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Genetic test should be new standard of care in UK for stroke patients
People who have had the most common type of stroke should have a genetic test to find out whether they can be treated with a drug to help reduce the risk of further brain attacks, the UK’s NHS watchdog has said.
New draft guidelines published on May 19 by the National Institute for Health and Care Excellence (NICE) recommend that people who have suffered an ischaemic stroke – where a clot blocks the flow of blood and oxygen to the brain – or a transient ischaemic attack (TIA) should be offered laboratory-based genotype testing if treatment with the drug clopidogrel is being considered by clinicians.
NICE currently recommends clopidogrel can be used as an option for treating people at risk of a secondary stroke but this treatment is not suitable for those with certain variations in a gene called CYP2C19 because they cannot convert the drug to the active form.
The genotype test would be used to find out who has these variants so they can be treated with an alternative drug = potentially saving thousands of lives.
If laboratory testing – estimated to cost around £139 per analysis – is not possible, NICE has said the Genomadix Cube point-of-care check at a cost of £197, which can be given at the bedside, can be used instead.
There are around 100,000 strokes every year in the UK, of which approximately43,000 are recurrent. Each year, 46,000 people in the UK have a TIA for the first time – a warning that they are at risk of stroke.
A stroke can occur in anyone of any age. but the chance of having one about doubles every 10 years after reaching 55. The majority of strokes occur in people who are 65 or older.
Clopidogrel – which also goes under the brand names Grepid and Plavix – is the standard anti-clotting medication given to patients.
But at present no testing takes place to find out who is suitable for treatment with the drug.
An estimated 32% of people in the UK have at least one of the highlighted CYP2C19 gene variants. They are more commonly found in people with an Asian family background but can be present in those of any ethnicity.
Evidence has suggested that people with these variants have around a 46% increased risk of another stroke when taking clopidogrel compared to those without them.
If the test discovers they have one of the CYP2C19 gene variants, the person will be treated with another medicine, which will be more effective at preventing future blood clots. 
Around 11 million items of clopidogrel are dispensed each year at a cost of around £16 million to the NHS.
Mark Chapman, interim director of medical technology and digital evaluation, at NICE, said: “The recommendation is a step forward in ensuring people who have had a stroke receive personalised care thanks to a genetic test run after their DNA is sequenced using their blood or saliva.
“Treatment with clopidogrel is effective in preventing further strokes for the majority of people who don’t have the gene variant. But until now doctors have not known who cannot be treated with clopidogrel until after they’ve had a second stroke or TIA and that could be too late.
“If the CYP2C19 variants are found, other treatment options can be used. This test ensures we’re getting the best care to people quickly, while at the same time ensuring value for money for the taxpayer.”
A consultation has begun on the draft recommendations and consultees can have their say via nice.org.uk until Wednesday June 8, 2023.
Juliet Bouverie, Chief Executive of the UK-based Stroke Association, has welcomed the NICE announcement. She said: “Stroke devastates lives and leaves people with life-long disability. We know that many stroke survivors spend the rest of their lives fearing another stroke, so it’s great to see that more people could be given appropriate help to significantly cut their risk of recurrent stroke.
“Anything we can do to prevent the misery that stroke can cause is ultimately good news. Getting on the right medication and taking it as advised can really go far to prevent further strokes.”
A team at NHS Tayside in Scotland led by stroke specialist Dr Alex Doney at Ninewells Hospital in Dundee, has already been pioneering routine gene testing for clopidogrelin in brain attack patients. It has been estimated the test, developed by East of Scotland Regional Genetic Laboratory, will lead to improved outcomes for about 400 patients with heart disease and 600 stroke patients each year.
One of the first patients in Tayside to be managed on the new stroke pathway has been 67-year-old Ian Anderson from Perth. He has previously said: “I felt privileged to be one of the first patients in Tayside to be involved in this new approach. It really is a step into the future and one that will benefit patients in the coming months and years.
“It is quite amazing that a simple blood test can show if my medication is working as effectively as possible and it is reassuring that my medication can be tailored more precisely to me.”
Clinicians believe this is just the tip of the iceberg and other conditions could soon benefit from the same precision prescribing, making routinely given medicines safer and more effective for individual patients.
