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The concept of nurse-led angiography was first introduced in the UK just over two decades ago. This was in response to concerns raised following implementation of the Calman report.¹ The Calman report recommended a structured training programme for cardiology registrars, thus, achieving clinical competence at a faster rate, with a view to filling anticipated consultant vacancies. However, it was presumed that this would negatively impact clinical service delivery. One particular concern was that there would be a reduced number of registrars available and able to perform coronary angiography. There was a fear that this shortfall would lead to reduced throughput within cardiology centres. Boulton et al. described a potential solution to this shortfall: the training of a clinical nurse specialist to perform coronary angiography.² The aim was to teach the nurse-angiographer the technical skills to undertake coronary angiography, with a head-to-head comparison of procedural time, radiation exposure, and complication rate. The results were impressive with the nurse-angiographer demonstrating a numerical reduction in complication rate and fluoroscopy time. These results were similar to those of DeMots et al., who trained a physician assistant in Portland, Oregon to perform coronary angiography with a view to reducing the workload of trainee cardiologists.³

In this issue of the British Journal of Cardiology Yasin et al. describe the implementation of nurse-led angiography at Wycombe Hospital. Although not novel, the findings are certainly interesting. They performed a comparison of nurse-led coronary angiography with registrar-led angiography in an observational study of 200 patients. They examined procedural time, radiation exposure, contrast load and complication rates. Albeit small numbers, they demonstrated that nurse-led angiography was associated with a reduction in radiation and contrast load, concluding that a non-medical operator can be taught the technical skills required to perform coronary angiography safely. However, the observational nature of this study limits the conclusions that can be drawn. Although appropriate at an early level of training, the patients that underwent nurse-led angiography were a highly select ‘safe’ patient group, and, without baseline characteristics, it is not possible to determine if one arm of the study had more comorbidities than the other.

Atrial fibrillation (AF) and diabetes are chronic conditions, which are increasing in prevalence. Stroke is a recognised complication of both conditions and can often be prevented through detection and appropriate intervention. Screening for disease has also improved over the last few decades through a plethora of tools and advances in technology. AF impacts physically, psychologically, socially and economically, and does not always present with symptoms. AF can be detected through electrocardiogram (ECG) monitoring and pulse checks, with high-risk groups typically targeted. When AF is detected, medication to control heart rate and anticoagulation can be started to reduce subsequent risks. AF is underdiagnosed in the community, particularly in the elderly, and the condition lends itself to screening.¹

A review of the evidence for AF screening demonstrates a lack of homogeneity, with different target populations. High-risk groups have varied and include those with hypertension, stroke, myocardial infarction, older age and diabetes. Although the pathophysiological relationship between AF and diabetes is not entirely understood, there is an acceptance that the coexistence imposes greater risk to the patient in terms of comorbidities including stroke.

Echocardiography is key for the assessment of aortic stenosis (AS), but taking a good history is also crucial and requires specialist competency. Symptomatic AS requires surgery and, if physicians miss the onset of symptoms, the risk of death rises from 1% per annum in patients without symptoms to 14% on a six-month surgical waiting list. A case is described illustrating the difficulty of obtaining the history in a patient with AS, and suggests how to take a careful history and questions to ask. Patients with a murmur suggesting AS should be considered for a specialist valve clinic.

Over 50,000 cardiac implantable electronic device procedures are undertaken annually in the UK. Despite prophylactic measures, device infection still occurs. Anaphylaxis following teicoplanin is extremely rare with evidence limited to case reports and one case series. We present two fatal cases of anaphylaxis following teicoplanin administration. Both cases meet the World Allergy Organisation definition of anaphylaxis. These cases highlight the importance of anaphylaxis to teicoplanin as a procedural complication. Despite prompt treatment, this reaction was fatal. Operators should be aware of this risk in an era of increasing procedures and rising incidence of anaphylaxis.

Pericardial involvement is sporadic during pregnancy. We present the case of a young woman who presented to the emergency department with a short history of rapidly progressive dyspnoea in her 38^th week of pregnancy. Coronary arteriovenous fistula (CAVF) has been uncommonly described as a cause of pericardial effusion. We believe this is a rare case of a CAVF presenting as cardiac tamponade in pregnancy.