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As a world-leading Read Full Article authority on adult congenital heart disease kamagra 100mg oral jelly price (ACHD), Professor Michael A. Gatzoulis believes the field is a success story of modern medicine with an ever-increasing number of patients able to reach and enjoy adulthood, including those with complex disease who previously had a guarded prognosis.Yet he also concedes there is still a long way to go to improve the care for this group of patients with life-long disease. In addition to more evidence-based practice for this global disease affecting approximately 1% of new-borns, he advocates a personalized ACHD approach with patient education and empowerment at its heart, and kamagra 100mg oral jelly price better use of technology.A Consultant Cardiologist at the Royal Brompton &.

Harefield NHS Trust in London, and the Academic Head of ACHD and Pulmonary Arterial Hypertension (PAH), his key objective has been Ã¢ÂÂto promote the needs of patients with congenital heart disease, including delivery of best care, translation research, training, and educationÃ¢ÂÂ.Prof. Gatzoulis was born into an Ã¢ÂÂopen-minded and supportiveÃ¢ÂÂ medical family in Drama, a city in the north-east of Greece, where his older brother KonstantinosÃ¢ÂÂcurrently Professor of Cardiology at the University of AthensÃ¢ÂÂand younger sister Thalia (now a successful artist) also studied medicine. His father, Athanasios, was kamagra 100mg oral jelly price a paediatrician.Ã¢ÂÂI was very rebellious as a teenagerÃ¢ÂÂ, he recalled, Ã¢ÂÂmy old friends hardly recognize me nowÃ¢ÂÂ.

Indeed, he failed to enter the Aristotelian University of Thessaloniki at the first attempt but was accepted the following year in 1977. Following graduation and his national service as a soldier and a yearÃ¢ÂÂs provincial service as a young doctor, he left his homeland kamagra 100mg oral jelly price for London in 1987 Ã¢ÂÂfor a new challengeÃ¢ÂÂ, securing a paediatric Senior House Officer role working long hours. ÃÂÂI liked the environment and the responsibility, though in the beginning it was challenging.

For the first few months I was coming home totally exhausted, but it got better, and I have no regretsÃ¢ÂÂ.With an interest in the heart, he felt the natural next step was paediatric cardiology, so he seized the opportunity when consultant paediatric cardiologist Dr Michael Rigby asked him to join the Royal Brompton Hospital in 1992 (Figure 1). Figure 1Royal Brompton Hospital, kamagra 100mg oral jelly price South Block, Circa 1880.Figure 1Royal Brompton Hospital, South Block, Circa 1880.With his PhD mentor there, Prof. Andrew Redington, he began studying the right ventricle (RV) in adult patients with Tetralogy of Fallot, which led to several important publications.Right ventricular diastolic function, he added, was linked for the first time to arrhythmia and propensity to sudden cardiac death, the Ã¢ÂÂmechano-electric conceptÃ¢ÂÂ, which had implications on prognostication and led to a proactive approach towards pulmonary valve replacement (Figure 2).1 Figure 2ECG with broad QRS complex and a CMR of a dilated RV with pulmonary regurgitation (PR).

ECG with broad QRS complex and 1st degree heart block of a patient with kamagra 100mg oral jelly price repaired Tetralogy of Fallot presenting with sustained VT. Note QRS >. 180 ms.

Composite shows cardiac MRI kamagra 100mg oral jelly price from the patient with (A) and (B) moderate to severe pulmonary regurgitation, (C) marked dilatation and some hypertrophy of the right ventricle with secondary tricuspid regurgitation and (D) Right pulmonary artery (RPA) stenosis at the site of a previous BlalockÃ¢ÂÂTaussig Shunt. Patient underwent surgical PV implantation, relief of RPA stenosis, and AICD implantation.Figure 2ECG with broad QRS complex and a CMR of a dilated RV with pulmonary regurgitation (PR). ECG with broad QRS complex and 1st degree heart kamagra 100mg oral jelly price block of a patient with repaired Tetralogy of Fallot presenting with sustained VT.

Note QRS >. 180 ms. Composite shows cardiac MRI from the patient with (A) and (B) moderate to severe pulmonary regurgitation, (C) marked dilatation and some hypertrophy of the right ventricle with secondary tricuspid regurgitation and kamagra 100mg oral jelly price (D) Right pulmonary artery (RPA) stenosis at the site of a previous BlalockÃ¢ÂÂTaussig Shunt.

Patient underwent surgical PV implantation, relief of RPA stenosis, and AICD implantation.Ã¢ÂÂIt was a golden era for paediatric cardiology at the BromptonÃ¢ÂÂ, said Prof. Gatzoulis, Ã¢ÂÂand I could clearly see that ACHD was an area of growth and needÃ¢ÂÂ.Having completed his post-graduate training in London by the end of 1996, and smitten by clinical research, he decided not to go back to Greece but moved instead to Canada to work with Gary kamagra 100mg oral jelly price Webb at the Toronto General Hospital.Returning to London in 1999, he became head of the GUCH (Grown-up CHD) unit at Royal Brompton Hospital, succeeding Prof. Jane Somerville, to run and expand one of the worldÃ¢ÂÂs largest ACHD clinical, training and research programmes.Today, Prof.

Gatzoulis is the academic head of the Adult Congenital Heart Centre and the Centre for Pulmonary Hypertension and clinical lead for ACHD at the Royal Brompton Hospital and a Professor of Cardiology and CHD at the National Heart and Lung Institute, Imperial College, London. Together with his colleagues, he looks after more than 10 000 ACHD and 1000 PAH patients, including those with the greatest disease complexity.Among his kamagra 100mg oral jelly price influences was his father, Ã¢ÂÂan amazing person ahead of his timeÃ¢ÂÂ, who after a successful career as a paediatrician retired at 60 and embarked on a new calling on nature preservation and community work. Prof.

Redington taught him how to conduct and report research, while Dr Webb kamagra 100mg oral jelly price was inspiring with his Ã¢ÂÂinclusivity and painstaking work on databasesÃ¢ÂÂ. But he also reflects on the influence of obstetrician Prof. Phil Steer from the Chelsea &.

Westminster Hospital, kamagra 100mg oral jelly price Ã¢ÂÂfor his patient-centred holistic approach and team building, while maintaining academic rigour and outputÃ¢ÂÂ.Prof. GatzoulisÃ¢ÂÂ research focus has been on mechanisms and prevention of heart failure (HF) and sudden cardiac death in CHD and the treatment of PAH. He said kamagra 100mg oral jelly price.

ÃÂÂWe have improved the outlook for CHD patients a great deal, but for the most part we have not fixed itÃ¢ÂÂ. Prof. Gatzoulis recalls how Prof kamagra 100mg oral jelly price.

Andrew Coats, then head of research at the Royal Brompton, was supportive of his early descriptive work on heart failure markers and exercise intolerance in ACHD, which have now become standard practice (Figure 3). ÃÂÂOur work reinforced that we have not cured CHD and at the same time we have opened new therapeutic opportunitiesÃ¢ÂÂ. Figure 3Heart failure and kamagra 100mg oral jelly price transplantation teams from the Royal Brompton and Harefield NHS Trust at their regular Multi-disciplinary Team (MDT) meeting at the Brompton site.Figure 3Heart failure and transplantation teams from the Royal Brompton and Harefield NHS Trust at their regular Multi-disciplinary Team (MDT) meeting at the Brompton site.The BromptonÃ¢ÂÂs designation as a national centre for ACHD and PAH in 2002 was a significant step forward, delivering greater patient numbers for his team to understand the pathophysiology and try novel therapies.

