Prof. Doutor Fausto Pinto

Cardiology in Portugal and FML / HSM 
In Portugal, several figures have contributed to the development of cardiology care, and since its inception the Faculty of Medicine, University of Lisbon (FMUL) / Santa Maria Hospital (SMH) has always been at the center of these advances. Some names must be highlighted because of their contribution to this field: Professor Eduardo Coelho, who performed the first human coronary arteriography in 1952, (even if unfortunately this is rarely mentioned in textbooks) and Professor Arsénio Cordeiro, who opened the first Intensive Coronary Care Unit in Portugal, at SMH in 1968. After the retirement of these two masters the legacy of cardio-care at the FMUL was placed in the safe hands of Professors Solomon Sequerra Amram, Carlos Ribeiro and Fernando de Padua. On their retirement, the now unified Cardiology Service was run by Professors Celeste Vagueiro, Correia da Cunha, Mário Lopes, António Nunes Diogo successively. Since 27th July of this year this task has fallen to myself. Following the recent creation of the North Lisbon Hospital Center (NLHC), the Cardiology Service of Pulido Valente Hospital (PVH), initially designated Cardiology Service II, was merged with the Cardiology Service at SMH.

The current NLHC Cardiology Service is thus composed of services located at SMH and the pole in PVH.

Nowadays, it is increasingly important to generate management methodologies that enable the efficient use of resources; an issue which is particularly relevant when dealing with public structures and in countries with economic difficulties, as is our case. I think the great cost containing efforts and the rationalisation and rigorous management practices of public funds made by the current Administration of NLHC are plain for all to see. It is also very important that physicians are aware of the concepts of efficiency and effectiveness in diagnostic methods and therapeutic options, as they desire to be part of the effort towards transparency and rigor. I also think that, in a university hospital setting, there are windows of opportunity that can help solve some problems. In its essence, a university hospital service can and should be imaginative in its management. For example, access to other sources of funding may contribute to self-sustainability. I refer, for example, to participation in registries, clinical trials, research projects established through the initiative of individual researchers, and cooperation agreements with different entities including the pharmaceutical and medical equipment industries. While, this type of cooperation must be carried out with total transparency and within the correct legal restraints, it is common practice in the most advanced centers worldwide today.

The current circumstances allow one to consider the integration of the different cardiovascular areas (cardiology, cardiothoracic surgery and vascular surgery) into one large Heart and Vein Service which could provide a comprehensive and integrated response to problems related to cardiovascular pathologies. As these pathologies are responsible for much of the mortality and morbidity in our population, it is crucial to have a service functioning in the modern perspective of a Tertiary University Hospital, as the NLHC is, and in the true spirit of what is called a “Heart Team”.

General operational objectives:
The key objectives of the Cardiology Service can be summarized as the following:

1) Clinical cardiology and modern treatment practices in a tertiary teaching hospital that is part of the National Health Service including: invasive diagnostic techniques and therapeutic cardiology operations (cardiac catheterization / evaluation haemodynamics, electrophysiology and pacing), non-invasive diagnostic techniques (electrocardiography, stress testing, various applications of echocardiology and other imaging methods, Holter registration, event marking, vasoreactivity testing, ABPM ‘Ambulatory Blood Pressure Monitoring’, etc) in addition to medical consultations (general and specialized), cardiology care in Intensive Care Units and offering cardiology services to the Emergency Room.

2) Training new medical specialists in adult cardiology (interned hospital patients), medical sub-specialists in cardiology (electrophysiology and pacing, advanced cardiac imaging, interventional cardiology and cardiology specialists for Intensive Care Units) as well as cardio-pneumology technicians and specialised nurses.

3) Clinical and translational scientific research in conjunction with the Cardiovascular Center of the University of Lisbon (CCUL), of which I am the Scientific Coordinator, and with FMUL (where I am the Chair of Cardiology), also with IMM and other national and international institutions, in the several areas and sub-areas of Cardiovascular Medicine. For this reason the Support Bureau for Scientific and Technological Research and Innovation (STRI -GAIC) was established under AIDFM, and has been a key instrument in the planning and implementation of clinical research in the Service.

4) Offering medical training at under- and post-graduate levels appropriate for current requirements. This includes assuming responsibility for all cardiovascular medicine teaching on the Integrated Masters programme in Medicine at FMUL (about 350 students per year), as well as collaborating with other third level institutions in pre and post-graduate training (these include Instituto Superior Técnico, Escola Superior de Tecnologias da Saúde, among others).

5) Management of a Cardiology Service with academic objectives supported by new information and communication technologies, with strong concerns about ethics, the humanization of medical practice and the economics of cardiology healthcare.

