Figures of the Heart Failure Association: Andrew J. Stewart Coats, President-Elect, 2018–2020

Andrew is a native Aussie (Australian to those north of the equator). He can claim to be truly international however. His father was a Medical Professor as well, and took him at an early age to spend his kindergarten years in Lund in southern Sweden (later to find out he was in the same year as the well-known Swedish cardiologist, Ronnie Willenheimer). This early international exposure must have affected Andrew, for he has gone on to spend many years living in different countries; he can list the major ones: UK – 30 years, Australia – 24, Japan – 5, Hong Kong, − 2, Sweden – 2, Germany – 1, United States, − 1. Andrew studied medicine at Oxford and then Cambridge, and he says fell in love with cardiovascular physiology in his first week as a medical student, from his first tutorial with his medial tutor, the charismatic Oxford physiologist, Derek Bergel, an early Editor of the ESC journal, Cardiovascular Research. Oxford featured prominently Andrew's cardiology training, working with Prof. Peter Sleight from 1986–1991, until he was recruited by Philip Poole-Wilson to the UK's first dedicated Cardiomyopathy/Heart Failure chair at the National Heart and Lung Institute, and Royal Brompton Hospital in London. Whilst working extremely long hours in an intensively clinical role in Oxford ‘basically living in the catheter lab and adjoining ward’, with the hard-working consultant Dr. Brian Gribbin, Andrew opened his mail late one evening to see a tiny torn out job advert from the British Medical Journal, with no other indication of from whom it came, other than the penciled words: ‘interested? – Philip’. Andrew was. Thereafter it was in London that most of us came to recognize Andrew's particular brand of heart failure research, intensely physiological, integrated and addressing issues very diverse from mainline heart-centred cardiology, encompassing studies on neural reflexes, control of breathing, skeletal muscle function, brain activation, mathematical modelling, insulin and growth hormone sensitivity, immune function, cachexia, etc. He often joked ‘my colleagues studied everything that happened up to the aortic valve, and I looked at everything that happened beyond it.’ He introduced the concept of ‘The Muscle Hypothesis’ to explain the generation of exercise-limiting symptoms in the patient with well-treated chronic heart failure and conducted the world's first randomised controlled trial of exercise training for chronic heart failure. But it is his long list of colleagues and one-time research fellows that most marks Andrew's particular contribution to heart failure. ‘I had the advantage of working in wonderful places (Oxford and then Chelsea) which meant great fellows came to work and I tended to adopt them early, acting as a mentor to home-sick foreigners in the strange world of a cardiology department in the UK in the 80’s and 90's.' His long list of one-time fellows includes many familiar to the Heart Failure Association: Stamatis Adamapoulos, Massimo Piepoli, Andrew Clark, Stefan Anker, Piotr Ponikowski, Maurizio Volterrani, Viorel Florea, Wolfram Doehner, Stephan von Haehling, Darrel Francis, Rakesh Sharma, as well as working closely with others including Michael Henein, Giuseppe Rosano, Martin Cowie and briefly Alex Lyon. A: That's a hard one to answer. If you had said Medicine rather than Cardiology, then an early mentor Prof. David Penington, a haematologist and one-time Vice-Chancellor, was a major role model early in my career, but for cardiology, it would have to be Oxford's Peter Sleight, a wonderfully open, friendly and innovative cardiologist who ran a mildly madcap, but always successful academic department of Cardiovascular Medicine, arguably the birthplace of the modern cardiology mega-trial (starting with ISIS 1), which Peter developed with Richard Peto, Salim Yusuf and Rory Collins. Philip Poole-Wilson was also an enormous influence, ‘We conducted a joint ward-round and clinic for over a decade’, and whilst working closely with amazing leaders in their fields, including Derek Gibson, Kim Fox, Jane Somerville, Tony Rickards, to name a few. And of course the amazing fellows I have worked with, many of them my greatest friends and colleagues, Stefan, Stam, Massimo, Piotr, the Giuseppes. Maurizio, I will not go on purely because I know the editors will trim the list in the needs of space.' A: The 90's were the years of the mega-trials of our fantastic heart failure drugs, trials that took an untreatable condition in the 80's into the one with the widest range of effective therapies to improve survival, in the whole of cardiology. The years 2000–2010 consolidated this, but with the use of devices. In the future I see percutaneous procedures, surgery, and the combination of device implantations with biologics and other strategies revolutionizing how we treat heart failure. We will never eradicate heart failure, because it is the end-stage of many cardiovascular disorders, that we treat well enough to prevent death. But we can never prevent the effects of ageing, and as we get older we will see more well-treated and hopefully sympathetically managed chronic illness, that has much less impact of quality of life than hitherto. Chronic heart failure will, we hope, become a minor condition to be managed for many many years of productive post-retirement life using advanced monitoring technology,1, 2 and without the need for regular hospitalisation.3-5 A: My first trial of exercise training in heart failure, 11 patients in a cross-over design trial, and published in the Lancet when I was still a trainee6; it was great fun and came out the day I interviewed for Philip's post in London I mentioned earlier. To this day I suspect he was the Lancet's main reviewer! The field has exploded since and remains of considerable interest.7, 8 I have published many papers since then, a reflection of the fantastic people I have worked with over the years, but my most recent change in direction is studying cancer cachexia,9 following work that Stefan Anker and I did together way back in the late 90's, showing the similarity of cardiac cachexia to other chronic illness-related cachexias, as summarized in many papers,10-12 in a new journal published by a new society in a field that did not even exist when Stefan Anker joined me, and that is now a major field in its own right.13 A: Renewed interest in sleep apnoea in heart failure, and appreciating the physiology of Cheyne–Stokes that we have known about out for more than a century,14, 15 and how we simply overlooked something as obvious and important as iron deficiency for so long.16, 17