ÃÂÂPatients with Eisenmenger Syndrome (ES), the extreme end of the CHD-PAH spectrum, were either neglected or mismanaged by dogma and we have done a lot of work on pathophysiology of their condition and advanced therapies (Figure 4), which has transformed their lives and relevant practiceÃ¢ÂÂ. Figure 4Peripheral kamagra 100mg oral jelly price cyanosis in a patient with ES PDA, Graph showing improved 6Ã¢ÂÂminute-walk-distance (MWD) and survival from disease targeting therapy (DTT), Composite Figure. Right panel.

Peripheral cyanosis. Only possible diagnosis is kamagra 100mg oral jelly price a Patent Ductus Arteriosus and Eisenmenger Syndrome (ES. Take the patientÃ¢ÂÂs socks off).

Left panel kamagra 100mg oral jelly price. (A, B) Improvement on pulmonary vascular resistance index (PVRi) and the 6 MWD in patients with ES after 16 weeks of Bosentan therapy versus placebo, BREATHE 5 study, (C) Improvement in symptoms and QoL after 16 weeks of intention to treat patients with ES with iron supplementation and (D) Survival benefit of patients with ES on PAH advanced therapies. From Gatzoulis et al.

IJC 2014, permission granted.Figure 4Peripheral cyanosis in a patient with ES PDA, Graph showing improved kamagra 100mg oral jelly price 6Ã¢ÂÂminute-walk-distance (MWD) and survival from disease targeting therapy (DTT), Composite Figure. Right panel. Peripheral cyanosis kamagra 100mg oral jelly price.

Only possible diagnosis is a Patent Ductus Arteriosus and Eisenmenger Syndrome (ES. Take the patientÃ¢ÂÂs socks off). Left panel kamagra 100mg oral jelly price.

(A, B) Improvement on pulmonary vascular resistance index (PVRi) and the 6 MWD in patients with ES after 16 weeks of Bosentan therapy versus placebo, BREATHE 5 study, (C) Improvement in symptoms and QoL after 16 weeks of intention to treat patients with ES with iron supplementation and (D) Survival benefit of patients with ES on PAH advanced therapies. From Gatzoulis kamagra 100mg oral jelly price et al. IJC 2014, permission granted.

Figure 5Paul Wood Textbook cover Ã¢ÂÂDiseases of the Heart and CirculationÃ¢ÂÂ.Figure 5Paul Wood Textbook cover Ã¢ÂÂDiseases of the Heart and CirculationÃ¢ÂÂ.He believes his original work on pulmonary regurgitation/right ventricular function, with his serendipitous ECG observations, the mechano-electric concept, together with the groundwork on HF and the clinical trials on PAH in the context of CHD, as among his most important.Asked how he thinks his work has advanced the field, Prof. Gatzoulis replied kamagra 100mg oral jelly price. ÃÂÂThere was a major impact from our research on ACHD practice with our proactive approach.

A lot of kamagra 100mg oral jelly price the recent focus of mainstream cardiologyÃ¢ÂÂfor example, the right ventricle, the pulmonary vascular bed, and even transaortic valve implantation (TAVI)Ã¢ÂÂrelate to original research or innovations originating from CHD.Ã¢ÂÂOverall, we have made progress, but we cannot be complacent. There is clearly more to do. More evidence is needed to inform our practice and we must work more collaboratively to achieve this.

CHD is a kamagra 100mg oral jelly price very heterogeneous disease. And we are not doing a good enough job in empowering patients to lead independent and full lives.Ã¢ÂÂNow is the time to move to a more patient-centred, holistic approach, where we are truly the patientÃ¢ÂÂs advocate. Education is central to this and merits further investment.2 Better use of technology, including Artificial Intelligence3 and remote monitoring are also due and have come to the fore due to kamagra 100mg oral jelly price the self-isolation protocols of the erectile dysfunction treatment kamagra'.Prof.

Gatzoulis is particularly proud of the 150+ ACHD Fellows that trained with him at the Brompton. ÃÂÂThe number one asset for me is the patient, but number twoÃ¢ÂÂand close behindÃ¢ÂÂare the Fellows who come to train with us in ACHD. The fact is that I learn from themÃ¢ÂÂand from the patientsÃ¢ÂÂmore than they learn kamagra 100mg oral jelly price from me!.

The ACHD Fellows are now all over the world practising ACHD and I am immensely proud of themÃ¢ÂÂ.A former president of the International Society for Adult Congenital Heart Disease, a council member of the ACHD WG of the ESC, and recipient of multiple awards including the prestigious Aristotle Medal for the Year for Science and Politics (2019), he is the author of over 380 peer-reviewed publications, edited or co-edited 10 cardiology textbooks, is an incoming Deputy Editor of the EHJ, Associate Editor of the International Journal of Cardiology and is launching a new journal with a CHD and PAH focus.A father of two teenage boys, away from medicine he enjoys tennis, watersports and cycling, food markets/cooking/restaurants, museums/arts, and travel.Advice he would give young researchers as they set out on a path toward success within the field is. ÃÂÂPursue your kamagra 100mg oral jelly price dreams and seek the right environment. Work hard and stay close to the patient and to your research, and do not be put off by obstaclesÃ¢ÂÂ.Prof.

Gatzoulis, as one of the leading pioneers, points to future challenges in the Ã¢ÂÂcontinuously evolving cardiovascular subspecialtyÃ¢ÂÂ of ACHD. Understanding better the late course of the kamagra 100mg oral jelly price disease. Optimizing therapies.

Ensuring patient access to tertiary care. Training of kamagra 100mg oral jelly price the new generation of professionals to serve ACHD patients. And securing resources (Figure 5).4Ã¢ÂÂVisionary heads of cardiology always had space for this unique cardiovascular subspecialty for the wealth of its anatomic spectrum, the intriguing physiology, the wonderful clinical signs and the deserving patients.

The examples are multiple, from the late Paul Wood at the Brompton, to Eugene Braunwald in Boston, to Pavlos Toutouzas in Athens and many others.Ã¢ÂÂThe number of adult ACHD patients has long exceeded the kamagra 100mg oral jelly price number of children with CHDÃ¢ÂÂ, he said, Ã¢ÂÂyet the provision of care for the former is lacking. Furthermore, patients and their families have not been educated and empowered enough regarding their CHD, lifestyle issues and outlook and, yet they navigate their lives with a positive attitude, despite uncertainty, multiple operations, and physical disability in some. For me, the patients are the true heroes in this journey, and a daily inspirationÃ¢ÂÂ.

ReferencesReferences are available as supplementary material at European kamagra 100mg oral jelly price Heart Journal online.Conflict of interest. None declared. Published on behalf of the European Society of kamagra 100mg oral jelly price Cardiology.

Journals.permissions@oup.com.Ã¢ÂÂFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This is a Focus Issue on congenital heart disease (CHD). The population of adults with CHD has risen dramatically over the kamagra 100mg oral jelly price last 60 years, in large part due to the success of cardiac surgery and paediatric cardiac care. In most western civilizations, >85% of babies born with CHD can now be expected to survive to adulthood.

Almost 1 in 100 babies are born with CHD, and the adult population of patients in Europe is estimated at 2.3 million and in the USA at >1 million, both outnumbering the paediatric CHD population.1,2 This leads to unique challenges that the surgical and medical community, together with the patients themselves, face.3,4 Some have largely been overcome, while others remain to be solved. In addition, there are unexpected new challenges which have emerged kamagra 100mg oral jelly price. This issue addresses some of these challenges regarding treatment, participation in competitive sports, and advance care planning in adults with congenital heart disease (ACHD).The first contribution is a clinical research article entitled Ã¢ÂÂCurrent use and safety of novel oral anticoagulants in adults with congenital heart disease.

