- by Fausto Pinto, in the month of the Heart
Maybe it's no longer impactful enough if we tell you that the podium of world deaths belongs to Cardiovascular Diseases.
But do you have any idea how many lives come to an end each year all over the world? Do you wish to save a few seconds for the right guess?
Data advanced by the World Health Organization point to 18 million and 500 thousand deaths each year, just from diseases related to the cardiovascular system, which translates into 31% of total deaths worldwide, in a single year. This information becomes more impactful if we tell you that most of these deaths could have been avoided by changing lifestyle habits in a timely manner and through early monitoring.
It is therefore not unimportant to celebrate dates to insist on a message that is still not strong enough to change numbers worldwide.
May was the month chosen to remember that this message has not yet reached everyone's heart and that is why this was another year of national initiatives insisting on the emphasis “May, Month of the Heart”.
Projects conducted by various work teams always have a mentor who directs the coordination of all teams and actions.
He took over as Director of the Cardiology Service in 2014, 7 years ago. In 2016, he accumulated another position within the Northern Lisbon University Hospital Centre, the Department of the Heart and Vessels. President of the World Heart Federation until 2022, and current Director of the Faculty of Medicine, Fausto Pinto welcomes us in his large management area. It has 103 doctors, 67 of whom specialists and 36 still in training. There are 180 nurses, 39 diagnostic technicians, 19 technical assistants and 111 operational assistants. Fausto Pinto expects his 472 people to work an average of 16,500 hours a week at the service of those who continue to stand on the podium of deaths, cardiovascular patients.
We walk with him through the corridors and talk to the teams working in that precise shift. In the intervention cardiology room, there is a Covid patient undergoing procedures. In all rooms, there are hospitalized patients, support carts full of material and so many people in uniforms circulating, while the monitors scattered throughout the corridors register the vital parameters of all patients. There is no alarm or agitation when a Covid patient arrives, as there is no tension when it comes to the sound of vital signs. These dynamics are the usual routine of these teams and everyone is trained to react and act naturally.
If we think that we are in a University Hospital that is also tertiary and main one, then we know that this means that it provides assistance to all types of patients, especially the most delicate and complex cases. And we know that this requires an inherent demand for clinical excellence, also instilled by these teams in teaching and research.
All these aspects are balanced through the management, organization and structuring of the Cardiology Service/Department. It was in this framework that we asked to know more about these teams that daily try to reverse the national numbers. The successive efforts of these persons are supported by a human, but also technological, quality, one of the areas of greatest access to innovation and development, which is why they are known as one of the groups closest to modern Medicine. "This should be one of the main objectives of an academic medical Department", reinforces its Director. Fausto Pinto explains that “since this is a very technological area, access to, and the ability to implement new technologies is preponderant and, as it is developing very quickly, it requires simultaneous monitoring of the entire area and teams. It is, therefore, a very expensive area, which nevertheless allows a type of intervention that has been responsible for the very significant improvement in the quality and quantity of life of people who need care in the Cardiovascular area”.
But who are the teams and how are they organized?
Distributed by three Services, the Department of Heart and Vessels is made up of the Cardiology, Cardiothoracic Surgery and Vascular Surgery services. Within the Cardiology Service there are Units, each with a coordinator and a team under his responsibility. In parallel, there are also two Major Buildings, Santa Maria and Pulido Valente Hospitals. Santa Maria contains the Inpatient, Intensive Care, Intervention Cardiology Unit, where the Structural Cardiology Centre is located, which is a national reference, the Non-invasive Techniques Unit, the Electrophysiology and Pacing Unit, as well as the Ambulatory Unit.
The Cardiovascular Rehabilitation Unit, the Pulmonary Hypertension Consultation, also a reference centre, the Heart Failure Day Hospital, and a small Palliative Care Unit for patients with Heart Failure are located at Pulido Valente Hospital. There is also a Unit consisting of 11 inpatient beds, external consultation and additional tests for non-invasive diagnoses.
Some of the professionals work in more than one Unit, since there are so many areas of action, and they do clinical practice and teaching. Most also conduct research. In order to ensure good coordination, multiple periodic meetings are held. The interaction between Units guarantees the internal activities, and also ensures the monitoring of patients who are admitted to other various clinical areas of Santa Maria Hospital, and also to hospitals outside Lisbon.
Over time, Fausto Pinto surrounded himself with his best choices to coordinate all the teams in his Units, all with a senior profile. The Service Directions are appointed by the Hospital Administration, but within each Service the appointments are the responsibility of the Director, in direct articulation with the Hospital Administration.
