Editorial
Arno Massee/Science Photo Library
Growing older with congenital heart disease
For the AHA scientific statement: Congenital Heart Disease in the Older Adult see http://circ.ahajournals.org/ content/early/2015/04/20/ CIR.0000000000000204.full. pdf+html
Advances in cardiac surgery and postoperative care during the past few decades mean that more people with congenital heart disease are living longer with a better quality of life. Despite this progress, death rates in people with the condition aged 20 to 70 years or older might be two to seven times higher than in their peers. The natural progression of congenital heart disease and sequelae of earlier interventions must now be treated in the context of late complications and arrhythmia or heart failure superimposed on congenital heart disease, in addition to the comorbidities of the natural ageing process. Essentially, these adults will need lifelong health care. On April 20, the American Heart Association (AHA) issued the first scientific statement for treating adults older than 40 years with congenital heart disease. The recommendations, published online in Circulation, are broad in scope and cover diagnosis, treatment, and management of complications and atherosclerotic cardiovascular disease risk factors. The recommendations emphasise a multidisciplinary approach and the importance of collaborating with adult
congenital heart disease specialists in this population’s care, especially since anatomical diagnosis alone does not define complexity. The statement recommends obtaining original medical records regarding diagnosis and interventions. However, it asserts that physiological changes in older adults and their subsequent trajectory are not yet completely understood as the population continues to age. Patients should be monitored regularly for coronary artery disease, and screened routinely for pulmonary function, and lung, kidney, and liver disease. Physical activity and maintenance of an ideal bodyweight should be encouraged in these patients. The statement targets the issues specific to older adults that might arise, including primary care complications, such as sexual dysfunction and cognitive impairment. There are now more adults than children with congenital heart disease in the USA, which is also the case in other developed countries. The AHA recommendations will be invaluable for health-care providers and, when implemented, should lead to improved care for this population and identify their research needs. The Lancet
Darrin Zammit Lupi/Reuters/Corbis
Migrant crisis in the Mediterranean
See World Report page 1713
For more on migrant deaths in the Mediterranean see Europe’s Sinking Shame http://www. amnesty.org.uk/webfm_ send/1345 For more on the outcomes of the European Council’s emergency meeting see http:// www.consilium.europa.eu/en/ meetings/europeancouncil/2015/04/23/
1698
In October, 2014, the British Government quietly announced its decision to withdraw support for Mare Nostrum, a search and rescue operation for migrants in the Mediterranean Sea. “We do not support planned search and rescue operations in the Mediterranean,” said Baroness Anelay, to avoid “an unintended ‘pull factor’, encouraging more migrants to attempt the dangerous sea crossing and thereby leading to more tragic and unnecessary deaths.” As of April 27, more than 1700 men, women, and children— each seeking a better and safer life in Europe—have drowned trying to cross the Mediterranean, compared with 96 over the same period in 2014. A humanitarian crisis is taking place on Europe’s doorstep. After 800 migrants drowned on April 19, the European Council pledged to take action but its plans are mixed at best. A search and rescue programme similar to Mare Nostrum is clearly needed, but the European Council has promised only to increase the budget and capacity of Triton, which is responsible for maintaining Europe’s borders within 30 nautical miles of Maltese and Italian
shores. All ships are bound by law to respond to distress signals, but Triton vessels are often far from the areas where migrant boats sink, limiting their effectiveness in rescue operations. The Council has also focused on combating illegal migration and made the pledge to capture and destroy vessels used by traffickers. Proper rescue programmes will prevent immediate deaths, but—as European Governments failed to appreciate—push factors, not pull factors, are forcing migrants to risk the crossing. Many migrants and refugees from Africa and the Middle East are stranded in Libya, where they are exposed to conflict and violence, damage to hospitals, schools, and transport, and shortages of food, electricity, and medical supplies. Foreign aid and sustainable development are needed. The UK’s aid budget is likely to be maintained, no matter what the outcome of the forthcoming election. But if the European Council wants to solve the crisis—and it has a moral obligation to do so—it would do well to help those beyond its borders rather than fear them. The Lancet www.thelancet.com Vol 385 May 2, 2015