Results of a nationwide analysis including more than 44 000 patientsÃ¢ÂÂ by Gerhard-Paul Diller from the University Hopital MÃÂ¼nster in Germany and colleagues.5 Although the use of novel oral anticoagulants (NOACs) is well established in patients with atrial fibrillation and pulmonary thrombo-embolism,6Ã¢ÂÂ8 kamagra 100mg oral jelly price their value in patients with ACHD is still largely unexplored. The authors evaluated the use of NOACs compared with vitamin K antagonists (VKAs) in ACHD patients and assessed the outcome in a nationwide analysis. Using data from one of GermanyÃ¢ÂÂs largest health insurers, all ACHD patients treated with VKAs or NOACs were identified and changes in prescription patterns assessed.

Furthermore, the association between anticoagulation regimen and complications including kamagra 100mg oral jelly price mortality was studied. About 44 000 ACHD patients were included. Between 2005 and 2018, the use of oral anticoagulants in kamagra 100mg oral jelly price those with ACHD increased from 6.3% to 12.4%.

Since NOACs became available their utilization has increased continually, accounting for 45% of prescribed anticoagulants in ACHD patients in 2018. ACHD patients on NOACs had higher thrombo-embolic events (3.8% vs. 2.8%), major kamagra 100mg oral jelly price cardiovascular events (7.8% vs.

6.0%), bleeding rates (11.7% vs. 9.0%), and kamagra 100mg oral jelly price all-cause mortality (4.0% vs. 2.8%.

All P <. 0.05) after 1 year of kamagra 100mg oral jelly price therapy compared with VKAs. After comprehensive adjustment for patient characteristics, NOACs were still associated with increased risk of major cardiovascular events [hazard ratio (HR) 1.22] and increased all-cause mortality (HR 1.43) during long-term follow-up (Figure 1).

Figure 1Upper panel kamagra 100mg oral jelly price. Increased use of (novel) oral anticoagulants in adults with congenital heart disease over time. The figure displays the annual prescription of vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs) in adults with congenital heart disease (ACHD) patients between 2005 and 2018 covering 521 493 patient-years in a total cohort size of n = 44 097 ACHD patients.

The proportion of ACHD patients on oral anticoagulation increased from 6.3% in 2005 to kamagra 100mg oral jelly price 12.8% in 2018. Vitamin K antagonists were supplemented but also increasingly replaced by novel oral anticoagulants, with the latter accounting for 45% of all oral anticoagulants prescribed in 2018. The numbers over the bars represent the proportion of ACHD patients on oral anticoagulation during the respective year, while the white numbers represent the percentage of anticoagulated patients receiving novel oral anticoagulants.

Lower panel kamagra 100mg oral jelly price. Results of the adjusted multivariable time-dependent Cox regression analysis. The figure illustrates vitamin K antagonists were superior to novel oral anticoagulants regarding all-cause mortality, major adverse cardiovascular events and bleeding, whereas no statistical difference could be established for thromboembolic events (from Freisinger E, GerÃÂ² J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe kamagra 100mg oral jelly price J, Diller G-P.

Current use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a nationwide analysis including more than 44 000 patients. See pages 4168Ã¢ÂÂ4177).Figure 1Upper kamagra 100mg oral jelly price panel.

Increased use of (novel) oral anticoagulants in adults with congenital heart disease over time. The figure displays the annual prescription of vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs) in adults with congenital heart disease (ACHD) patients between 2005 and 2018 covering 521 493 patient-years in a total cohort size of n = 44 kamagra 100mg oral jelly price 097 ACHD patients. The proportion of ACHD patients on oral anticoagulation increased from 6.3% in 2005 to 12.8% in 2018.

Vitamin K antagonists were supplemented but also increasingly replaced by novel oral anticoagulants, with the latter accounting for 45% of all oral anticoagulants prescribed in 2018. The numbers over the bars represent the proportion of ACHD patients kamagra 100mg oral jelly price on oral anticoagulation during the respective year, while the white numbers represent the percentage of anticoagulated patients receiving novel oral anticoagulants. Lower panel.

Results of the adjusted kamagra 100mg oral jelly price multivariable time-dependent Cox regression analysis. The figure illustrates vitamin K antagonists were superior to novel oral anticoagulants regarding all-cause mortality, major adverse cardiovascular events and bleeding, whereas no statistical difference could be established for thromboembolic events (from Freisinger E, GerÃÂ² J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe J, Diller G-P. Current use and safety of novel oral anticoagulants in adults with congenital heart disease.

Results of a nationwide analysis including more than 44 kamagra 100mg oral jelly price 000 patients. See pages 4168Ã¢ÂÂ4177).The authors conclude that despite the lack of prospective studies in ACHD patients, NOACs are increasingly replacing VKAs and now account for almost half of all oral anticoagulant prescriptions. In particularly, NOACs were associated with excess long-term risk of major cardiovascular events and mortality in this nationwide analysis, emphasizing the need for prospective studies before kamagra 100mg oral jelly price solid recommendations for their use in ACHD patients can be provided.

The manuscript is accompanied by an Editorial by Frans Van de Werf from KU Leuven in Belgium and colleagues.9 They note that while awaiting the results of controlled studies, it is wise to use VKAs as the standard anticoagulant therapy in ACHD patients and consider NOACs for selected cases after consultation with a multidisciplinary team. Figure 2Event free survival. Time = 0 refers to the kamagra 100mg oral jelly price date of randomization.

The dotted line indicates the end of the initial COMPARE trial period. CI, confidence kamagra 100mg oral jelly price interval. HR, hazard ratio (from van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M.

Long-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre randomized controlled kamagra 100mg oral jelly price COMPARE trial. See pages 4181Ã¢ÂÂ4187).Figure 2Event free survival.

Time = 0 refers to the date of randomization kamagra 100mg oral jelly price. The dotted line indicates the end of the initial COMPARE trial period. CI, confidence interval.

HR, hazard ratio (from van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, kamagra 100mg oral jelly price de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre randomized kamagra 100mg oral jelly price controlled COMPARE trial.

See pages 4181Ã¢ÂÂ4187).The COMPARE trial showed a small but significant beneficial effect of 3-year losartan treatment on aortic root dilatation rate in adults with Marfan syndrome (MFS).10 However, no significant effect was found on clinical endpoints, possibly due to a short follow-up period. In a clinical research manuscript entitled Ã¢ÂÂLong-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre randomized controlled COMPARE trialÃ¢ÂÂ, kamagra 100mg oral jelly price Mitzi van Andel from the University of Amsterdam in the Netherlands and colleagues investigate the long-term clinical outcomes after losartan treatment.11 In the original COMPARE study (inclusion 2008Ã¢ÂÂ2009), 233 adult patients with MFS were randomly allocated to either the angiotensin II receptor blocker losartan on top of regular treatment (beta-blockers in 71% of the patients) or no additional medication.

After the COMPARE trial period of 3 years, study subjects chose to continue their losartan medication or not. In a median follow-up period of 8 years, 75 patients continued losartan medication, whereas 78 patients, originally allocated to the control group, never used losartan after inclusion. No differences existed between baseline characteristics of the two groups except for age at inclusion and kamagra 100mg oral jelly price beta-blocker use (losartan 81%, control 64%).

Clinical endpoints, defined as all-cause mortality, aortic dissection/rupture, elective aortic root replacement, reoperation, and vascular graft implantation beyond the aortic root, were compared between the two groups. A per patient composite endpoint kamagra 100mg oral jelly price was also analysed. Patients who used losartan during the entire follow-up period showed a reduced number of events compared with the control group and exhibited a significantly lower number of deaths (0 vs.

