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Atrial fibrillation (AF) is known to increase stroke risk and can be stratified clinically by the CHA₂DS₂-VASc scoring system, which then informs recommendations for long-term anticoagulation. Susceptibility to thromboembolism is also increased around the time of catheter ablation of AF. Mechanistically, this is accounted for by endothelial injury, hypercoagulability due to contact of blood with foreign surfaces and altered blood flow after conversion to normal sinus rhythm (figure 1).¹ The risk of stroke persists post-ablation, even in patients with low CHA₂DS₂-VASc scores, as the atria may remain stunned for several weeks post-ablation, and the endothelium takes time to heal. This phenomenon forms the rationale for guidelines currently recommending anticoagulation for two to three months post-ablation.² 

Brugada syndrome is a distinct arrhythmogenic disorder widely recognised as a sudden cause of death in the young. It is identified by a classical ST-segment elevation on electrocardiogram (ECG) that may be provoked in the context of a fever or vagal stimulation. The pathophysiology and genetic basis have been elucidated as an abnormality in ion channels. Diagnosis takes into account, not only the ECG, but clinical features and modulating factors; the inducibility of a suspect ECG when febrile is one such observation. Anti-arrhythmic drugs like ajmaline can also induce Brugada syndrome and have a role in its work-up. Electrophysiology studies may be useful in assessment and risk stratification of select cases. The management is centred around device therapy with the implantable cardioverter defibrillator (ICD), though pharmacological treatments are being actively pursued.

This article won first prize in the recent British Junior Cardiologists’ Association (BJCA) essay competition.

Coronary angiography stubbornly bucks the hospital-wide trend to non-invasive diagnostic tests. New imaging technologies offer paths to better ways to investigate and manage ischaemic heart disease. 

Spasm after transradial approach for catheterisation decreases procedural success and offers discomfort to the patient. Nitroglycerin is one of the drugs applied prophylactically to prevent spasm. The aim of this study was to assess the effect of preventive nitroglycerin on the comfort of patients during cardiac catheterisation.

A total of 328 patients were randomly assigned to receive either 200 µg nitroglycerin (n=164) or placebo (n=164). The main outcome was the evaluation of spasm using a visual analogue scale to measure the pain of the patient, and procedural time and radiation used to measure the operator difficulty during the examination. 

The pain evaluation was equal in both groups (nitroglycerin 24.74 vs. placebo 24.75, p=0.72). Using the operator’s impression, there was a higher incidence of spasm in the placebo group (9.1% grade 3 or 4 vs. 2.4% in the nitroglycerin group, p=0.004), while procedural time (21.36 minutes vs. 22.24 minutes, p=0.23) and radiation exposure (655.61 mGy vs. 660.92 mGy, p=0.63) were comparable in both arms.

In conclusion, the prophylactic use of nitroglycerin offers no advantage in terms of comfort to the patient during cardiac catheterisation by a transradial approach. Although there was difference in operators’ perception of spasm, omission of vasodilator does not cause any objective difficulty to operators.