Successful interventions have names and faces. In Intervention Cardiology, Pedro Cardoso, in Electrophysiology and Pacing, João de Sousa, in Admissions, Dulce Brito, in the Outpatient Clinic, Manuela Fiúza, in the Non-Invasive Techniques, Ana Almeida, and in Pulmonary Hypertension, Nuno Lousada. Having already undergone a reformulation this year, UTIC has a person responsible for the Department's Intensive Care Unit, Hugo Corte Real. In Pulido Valente Hospital, Palma dos Reis, in the Cardiovascular Rehabilitation, Ana Abreu and in Palliative Care, Parente Martins.
But the heart teams are not just these.
As this is a University Hospital, teaching is not played down, and training takes place at various levels. In undergraduate education, they welcome students from the Integrated Master Degree in Medicine. In postgraduate training, there are specialty interns. Then there are several extracurricular activities, such as the Congress of New Frontiers in Cardiovascular Medicine, developing even more thematic areas such as New Frontiers in Cardiomyopathy, in Cardio-Oncology, in Pulmonary Hypertension, or Chronic Coronary Occlusions.
In each of the major areas, there are also specific training courses for those looking for sub-specializations within Cardiology.
Not least, research is very important. There are several active groups. The Cardiovascular Research Support Office (GAIC), which provides administrative support to the approximately 100 studies currently taking place, is coordinated by Inês Zimbarra Cabrita. There is the Cardiovascular Centre of the University of Lisbon (CCUL), which encompasses several research units, from the most basic research to the most clinical and both with vast output. It is presided by Fausto Pinto and has Susana Constantino as executive director. Finally, Cetera, a CRO (clinical research organization) ensures the coordination of studies that are carried out nationally or internationally. Links are maintained with various centres in Europe and other parts of the world. Various members of the Department participate in the activity of various national and international scientific societies.
There are periodic coordinators’ meetings between Fausto Pinto, Ângelo Nobre (Cardio-Thoracic Director) and Luis Mendes Pedro (Vascular Surgery), with the coordination of nursing and cardiopulmonology technicians. On Wednesdays at 8:30 am, the Heart Team meeting takes place, where patients' cases are discussed in the Surgical and Cardiac areas, thus defining the best therapeutic strategies.
Also on Wednesdays, at 12:30 pm, they gather for the Service's weekly clinical meeting. There are other periodic meetings involving several of the groups, such as Cardiovascular Rehabilitation, Non-invasive Techniques and Pulmonary Hypertension.
There are daily visits to the wards and intensive care units, which act as an interface for the didactic component.
It is extremely important to talk about these Units and people if we stress that 80% of the increase in life expectancy in the last 50 years has been due to advances in the Cardiovascular area. Contradiction, right? Since it persistently remains the leading cause of death worldwide. That's precisely where we started our conversation.
Professor, how do you explain these numbers regarding efficacy in treatments and such a high mortality rate?
Fausto Pinto: We are very good at treating, but terrible at preventing. We were able to identify the therapeutic targets very well and to develop the technologies that allow both the diagnosis and the treatment of most cardiovascular situations, but we continue to witness an increase in Cardiovascular Disease. We still have the so-called cardiovascular risk factors, which result in an increase in the prevalence of diabetes, hypertension, dyslipidaemia, and even smoking. These factors end up having, even today, the impact we know. But let's go back to the numbers. It would be a problem if these factors were unavoidable, but 80% have a solution, they are avoidable and potentially preventable. The effort lies in the cyclical attempt to prevent risks and promote healthy lifestyles, trying as much as possible to reduce the impact (internationally called burden) of these diseases.
There is a directive from the World Health Organization that sets the objective of reducing, by 2030, premature death from cardiovascular diseases by one third. And despite these goals having suffered some impact with the pandemic, it remains one of the goals.
You said that due to the pandemic, many meetings have become remote, mostly regarding research. The clinical meetings are hybrid, some face-to-face, but many at peoples 's work stations. Has the pandemic brought about a new paradigm in the work teams?
Fausto Pinto: Undoubtedly, the digital component and remote meetings are here to stay, not least because it saves time and allows one to extend and better schedule a person's activity. Of course, face-to-face meetings will always be important, but there are some types of meetings that can really change.
Another advantage of online meetings is that it allows access to many more people. Congresses, which in the past had a limited number of participants, are now much more open, maintaining access rules, of course. But congresses became more comprehensive, opening doors to people who would hardly attend if they were in face-to-face. Just look at the European Congress of Cardiology, which is the largest in the field of Cardiology worldwide. Usually it has 30 000 people in round numbers. Last year, as it was completely virtual, it had 120 thousand persons registered. It reached places it had never reached before. And this is the positive side, dissemination. Not detracting from the importance of face-to-face and informal contacts to establish networks, the fact is that communication is valued and technology is developed. There is another curious point that is important. Before we needed to go on long flights to Japan and, after a congress, depart for Brazil. Today it is enough to schedule the right times for the meeting in the same day and everything is possible.