5) and aortic dissections (3 vs. 11). They also experienced a non-significant lower number of elective aortic root replacement (10 vs.

13), reoperation (1 vs. 2), and vascular graft implantation beyond the aortic root (0 vs. 3) (Figure 2).

These results remained similar when corrected for age and beta-blocker use in a multivariate analysis.Van Andel et al. Conclude that these results suggest a clinical benefit of combined losartan and beta-blocker treatment in patients with MFS. The manuscript is accompanied by an Editorial by Guillaume Jondeau from the HÃÂ´pital Bichat in Paris, France.12 Jondeau and colleagues hope that a forthcoming meta-analysis combining all of the randomized studies already published or unpublished will confirm the early results of this study.The issue continues with the Special Article Ã¢ÂÂRecommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD).

Position statement of the Sport Cardiology &. Exercise Section of the European Association of Preventive Cardiology (EAPC), The European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease, and the Sports Cardiology, Physical Activity and Prevention Working Group of The Association for European Paediatric and Congenital Cardiology (AEPC)Ã¢ÂÂ by Werner Budts from the Catholic University Leuven in Belgium and colleagues.13 The authors note that improved clinical care has led to an increase in the number of ACHD patients engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with ACHD are well established, there is a low but appreciable risk of exercise-related complications.

The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with ACHD who wish to participate in competitive sports.Finally, this issue also contains the Special Article Ã¢ÂÂRecommendations for advance care planning in adults with congenital heart disease. A position paper from the ESC Working Group of Adult Congenital Heart Disease, the Association of Cardiovascular Nursing and Allied Professions (ACNAP), the European Association for Palliative Care (EAPC), and the International Society for Adult Congenital Heart Disease (ISACHD)Ã¢ÂÂ by Markus Schwerzmann from the University of Bern in Switzerland and colleagues.14 The authors remind us that survival prospects in ACHD, although improved in recent decades, still remain below expectations for the general population. Patients and their loved ones benefit from preparation for both unexpected and predictable deaths, sometimes preceded by a prolonged period of declining health.

Hence, advance care planning (ACP) is an integral part of comprehensive care in those with ACHD. This position paper summarizes evidence regarding benefits of and patientsÃ¢ÂÂ preferences for ACP and provides practical advice regarding the implementation of ACP processes within clinical ACHD practice. They suggest that ACP be delivered as a structured process across different stages, with content dependent upon the anticipated disease progression.

They also acknowledge potential barriers to initiate ACP discussions and emphasize the importance of a sensitive and situation-specific communication style. Conclusions presented in this paper reflect agreed expert opinions, and include both patient and provider perspectives.The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Warnes CA.

Adult congenital heart disease. The challenges of a lifetime. Eur Heart J 2017;38:2041Ã¢ÂÂ2047.2Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, Lung B, Kluin J, Lang IM, Meijboom F, Moons P, Mulder BJM, Oechslin E, Roos-Hesselink JW, Schwerzmann M, Sondergaard L, Zeppenfeld K.

2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J 2020;doi.org/10.1093/eurheartj/ehaa554.3Baumgartner H, Budts W, Chessa M, Deanfield J, Eicken A, Holm J, Iserin L, Meijboom F, Stein J, Szatmari A, Trindade PT, Walker F. Recommendations for organization of care for adults with congenital heart disease and for training in the subspecialty of Ã¢ÂÂGrown-up Congenital Heart DiseaseÃ¢ÂÂ in Europe.

A position paper of the Working Group on Grown-up Congenital Heart Disease of the European Society of Cardiology. Eur Heart J 2014;35:686Ã¢ÂÂ690.4Moons P, Meijboom FJ, Baumgartner H, Trindade PT, Huyghe E, Kaemmerer H. Structure and activities of adult congenital heart disease programmes in Europe.

Eur Heart J 2010;31:1305Ã¢ÂÂ1310.5Freisinger E, GerÃÂ J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe J, Diller G-P. Current use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a nationwide analysis including more than 44 000 patients.

Eur Heart J 2017;38:2137Ã¢ÂÂ2149.7Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, BlomstrÃÂ¶m-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;41:XXXÃ¢ÂÂXXX.8Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, JimÃÂ©nez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, F NÃÂ, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL.

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543Ã¢ÂÂ603.9Verhamme P, Budts W, Van de Werf F. Non-vitamin K oral anticoagulants in adults with congenital heart disease.

Quod non?. Eur Heart J 2020;41:4178Ã¢ÂÂ4180.10Groenink M, den Hartog AW, Franken R, Radonic T, de Waard V, Timmermans J, Scholte AJ, van den Berg MP, Spijkerboer AM, Marquering HA, Zwinderman AH, Mulder BJ. Losartan reduces aortic dilatation rate in adults with Marfan syndrome.

A randomized controlled trial. Eur Heart J 2013;34:3491Ã¢ÂÂ3500.11van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome.

Follow-up of the multicentre randomized controlled COMPARE trial. Eur Heart J 2020;41:4181Ã¢ÂÂ4187.12Jondeau G, Milleron O, Boileau C. Marfan sartan saga, episode X.

Eur Heart J 2020;41:4188Ã¢ÂÂ4190.13Budts W, Pieles GE, Roos-Hesselink JW, Sanz de la Garza M, DÃ¢ÂÂAscenzi F, Giannakoulas G, MÃÂ¼ller J, Oberhoffer R, Ehringer-Schetitska D, Herceg-Cavrak V, Gabriel H, Corrado D, van Buuren F, Niebauer J, BÃÂ¶rjesson M, Caselli S, Fritsch P, Pelliccia A, Heidbuchel H, Sharma S, Stuart AG, Papadakis M. Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD). Position statement of the Sports Cardiology &.

Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2020;41:4191Ã¢ÂÂ4199.14Schwerzmann M, Goossens E, Galle go P, Kovacs AH, Moons P, Swan L, Tobler D, de Stoutz N, Gabriel H, Greutmann M, Roos-Hesselink JW, Sobanski PZ, Thomet C. Recommendations for advance care planning in adults with congenital heart disease.

As a world-leading authority on adult congenital heart disease (ACHD), Professor kamagra tablet online Michael A. Gatzoulis believes the field is a success story of modern medicine with an ever-increasing number of patients able to reach and enjoy adulthood, including those with complex disease who previously had a guarded prognosis.Yet he also concedes there is still a long way to go to improve the care for this group of patients with life-long disease. In addition to more evidence-based practice for this global disease affecting approximately 1% of new-borns, he kamagra tablet online advocates a personalized ACHD approach with patient education and empowerment at its heart, and better use of technology.A Consultant Cardiologist at the Royal Brompton &. Harefield NHS Trust in London, and the Academic Head of ACHD and Pulmonary Arterial Hypertension (PAH), his key objective has been Ã¢ÂÂto promote the needs of patients with congenital heart disease, including delivery of best care, translation research, training, and educationÃ¢ÂÂ.Prof.

Gatzoulis was born into an Ã¢ÂÂopen-minded and supportiveÃ¢ÂÂ medical family in Drama, a city in the north-east of Greece, where his older brother KonstantinosÃ¢ÂÂcurrently Professor of Cardiology at the University of AthensÃ¢ÂÂand younger sister Thalia (now a successful artist) also studied medicine. His father, Athanasios, was a paediatrician.Ã¢ÂÂI was very rebellious as a teenagerÃ¢ÂÂ, kamagra tablet online he recalled, Ã¢ÂÂmy old friends hardly recognize me nowÃ¢ÂÂ. Indeed, he failed to enter the Aristotelian University of Thessaloniki at the first attempt but was accepted the following year in 1977. Following graduation and his national service as a soldier and a yearÃ¢ÂÂs provincial service as a young doctor, he left his homeland for London in 1987 Ã¢ÂÂfor a new challengeÃ¢ÂÂ, securing a paediatric kamagra tablet online Senior House Officer role working long hours.

