Taboo: crossing the specialty barrier.

A rguably the greatest therapeutic breakthroughs have resulted from increased medical specialisation, particularly in major disciplines, such as cardiology and respiratory medicine. Generalism now remains the province of primary and community care, and of elderly care teams. However, what works well for research may work against the delivery of these medical advances to the patients most in need. A movement away from the established reductionist approach in medicine may facilitate the delivery of best care for a number of reasons in both cardiology and respiratory medicine, as follows. 1) Huge efforts are currently directed at preventing repeat admissions from exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), facilitating early discharge and managing patients in the community [1–4]. Home support, including telecare, may help both groups. Moreover, a number of telecare schemes now have joint networks serving COPD and heart failure patients [5]. 2) Pulmonary and cardiac rehabilitation programmes are crucial and effective components of long-term care plans in chronic cardiac and respiratory patients, yet in many centres rehabilitation programmes have evolved, and are staffed, separately. While there is a need to tailor programmes to the nature of the disease and its severity, courses could easily improve coordination with each other, and share facilities and expertise. Also, the role of joint exercise courses should be examined earlier in the natural history of cardiorespiratory disease. 3) Sleep-disordered breathing (SDB) is increasingly recognised in patients with ischaemic heart disease where obstructive sleep apnoea (OSA) may compound cardiac risk. Chronic heart failure patients also experience SDB. Whereas this was previously considered an end-stage phenomenon, recent work shows SDB occurs in as many as 50% of patients with mild to moderate heart failure [6], and these patients predominantly have central sleep apnoea (CSA)/Cheyne–Stokes respiration. While the evidence to support continuous positive airway pressure (CPAP) therapy in sleepy heart disease patents with OSA is secure [7, 8], controversy reigns over the value of treating CSA [9, 10]. The identification of heart failure patients with SDB is problematic, as while OSA patients are sleepy, heart failure patients with CSA are not [11]. In many European centres, sleep services fall within the compass of respiratory medicine, so cardiology and respiratory medicine teams must work together to develop sensible, practical strategies for screening sleep studies and applying effective therapy. As a by-product, this cooperative approach will facilitate research trials determining, for example, whether CPAP reduces cardiovascular risk …