What about the patients’ proximity to the doctor? Did they keep coming to the Hospital?
Fausto Pinto: In the initial phase of the pandemic, there was fear and people did not come to the hospital. In the first weeks, from March to April, we had a drop of about half of the patients, as was the case in hyper acute situations, such as acute myocardial infarction. This happened all over the world, there are data to prove it. In the case of acute myocardial infarction, when the person comes in time, we can treat him. The problem was when we had cases where people came a week later and there wasn't much we could do to save the situation. On the other hand, mortality at home and in hospitals increased. Due to fear, people did not come to the hospital and some died at home, or when they arrived the situation was already quite serious, ending up dying here.
There are more numbers to take into account. Worldwide, we have two to three times more mortality than would normally happen under normal conditions. If the person comes in the first 12 hours, the risk of mortality is around 3%, but if the person comes a week later, the rate can go up to 12%. It's pretty frustrating. In just one day in Santa Maria Hospital, something completely atypical happened. We had three heart ruptures, something that we rarely see nowadays.
After the most complicated first weeks, in May 2020 we drew up a plan to ensure the rapid recovery of the Department's activity. We believed that cardiovascular patients should have the greatest possible protection and that this pathology is one of the most urgent. With the support of the Administration, the resumption of activity was progressive and rapid, which allowed us to eliminate waiting lists in some areas. There was the need to adapt and restructure the functioning of the services and eliminate the long queues. This allowed reorganizing spaces and offer more teleconsultations, which facilitated the maintenance of contact and trust with patients.
Has the pandemic brought technological growth and new support mechanisms for patients?
Fausto Pinto: Regarding the specific cardiology part, not directly. What happened was that certain technological devices were more used, such as ECMO machines. As for the virus itself, it is another topic. Whereas for a long time there was nothing to treat and even today, there is very little, we cannot ignore the greatest discovery in science in recent times, the Covid-19 vaccine.
How is Cardiology at the moment?
Fausto Pinto: We are working normally, with just small fluctuations. We expect that there will be a significant increase in the number of patients with cardiovascular disease. The same applies to oncology, the areas with the greatest indirect impact due to the Covid-19 pandemic. In global terms, during the pandemic, people were less followed regarding control of hypertension, diabetes, etc. People’s inactivity during periods of confinement increased the likelihood that they would develop more significant problems. Therefore, now we expect a peak in cardiovascular pathology and it is necessary to prepare the National Health System (NHS) to respond not only to the pandemic, but also to the increase in demand, mainly in the cardiovascular and oncological areas. In this sense, we are organizing the services to be able to provide an appropriate response to each case.
We also have a large project we have been working on for a few years. It involves expanding and physically restructuring the Cardiovascular Department, with the creation of a single Intensive Care Unit that will bring together all areas in one place.
It is unavoidable to mention your connection to teaching. You have always stressed that this is a University Hospital and you have fought a lot for it. Do you feel that when you pass on this message it is in vain and it goes unnoticed?
Fausto Pinto: It is not enough just joining the words University and Hospital. It is important to give it instruments that allow it to be managed in an adequate way. If this doesn't happen, the functioning of these structures will be difficult. In my opinion, the type of organization for a hospital whose sole function is the provision of medical care, which is obviously very important, is completely different from another that has three activities within the same space. And today, regarding the way we are organized in Portugal, regardless of the type of hospital, the hierarchical organization is the same. I think that a University Hospital should have different management and hierarchy. It should have a distinctive form of funding and it should be managed in an integrated manner. When we divide the heads a lot, we are diluting responsibilities a lot and losing effectiveness. It would be much more efficient to have only one structure with only one authority to fulfil these multiple functions.
In Portugal, we still have a system that has great difficulty in keeping health professionals in the same institution and this is important for its development.
You have intervened in the causes you believe in, particularly throughout the pandemic. As President of the Council of Portuguese Medical Schools, there were several requests for the CEMP to be taken into account before some national decisions, related to Health, were made. Where will you be in the near future?
Fausto Pinto: (Smiling) I finish my term in the board of FMUL in July 2022. As Director of the Department of Heart and Vessels, I hope to continue for a few years and see the restructuring plan implemented. It will represent a major reinforcement of the institution's capacity to respond to its triple function of providing medical care, offer undergraduate and postgraduate training and conduct research in the cardiovascular area.