Nick Linker (consultant cardiologist, The James Cook University Hospital, Middlesbrough, UK) is president-elect of the British Heart Rhythm Society (BHRS), an executive committee member of the Arrhythmia Alliance-UK’s heart rhythm charity-and programme director of Heart Rhythm Congress (HRC). In this profile, he remembers how John Camm, a former mentor, influenced his career development advising him against being “a jack of all trades,” which led him to specialise in arrhythmias and currently in device therapy. He also tells Cardiac Rhythm News about his leadership in the re-design of the BHRS certification process, his goals for his presidential tenure, the key aspects of running a successful electrophysiology department and the highlights of this year’s HRC.
Why did you choose a career in medicine and, in particular, why did you choose to specialise in electrophysiology?
From my schoolboy days, I remember always wanting a career in medicine. I was interested in cardiology and neurology but I felt that cardiology offered a greater opportunity to benefit patients since-at the time when I was making career choices-there was little, if any, treatments that could be offered for neurological conditions.
I developed an interest in electrophysiology by chance when I obtained my first registrar post working for Dr David Shaw in Exeter, UK. He had an interest in bradycardia and pacing which rubbed off on me. Then, Dr Shaw introduced me to Professor John Camm-who was just moving from St Bartholomew’s Hospital (London, UK) to St George’s Hospital (London, UK). Prof Camm, then [in 1986], offered me a research post at St George’s and my career developed from there.
Who were your career mentors and what advice did they impart to you?
My initial mentor was Dr David Shaw who awoke my interest in arrhythmias. Prof John Camm and Dr David Ward had a major part in my career development. They fostered my interest in electrophysiology but Prof Camm cautioned me against being a “jack of all trades” advising me to focus on one area, ie. arrhythmias. Having said that, my work environment at St George’s with colleagues such as Mark de Belder, Mike Griffith, Cliff Garratt, Chu Pak Lau, Davendra Mehta and others, was a major influence in my career development.
How has electrophysiology evolved since you began your career?
There have been many developments in electrophysiology since I started at St George’s. Perhaps, the greatest is the evolution of ablation of cardiac arrhythmias. At that time , electrophysiology was very interesting intellectually but there was little one could do in terms of treatment, apart from a few antiarrhythmic drugs. Radiofrequency ablation had not been invented, implantable cardioverter defibrillators (ICDs) were in their infancy and required major surgery for implantation. The first successful treatment for arrhythmias I was involved in was surgical; working with Mr John Parker on surgical treatment of Wolff Parkinson White syndrome and atrioventricular (AV) nodal tachycardia was a breakthrough. Now we have effective and less invasive therapies for these patients.
What area in the field do you feel most passionate about and why?
In the last couple of years, I have moved more into device therapy rather than electrophysiology. I think the revolution in the management of heart failure with the advent of cardiac resynchronisation therapy (CRT) is very exciting. I can still remember the first patient I implanted with a CRT device, he could not walk from his bed to the nurses’ station on the ward before the procedure. The next day, he was not in the ward when I went to see him, he had walked with his father to the entrance of the hospital.
Of the research you have been involved in, what do you consider to be your greatest achievement and why?
I have been involved in many research projects over the years; however, on a personal basis my most satisfying project has been the Protect-Pace trial. This was a study that tried to answer a question that has interested cardiologists for many years, which is: where is the best place to pace the right ventricle in order to minimise deleterious effects on cardiac function? There has been concern over the years that traditional apical pacing might not be optimal. This trial, which was recently presented at Heart Rhythm 2014 showed that there is no difference between apical and septal pacing in terms of left ventricular function over two years. Although in one sense a negative trial, it nevertheless does, to a large extent, answer this question.
Can you describe a memorable case you treated?
It is difficult to think of one single case that stands out over the years. One recent case that sticks in my memory regards to the extraction of an infected pacing system. The patient was unwell with endocarditis and lung abscesses. He had his original system implanted in 1994 via a left sided superior vena cava and then had a second system implanted via the right side a few years later. This was incredibly difficult to extract as the left sided electrodes were heavily calcified and there was an acute bend into the left superior vena cava. With the help of my surgical colleagues we ended up opening his chest to remove the electrodes, a procedure which took 11 hours to do. He had a stormy course but eventually got better and is now well and back at work. It was a very long case but ultimately satisfying as we managed to get everything out.
As a reviewer of various renowned journals, which research paper in the last year did you think was the most interesting?
In the last year, I have reviewed an interesting paper [the paper is still under review with the European Heart Journal] on the re-interpretation of tilt testing that, rather than being used as a diagnostic test, can show a susceptibility to reflex hypotension which may exist in coincidence with any cause of syncope. This may be one explanation as to why some patients will become syncopal in certain situations eg. with the onset of an arrhythmia whereas other patients appear to tolerate the situation.
What are your current research interests?
Currently, I am involved in a number of research projects both commercial and academic. The commercial projects include the evaluation of new products such as the insertable cardiac monitor (Reveal Linq from Medtronic) and the leadless pacemaker (Nanostim from St Jude Medical). Academic projects include a variety of audits looking at device complications and ablation outcome data.
