Cecilia Linde (professor, consultant Department of Cardiology, Karolinska University Hospital Solna, Stockholm, Sweden, Scientific Program chair for EHRA EUROPACE – Cardiostim 2014-2015), a specialist in heart failure treatment, has dedicated a considerable part of her career to teaching and training. She created the first European Heart Rhythm Association (EHRA) exam in cardiac pacing together with Jose Merino, as well as the EP Fellows initiative with Jose Brugada. She is currently helping to build up a research platform for new onset heart failure in greater Stockholm, in the hope to find future drug targets. She speaks to Cardiac Rhythm News about the details of this research platform, other research interests, the highlights of this year’s EHRA EUROPACE – Cardiostim Congress and her views on what is needed to improve cardiac care in Europe.
When did you decide you wanted a career in medicine?
It was very early in my life. I used to hear my mother-a lawyer at the Medical Board of Health in Sweden-talking about doctors she used to meet and what happened at hospitals. It all sounded very exciting. I also enjoyed reading a lot about archaeology, so at the age of seven, I decided to become either a doctor or an archaeologist.
Why did you choose to specialise in cardiology?
Because at that time there were a lot of new treatments in the field under scientific evaluation. I was impressed by the dedication of the cardiologists and their educational structure. A lot of what was done was built on earlier research.
Who were your mentors and what influence did they have on your career?
One of my mentors was my biology teacher at school Erik Friden, he taught me how to think critically and to aim high. Later, Dr. Björn Beermann, head of the Medical Products Agency in Sweden, became my mentor for teaching me clinical cardiology, as well as professor Rolf Nordlander who was my tutor in my doctoral thesis. Professor Lars Ryden was also my mentor for introducing me to international cardiology and for bringing out the best in me. Finally, professor Jean Claude Daubert from Rennes University, who was initiator and collaborator in the KAREN, REVERSE and MUSTIC studies, which we led together, was also another important mentor. He is a great scientist, a fantastic person and a great friend.
What is your biggest motivation for working in medicine?
My motivation for working in medicine is a constant wish to do better and to translate those ideas patients give me into research and improvements in cardiology care. Additionally, the fantastic staff and colleagues who I work with are a great motivation.
What have your proudest moments been?
One of those proudest moments is when I presented my thesis in 1992. Another one is when I became professor of cardiology and when I was appointed doctor honoris causa at the University of Rennes in France. It has also been thrilling and nerve-wrecking to present study results at late-breaking clinical trials and highlight sessions at different conferences.
Could you tell us about one of your most memorable clinical cases?
The case is of a young woman, just about to get married, who presented with frequent non-sustained ventricular tachycardia attacks with cardiac sarcoidosis. She consented to receive an implantable cardioverter-defibrillator (ICD) on top of cortisone and azathioprine to suppress inflammation. Later, she decided to remove her silicone breast implants and became totally cured of ventricular tachycardia; her medication, as well as her ICD, could also be removed. I found out this association had been described before but was not aware of it from the start.
What are your current areas of research?
My current areas of research are regarding devices for heart failure treatment, oral anticoagulation in device patients with subclinical atrial fibrillation and heart failure with preserved ejection fraction (HFpEF). I am helping to build up a research platform for new-onset heart failure in greater Stockholm, an area of two million inhabitants. All patients will be characterised according to computerised patient files, common imaging protocol, and biobanking. The unique property of this patient material is the detail inpatient and imaging characteristics together, which enables us to correlate findings from genomics and transcriptomics to clinical details in the hope to find future drug targets.
You have been involved in various clinical trials for heart failure treatment and also have been a member in the design of European guidelines in the field; could you tell us what is the major improvement in this area?
Guidelines in Europe have tended to become more user-friendly meaning that they make sense to general cardiologists. I believe that this development will continue because it is the implementation capacity of guidelines in everyday practice that has a true impact on health. Apps developed to help the practising physician based on a case may be of further assistance and that needs development; although, a lot has already been done in this area.
What current technologies, techniques or therapies are showing the most effective results in the treatment of heart failure?
Cardiac resynchronisation therapy (CRT), implementation of medical therapy, lifestyle adjustments and remote monitoring of arrhythmia parameters and central pressures.
You have been involved in various clinical trials for heart failure treatment and also have been a member in the design of European guidelines in the field; could you tell us what is the major improvement in this area?
Guidelines in Europe have tended to become more user-friendly meaning that they make sense to general cardiologists. I believe that this development will continue because it is the implementation capacity of guidelines in everyday practice that has a true impact on health. Apps developed to help the practising physician based on a case may be of further assistance and that needs development; although, a lot has already been done in this area.
