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July 2024 Br J Cardiol 2024;31(3) doi: 10.5837/bjc.2024.027 Online First

Understanding the failings of yesterday to improve the outcomes of tomorrow: a Cardiorenal story

Matthew P M Graham-Brown, James O Burton, Rupert W Major

Abstract

“In spite of the accumulating evidence of their efficacy, established treatments for maintaining renal function remain woefully underutilized. Clinicians and health care systems must be encouraged to make use of these treatments.”1

The above was written in an editorial by Thomas Hostetter1 that accompanied three landmark nephrology trials published in 2001.2–4 The studies will be well-known to nephrologists and demonstrated that angiotensin-receptor blockers (ARBs) had anti-proteinuric effects and/or slowed the decline of kidney function in patients with diabetic kidney disease. These trials added weight to the evidence that supported the use of both angiotensin-converting enzyme inhibitors (ACEi) or ARBs in diabetic kidney disease and chronic kidney disease (CKD), particularly in patients with proteinuria.5 The evidence-base supporting the use of these drugs for patients with heart failure and cardiovascular diseases is unquestioned, and given the inter-related nature of the heart and the kidneys, the hope and optimism around these drugs was understandable. Dr Hostetter, however, was right to be cautious in his appraisal of the impact these medications might have on outcomes for patients with CKD, not because of the quality or compelling nature of the trial data, but because of the difficulties overcoming clinical and systems-related inertia to achieve effective implementation of the drugs. His predictions have proved cogent.

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July 2024 Br J Cardiol 2024;31(3) doi: 10.5837/bjc.2024.028 Online First

Correlation between simplified treadmill score, significantly stenosed blood vessels and SYNTAX score in CAD

Yusra Pintaningrum, Jeffrey D Adipranoto, Ketut Angga Aditya Putra Pramana

Abstract

The purpose of this study was to determine the correlation between the simplified treadmill score (STS) and both the number of blood vessels with significant stenosis and the severity of the SYNTAX score in patients with coronary artery disease (CAD). This was an observational, cross-sectional study conducted at Dr. Soetomo General Hospital and Premier Surabaya Hospital in Indonesia from January 2011 to February 2012.

The results of the analysis using the Spearman correlation showed that there was a strong positive relationship between STS and the number of blood vessels with significant stenosis (rs=0.616 and p<0.001). Similarly, the relationship between STS and SYNTAX score obtained (rs=0.500 and p<0.001) indicates a fairly strong positive relationship.

In conclusion, there is a significant correlation between the STS as a clinical reference for estimating the probability of CAD through a weight-training test with the number of blood vessels experiencing significant stenosis.

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July 2024 Br J Cardiol 2024;31(3) doi: 10.5837/bjc.2024.029 Online First

Simultaneous Takotsubo syndrome and spontaneous coronary artery dissection: a case report

Carla Oliveira Ferreira, Cátia Costa Oliveira, Carlos Galvão Braga, Jorge Marques

Abstract

A 59-year-old woman presented to the emergency room with sudden onset of retrosternal thoracic pain following emotional stress. The electrocardiogram (ECG) revealed T-wave inversions on precordial leads. Her blood analyses demonstrated elevation of myocardial necrosis markers (peak of troponin I of 3.4 ng/ml). Transthoracic echocardiogram (TTE) findings were consistent with Takotsubo syndrome, accompanied by mild left ventricular dysfunction. The patient underwent invasive coronary angiography revealing a spontaneous coronary artery dissection in the left anterior descending artery and left main artery. A repeat TTE one week later showed complete resolution of the segmental contractility with a full recovery of left ventricular function. Cardiac magnetic resonance imaging revealed no abnormalities. The patient was discharged on dual-antiplatelet therapy. A follow-up coronary angiography performed one month later confirmed complete resolution of the dissection. Takotsubo syndrome and spontaneous coronary artery dissection predominantly affect women and share common triggers. This case highlights the often misdiagnosed association and emphasises the specific diagnosis and treatment nuances associated with it.

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July 2024 Br J Cardiol 2024;31(3) doi: 10.5837/bjc.2024.030 Online First

Shortness of breath caused by a right ventricular metastasis: a case report

Muhammad Qasim Shahid, Suat Loo

Abstract

Cardiac metastases normally reflect diffuse metastatic spread of the primary tumour and are rarely found in isolation. We present a case of a 71-year-old man with a history of completely resected high-grade spindle cell sarcoma of the left thigh, who presented with shortness of breath, and was found to have a large right ventricular mass, subsequently diagnosed as a metastasis of the prior sarcoma. It was deemed inoperable and incurable, and the patient was offered palliative chemotherapy. Unfortunately, the patient died within four months of his original presentation.

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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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