Which are the main research priorities in electrophysiology?
Important trials recently presented include SIMPLE, which shows that routine defibrillation testing is not necessary; however, it does not address the opposite question of which patients should have defibrillation tests. This is an important area that will need to be evaluated. We are still awaiting the outcome of CABANA, looking at the long-term efficacy of atrial fibrillation ablation versus antiarrhythmic drugs. We still need good evidence for efficacy of ablation in persistent atrial fibrillation. This is a controversial area where cost-effectiveness needs to be looked at and linked to outcome measures such as patient reported outcome measures (PROMS).
You have a low infection and complication rate with implantation of cardiac devices. What advice can you give to physicians starting in this field?
Your question almost answers itself! The problem is that we tend to look at device implantation as physicians rather than as surgeons. Without doubt, the main factor in reducing device related infection is a sound knowledge of surgical technique and treating device implantation as a surgical procedure rather than just another cath lab procedure. Emphasising the importance of ensuring good sterile technique both for the implanter and other people in the lab/theatre is paramount. Being obsessional in this area I am sure is the most important factor in reducing device infection.
You have dedicated a good part of your career to teaching and training. Could you describe your greatest achievement in this area?
This is very difficult to answer. I think two areas stand out. The first is the development and re-formatting of the BHRS certification process. When I took this over, there was a single examination, the BPEG certificate of competency. I re-designed the process, developing examinations on devices, electrophysiology and clinical practice. I have also introduced a more robust question setting and validation system with electronic marking. Because of this, I was asked by the European Heart Rhythm Association (EHRA) to develop a similar system for allied professionals.
I am also very proud to have developed an MSc in Cardiac Care at Teesside University in Middlesbrough, UK. I was initially part of a programme developing an MSc in implantable cardiac devices at the University and with the emergence of the arrhythmia nurse role I was involved in setting up an arrhythmia module at Masters’ level. Developing this into an MSc programme took a lot of work and negotiating with the University plus working with colleagues in both the arrhythmia field and in other areas of cardiology to get this off the ground.
You were appointed to lead and develop the electrophysiology unit at The James Cook University Hospital in Middlesbrough, UK. Could you tell us what the key aspects of running a successful electrophysiology unit are?
Without doubt the key to setting up a successful department is appointing the right people who can work together as a team. Running an electrophysiology department requires working with specialist nurses and physiologists as well as physicians and developing a strong team ethic is essential to running a cohesive and successful unit. It is not good enough to appoint individuals, no matter how good they may be academically or practically, if they cannot function as part of the team.
What are the highlights of this year’s Heart Rhythm Congress (HRC)?
This year will be another exciting year at HRC. There will be a high quality faculty with a number of international speakers. The programme has yet to be finalised but will include more interactive sessions and lunchtime teaching.
What are your goals as president-elect of BHRS during your tenure?
The most important goal I have is to cement and develop the relationship between BHRS and Arrhythmia Alliance. Arrhythmia Alliance is the patients’ advocate and we, as physicians and allied professionals, will be stronger as a team working together with Arrhythmia Alliance and I believe this will benefit both organisations.
Over the next few years, financial constraints will determine how arrhythmia services develop within the UK and I believe BHRS needs to engage with the UK’s National Health Service (NHS) to ensure that patients’ needs are addressed and met in this area, particularly with the development of new technology and new indications for device and ablation therapy. This will be a challenging area!
Outside of medicine, what are your interests and hobbies?
I try to keep fit running and walking our giant schnauzers (Archie and Margot) and I look forward to my skiing holiday. I also enjoy reading-mainly fiction-for relaxation. I follow sport and whilst not an avid football supporter in my youth, as my wife is a very keen Liverpool supporter, I have learned the wisdom of following the same team! As with most men and also, I think, in common with many electrophysiologists, I am a keen gadget geek/nerd and have to have the latest Mac, iPad, etc, plus as many accessories as possible in my car.
1978 BSc, (Upper 2nd class honours), Anatomy, Manchester University, Manchester, UK
1981 MB ChB, Manchester University, Manchester, UK
1984 MRCP (UK)
1992 MD, Manchester University, Manchester, UK
1995 Accreditation in Cardiology, RCP London, UK
1987 Squibb Cardiovascular Research Fellowship
2000 Fellowship of the European Society of Cardiology
2001 Fellowship of the Royal College of Physicians
2003 Fellowship of the American College of Cardiology
2011 Fellowship of the Heart Rhythm Society
-2000– Associate clinical lecturer, Teesside Division, Faculty of Medicine, University of Newcastle upon Tyne, UK-
-2004– Visiting fellow, School of Health and Social Studies, University of Teesside, UK
-2005– Executive committee member Arrhythmia Alliance
-2006– Programme director and executive committee member, Heart Rhythm Congress
2006– Chair, BHRS Certification Committee
-2009– Vice-chair, Certification Committee, European Heart Rhythm Association
-2011– Chair, North of England Cardiovascular Network CRM Group
-2013– North East clinical senate representative: Complex Invasive Cardiology Clinical Reference Group
-2013– Co-chair, BHRS Registry and Audit Steering Committee
-2014–2017 President, British Heart Rhythm Society