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October 2019 Br J Cardiol 2019;26:149–52 doi: 10.5837/bjc.2019.033 Online First

Transcatheter aortic valve replacement in patients with systolic heart failure

Tariq Enezate, Jad Omran, Obai Abdullah, Ehtisham Mahmud

Abstract

New York Heart Association (NYHA) class IV heart failure is one of the factors used in predicting in-hospital mortality in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of systolic heart failure (SHF), aside from NYHA classification, on peri-procedural outcomes is unclear.

The study population was identified from the 2016 Nationwide Readmissions Data database using International Classification of Diseases-Tenth Revision codes for TAVR and SHF. Study end points included in-hospital all-cause mortality, the length of hospital stay, cardiogenic shock, acute myocardial infarction (AMI), acute kidney injury (AKI), mechanical complications of prosthetic valve, bleeding, and 30-day readmission rate. Propensity matching was used to create a control group of TAVR patients without a SHF diagnosis (TAVR-C).

A total of 5,674 patients were included in each group (mean age 79.9 years; 35.6% female). The groups were comparable in terms of baseline characteristics and comorbidities. TAVR-SHF was associated with significantly higher in-hospital all-cause mortality (2.7% vs. 1.9%, p<0.01), longer hospital stay (7.5 vs. 5.5 days, p<0.01), higher cardiogenic shock (5.1% vs. 1.6%, p<0.01), AMI (4.0% vs. 1.9%, p<0.01), AKI (18.7% vs. 12.4%, p<0.01) and mechanical complications of prosthetic valve (1.2% vs. 0.6%, p<0.01). There was no significant difference between TAVR-SHF and TAVR-C in terms of bleeding (19.5% vs. 18.2%, p=0.08) and 30-day readmission rate (10.8% vs. 10.2%, p=0.29).

Compared with TAVR-C, TAVR-SHF was associated with higher in-hospital peri-procedural complications and all-cause mortality.

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October 2019 Br J Cardiol 2019;26:157–8 doi: 10.5837/bjc.2019.034 Online First

The effect of ageing on the frontal QRS-T angle on the 12-lead ECG

Sadia Chaudhry, Jagan Muthurajah, Keoni Lau, Han B Xiao

Abstract

The frontal QRS-T angle (QTA) is widely available on routine 12-lead electrocardiograms (ECGs), but its practical significance is little recognised. An abnormally wide QTA is known to be a prognostic predictor of cardiovascular events. It has even been considered as a stronger prognostic predictor than the commonly used ECG parameters including ST-T abnormality and QT prolongation. The aim of this study was to investigate the influence of ageing on the QTA in a low-risk population where there were no obvious ECG abnormalities. Having analysed 437 consecutive patients, we found a positive correlation between age and QTA, but no age difference in heart rate, QRS duration, QT interval and P-wave axis. As hypertension was more prevalent in older patients, we compared patients with hypertension to those without and found no significant difference in QTA. Therefore, ageing alone is a significant contributory factor to the widening of QRS-T angle. Further study to confirm QTA as a prognostic predictor for all-cause mortality, independent of age itself and in the absence of ECG abnormalities, in an older population would be significant.

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October 2019 Br J Cardiol 2019;26:145–8 doi: 10.5837/bjc.2019.035 Online First

Clinical CMR: one-year case mix, outcomes and stress-testing accuracy from a regional tertiary centre

Protik Chaudhury, Min Aung, Rossella Barbagallo, Edward Barden, Swamy Gedela, Stuart J Harris, Henry O Savage, Jason N Dungu

Abstract

Cardiac magnetic resonance (CMR) imaging has developed into a crucial diagnostic tool in all patients with known or suspected heart disease. The aim of this study was to review real-world data regarding the case mix and performance of stress CMR for the large Essex region, a population of 1.4 million.

All studies from April 2017 to April 2018 were reviewed. All scans were performed on a 1.5-T scanner (Siemens MAGNETOM Aera). We have not included research scans or repeat studies. A total of 1,706 clinical studies were performed, including 592 adenosine stress perfusion scans (35%). Mean age of patients was 59 years ± 16 (range 16–97) and the majority were male (66%). Ischaemic heart disease (IHD) was diagnosed in 28% of patients. Objective ischaemia was evident in 226 cases (38% of all stress scans). The positive predictive value of stress imaging was 91%. Non-ischaemic cardiomyopathies were diagnosed in 598 patients (35%), including dilated cardiomyopathy (DCM, 23%) and hypertrophic cardiomyopathy (HCM, 8%) as the most common phenotypes. The mean left ventricular ejection fraction (LVEF) was 51% across all groups (range 3–78%) with a significant difference between ischaemic and non-ischaemic cardiomyopathy (48% vs. 41%, p<0.0001); despite this, there was no significant difference in survival (p=0.177).