Gut-friendly foods such as kimchi and kombucha may carry hidden risks for heart health when eaten in excess, the British Heart Foundation (BHF) has warned.
The charity said foods marketed as prebiotic, probiotic or otherwise good for the gut can support the microbiome, but some may also be high in salt or sugar, which can raise the risk of cardiovascular disease.
Products highlighted by the British Heart Foundation included kimchi, kombucha, fruit yoghurts, smoothies and sauerkraut. It said there is no harm in including them as part of a healthy diet, but advised people to check labels for added salt and sugar and eat them in moderation.
Tracy Parker, the charity’s nutrition lead, said: “We encourage everyone to choose foods that can keep their gut microbiome healthy. The benefits are clear, and we are continuing to improve our understanding of how a gut-friendly diet may help our hearts.
“A lot of these products can contain high levels of salt or sugar though, so it is important to be aware of the potential drawbacks.
“By ensuring you check package labels for added salt and sugars, and eat each in moderation, you can make sure the risks do not outweigh the benefits for your heart health.”
Fermented foods such as kimchi and sauerkraut are rich in probiotics, the healthy bacteria produced during fermentation that can help support a diverse and healthy gut microbiome.
However, both are traditionally made using a lot of salt, which can raise blood pressure if eaten frequently or in large quantities. High blood pressure is known to increase the risk of heart attack and stroke.
Kombucha, a fermented tea, also contains probiotics and can be a healthier alternative to fizzy drinks, but many commercial and shop-bought versions contain added sugar.
Eating too much sugar can lead to weight gain, which can increase the risk of heart attack, stroke and other cardiovascular disease.
Fruit yoghurts can contain probiotic live bacteria cultures, but may also be high in sugar and have fewer live cultures than plain versions.
The charity said plain yoghurt with live and active cultures on the label can be a lower-sugar option, with whole fruit added at home for sweetness.
Smoothies made with whole fruits provide prebiotic fibre, which feeds beneficial gut bacteria and supports digestive health.
They can also provide vitamins and antioxidants, especially when made with a variety of plant-based ingredients.
But blending breaks down the structure of fruit, releasing free sugars that behave like added sugars in the body and can cause faster rises in blood sugar levels.
Regularly consuming too much sugar can lead to weight gain, which can increase the risk of developing type 2 diabetes, heart disease and kidney disease.
The charity said only one 150ml serving of any smoothie counts towards five-a-day, and suggested adding nuts or seeds for extra protein and fibre to help keep blood sugar levels more stable.
The BHF also noted that some shop-bought sauerkraut is pasteurised, which removes most of the live bacteria.
It advised checking the label, eating small portions and choosing unpasteurised products for those seeking the probiotic benefits.
The charity said beneficial gut bacteria produce short-chain fatty acids during digestion, which are linked to reduced inflammation, better metabolism and better heart and circulatory health.
These good bacteria also help digest polyphenols, natural plant chemicals thought to have antioxidant properties and which may help lower blood pressure.
By contrast, harmful gut bacteria, which thrive on diets high in fat and red meat, produce chemicals that can cause problems in the heart and blood vessels by increasing inflammation and altering how cholesterol is processed in the body.
Beneficial bacteria thrive on varied diets high in prebiotics, non-digestible fibres found in foods such as wholegrains, oats, beans, lentils, bananas and onions.
People with diabetes may have undiagnosed heart failure that could be detected by a simple screening blood test, research suggests.
The TARTAN-HF trial found that one in four patients with diabetes who had at least one other risk factor for heart failure had undiagnosed heart failure detected through screening with a blood test and ultrasound scanning of the heart.
Experts said the findings show the extent of unrecognised heart failure in people with diabetes, and how the condition can be detected using a widely available blood test called NT-proBNP, which measures how much strain the heart is under.
They suggest a heart failure screening programme for diabetics could improve diagnosis rates, lead to earlier treatment and potentially reduce the risk of hospitalisation and death.
The study, involving 700 patients, was led by the University of Glasgow in collaboration with AstraZeneca, Roche Diagnostics, Us2.ai, NHS Greater Glasgow and Clyde and NHS Lanarkshire.
