This year’s BGS Rising Star Award for Research has been jointly awarded to Dr Atul Anand and Dr Richard Dodds. Atul is a newly appointed consultant geriatrician at the Royal Infirmary in Edinburgh, and Senior Clinical Research Fellow at the University of Edinburgh. Here he discusses his research into the cardiovascular care of older adults. He tweets @atula_tweets.
I am absolutely delighted to be awarded one of the BGS Rising Star Awards for Research this year. I first started working in the field of cardiovascular research as a medical student in 2005, with a small project looking at the effects of air pollution on the heart. All the participants were healthy colleagues with no older people in sight! I would not have believed anyone telling me that a decade later, then as a geriatric medicine registrar, I would start a PhD in the same department. By that time, I had developed a keen interest in blood biomarkers and data research. I was increasingly aware of variation in practice for older patients, even when it came to seemingly fundamental aspects of care, like how to diagnose and effectively treat heart attacks. Cardiology is one of the most evidence-based specialities in medicine, with countless randomised trials seeking progressively smaller absolute improvements in progressively obscure outcomes. But until recently, many of these studies have actively excluded the oldest and frailest in society, a bias that followed on from decades of largely ignoring women. The tide is now happily turning, with several cardiac trials focussed on older patients underway.
I was privileged to work on the High-Sensitivity Troponin in the Evaluation of patients with suspected Acute Coronary Syndrome (High-STEACS) trial. We used cluster-randomised trial methodology to randomise hospitals across the central belt of Scotland, rather than individual patients. This allowed us to include everyone attending hospital with a suspected heart attack – old or young, frail or robust, cognitively impaired or not, admitted at 4am or 4pm – a total of 48,282 people over 3 years. I firmly believe these types of trial design are critical for the inclusion of older people in research. There are not many cardiology trial databases including over 1,500 nonagenarians and dozens of centenarians! The primary trial analysis looked at the impact of a new high-sensitivity troponin blood test on the diagnosis of myocardial infarction. I also worked on the early rule-out of heart attacks based on a single blood test, and on the effect of kidney disease. Importantly we showed that a single low concentration troponin result, allowed the rapid and safe exclusion of heart attacks even in the oldest old, or those with advanced kidney disease. This goes against much conventional wisdom suggesting cautious repeated testing in apparently vulnerable patients ‘just to be sure’. We applied this learning in a recently presented trial of a new early rule-out pathway for suspected heart attack patients (the HiSTORIC Trial), which safely increased direct discharges from Emergency Departments by 57% and shortened length of stay. These pathways are being rapidly adopted across the world. Making earlier decisions in older people with suspected heart attacks is helpful to avoid unnecessary hospital admission and to focus attention on other important pathology that may be driving symptoms.
My interest in blood biomarkers expanded into aortic stenosis, looking at new ways to objectively measure risk of disease progression. I know a lot of geriatricians are sceptical of many of these blood tests in older patients, particularly when trying to interpret an abnormal troponin result from a complex multimorbid patient with fleeting chest pain of uncertain significance. But I like to make the case for embracing some of these markers as objective tests for our patients, in a world where frail older patients are frequently treated inconsistently based on vague notions of risk, or worse chronological age. To take troponin as an example – this is an incredibly specific blood test for cardiac injury, but not for plaque rupture (or ‘type 1’) myocardial infarction. So yes, if the test is used indiscriminately, older people will be much more likely to have elevated blood troponin concentrations when not having a heart attack. But such changes are not false or spurious – this still represents potentially important, measurable cardiac injury. The challenge for our ongoing research is to understand the importance of these findings and what treatments (if any) can improve outcomes that are important to our patients.
Working on two large trials developed my data analysis skills and my interest in the power of routine health data research. In my post-PhD clinical lectureship, I developed a real-time hospital frailty measure based on health data within the electronic health record. The validation of this tool has been delayed by the COVID-19 pandemic, but I hope to shortly demonstrate the value of this approach to automatically identify, track and then test interventions for hospitalised frail patients at risk of functional and cognitive decline. Geriatric medicine continues to spread beyond the confines of specialist hospital units – we need efficient and reproducible ways of finding older people who could benefit from comprehensive geriatric assessment.
All this would not have been possible without the incredible support of excellent clinical and academic mentors, notably Dr Susan Shenkin, Professor Alasdair MacLullich and Professor Nick Mills. As a newly appointed consultant, I can only hope to replicate their enthusiasm and support for future researchers! I would strongly encourage cross-speciality working – we can all help improve representation in research, to ultimately deliver meaningful improvements for the health and care of older people.