In conclusion, stress perfusion imaging accurately identifies true-positive ischaemia, as well as offering additional information regarding cardiac structure. The burden of non-ischaemic cardiomyopathy in Essex is significant, with 50 new diagnoses per month, across five hospitals. Coordination of services is needed to standardise practice and management of cardiomyopathy patients.

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October 2019 Br J Cardiol 2019;26:137–40 doi: 10.5837/bjc.2019.036 Online First

PCSK9 inhibitors in familial hypercholesterolaemia: a real-world experience and a meta-analysis

Harshal Deshmukh, Deepa Narayanan, Maria Papageorgiou, Yvonne Holloway, Sadaf Ali, Thozhukat Sathyapalan

Abstract

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have opened a new avenue in the management of dyslipidaemia in patients with familial hypercholesterolaemia (FH), but real-world experience with PCSK9 inhibitors is limited.

We aimed to explore the efficacy and safety of PCSK9 inhibitors in a single-centre study, and to conduct a meta-analysis of the available observational studies to report pooled data on these efficacy and safety parameters.

The Hull PCSK9 inhibitor study consisted of patients from the Lipid Clinic at the Hull Royal Infirmary–Hull University Teaching Hospitals NHS Trust during the period 2016–2018. Patients with FH and atherosclerotic cardiovascular disease (ASCVD) were screened for eligibility and were prescribed PCSK9 inhibitors. Lipid profile, liver function, renal function, and creatine kinase levels were measured at baseline and after a 12-week follow-up. For the meta-analysis, review of the literature identified six additional observational studies for FH, which were used to calculate pooled percentage low-density lipoprotein (LDL)-cholesterol (LDL-C) reduction.

The Hull PCSK9 inhibitor study consisted of 16 patients with definite FH (LDL-receptor mutation-positive), 20 patients with clinical FH and 15 patients with ASCVD with a mean age of 60.6 ± 13.9 years, 60% female. Baseline median (interquartile range) LDL-C levels (mmol/L) in the definite FH, clinical FH and ASCVD were 4.9 (4.6–5.9), 6.7 (5.3–7.1) and 4.4 (4.1–4.7). After 12 weeks, the LDL-C levels (mmol/L) dropped significantly (p<0.0001) in all three groups to 2.0 (1.6–3.4), 2.3 (1.9–2.6) and 2.2 (1.7–2.8) in the definite FH, clinical FH and ASCVD groups, respectively. The meta-analysis of the seven observational studies in 446 patients with FH showed pooled mean reduction of 55.5 ± 18.1% in the LDL-C levels, with 58% of patients reaching treatment targets. Treatment-associated side effects occurred in 6% to 45% of patients, and 0–15% of patients discontinued treatment due to intolerable side effects.

In conclusion, we showed that PCSK9 inhibitors are overall well-tolerated when used in real-world settings, and their efficacy is comparable with that reported in clinical trials. Longitudinal population-based registries are needed to monitor responses to treatment, treatment adherence and side effects of these lipid-lowering agents.

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October 2019 Br J Cardiol 2019;26:159–60 doi: 10.5837/bjc.2019.037 Online First

Atypical presentation of STEMI with pericardial effusion causing cardiac tamponade related to malignancy

Matthew J Johnson, Rohan Penmetcha

Abstract

Cardiac tamponade and myocardial infarction (MI) are rare as the initial presentation of a malignancy. ST-elevation myocardial infarction (STEMI) and cardiac tamponade have been described to present together in the setting of a type-A aortic dissection causing coronary malperfusion. We describe a case with an atypical presentation of an MI due to a thrombus in the right coronary artery occurring simultaneously with a pericardial effusion causing tamponade physiology, related to malignancy. We present this unique case of MI and cardiac tamponade as it was not caused by a type-A aortic dissection. We suggest that malignancy be considered in the differential diagnosis when these findings present together.

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