ÃÂÂI liked the environment and the responsibility, though in the beginning it was challenging. For the first few months I was coming home totally exhausted, but it got better, and I have no regretsÃ¢ÂÂ.With an interest in the heart, he felt the natural next step was paediatric cardiology, so he seized the opportunity when consultant paediatric cardiologist Dr Michael Rigby asked him to join the Royal Brompton Hospital in 1992 (Figure 1). Figure 1Royal Brompton Hospital, South Block, Circa kamagra tablet online 1880.Figure 1Royal Brompton Hospital, South Block, Circa 1880.With his PhD mentor there, Prof. Andrew Redington, he began studying the right ventricle (RV) in adult patients with Tetralogy of Fallot, which led to several important publications.Right ventricular diastolic function, he added, was linked for the first time to arrhythmia and propensity to sudden cardiac death, the Ã¢ÂÂmechano-electric conceptÃ¢ÂÂ, which had implications on prognostication and led to a proactive approach towards pulmonary valve replacement (Figure 2).1 Figure 2ECG with broad QRS complex and a CMR of a dilated RV with pulmonary regurgitation (PR).

ECG with broad QRS complex and 1st degree heart block of a patient with repaired kamagra tablet online Tetralogy of Fallot presenting with sustained VT. Note QRS >. 180 ms. Composite shows cardiac MRI from the patient with (A) and (B) moderate to severe pulmonary regurgitation, (C) marked dilatation and some hypertrophy of the right ventricle with secondary tricuspid regurgitation and (D) kamagra tablet online Right pulmonary artery (RPA) stenosis at the site of a previous BlalockÃ¢ÂÂTaussig Shunt.

Patient underwent surgical PV implantation, relief of RPA stenosis, and AICD implantation.Figure 2ECG with broad QRS complex and a CMR of a dilated RV with pulmonary regurgitation (PR). ECG with broad QRS kamagra tablet online complex and 1st degree heart block of a patient with repaired Tetralogy of Fallot presenting with sustained VT. Note QRS >. 180 ms.

Composite shows cardiac MRI from the patient with (A) and (B) kamagra tablet online moderate to severe pulmonary regurgitation, (C) marked dilatation and some hypertrophy of the right ventricle with secondary tricuspid regurgitation and (D) Right pulmonary artery (RPA) stenosis at the site of a previous BlalockÃ¢ÂÂTaussig Shunt. Patient underwent surgical PV implantation, relief of RPA stenosis, and AICD implantation.Ã¢ÂÂIt was a golden era for paediatric cardiology at the BromptonÃ¢ÂÂ, said Prof. Gatzoulis, Ã¢ÂÂand I could clearly see that ACHD was an area of growth and needÃ¢ÂÂ.Having completed his post-graduate training in London by the end of 1996, and smitten by clinical research, he decided not to go back to Greece but moved instead to Canada to work with Gary Webb at the Toronto General Hospital.Returning to London kamagra tablet online in 1999, he became head of the GUCH (Grown-up CHD) unit at Royal Brompton Hospital, succeeding Prof. Jane Somerville, to run and expand one of the worldÃ¢ÂÂs largest ACHD clinical, training and research programmes.Today, Prof.

Gatzoulis is the academic head of the Adult Congenital Heart Centre and the Centre for Pulmonary Hypertension and clinical lead for ACHD at the Royal Brompton Hospital and a Professor of Cardiology and CHD at the National Heart and Lung Institute, Imperial College, London. Together with his colleagues, he looks after more than 10 000 ACHD and 1000 PAH patients, including those with the greatest disease complexity.Among his influences was his father, Ã¢ÂÂan amazing person ahead of his timeÃ¢ÂÂ, who after a successful career as kamagra tablet online a paediatrician retired at 60 and embarked on a new calling on nature preservation and community work. Prof. Redington taught him how to conduct and report research, while Dr Webb was inspiring with kamagra tablet online his Ã¢ÂÂinclusivity and painstaking work on databasesÃ¢ÂÂ.

But he also reflects on the influence of obstetrician Prof. Phil Steer from the Chelsea &. Westminster Hospital, Ã¢ÂÂfor his patient-centred holistic approach and team kamagra tablet online building, while maintaining academic rigour and outputÃ¢ÂÂ.Prof. GatzoulisÃ¢ÂÂ research focus has been on mechanisms and prevention of heart failure (HF) and sudden cardiac death in CHD and the treatment of PAH.

He said kamagra tablet online. ÃÂÂWe have improved the outlook for CHD patients a great deal, but for the most part we have not fixed itÃ¢ÂÂ. Prof. Gatzoulis recalls kamagra tablet online how Prof.

Andrew Coats, then head of research at the Royal Brompton, was supportive of his early descriptive work on heart failure markers and exercise intolerance in ACHD, which have now become standard practice (Figure 3). ÃÂÂOur work reinforced that we have not cured CHD and at the same time we have opened new therapeutic opportunitiesÃ¢ÂÂ. Figure 3Heart failure and transplantation teams from the Royal Brompton and Harefield NHS Trust at their regular Multi-disciplinary Team (MDT) meeting at the Brompton site.Figure 3Heart failure and transplantation teams from the Royal Brompton and Harefield NHS Trust at their regular Multi-disciplinary Team (MDT) meeting at the Brompton site.The kamagra tablet online BromptonÃ¢ÂÂs designation as a national centre for ACHD and PAH in 2002 was a significant step forward, delivering greater patient numbers for his team to understand the pathophysiology and try novel therapies. ÃÂÂPatients with Eisenmenger Syndrome (ES), the extreme end of the CHD-PAH spectrum, were either neglected or mismanaged by dogma and we have done a lot of work on pathophysiology of their condition and advanced therapies (Figure 4), which has transformed their lives and relevant practiceÃ¢ÂÂ.

Figure 4Peripheral cyanosis in a patient with ES PDA, Graph kamagra tablet online showing improved 6Ã¢ÂÂminute-walk-distance (MWD) and survival from disease targeting therapy (DTT), Composite Figure. Right panel. Peripheral cyanosis. Only possible diagnosis is a Patent Ductus Arteriosus kamagra tablet online and Eisenmenger Syndrome (ES.

Take the patientÃ¢ÂÂs socks off). Left panel kamagra tablet online. (A, B) Improvement on pulmonary vascular resistance index (PVRi) and the 6 MWD in patients with ES after 16 weeks of Bosentan therapy versus placebo, BREATHE 5 study, (C) Improvement in symptoms and QoL after 16 weeks of intention to treat patients with ES with iron supplementation and (D) Survival benefit of patients with ES on PAH advanced therapies. From Gatzoulis et al.

IJC 2014, permission granted.Figure 4Peripheral cyanosis in a patient with ES PDA, Graph showing improved 6Ã¢ÂÂminute-walk-distance (MWD) and survival from disease targeting therapy (DTT), Composite Figure kamagra tablet online. Right panel. Peripheral cyanosis kamagra tablet online. Only possible diagnosis is a Patent Ductus Arteriosus and Eisenmenger Syndrome (ES.

Take the patientÃ¢ÂÂs socks off). Left panel kamagra tablet online. (A, B) Improvement on pulmonary vascular resistance index (PVRi) and the 6 MWD in patients with ES after 16 weeks of Bosentan therapy versus placebo, BREATHE 5 study, (C) Improvement in symptoms and QoL after 16 weeks of intention to treat patients with ES with iron supplementation and (D) Survival benefit of patients with ES on PAH advanced therapies. From Gatzoulis kamagra tablet online et al.

