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June 2024 Br J Cardiol 2024;31:58–60 doi: 10.5837/bjc.2024.022

Reducing heart failure deaths by 25% in 25 years: the ‘25in25’ heart failure summit

Lucy Beishon, Rebecca Jayasinghe, Carys Barton, Shahbaz Roshan-Zamir

Abstract

Heart failure (HF) is a major cause of morbidity and mortality in older people, and 80% of people with HF are aged over 60 years. HF is the end point for almost all common cardiovascular diseases, as well as many non-cardiovascular diseases. Despite this, HF remains underdetected and undertreated. Detection and treatment of HF has improved significantly in recent years, with several novel treatments developed in the last decade improving outcomes for patients. Therefore, earlier detection and improved treatment of HF has the potential to reduce morbidity and mortality for older people, particularly given the shift in ageing demographics anticipated over the coming decades. The British Geriatrics Society Cardiovascular Specialist Interest Group recently participated in the British Society for Heart Failure (BSH) ‘25in25’ Heart Failure Summit, which aims to reduce deaths due to HF by 25% in the next 25 years. The 2023 summit comprised experts from over 45 top health organisations across Europe, Canada and the US. The summit brought together cross-disciplinary expertise to support the implementation of strategies to improve outcomes for people living with HF, and, in this commentary, we reflect upon the priorities identified. We discuss the current barriers to the early detection and management of HF, and the particular challenges and complexity of managing HF in older people. Finally, we discuss the role of patient empowerment and how this can lead to improved care for older people living with HF.

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June 2024 Br J Cardiol 2024;31:65–8 doi: 10.5837/bjc.2024.023

The 2023 ESC heart failure guideline update and its implications for clinical practice

Ameer Rashed, Mohammad Wasef, Paul R Kalra

Abstract

In this article we focus on areas of the European Society for Cardiology (ESC) heart failure guideline 2023 update that will be most relevant in the day-to-day management of patients with heart failure. These include an expanded indication for sodium-glucose cotransporter 2 (SGLT2) inhibitors and intravenous iron, together with rapid optimisation of foundation therapies. With important outcomes for patients, there will undoubtedly need to be modifications to service delivery to ensure that they are widely available for patient benefit.

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June 2024 Br J Cardiol 2024;31:80 doi: 10.5837/bjc.2024.024

Emergency pacemaker implantation in nonagenarians with CHB: single- versus dual-chamber pacing

Edd Maclean, Karishma Mahtani, Maurizio Parker, Rohan Vyas, Roy Bo Wang, Marina Roelas, Nikhil Ahluwalia, Vijayabharathy Kanthasamy, Antonio Creta, Malcolm Finlay, Ross J Hunter, Syed Ahsan, Mark J Earley, Pier D Lambiase, James Elliott, Filip Zemrak, Amal Muthumala, Philip Moore, Simon Sporton, Anthony Chow, Christopher Monkhouse

Abstract

In ambulatory patients with complete heart block (CHB), dual-chamber (DDD) pacing confers physiological benefits versus single-chamber (VVI) pacing, however, the impact on mortality is disputed. Nonagenarians constitute an expanding proportion of pacemaker recipients, yet data on device selection and outcomes are limited, especially in emergency situations.

In nonagenarians with emergent CHB, we compared the clinical characteristics and outcomes of patients receiving VVI versus DDD pacemakers. Cox proportional-hazards analysis examined all-cause mortality and death from congestive cardiac failure (CCF).