Cardiology care is supported by the tripod of clinical practice, research and training, and the problems that currently face these areas and will do so in the near future, could be resumed as follows:

a) Hospital Care. Hospitalized patients with primary disease (such as malignant arrhythmias, acute coronary syndromes, refractory heart failure or pulmonary hypertension, as examples) need to have quick access to differentiated health care, where the most advanced methods of cardiology diagnosis and treatment are available. These may include sophisticated diagnostic equipment (cardiovascular imaging, electrophysiology and haemodynamics laboratories) and treatments (interventional cardiology, intervention arrhythmology, functional articulation cardiac surgery). All this implies a very active dynamics permitting an adequate use of and return from investments in resources, and the establishment of operating guidelines balancing the cost-benefit ratio. These points are particularly relevant at a time of scarce resources when the appropriate and judicious use of resources is paramount.

A modern Cardiology Service should encompass all areas of cardiology, as this is essential today for the quality of care that the heart patient requires. These include the Cardiac Intensive Care Unit, electrocardiography, electrophysiology and pacing laboratories, complementary, multi/faceted, non-invasive diagnosis equipments, but with particular emphasis on echocardiology, MRI, haemodynamics, interventional cardiology, non intensive inpatient cardiology, outpatient cardiology and cardiology support consultations to other services.

It is only possible to construct efficient, modern and profitable cardiology care, in accordance with well established standards, if indeed there are excellent functional links between all these components.

The multiple components of modern cardiology should therefore be perfectly coordinated and interconnected. These include Intensive Care Units, which should be well equipped and with appropriately trained staff ready to receive the cardiac patient, the Invasive Cardiology Diagnosis and Intervention Unit, cardiovascular imaging, with emphasis on advanced echocardiology (transesophageal and stress) and cardiac magnetic resonance imaging, electrocardiology with Holter, delayed potentials, stress, pacing and electrophysiology and cardiology outpatient clinic. All these activities should be carried out in close collaboration with nearby specialties, with special emphasis firstly, on cardiac surgery and also vascular surgery.

b) Research. It can be proposed that there will be three main research objectives in cardiology over the coming years: 1. To continue the enhancement of the state of the art, through improvements and new developments in the fields of imaging, invasive cardiology / intervention and cardiovascular drugs; 2. The evaluation of new technologies, whether these be diagnostic techniques or therapeutic interventions and the definition of “guidelines” for their use; 3. Application of knowledge and techniques on prevention and treatment of cardiovascular diseases acquired from modern biology on awareness.

Scientific research is one of the key areas of a hospital with an academic orientation. Thus, the development of research protocols in the most recent and relevant areas, in close collaboration with services operating in clinical areas, or at a scientific level (looking at a translational application of knowledge) will also be one of our priorities. This dynamic approach to research will certainly promote scientific output and should naturally result in the publication of scientific articles in journals with high impact factors, which will significantly increase the national and international visibility of the Cardiology Service at FMUL and hence the institution itself . We will also continue to participate in clinical research trials and multicenter registries, which will result not only in increased visibility for the center, but also in enhancing its sustainability, which is critical in any institution today.

c) Training. The educational role of the University Cardiology Service must by fulfilled by teaching Cardiology to undergraduate students and at postgraduate courses to future specialists in Cardiology and Continued Medical Education, be they cardiologists or not. The aim should naturally be to educate cardiologists of the future – here international recommendations need to be followed, especially those defined by the European Society of Cardiology in the Core Curriculum, where different stages of the cardiologist studies are outlined. It is also important, however, to be aware of the need for postgraduate training of other medical personnel, such as physicians of other specialties, with special focus on anesthesia, intensive care/intensive medicine, and cardiothoracic and vascular surgery.

Cardiovascular diseases are the main cause for mortality and morbidity in our country which reflects a global trend. As it is, in order to provide services nowadays required of a hospital such as CHLN, there is every need for a functional and modern Cardiology Department, and one well-integrated with other specialties, especially those inherently closely connected with it. With this in mind, I would like to mention some of the areas which I believe demand special focus:

a) Coronary artery disease is a major source of concern, manifested in the daily admissions of patients to our Hospital, and those referred to other hospitals. It is therefore fundamental to continue our response to the high number of patients admitted with signs of acute coronary syndrome/myocardial infarction which is an everyday reality in A&E departments (as well as with other acute and sub-acute conditions: unstable angina, acute dysrhythmia, acute haemodynamic dysfunction). To give but an example, according to recent publications, 20% of all hospitalisations in Sweden are caused by acute coronary disease. In the USA, in a Community Hospital in an area with 250,000 inhabitants, there are 18 beds at the Coronary Ward and 32 at the Intermediate Care Ward. We perform around 500 primary angioplasties in patients with myocardial infarction, which is the highest number of such procedures in any Portuguese hospital centre.