IJC 2014, permission granted. Figure 5Paul Wood Textbook cover Ã¢ÂÂDiseases of the Heart and CirculationÃ¢ÂÂ.Figure 5Paul Wood Textbook cover Ã¢ÂÂDiseases of the Heart and CirculationÃ¢ÂÂ.He believes his original work on pulmonary regurgitation/right ventricular function, with his serendipitous ECG observations, the mechano-electric concept, together with the groundwork on HF and the clinical trials on PAH in the context of CHD, as among his most important.Asked how he thinks his work has advanced the field, Prof. Gatzoulis replied kamagra tablet online. ÃÂÂThere was a major impact from our research on ACHD practice with our proactive approach.

A lot of the recent focus of mainstream cardiologyÃ¢ÂÂfor example, the right ventricle, the pulmonary vascular bed, and kamagra tablet online even transaortic valve implantation (TAVI)Ã¢ÂÂrelate to original research or innovations originating from CHD.Ã¢ÂÂOverall, we have made progress, but we cannot be complacent. There is clearly more to do. More evidence is needed to inform our practice and we must work more collaboratively to achieve this. CHD is a kamagra tablet online very heterogeneous disease.

And we are not doing a good enough job in empowering patients to lead independent and full lives.Ã¢ÂÂNow is the time to move to a more patient-centred, holistic approach, where we are truly the patientÃ¢ÂÂs advocate. Education is central to this and merits further kamagra tablet online investment.2 Better use of technology, including Artificial Intelligence3 and remote monitoring are also due and have come to the fore due to the self-isolation protocols of the erectile dysfunction treatment kamagra'.Prof. Gatzoulis is particularly proud of the 150+ ACHD Fellows that trained with him at the Brompton. ÃÂÂThe number one asset for me is the patient, but number twoÃ¢ÂÂand close behindÃ¢ÂÂare the Fellows who come to train with us in ACHD.

The fact is that I learn from themÃ¢ÂÂand from kamagra tablet online the patientsÃ¢ÂÂmore than they learn from me!. The ACHD Fellows are now all over the world practising ACHD and I am immensely proud of themÃ¢ÂÂ.A former president of the International Society for Adult Congenital Heart Disease, a council member of the ACHD WG of the ESC, and recipient of multiple awards including the prestigious Aristotle Medal for the Year for Science and Politics (2019), he is the author of over 380 peer-reviewed publications, edited or co-edited 10 cardiology textbooks, is an incoming Deputy Editor of the EHJ, Associate Editor of the International Journal of Cardiology and is launching a new journal with a CHD and PAH focus.A father of two teenage boys, away from medicine he enjoys tennis, watersports and cycling, food markets/cooking/restaurants, museums/arts, and travel.Advice he would give young researchers as they set out on a path toward success within the field is. ÃÂÂPursue your kamagra tablet online dreams and seek the right environment. Work hard and stay close to the patient and to your research, and do not be put off by obstaclesÃ¢ÂÂ.Prof.

Gatzoulis, as one of the leading pioneers, points to future challenges in the Ã¢ÂÂcontinuously evolving cardiovascular subspecialtyÃ¢ÂÂ of ACHD. Understanding better the late course of the disease kamagra tablet online. Optimizing therapies. Ensuring patient access to tertiary care.

Training of the new generation of kamagra tablet online professionals to serve ACHD patients. And securing resources (Figure 5).4Ã¢ÂÂVisionary heads of cardiology always had space for this unique cardiovascular subspecialty for the wealth of its anatomic spectrum, the intriguing physiology, the wonderful clinical signs and the deserving patients. The examples are multiple, from the late Paul Wood at the Brompton, to Eugene Braunwald in Boston, to Pavlos Toutouzas in Athens and many others.Ã¢ÂÂThe number of adult ACHD patients kamagra tablet online has long exceeded the number of children with CHDÃ¢ÂÂ, he said, Ã¢ÂÂyet the provision of care for the former is lacking. Furthermore, patients and their families have not been educated and empowered enough regarding their CHD, lifestyle issues and outlook and, yet they navigate their lives with a positive attitude, despite uncertainty, multiple operations, and physical disability in some.

For me, the patients are the true heroes in this journey, and a daily inspirationÃ¢ÂÂ. ReferencesReferences are available as supplementary material at European kamagra tablet online Heart Journal online.Conflict of interest. None declared. Published on kamagra tablet online behalf of the European Society of Cardiology.

All rights reserved. ÃÂ© The Author(s) 2020. For permissions, please kamagra tablet online email. Journals.permissions@oup.com.Ã¢ÂÂFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This is a Focus Issue on congenital heart disease (CHD).

The population of adults with CHD has risen dramatically over the last kamagra tablet online 60 years, in large part due to the success of cardiac surgery and paediatric cardiac care. In most western civilizations, >85% of babies born with CHD can now be expected to survive to adulthood. Almost 1 in 100 babies are born with CHD, and the adult population of patients in Europe is estimated at 2.3 million and in the USA at >1 million, both outnumbering the paediatric CHD population.1,2 This leads to unique challenges that the surgical and medical community, together with the patients themselves, face.3,4 Some have largely been overcome, while others remain to be solved. In addition, there kamagra tablet online are unexpected new challenges which have emerged.

This issue addresses some of these challenges regarding treatment, participation in competitive sports, and advance care planning in adults with congenital heart disease (ACHD).The first contribution is a clinical research article entitled Ã¢ÂÂCurrent use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a nationwide analysis including more than 44 000 patientsÃ¢ÂÂ by Gerhard-Paul Diller from the University Hopital MÃÂ¼nster in Germany and colleagues.5 Although the use of novel oral anticoagulants (NOACs) is well established in patients kamagra tablet online with atrial fibrillation and pulmonary thrombo-embolism,6Ã¢ÂÂ8 their value in patients with ACHD is still largely unexplored. The authors evaluated the use of NOACs compared with vitamin K antagonists (VKAs) in ACHD patients and assessed the outcome in a nationwide analysis. Using data from one of GermanyÃ¢ÂÂs largest health insurers, all ACHD patients treated with VKAs or NOACs were identified and changes in prescription patterns assessed.

Furthermore, the association between anticoagulation regimen and complications kamagra tablet online including mortality was studied. About 44 000 ACHD patients were included. Between 2005 and 2018, the use of oral anticoagulants in those with ACHD increased from 6.3% to kamagra tablet online 12.4%. Since NOACs became available their utilization has increased continually, accounting for 45% of prescribed anticoagulants in ACHD patients in 2018.

ACHD patients on NOACs had higher thrombo-embolic events (3.8% vs. 2.8%), major cardiovascular events (7.8% vs kamagra tablet online. 6.0%), bleeding rates (11.7% vs. 9.0%), and all-cause kamagra tablet online mortality (4.0% vs.

2.8%. All P <. 0.05) after 1 kamagra tablet online year of therapy compared with VKAs. After comprehensive adjustment for patient characteristics, NOACs were still associated with increased risk of major cardiovascular events [hazard ratio (HR) 1.22] and increased all-cause mortality (HR 1.43) during long-term follow-up (Figure 1).

Figure 1Upper kamagra tablet online panel. Increased use of (novel) oral anticoagulants in adults with congenital heart disease over time. The figure displays the annual prescription of vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs) in adults with congenital heart disease (ACHD) patients between 2005 and 2018 covering 521 493 patient-years in a total cohort size of n = 44 097 ACHD patients. The proportion of ACHD patients on oral anticoagulation increased from 6.3% in 2005 to 12.8% in 2018 kamagra tablet online.

