Dr Ranil de Silva is senior lecturer in clinical cardiology at the National Heart and Lung Institute, Imperial College London and consultant interventional cardiologist at Royal Brompton Hospital, London, where he also leads the specialist angina service. His clinical and research interests focus on the pathophysiology, investigation, risk stratification and treatment of complex stable coronary artery disease and acute coronary syndromes. He is a lead clinical investigator at the National Institute for Health Research cardiovascular biomedical research unit at the Trust.
Dr de Silva has been the recipient of a Foulkes Foundation Fellowship, NIH Bench to Bedside Award and has ongoing collaborative research programmes with investigators at the University of Aarhus, National Institutes of Health and University of Wisconsin. He has previously published in a number of leading academic journals including NEJM, The Lancet, Circulation, JACC and European Heart Journal.
Dr de Silva was interviewed for our newsletter, RESEARCHTALK.
We were investigating the control of blood flow and metabolism in the heart and how that changed in patients with coronary artery disease and in people who had heart attacks previously. In addition, we were interested in those people with coronary artery disease who had impaired heart function, to see if we could predict the recovery of heart function, either by angioplasty or bypass surgery. I think that set the stage for me because I stopped my medical training half-way through to continue this work as a PhD, and then continued on with my clinical training afterwards. For me, that was a really pivotal period of my career, which determined my interest in cardiology as well as my interest in imaging and a career in research.
What research are you currently working on?
My interests continue in the management of patients with coronary artery disease which results from build-up of deposits of fatty-type material within their heart arteries that cause obstruction of blood supply to the heart muscle. This can present itself in one of three major ways: in people who develop exertional angina this is central chest discomfort, tightening or heaviness in the chest, which can go up to the throat or jaw when they walk; in those people that present as an emergency with a heart attack; and then in those people who present with the downstream effects of coronary disease as a result of impaired pump function of the heart and heart failure. What we are interested in is:
Can we identify those people who are at risk of developing an acute heart attack?
In terms of stratifying people and their risk of development and progression of coronary disease, we are interested in using new imaging techniques within coronary arteries to understand local blood flow patterns within the heart arteries. We think this is an important component of why certain types of heart narrowing develop in certain locations within these arteries. Narrowings of the heart arteries are not occurring throughout the whole of the arterial tree, but tend to develop in specific locations. The propensity for those narrowings to progress over time seems to be very much influenced by the local pattern of blood flow. We’ve now developed some techniques so we can look at that in very high resolution. We hope that by using these methods, combined with measurement of the structural strength of heart artery narrowings, we can improve prediction of those types of artery narrowings that are at risk of causing a heart attack.
Can we improve quality of life in those patients who still remain symptomatic despite conventional treatment for coronary artery disease?
We have an increasing number of survivors from heart attacks. We have an increasing number of people living with the background of angioplasty or bypass surgery who still remain symptomatic. For these people, we need to try and find new treatments to improve symptoms and quality of life. In many cases the causes of ongoing symptoms are multifactorial and the patients have many complex needs, which need to be addressed.
Developing advanced treatment for people with well-established or advanced coronary artery disease is carried out within our specialist angina service. A major area of focus is investigation of new devices or biologic therapies to improve blood supply to the heart, therefore reducing people’s symptoms and improving quality of life. We have recently been involved in an international, multi-centre clinical trial evaluating a new device which is a stent, but rather than placing the stent in one of the heart arteries, we stent the main outflow vein of the heart called the coronary sinus. This is what I think of as a “Robin Hood” procedure - stealing from the rich to give to the poor, where we redistribute the blood supply within the heart muscle to improve supply to those areas of the heart which are particularly short of blood. In this trial, we found that patients' symptoms and quality of life improved quite significantly. This is important because if we compare the quality of life in patients with symptomatic chronic artery disease, it is much worse than many other common chronic conditions, including chronic lung disease and certain types of cancer. Addressing this is an important issue, particularly as we have an ageing population, and therefore the burden and frequency of this type of problem is going to get greater and greater. In order to address this, we need new treatments. We will be able to offer this procedure to appropriate patients and undertake new research using this device.
Where do you see coronary artery disease research heading in the future?
I think the first thing is that we are increasingly understanding the determinants of coronary artery disease so I think as we understand more, we are heading more and more towards preventive strategies. Prevention doesn’t start in adulthood, it starts in childhood. We need to put in place ways to promote healthy lifestyles, healthy eating, exercise and weight management in our young children - those sorts of good patterns need to be firmly set in childhood. That’s what I think will deliver the greatest benefit in terms of coronary disease reduction in years to come.
Of course, we must also consider the huge challenge to healthcare systems of treating the large and growing number of patients with established coronary disease. While we do currently have many good treatments for them, we still face a great challenge in terms of preventing progression and development of future adverse events in patients with established disease. With our ageing population, we have also got large and growing numbers of older people with very advanced coronary disease. We need to think about new treatment options for these patients, especially as they have a large number of co-existing medical problems which add significant complexity to their treatment. So the message is “prevention, prevention, prevention” for our young people, to avoid development of disease. For those with established disease, we also need to think of innovative ways of lowering their risk profiles and developing new treatments for those who remain symptomatic. This is especially for the growing population of patients with very advanced disease for whom conventional options have been exhausted. I think these are several of the broad areas where the future of coronary disease research is going.
I get the feeling that some people think of coronary disease as being a done deal in the context of the death rates from heart attacks falling so dramatically over the last 30 to 40 years. There is no doubt we have made huge strides forwards, but we still have to remember that heart disease is still the biggest killer worldwide. Around 17 million deaths a year are caused by cardiovascular disease so this clearly remains a huge healthcare and health economic issue worldwide, which we as a society need to address. Thinking about the UK, if we compare death rates 20 years ago to now, despite the fall in coronary mortality it’s interesting that it still remains the number one cause of death - there is still so much work for us to do!
Dr Ranil de Silva took part in the café scientifique: Chest pain and the heart organised by the cardiovascular biomedical research unit.
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