b) The need for reinforcement of the Programme of Interventional Cardiology, today one of the greatest advancements in Modern Cardiology, including not just the treatment of coronary artery disease, but also of structural cardiopathies. Here again the integration with the Cardiothoracic Surgery Department is crucial to put the “Heart Team” into practice, a formal protocol used in the treatment of the majority of pathologies. There is a strong need for a facility with a hybrid surgery room where combined procedures could be performed, based on close cooperation of interventional cardiology with cardiac and vascular surgery. The pathologies currently encompassed by this area include valvular pathology, especially aortic valve stenosis, with percutaneous implantation of valve prosthesis, as well as mitral insufficiency with Mitraclip system; auricular appendage closure in prevention of tromboembolism in patients with atrial fibrillation; Patent Foramen Ovale (PFO) closure, Atrial Septal Defects (ASDs) or Ventricular Septal Defect (VSDs); renal sympathetic denervation, to name but a few.

c) Another clinical area which mobilises considerable resources, and according to predictions will mobilise significantly more of them, is Heart Failure. This prediction rests on the fact that more and more patients survive serious conditions such as acute myocardial infarction, not to mention increased longevity.

The Service has a very important role in treatment and follow-up here, seen as the complexity of some of the therapies recommended nowadays (eg. cardiac resynchronisation, among others) involves the work of teams trained exactly in acute treatment and in following up those patients.

As one of the priorities I consider boosting the effort of the cardiac insufficiency team by creating a real Cardiac Insufficiency Service which would allow to respond to those patients promptly and applying the state-of-the-art advancements in the area.

Also here the emphasis on cardiac surgery must must go hand in hand with the creation of ventricular assistence programme (ECMO; artificial heart etc.) as a “bridge to recovery or to transplant”, already foreseen in the Cardiac Surgery Service’s programme (Transplant Services – from the initial protocol with the transplant centre leading to the future transplant service at HSM).

d) Pulmonary Hypertension has traditionally been a strong point of the Service’s which in Portugal has served as a benchmark in its own right.

We are talking here about an area where strong link between outpatient and hospital services is absolutely vital, as is the demand for teams highly qualified in treating these patients. In view of that, it will be very important to keep and, if possible, enhance the current team.

e) Prompt carrying out of all cardiac diagnostic techniques (invasive and non-invasive) for patients referred from other Services or sent to the Hospital: Electrocardiology (simple or high-resolution ECG, Cardiac stress test, Holter dynamic electrocardiography), Cardiovascular imaging, with special focus on Echocardiology (M Mode, two-dimensional, Doppler, stress and transesophageal in special cases, not to mention intracoronary and three-dimensional ultrasouns), Invasive haemodynamic monitoring and coronary angiography, Routine and advanced electrophysiological studies.

f) The Centre of “Pacemakers” and Diagnostic and Intervention Arrhythmology. Traditionally a centre of excellence of the Service, with an annual flow of patients comparable to this of major European institutions.

g) Pre-surgery assessment and selection of patients potentially with indication for surgery and support to those with post-surgery problems, in close cooperation with Cardiothoracic Surgery, including regular carrying out of joint clinical sessions, already in place once a month.

h) Assess cardiac risk in patients awaiting a non-cardiac surgery through establishing a functional structure of support to other Services.

i) A cardiac outpatient centre which should be a real tertiary hospital centre, in close coordination with the Units of Family Health, and Hospitals which are part of our referral system

It will also be important to set up a specialist consultation system (partly already in place) which would allow to develop and demonstrate the excellence of the Service

j) The Centre for Cardiac Rehabilitation, already set up in the PVH Nucleus, in cooperation with the Physical and Rehabilitation Medicine, representative of an area that is slightly forgotten in the institution, but which, in this Service, could receive a significant boost.

The Cardiovascular Centre of the University of Lisbon (CCUL): The mission of CCUL is to contribute to the knowledge of the CV system, of the health condition and the disease, through interdisciplinary research, to allow to translate basic knowledge into clinical practice. The aim here is to decisively influence the prognosis, the care and the quality of life of patients, to develop disruptive innovation and to ensure the leading position in educating future generation of scientists.

The current strategy of CCUL is to create in Portugal, in parallel with the Service’s objectives, a platform for translational research in cardiovascular sciences that would be tangible, mature and efficient, with excellence in basic and clinical sciences as its underlying principle, integrated with the wide research strategy of the Service and with the objectives of the national health service.

The dedication and effort of the researchers of the Cardiology Service, and of its partner network, accompanied by a reliable strategic and structural base will certainly contribute to the enhanced role of Portugal in cardiovascular sciences, with clear benefits for scientific community and for patients.

Prof. Fausto J. Pinto