Vitamin K antagonists were supplemented but also increasingly replaced by novel oral anticoagulants, with the latter accounting for 45% of all oral anticoagulants prescribed in 2018. The numbers over the bars represent the proportion of ACHD patients on oral anticoagulation during the respective year, while the white numbers represent the percentage of anticoagulated patients receiving novel oral anticoagulants. Lower panel kamagra tablet online. Results of the adjusted multivariable time-dependent Cox regression analysis.

The figure illustrates vitamin K antagonists were superior to novel oral anticoagulants regarding all-cause mortality, major adverse cardiovascular events and bleeding, whereas no statistical difference could be established for thromboembolic events (from Freisinger E, GerÃÂ² J, Makowski L, Marschall U, Reinecke H, Baumgartner H, kamagra tablet online Koeppe J, Diller G-P. Current use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a nationwide analysis including more than 44 000 patients. See pages kamagra tablet online 4168Ã¢ÂÂ4177).Figure 1Upper panel.

Increased use of (novel) oral anticoagulants in adults with congenital heart disease over time. The figure displays the annual prescription of vitamin K antagonists (VKAs) and novel kamagra tablet online oral anticoagulants (NOACs) in adults with congenital heart disease (ACHD) patients between 2005 and 2018 covering 521 493 patient-years in a total cohort size of n = 44 097 ACHD patients. The proportion of ACHD patients on oral anticoagulation increased from 6.3% in 2005 to 12.8% in 2018. Vitamin K antagonists were supplemented but also increasingly replaced by novel oral anticoagulants, with the latter accounting for 45% of all oral anticoagulants prescribed in 2018.

The numbers over the bars represent the proportion of ACHD patients on oral anticoagulation during the respective year, while the white numbers represent the percentage of anticoagulated patients receiving kamagra tablet online novel oral anticoagulants. Lower panel. Results of the adjusted multivariable time-dependent Cox regression analysis kamagra tablet online. The figure illustrates vitamin K antagonists were superior to novel oral anticoagulants regarding all-cause mortality, major adverse cardiovascular events and bleeding, whereas no statistical difference could be established for thromboembolic events (from Freisinger E, GerÃÂ² J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe J, Diller G-P.

Current use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a kamagra tablet online nationwide analysis including more than 44 000 patients. See pages 4168Ã¢ÂÂ4177).The authors conclude that despite the lack of prospective studies in ACHD patients, NOACs are increasingly replacing VKAs and now account for almost half of all oral anticoagulant prescriptions. In particularly, kamagra tablet online NOACs were associated with excess long-term risk of major cardiovascular events and mortality in this nationwide analysis, emphasizing the need for prospective studies before solid recommendations for their use in ACHD patients can be provided.

The manuscript is accompanied by an Editorial by Frans Van de Werf from KU Leuven in Belgium and colleagues.9 They note that while awaiting the results of controlled studies, it is wise to use VKAs as the standard anticoagulant therapy in ACHD patients and consider NOACs for selected cases after consultation with a multidisciplinary team. Figure 2Event free survival. Time = 0 refers to the date kamagra tablet online of randomization. The dotted line indicates the end of the initial COMPARE trial period.

CI, confidence kamagra tablet online interval. HR, hazard ratio (from van Andel MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre kamagra tablet online randomized controlled COMPARE trial.

See pages 4181Ã¢ÂÂ4187).Figure 2Event free survival. Time = 0 refers to the date of randomization kamagra tablet online. The dotted line indicates the end of the initial COMPARE trial period. CI, confidence interval.

HR, hazard ratio (from van Andel kamagra tablet online MM, Indrakusuma R, Jalalzadeh H, Balm R, Timmermans J, Scholte AJ, van den Berg MP, Zwinderman AH, Mulder BJM, de Waard V, Groenink M. Long-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre randomized kamagra tablet online controlled COMPARE trial. See pages 4181Ã¢ÂÂ4187).The COMPARE trial showed a small but significant beneficial effect of 3-year losartan treatment on aortic root dilatation rate in adults with Marfan syndrome (MFS).10 However, no significant effect was found on clinical endpoints, possibly due to a short follow-up period.

In a clinical research manuscript entitled Ã¢ÂÂLong-term clinical outcomes of losartan in patients with Marfan syndrome. Follow-up of the multicentre randomized controlled COMPARE trialÃ¢ÂÂ, Mitzi van Andel from the University of Amsterdam in the Netherlands and colleagues investigate the long-term clinical outcomes after losartan treatment.11 In the original COMPARE study (inclusion 2008Ã¢ÂÂ2009), 233 adult patients with MFS were randomly allocated to either the angiotensin II receptor blocker losartan on top of regular treatment (beta-blockers kamagra tablet online in 71% of the patients) or no additional medication. After the COMPARE trial period of 3 years, study subjects chose to continue their losartan medication or not. In a median follow-up period of 8 years, 75 patients continued losartan medication, whereas 78 patients, originally allocated to the control group, never used losartan after inclusion.

No differences existed between baseline characteristics of the two groups except for age at inclusion and beta-blocker kamagra tablet online use (losartan 81%, control 64%). Clinical endpoints, defined as all-cause mortality, aortic dissection/rupture, elective aortic root replacement, reoperation, and vascular graft implantation beyond the aortic root, were compared between the two groups. A per kamagra tablet online patient composite endpoint was also analysed. Patients who used losartan during the entire follow-up period showed a reduced number of events compared with the control group and exhibited a significantly lower number of deaths (0 vs.

5) and aortic dissections (3 vs. 11). They also experienced a non-significant lower number of elective aortic root replacement (10 vs. 13), reoperation (1 vs.

2), and vascular graft implantation beyond the aortic root (0 vs. 3) (Figure 2). These results remained similar when corrected for age and beta-blocker use in a multivariate analysis.Van Andel et al. Conclude that these results suggest a clinical benefit of combined losartan and beta-blocker treatment in patients with MFS.

The manuscript is accompanied by an Editorial by Guillaume Jondeau from the HÃÂ´pital Bichat in Paris, France.12 Jondeau and colleagues hope that a forthcoming meta-analysis combining all of the randomized studies already published or unpublished will confirm the early results of this study.The issue continues with the Special Article Ã¢ÂÂRecommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD). Position statement of the Sport Cardiology &. Exercise Section of the European Association of Preventive Cardiology (EAPC), The European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease, and the Sports Cardiology, Physical Activity and Prevention Working Group of The Association for European Paediatric and Congenital Cardiology (AEPC)Ã¢ÂÂ by Werner Budts from the Catholic University Leuven in Belgium and colleagues.13 The authors note that improved clinical care has led to an increase in the number of ACHD patients engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with ACHD are well established, there is a low but appreciable risk of exercise-related complications.

Published exercise recommendations for individuals with ACHD are predominantly centred on anatomic lesions, hampering an individualized approach to exercise advice in this heterogeneous population. This document presents an update of the recommendations for competitive sports participation in athletes with cardiovascular disease. It introduces an approach which is based on assessment of haemodynamic, electrophysiological, and functional parameters, rather than anatomical lesions. The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with ACHD who wish to participate in competitive sports.Finally, this issue also contains the Special Article Ã¢ÂÂRecommendations for advance care planning in adults with congenital heart disease.