Arno Massee/Science Photo Library
Growing older with congenital heart disease
For the AHA scientific statement: Congenital Heart Disease in the Older Adult see http://circ.ahajournals.org/ content/early/2015/04/20/ CIR.0000000000000204.full. pdf+html
Advances in cardiac surgery and postoperative care during the past few decades mean that more people with congenital heart disease are living longer with a better quality of life. Despite this progress, death rates in people with the condition aged 20 to 70 years or older might be two to seven times higher than in their peers. The natural progression of congenital heart disease and sequelae of earlier interventions must now be treated in the context of late complications and arrhythmia or heart failure superimposed on congenital heart disease, in addition to the comorbidities of the natural ageing process. Essentially, these adults will need lifelong health care. On April 20, the American Heart Association (AHA) issued the first scientific statement for treating adults older than 40 years with congenital heart disease. The recommendations, published online in Circulation, are broad in scope and cover diagnosis, treatment, and management of complications and atherosclerotic cardiovascular disease risk factors. The recommendations emphasise a multidisciplinary approach and the importance of collaborating with adult
congenital heart disease specialists in this population’s care, especially since anatomical diagnosis alone does not define complexity. The statement recommends obtaining original medical records regarding diagnosis and interventions. However, it asserts that physiological changes in older adults and their subsequent trajectory are not yet completely understood as the population continues to age. Patients should be monitored regularly for coronary artery disease, and screened routinely for pulmonary function, and lung, kidney, and liver disease. Physical activity and maintenance of an ideal bodyweight should be encouraged in these patients. The statement targets the issues specific to older adults that might arise, including primary care complications, such as sexual dysfunction and cognitive impairment. There are now more adults than children with congenital heart disease in the USA, which is also the case in other developed countries. The AHA recommendations will be invaluable for health-care providers and, when implemented, should lead to improved care for this population and identify their research needs. The Lancet
Darrin Zammit Lupi/Reuters/Corbis
Migrant crisis in the Mediterranean
See World Report page 1713
For more on migrant deaths in the Mediterranean see Europe’s Sinking Shame http://www. amnesty.org.uk/webfm_ send/1345 For more on the outcomes of the European Council’s emergency meeting see http:// www.consilium.europa.eu/en/ meetings/europeancouncil/2015/04/23/
1698
In October, 2014, the British Government quietly announced its decision to withdraw support for Mare Nostrum, a search and rescue operation for migrants in the Mediterranean Sea. “We do not support planned search and rescue operations in the Mediterranean,” said Baroness Anelay, to avoid “an unintended ‘pull factor’, encouraging more migrants to attempt the dangerous sea crossing and thereby leading to more tragic and unnecessary deaths.” As of April 27, more than 1700 men, women, and children— each seeking a better and safer life in Europe—have drowned trying to cross the Mediterranean, compared with 96 over the same period in 2014. A humanitarian crisis is taking place on Europe’s doorstep. After 800 migrants drowned on April 19, the European Council pledged to take action but its plans are mixed at best. A search and rescue programme similar to Mare Nostrum is clearly needed, but the European Council has promised only to increase the budget and capacity of Triton, which is responsible for maintaining Europe’s borders within 30 nautical miles of Maltese and Italian
shores. All ships are bound by law to respond to distress signals, but Triton vessels are often far from the areas where migrant boats sink, limiting their effectiveness in rescue operations. The Council has also focused on combating illegal migration and made the pledge to capture and destroy vessels used by traffickers. Proper rescue programmes will prevent immediate deaths, but—as European Governments failed to appreciate—push factors, not pull factors, are forcing migrants to risk the crossing. Many migrants and refugees from Africa and the Middle East are stranded in Libya, where they are exposed to conflict and violence, damage to hospitals, schools, and transport, and shortages of food, electricity, and medical supplies. Foreign aid and sustainable development are needed. The UK’s aid budget is likely to be maintained, no matter what the outcome of the forthcoming election. But if the European Council wants to solve the crisis—and it has a moral obligation to do so—it would do well to help those beyond its borders rather than fear them. The Lancet www.thelancet.com Vol 385 May 2, 2015