What current technologies, techniques or therapies are showing the most effective results in the treatment of heart failure?
Cardiac resynchronisation therapy (CRT), implementation of medical therapy, lifestyle adjustments and remote monitoring of arrhythmia parameters and central pressures.
What is your view on autonomic regulation therapies for heart failure treatment?
Following some enthusiasm I now have an open mind. The concept theoretically is great. But spinal cord stimulation (as it was delivered in the DEFEAT study, which I participated in) did not work, vagal stimulation as evidenced from the NECTAR study also did not work and renal denervation need to find its role. Baroreceptor stimulation may have the greatest promise in particular if it can halt disease progression in patients with hypertension and with diastolic dysfunction.
You have dedicated a considerable part of your career to teaching and training; could you describe your greatest achievement in this area?
I am proud of having created the first European Heart Rhythm Association (EHRA) exam in cardiac pacing together with professor Jose Merino. It was a true challenge to develop the first bank of questions and I had great help from my Swedish colleagues Dr Fredrik Gadler and Dr Johan Brandt, professor Jacques Clementy from France, and Dr Lars-Immo Krämer from Germany as well as the EHRA team. I am also proud to have helped to initiate EP Fellows, a teaching initiative of professor Pedro Brugada for young electrophysiologists in training, which also gives them a great European network and the basis for taking the EHRA exam in EP, pacing or both.
Additionally, giving didactic courses in cardiac pacing at Cardiostim – EHRA EUROPACE meetings with Philippe Ritter has been a true pleasure.
You are currently the Scientific Program chair of the European Heart Rhythm Association (EHRA) EUROPACE – Cardiostim; could you tell us what the highlights of this year’s Congress are?
The highlights of this year’s Congress include live sessions from Milan covering atrial fibrillation ablation, left atrial appendage (LAA) occlusion device placement and CRT. Additonally, electrocardiogram (ECG) interpretation sessions will be taught with world experts. Delegates will also learn about leadless pacing, arrhtyhmias and ablations in grown-up congenital heart disease and paediatric disease, gender aspects of arrhythmia and ablation techniques for ventricular tachycardia and atrial fibrillation. We will also have a late-breaking clinical trials session, young investigators awards for clinical as well as basic research. New for this year are highest graded abstract poster sessions and allied professional dedicated sessions both in Italian and English. There is also a session on the best innovations for doctors and another for the industry. The Young EP committee has sessions on the best research and case presentations discussed with peers. We have three honorary lectures to be presented by Melvin Scheinmann, Gunther Breithardt and Jean-Claude Daubert. The collaboration with EUROPACE has been a pleasure with the great help of my co-chair professor Michael Glikson from Tel Aviv, Israel, and the scientific programme committee as well as the expert help of the EHRA team, in particular that of Mr Damian Basto.
You have been highly involved with EHRA for more than 12 years; in your view what is the biggest impact the Association has had in the field and before that in the former European Working Group of Cardiac Pacing?
The biggest impact is the ability to create a community for the European and associated countries around the Meditarranean area and beyond. EHRA has an immense impact by bulding-up education and examinations in cardiac pacing, CRT and clinical electrophysiology through the accreditation committee. The Association has also benefited our community by giving research grants to fellows, visualising the field of arrhythmology, initiating research and by developing our EHRA EUROPACE – Cardiostim meetings into one of the most prominent arrhythmology meetings in the world.
What is needed to improve the delivery of cardiac care in Europe?
Equal implementation of therapy in the European countries. At present, there is under-implementation of therapy in many countries regarding device therapy such as CRT and ICD not to mention curative electrophysiological therapies. To make this possible, a wider recruitment and training of young cardiologists to become arrhythmologists is required.
We need better possibilities to test new device therapies for the purpose of research – economic constraints make it very difficult in most countries at the moment.
Recovery hinges on lifestyle changes for example after atrial fibrillation ablation. We need to become better at follow-up and secondary prevention in all fields of cardiology.
Outside of medicine, what other hobbies or interests do you have?
I read a lot of literature including old classics and current books. I am trying to be up to date following several news channels: CNN, BBC, TV5 and ZDF (German channel) to get a better picture of current events.
I attend cultural events such as opera, arts, concerts and discussions. I have been lately listening to the provocative debates with Bernard-Henry Levy.
I do regular exercise indoors and outdoors and look forward to time for ballet classes. I spend as much time as I can with my daughter and family. Walking in the mountains is another of my great interests.