Dr Kieran Docherty, clinical senior lecturer at the University of Glasgow’s School of Cardiovascular and Metabolic Health, said: “Our results from the landmark TARTAN-HF trial identified heart failure in a large proportion of people living with diabetes, emphasising the need for a heart failure screening strategy in this group of patients.
“We know that many of the symptoms and signs of heart failure are non-specific, and may go unrecognised as potentially being due to heart failure for a long time.
“The strategy used in our trial is simple and easy to implement in clinical practice, and will aid in the early identification of heart failure in people with diabetes, and facilitate the initiation of medications that we know improve outcomes in patients with heart failure.”
The study, which began more than three years ago, involved more than 700 people with diabetes from the two health board areas who had at least one other risk factor for heart failure.
They were randomly assigned either to receive heart failure screening or to continue with their usual care.
Researchers found screening uncovered a large number of previously unrecognised cases of heart failure. Around one in four, or 24.9 per cent, of those screened were found to have the condition within six months, compared with 1 per cent in the group continuing their usual care.
The study, involving patients with type 1 and type 2 diabetes, found almost all of the participants found to have heart failure had preserved ejection fraction, which can be difficult to detect without dedicated testing.
The findings of the TARTAN-HF trial were presented at the American College of Cardiology conference taking place from 28 to 30 March in New Orleans in the US.
Dr Edward Piper, medical director at AstraZeneca UK, said: “Delayed diagnosis and treatment of heart failure in people with type 2 diabetes contributes to poor long-term outcomes. TARTAN-HF demonstrates that targeted, risk-based screening can identify previously undiagnosed heart failure in approximately one in four high-risk patients with diabetes, enabling earlier intervention with guideline-directed therapy.”
Dr Christian Simon, head of global medical affairs at Roche Diagnostics, said: “We are proud to have supported the landmark TARTAN-HF trial. These findings demonstrate the transformative power of early, accessible diagnostics like the NT-proBNP blood test.
“By identifying unrecognised heart failure in people with diabetes, we enable clinicians to initiate appropriate treatments sooner, ultimately improving patient outcomes and lives.”
The UK has launched a £6.3m men’s health fund to back local projects aimed at helping men and boys live longer, healthier lives.
The Men’s Health Community Fund is a partnership between the Department of Health and Social Care, Movember and People’s Health Trust.
The government is contributing £3m, while the two charities are more than doubling that to take the total to £6.3m.
Grants will support community projects reaching underserved men and boys aged 16 and over, particularly in the most disadvantaged areas and at key points in their lives such as becoming a father, losing a job or retiring.
Projects could include support for new fathers, activities for men facing loneliness and social isolation, services to help young men engage with the health system, and support for men in work, out of work and moving into retirement.
The programme will bring together voluntary, community and social enterprise organisations to test new ways of reaching men who are least likely to use traditional health services.
An evaluation funded through the National Institute for Health and Care Research will assess what works and help inform future policy and delivery.
Health and social care secretary Wes Streeting said: “Too many men across the country are living shorter, less healthy lives, particularly those in our most disadvantaged communities.
“This new partnership will help men get the support they need in the places they feel most comfortable, their communities, among people they trust.
“By working with expert charities and local organisations, we can reach the men who are too often missed by traditional services and help them take better care of their mental and physical health.”
“It is a key step in delivering our first ever Men’s Health Strategy and driving forward our ambition to halve the gap in healthy life expectancy between the richest and poorest areas.”
The Men’s Health Strategy sets out plans to tackle the physical and mental health challenges men and boys face.
Men can be less likely to seek help and more likely to suffer in silence, while higher rates of smoking, drinking, gambling and drug use are damaging men’s health and affecting families, workplaces and communities.
The government is also investing £3.6m over the next three years in suicide prevention projects for middle-aged men in local communities across areas of England where men are most at risk, many of which are also among the most deprived. Suicide is one of the biggest killers of men under 50, and three-quarters of all suicides are men.
The projects will aim to break down barriers middle-aged men face in seeking support, including stigma around asking for help and a lack of awareness of what is available and how to access it.
They will be co-designed with experts and men with lived experience of mental health crises and suicidal thoughts.
Gut-friendly foods may damage heart, charity warns
Diabetes patients face increased risk of undiagnosed heart failure
UK government announces £6.3m fund to boost men’s health
Brain health collaboratory launches in Gulf South
