1. Introduction
As part of our special focus issue on pharmacotherapy for hypertension, we had the opportunity to interview one of contributors, Professor Gregory Lip. Professor Lip currently serves as Price-Evans Chair of Cardiovascular Medicine and Director of the Liverpool Center for Cardiovascular Science at the University of Liverpool in the United Kingdom. He is a Distinguished Professor at Aalborg University in Denmark and serves as an Adjunct Professor at both Yonsei University and Seoul National University in Seoul, Korea. Professor Lip spends half of his time as a clinical cardiologist at Liverpool Heart & Chest Hospital, including outpatient clinics (leading atrial fibrillation and hypertension specialist services) and acute cardiology. We were delighted to have the opportunity to put the following questions to him.
2. The Interview
Q1: What was it about cardiovascular medicine that attracted you to specialize in it?
In cardiovascular medicine we never stop asking questions and learning new things, whether studying the epidemiology, pathophysiology, clinical studies or applied health research – ultimately improving our understanding of patient management and improving their care. It has been a fascinating journey, learning from my peers, students and patients. We never stop learning.
Q2a: Were there any people within the field of cardiovascular medicine that you have looked up to during your career?
I have a great debt to my old boss and mentor, Gareth Beevers, who’s now Emeritus Professor of Medicine. He was a physician with a major research interest in hypertension and clinical epidemiology. He taught me to ask questions pertaining to clinical care of our patients.
Q2b: Why?
Gareth was very much a clinical researcher and has shaped my approach to cardiovascular medicine research.
Q3: As someone with a long career in medicine, what would you say have, thus far, been your highlights and/or proudest achievements?
My primary clinical and research interests have been into atrial fibrillation and hypertension, the latter being the commonest etiological factor for atrial fibrillation on a population-wide basis.
My research work has delivered impacts in changing national and international clinical practice guidelines and improvements in patient care within three principal areas: (i) treatment decisions related to stroke and bleeding risk in atrial fibrillation, which is the commonest cardiac arrhythmia in the general population, (ii) screening practice in primary care, and (iii) stroke and bleeding risk assessment. Clinical risk scores developed and validated by my work to assess stroke & bleeding risk in atrial fibrillation (AF) (ie. CHA2DS2-VASc & HAS-BLED) are used internationally.
I have also characterized the clinical epidemiology of malignant hypertension, and the worked on the risks of pregnancy induced hypertension on subsequent risks, as well as the impact of antihypertensive drugs used in pregnancy.
Q4: And as of today, where do your current research interests lie?
I have recently been working on patient management pathways to optimize holistic or integrated care. For atrial fibrillation, has been promoted as a streamlined, simple integrated ABC care (Atrial Fibrillation Better Care) pathway: ‘A’ Anticoagulation to Avoid stroke; ‘B’ Better symptom management with patient-centered symptom-directed shared decisions for rate or rhythm control; and ‘C’ Cardiovascular risk and comorbidity management, plus lifestyle changes. This pathway (‘Easy as ABC....’) has been shown in a randomized trial to improve patient outcomes, and has been incorporated into guidelines.
In addition, the ABC pathway allows its utilization in mobile health (mHealth) technology, where we can use App-based management for dynamic risk assessments and incorporation of machine learning methodology.
Q5: Hypertension comes in many forms but on the whole, how well do you feel that is being treated worldwide?
Hypertension is still a major risk factor globally and leads to many associated cardiovascular complications that increase mortality and morbidity, such as atrial fibrillation, heart failure, stroke and dementia. We could do much better, since optimal blood pressure control will lead to overall better outcomes.
Q6: Given that you are currently based in the UK, do you feel that the UK reflects the current state of the art in terms of hypertensive treatment?
The UK has contributed much to our understanding and management of hypertension, and we can always do better. We never stop learning and collaborations with colleagues in Europe and internationally are crucial for research progress. These days, research is without borders or boundaries.
Q7: In terms of those being treated, do you feel that clinicians these days are overly cautious about prescribing anti-hypertensives and what is your opinion on their use?
Not necessarily. Hypertension guidelines are emphasizing the need to treat to target blood pressures, especially when there is evidence of hypertension target organ damage.
Q8: What do you feel the next five years has in stall for the treatment of hypertension? Will it be more of the same or do you anticipate any major breakthroughs?
We have many antihypertensive drugs at our disposal, but we need better optimization of care pathways, drug dose titration to achieve blood pressure control, and improved efforts at drug adherence and persistence. There are some promising approaches at non-drug interventions, but more data and trials are currently needed. We must not forget lifestyle factors that are complementary to hypertension and cardiovascular disease management, for example, weight reduction, smoking cessation, alcohol and salt restriction, etc – as well as addressing potentially reversible risks such as sleep apnea.
Declaration of interest
Professor Lip serves as a consultant for Bayer/Janssen, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi Sankyo. He also serves as a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi Sankyo. No fees are directly personally received. He has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.