There were 168 consecutive patients followed-up for 30.6 ± 15.5 months. Of these, 22 patients (13.1%) received VVI pacemakers; when compared with DDD recipients, these patients had similar median age (93 vs. 91 years, p=0.15) and left ventricular (LV) systolic function (LV ejection fraction [EF] 49.2% ± 9.7 vs. 50.7% ± 10.1, p=0.71), but were more frail (Rockwood scale 5.2 ± 1.8 vs. 4.3 ± 1.1, p=0.004) and more likely to have dementia (27.3% vs. 8.9%, p=0.011). Post-implant, device interrogation demonstrated that VVI recipients had higher respiratory rates (21.3 ± 2.4 vs. 17.5 ± 2.6 breaths per minute, p=0.002), lower mean heart rates (65.5 ± 10.1 vs. 71.9 ± 8.6 bpm, p=0.002), and lower daily activity levels (0.57 ± 0.3 vs. 1.5 ± 1.1 hours of activity, p=0.016) than DDD recipients. Adjusting for age, frailty and dementia, VVI pacing was associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.08 to 4.1, p=0.03) and death from CCF (adjusted HR 7.1, 95%CI 2.5 to 20.6, p<0.001).

In conclusion, in nonagenarians with emergent CHB, dual-chamber pacing was associated with improved symptomatic and prognostic outcomes versus single-chamber pacing.

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June 2024 Br J Cardiol 2024;31:68–72 doi: 10.5837/bjc.2024.025

Navigating the research landscape in cardiology. Part 3: the application process

Benjamin Dowsing, C Fielder Camm, Hibba Kurdi

Abstract

This editorial series explores research in UK cardiology and acts as a practical guide to trainees interested in pursuing early career research. Two earlier entries in the series have explored the rationale for pursuing research and how to identify a project and supervisor. We now take a closer look at navigating the application processes, including funding opportunities and regulatory approvals, to get your research off the ground.

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June 2024 Br J Cardiol 2024;31:79 doi: 10.5837/bjc.2024.026

Cardiovascular disease development in COVID-19 patients admitted to a tertiary medical centre in Iran

Erfan Kazemi, Salman Daliri, Reza Chaman, Marzieh Rohani-Rasaf, Ehsan Binesh, Hossein Sheibani

Abstract

Cardiovascular diseases (CVDs) have been reported to occur in a significant number of patients diagnosed with coronavirus disease 2019 (COVID-19). We report our experience regarding the occurrence of symptomatic and asymptomatic CVDs in COVID-19 patients. In this cross-sectional study, 690 COVID-19 patients were included. Cardiovascular consultation had been requested for all of the patients based on their primary clinical examination, vital signs, and electrocardiogram (ECG). Additionally, 2D transthoracic echocardiography (TTE), and myocardial injury serum biomarkers assays (creatine phosphokinase-MB [CPK-MB] and cardiac troponins [cTn]) were measured once. Manifestations of CVDs, such as chest pain, abnormal serum markers, unstable angina, myocardial infarction (MI), myocarditis, and new-onset hypertension, were documented. The most common symptom was left hemithorax and interscapular pain (317 patients, 46%). New-onset high systolic and diastolic blood pressures were seen in 67 patients (10%). Unstable angina, MI, and myocarditis were, respectively, diagnosed in 20 (2.8%), five (0.7%), and 12 (1.7%) patients. On TTE, pericardial effusion was diagnosed in 139 patients (31.1%). The most common abnormal ECG changes seen were regarding the T-wave, including flat T-wave (148 cases, 21.4%) and inverted T-wave (141 cases, 20.4%). Serum cTn levels were positive or weekly positive in 17 cases (7.4%). The incidence rate of cardiovascular involvements was high in COVID-19 patients.

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May 2024 Br J Cardiol 2024;31:49–54 doi: 10.5837/bjc.2024.018

Factor XI and XIa inhibition: a new approach to anticoagulant therapy

Mark Anthony Sammut, Nadir Elamin, Robert F Storey

Abstract

Factor (F) XI or XIa inhibition has attracted interest due to the protection from thrombotic events and minimal bleeding tendency observed in FXI-deficient individuals. The prospect of uncoupling the management of thrombosis from the bleeding risk inadvertently associated with current therapy inspired the development of agents directed towards this step in the coagulation process. This review describes the physiological rationale behind FXI/FXIa inhibition and the pharmacological properties of existing FXI/FXIa inhibitors. It also explores the potential clinical use of these agents in various thromboembolic pathologies, predominantly through the phase II clinical trials conducted so far comparing them to current anticoagulant therapy or placebo.