A position paper from the ESC Working Group of Adult Congenital Heart Disease, the Association of Cardiovascular Nursing and Allied Professions (ACNAP), the European Association for Palliative Care (EAPC), and the International Society for Adult Congenital Heart Disease (ISACHD)Ã¢ÂÂ by Markus Schwerzmann from the University of Bern in Switzerland and colleagues.14 The authors remind us that survival prospects in ACHD, although improved in recent decades, still remain below expectations for the general population. Patients and their loved ones benefit from preparation for both unexpected and predictable deaths, sometimes preceded by a prolonged period of declining health. Hence, advance care planning (ACP) is an integral part of comprehensive care in those with ACHD. This position paper summarizes evidence regarding benefits of and patientsÃ¢ÂÂ preferences for ACP and provides practical advice regarding the implementation of ACP processes within clinical ACHD practice.

They suggest that ACP be delivered as a structured process across different stages, with content dependent upon the anticipated disease progression. They also acknowledge potential barriers to initiate ACP discussions and emphasize the importance of a sensitive and situation-specific communication style. Conclusions presented in this paper reflect agreed expert opinions, and include both patient and provider perspectives.The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Warnes CA.

Eur Heart J 2020;doi.org/10.1093/eurheartj/ehaa554.3Baumgartner H, Budts W, Chessa M, Deanfield J, Eicken A, Holm J, Iserin L, Meijboom F, Stein J, Szatmari A, Trindade PT, Walker F. Recommendations for organization of care for adults with congenital heart disease and for training in the subspecialty of Ã¢ÂÂGrown-up Congenital Heart DiseaseÃ¢ÂÂ in Europe. A position paper of the Working Group on Grown-up Congenital Heart Disease of the European Society of Cardiology. Eur Heart J 2014;35:686Ã¢ÂÂ690.4Moons P, Meijboom FJ, Baumgartner H, Trindade PT, Huyghe E, Kaemmerer H.

Structure and activities of adult congenital heart disease programmes in Europe. Eur Heart J 2010;31:1305Ã¢ÂÂ1310.5Freisinger E, GerÃÂ J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe J, Diller G-P. Current use and safety of novel oral anticoagulants in adults with congenital heart disease. Results of a nationwide analysis including more than 44 000 patients.

Eur Heart J 2020;41:4168Ã¢ÂÂ4177.6Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Executive summary. Eur Heart J 2017;38:2137Ã¢ÂÂ2149.7Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, BlomstrÃÂ¶m-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL.

2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;41:XXXÃ¢ÂÂXXX.8Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, JimÃÂ©nez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, F NÃÂ, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543Ã¢ÂÂ603.9Verhamme P, Budts W, Van de Werf F.

Non-vitamin K oral anticoagulants in adults with congenital heart disease. Quod non?. Eur Heart J 2020;41:4178Ã¢ÂÂ4180.10Groenink M, den Hartog AW, Franken R, Radonic T, de Waard V, Timmermans J, Scholte AJ, van den Berg MP, Spijkerboer AM, Marquering HA, Zwinderman AH, Mulder BJ. Losartan reduces aortic dilatation rate in adults with Marfan syndrome.

Eur Heart J 2020;41:4181Ã¢ÂÂ4187.12Jondeau G, Milleron O, Boileau C. Marfan sartan saga, episode X. Eur Heart J 2020;41:4188Ã¢ÂÂ4190.13Budts W, Pieles GE, Roos-Hesselink JW, Sanz de la Garza M, DÃ¢ÂÂAscenzi F, Giannakoulas G, MÃÂ¼ller J, Oberhoffer R, Ehringer-Schetitska D, Herceg-Cavrak V, Gabriel H, Corrado D, van Buuren F, Niebauer J, BÃÂ¶rjesson M, Caselli S, Fritsch P, Pelliccia A, Heidbuchel H, Sharma S, Stuart AG, Papadakis M. Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD).

Position statement of the Sports Cardiology &. Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2020;41:4191Ã¢ÂÂ4199.14Schwerzmann M, Goossens E, Galle go P, Kovacs AH, Moons P, Swan L, Tobler D, de Stoutz N, Gabriel H, Greutmann M, Roos-Hesselink JW, Sobanski PZ, Thomet C. Recommendations for advance care planning in adults with congenital heart disease.

ÃÂ© The Author(s) 2020. For permissions, please email. Journals.permissions@oup.com..

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The events of the past year have accelerated our digital health progress significantly and have proven to Canadians just how important and helpful digital health can be,Ã¢ÂÂ says Michael Green, President and CEO of Infoway. ÃÂÂDigital Health Week is an important time to celebrate our progress and acknowledge the hard work of all those who have made it possible.Ã¢ÂÂWhile technology can help reduce barriers and improve access to health care, kamagra erfahrung the research also found that nearly six in 10 Canadians feel they donÃ¢ÂÂt know enough about digital health apps and services. As CanadaÃ¢ÂÂs digital health agency, Infoway is committed to working with its partners to address these gaps through activities like Digital Health Week.About InfowayÃ¢ÂÂs Commitment to ResearchA Healthy Dialogue is part of InfowayÃ¢ÂÂs commitment to contributing to digital health research in Canada. To support health care organizations, clinicians, policy maker and patients, families and caregivers, Infoway kamagra erfahrung conducts research into the value of digital health solutions as well as cliniciansÃ¢ÂÂ and CanadiansÃ¢ÂÂ attitudes and perceptions.

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This latest research project, A Healthy Dialogue, is one of the largest public consultations about digital health ever conducted in Canada. The consultation reached more than 58,000 Canadians Ã¢ÂÂ including those underserved by the health system Ã¢ÂÂ who shared how they thought technology would impact their care experience.The research reveals[i]:An overwhelming majority (92%) of Canadians want technology that makes health care as convenient as other aspects of their lives.More than half (53%) of Canadians who have used health technology in the past year say it helped them avoid an in-person visit to a provider or an emergency room.Of those Canadians who received virtual care during the kamagra, 91% were satisfied with the experience, 86% agreed that virtual care tools can be important alternatives to seeing doctors in-person, and more than three-quarters (76%) are willing to use virtual care after the kamagra tablet online kamagra.Ã¢ÂÂWeÃ¢ÂÂve gone from talking about ways to further integrate digital health into everyday health care to living it. The events of the past year have accelerated our digital health progress significantly and have proven to Canadians just how important and helpful digital health can be,Ã¢ÂÂ says Michael Green, President and CEO of Infoway.

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Today, the U.S kamagra tablet online. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of an estimated $103 million in American Rescue Plan funding over a three-year period to reduce burnout and promote mental health among the health workforce. These investments, which take into particular consideration the needs of rural kamagra tablet online and medically underserved communities, will help health care organizations establish a culture of wellness among the health and public safety workforce and will support training efforts that build resiliency for those at the beginning of their health careers.Ã¢ÂÂThe Biden-Harris Administration is committed to ensuring our frontline health care workers have access to the services they need to limit and prevent burnout, fatigue and stress during the erectile dysfunction treatment kamagra and beyond,Ã¢ÂÂ said HHS Secretary Xavier Becerra. ÃÂÂIt is essential that we provide behavioral health resources for our health care providers Ã¢ÂÂ from paraprofessionals to public safety officers Ã¢ÂÂ so that they can continue to deliver quality care to our most vulnerable communities.Ã¢ÂÂ Health care providers face many challenges and stresses due to high patient volumes, long work hours and workplace demands.

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On August 7-8, 2021, the HAS is hosting kamagra tablet online its second International Virtual Summit for young adults with chronic and rare conditions. Participants will explore identities of being young and chronically ill through sessions such as mental health, global health policy, media representation, and hear from speakers such as Selma Blair. The HAS is hoping to recruit more young adults with chronic and rare conditions from rural communities. Visit the kamagra tablet online event page and register for free!.

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