategy for women with minor heart attacks. In England and Wales around 18,947 women present with minor heart attacks every year according to the Myocardial Infarction National Audit Project data. Adequately powered randomised controlled trials to identify potential sex differences in treatment strategies in patients presenting with minor heart attacks is urgently needed.
How long have you been at Newcastle University?
I have been a member of staff at Newcastle University for 12 years now. But I have been in Newcastle and the North East for 25 years while undertaking my medical and clinical cardiology training.
I obtained my Doctor of Medicine Degree with Commendation in 2007 from Newcastle University. Having trained in cardiology and interventional cardiology in the North East and having received my MD degree from Newcastle, I was passionate to continue my clinical and academic activities in the area given the high burden of heart disease in the context of low socio-economic status. My academic experience and training in Harvard Medical School – where I undertook an international academic fellowship in cardiology at the TIMI/PERFUSE Study Group - boosted my enthusiasm for clinical research.
If you were to give advice to yourself when starting out early in your career, what advice would you give?
Go with your heart. Find good mentors who you trust and respect to guide you. There are some incredible, highly accomplished individuals who would be willing to mentor and guide you. Get your head down, stay focussed and you will see the fruits of your labour down the line.
In Cardiology, and Medicine in general, there is no shortcut. Sometimes you might think ‘I am not going anywhere’, but these are times of growth and development.
The bottom line is to make the most of opportunity and support from mentors, work hard, be proactive, always be willing to learn, be grateful, respectful of others, and go with your passion. That’s what brought me here.
Watch the recording from Professor Kunadian's INSIGHTS Lecture - Breaking down the barriers in the treatment of cardiovascular disease.
You might also like:
- A publication in The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI) The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI) - Coronary artery lesion phenotype in frail older patients with non-ST-elevation acute coronary syndrome undergoing invasive care
- The announcement from the British Heart Foundation about the SENIOR-RITA trial
- A publication in the Journal of American Heart Association - Cognitive Decline in Older Patients With Non‐ST Elevation Acute Coronary Syndrome
- A publication in British Medical Journal, Heart - Frailty and quality of life after invasive management for non-ST elevation acute coronary syndrome
- Explore the work we do at the Translational and Clinical Research Institute
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