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May 2024 Br J Cardiol 2024;31:45–8 doi: 10.5837/bjc.2024.019

Cardiac ejection fraction as a problematic metric for heart failure phenotyping

Rienzi A Diaz-Navarro, Peter L M Kerkhof

Abstract

“Seek simplicity and distrust it.”
Alfred North Whitehead (1861–1947), English philosopher and mathematician

The metric ejection fraction (EF) is widely employed to evaluate ventricular pumping performance, used for heart failure (HF) classification, and its calculation is simple.1–3 For example, with end-systolic volume (ESV) =50 ml and end-diastolic volume (EDV) =100 ml, the EF=50%. Unfortunately, its correct interpretation received insufficient attention. As EF is a ratio-based number (or percentage) without physical unit(s), it cannot provide unique information. The underlying problem, and also a logical solution, can be shown by the ventricular volume domain representation (figure 1A) that relates ESV to EDV. Volumes may be indexed (i) for body surface area, if appropriate. Focusing on ESVi and EDVi is important, as this combination is associated with the familiar pressure–volume (PV) loop description, which, in turn, connects with clinically relevant characteristics, such as stroke work and myocardial oxygen consumption (MVO2).1

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May 2024 Br J Cardiol 2024;31:65–7 doi: 10.5837/bjc.2024.020

A retrospective observational study of certain interactions with simvastatin 40 mg in an acute hospital in England

Danita Boamah, Liam Bastian, Michael Wilcock

Abstract

The use of simvastatin 40 mg with various interacting medicines may lead to an increased risk of myopathy. We examined the extent to which hospital inpatients were prescribed simvastatin 40 mg with amiodarone, amlodipine, diltiazem, or verapamil, and assessed if any action was taken by prescribers or the pharmacy team to avoid this interaction. We found 56 patients on a combination of interest during their stay. Of the 20 (36%) patients not discharged on the combination, in six instances this was due to pharmacy intervention, while the remaining instances when simvastatin 40 mg or the interacting drug was amended or ceased were due to other clinical reasons. There is a need among clinicians and pharmacy teams within the hospital for recognition and management of these particular interactions.

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April 2024 Br J Cardiol 2024;31:43–4 doi: 10.5837/bjc.2024.013

The impact of air pollution on atherosclerotic cardiovascular disease development

Clayton Tewma, Justin Lee Mifsud

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide, causing around 17.9 million deaths annually, a third of whom are adults aged <70 years.1 In addition to genetic and behavioural risk factors (unhealthy diet, physical inactivity, and tobacco and alcohol abuse), inhaling airborne pollutants, such as fine particulate matter (<2.5 µm [PM2.5] and <10 µm [PM10]), ultrafine particles (UFPs; <100 nm), nitrogen dioxide (NO2), ozone (O3), and sulphur dioxide (SO2), are associated with ASCVD among adults.2

Air pollution has been referred to as “the single most important environmental factor presenting a risk to health and represents a greater disease burden than polluted water, soil contamination and occupational exposures combined”.3 Air pollution is a silent killer and was highlighted as a significant public health concern in the recently published European Society of Cardiology (ESC) guidelines.4

The impact of urbanisation on air pollution levels is a critical concern for countries like Malta, which have adopted a city model to bolster their economies. Despite efforts to stimulate economic growth, the rise in urbanisation can pose risks to air quality. In London, mean PM2.5 concentrations stood at approximately 12.7 µg/m³ in 2017, 12.0 µg/m³ in 2018, and 11.4 µg/m³ in 2019.5 Conversely, Valletta, Malta’s capital, recorded mean PM2.5 concentrations of about 14 µg/m³ in 2017, 14.4 µg/m³ in 2018, and 14 µg/m³ in 2019.6 While both have seen improvements in their aggregated annual mean PM2.5 concentrations compared with the concentration levels recorded in the past decade, they still exceed the World Health Organisation (WHO) annual air quality guideline value by approximately 1.14 to 1.4 times, highlighting the persistent challenge of air pollution in urban environments.

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