February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.002 Online First
Nora C Fabich, Harpal Harrar, John B Chambers
Structural heart disease may be missed using clinical examination alone and limited echocardiograms or ‘quick-scans’ may be a way to improve rates of detection. To evaluate the finding of clinically unexpected abnormalities using ‘quick-scans’, scans were performed in a general practice by a level 7 sonographer using a GE V scan system. Indications were: murmur; potentially cardiac symptom (e.g. chest pain or breathlessness); cardiac history in the GP notes (e.g. myocardial infarction); atrial fibrillation; chronic obstructive pulmonary disease with disproportionate dyspnoea; age ≥75 years. Standard transthoracic echocardiograms were performed if clinically indicated or if the ‘quick-scan’ detected a significant abnormality.
There were 163 ‘quick scans’ indicated, which were normal in 80 (49%), mildly abnormal in 67 (41%) and significantly abnormal in 16 (10%). Abnormalities were moderate left ventricular (LV) systolic dysfunction, moderate mitral regurgitation, moderate-to-severe aortic stenosis and mild aortic dilatation. Within the 90 patients without agreed indications the ‘quick-scans’ were normal in 64 (71%) and mildly abnormal in 26 (29%) while none were significantly abnormal.
In conclusion, ‘quick scans’ can detect clinically unexpected pathology. These results are consistent with a global move to use the hand-held ultrasound machine as an extension of the clinical examination.
February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.003 Online First
Andrew Workman, Gavin Lewis, Peter Currie
Focused cardiac ultrasound using a pocket-sized imaging device (V scan) is increasingly being used to screen patients in the emergency setting for structural heart disease. We describe a patient who presented with light-headedness and pallor with elevated high-sensitivity troponin T (hs-TnT) and was initially thought to have acute coronary syndrome. A screening focused cardiac ultrasound revealed a dilated right ventricle with normal left ventricular function, and a computerised tomography pulmonary angiogram (CTPA) demonstrated a large saddle pulmonary embolus. The case highlights the application and utility of focused cardiac ultrasound and provides an overview of its current role in the acute setting reinforced by current guidelines from the European Society of Cardiology.
February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.004 Online First
Linzy Houchen-Wolloff, Amye Watt, Sally Schreder, Sally Singh
People with chronic heart failure (CHF) often experience exacerbations of their symptoms that require hospitalisation. The feasibility, safety and efficacy of early post-exacerbation rehabilitation are largely unknown in this population.
This was a single-centre, feasibility trial of early rehabilitation versus usual care. Those assigned to the intervention started rehabilitation within 10 days of discharge and attended supervised sessions twice per week for eight weeks. The primary outcomes were feasibility of uptake and safety. Assessments were performed at baseline and three months: exercise tolerance (shuttle walking tests) and health status (questionnaire).
There were 1,298 patients screened, 16 patients recruited (<1% of those screened) and 11 randomised (five rehabilitation, six control). The primary reasons for exclusion were contraindication to exercise and normal ejection fraction. There were improvements in exercise tolerance and health status in both groups at three months; however, the study was not powered to report any within- or between-group significance. The early rehabilitation intervention was safe with no adverse events reported.
In conclusion, early rehabilitation, for patients with CHF, was unfeasible. The 10-day recruitment target was too restrictive in this population. This is important because there has been a drive towards early rehabilitation in CHF guidelines.
February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.005 Online First
Rajdip Dulai, Azeem S Sheikh, Amer Qureshi, Shanit Katechia, Yulia Peysakhova, Moira Johns, Sajjad Mazhar
The proportion of patients with heart failure with preserved ejection fraction (HFPEF), compared with those with reduced ejection fraction (HFREF), is significant and rising. Studies have used an ejection fraction (EF) >50% as the sole criteria for identifying patients with HFPEF. However, European Society of Cardiology (ESC) guidelines include the diagnostic criteria of EF >50% and evidence of diastolic dysfunction.
In this retrospective cohort study based on admissions in 2012; we compared characteristics, treatment and outcomes between HFPEF and HFREF patients. One year readmission and survival rate was also assessed.
Overall, 41 (17%) patients had HFPEF (EF >50% and either medial or lateral E/E’ >15) compared with 200 (83%) with HFREF. Age was similar between the two groups (HFPEF: 84 ± 9 vs. HFREF: 82 ± 14, p=0.106). HFPEF patients were significantly more likely to be female (71% vs. 41.5%, p=0.001) and significantly less likely to have ischaemic heart disease (34% vs. 52%, p=0.043). Patients with HFPEF were significantly less likely to be taking loop diuretics, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors and aspirin on discharge. Ischaemic heart disease was a significant predictor of mortality in HFPEF patients (hazard ratio [HR] 7.14; 95% confidence interval [CI] 1.51–33.85, p=0.01). There was no difference in readmission and one-year survival rate (p=0.68 and p=0.551, respectively).
In conclusion, HFPEF patients are more likely to be female but less likely to have an ischaemic aetiology. There were significant differences in treatment of both phenotypes. Both groups have a similar poor prognosis.
February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.006 Online First
Cindy San, Doson Chua, Hilary Wu, Jian Ye
Delays in achieving target international normalised ratio (INR) with warfarin after cardiac surgery can lead to suboptimal outcomes. The aims of the study are to determine the difference in warfarin dosage requirements, before and after cardiac surgery, needed to achieve therapeutic anticoagulation.
A single-centre, retrospective review was conducted from 2012 to 2014 in cardiac surgery patients who were on warfarin pre-operatively and who had warfarin therapy resumed postoperatively in hospital. The primary outcome was the difference in warfarin dosage needed to achieve target INR before and after cardiac surgery.
Ninety-five patients were included in the study. The mean daily postoperative warfarin dose needed for achieving a therapeutic INR was 0.18 mg lower than the mean pre-operative dose (5.03 ± 2.10 vs. 4.85 ± 2.25 mg; p=0.358).
In conclusion, there was no statistically significant difference in the warfarin dosage before and after cardiac surgery needed to achieve target INRs.
February 2016 Br J Cardiol 2016;23:(1) doi: 10.5837/bjc.2016.007 Online First
Aaron Koshy, Andrew L Clark
Conducting clinical research is an ambition of many cardiologists and academic clinicians. Over the last decade, the National Health Service (NHS) has indicated that research is a clear priority in improving healthcare for patients. The processes leading to permission to start a clinical trial in the UK are, however, poorly understood, labyrinthine and fraught with difficulty. In this article, we aim to share our knowledge of initiating a clinical trial using a case study, with a focus on the essential documents and the communication required with different organisations.
MEETING REPORT Online First
MEETING REPORT Online First
MEETING REPORT Online First