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When I first arrived at Whitby Group Practice (WGP) in the middle 80s, my surgery was next to Whitby Hospital Outpatients, where Anthony Bacon conducted his cardiology clinic. Dr Bacon’s article on aortic stenosis was in our previous issue.¹ In this issue, Tariq Enezate and colleagues add to our knowledge of managing this condition.²

A syncope pathway for secondary care was launched in the Queen Elizabeth University Hospital (QEUH), Glasgow, in 2016. The pathway aims to risk stratify patients into three categories: high risk (requiring admission), intermediate risk (suitable for discharge ± outpatient review) or low risk (no further investigation required). There are clear referral procedures to the rapid access syncope clinic (RASCL). Our aim was to assess the impact of the pathway on unscheduled care in terms of admission rates, length of stay and referrals to RASCL.

Data were collected on three occasions: before the introduction of the pathway, immediately after and again 14 months later. Those patients with a diagnostic ICD-10 code of ‘syncope and collapse’ or ‘orthostatic hypotension’ presenting to the QEUH (both emergency department and immediate assessment unit, via GP referral) were identified.

There were 779 patients identified, 538 were included for analysis once other diagnoses were excluded: 46% were male with an age range from 16 to 95 years with a median age of 65.5 years.

All high-risk patients were admitted. For intermediate-risk patients the admission rate fell from 62% to 52% immediately after pathway introduction and after one year to 42%, suggesting sustained improvement (p=0.08). Admission for low-risk patients after one year of pathway roll out fell from 27% to 12% (p=0.04). The median length of stay prior to introduction was three days, this fell to one day one-year post-pathway, saving 56 bed days per month.

In conclusion, a syncope pathway and RASCL has reduced admission of low-risk patients, provided appropriate follow-up for intermediate risk, and reduced length of stay for those requiring admission.

National guidelines on lipid modification for cardiovascular disease advise checking a lipid profile in all patients admitted with acute coronary syndrome (ACS). It has been demonstrated that ACS can impact lipid profiles in an unpredictable fashion, so cholesterol measurements should be taken within 24 hours of an infarct. National guidelines also recommend initiating early high-intensity lipid-lowering therapy (i.e. statins) in ACS for secondary prevention of cardiovascular disease. We first assess compliance with these guidelines in a large city-centre teaching hospital and identify the need for any improvement. Following varied interventions aimed at highlighting the need for adherence to these guidelines we demonstrate a large increase in the number of ACS patients having lipids checked within 24 hours of their admission. In some instances, baseline cholesterol was not measured (either at all or prior to statin therapy), potentially leaving familial and non-familial hypercholesterolaemia undiagnosed. Encouragingly, statins are already prescribed in accordance with guidelines for the majority of ACS patients regardless of our campaign. We ultimately demonstrate there is still much work to be done locally to improve cholesterol management in ACS and hope that our findings will encourage others to ensure compliance and ultimately improve patient outcomes.

Emergency transvenous temporary pacing is a potentially lifesaving procedure that can be associated with significant complications. Historically, this procedure was performed by relatively inexperienced doctors. In recent years, there have been moves to improve the delivery of emergency pacing in UK hospitals.

We aimed to identify trends in temporary pacing experience among medical registrars in the southwest of England between 2008 and 2016. Registrars currently or previously accrediting with General Internal Medicine (GIM) were surveyed about experience in emergency transvenous pacing.

There have been significant changes in the delivery of temporary pacing over the two time points. Significantly fewer temporary pacing wires had been inserted by medical registrars in 2016 compared with 2008: mean 4.51 versus 9.82 (p<0.0001). Significantly more medical registrars had never inserted a temporary pacing wire in 2016 compared with 2008: 57/84 (67.9%) versus 18/94 (19.1%), p<0.0001. Registrars increasingly did not rate themselves to be fully competent to perform the procedure in 2016, 76/84 (90%), compared with 54/92 (59%) in 2008, p=0.0097. Perceptions regarding who should provide this service have changed. In 2008, 65/92 (79.6%) thought cardiologists should be the sole operators compared with 81/84 (96.4%) in 2016.

In conclusion, there has been a significant change in the provision of emergency temporary pacing services from 2008 to 2016. UK medical registrars no longer have the experience to perform this procedure. It is hoped that a rapidly delivered, cardiology-led pacing service will continue to improve safety and patient care.

Women are underrepresented in cardiology and there is a focus on increasing entry to the specialty and understanding how to overcome challenges. At the British Cardiovascular Society (BCS) annual conference 2019, there was a session dedicated to discussing barriers faced by women in cardiology and progress made in this area, making a ‘call to action’ for change. Representing and supporting women in cardiology is a priority of the BCS and the British Junior Cardiologists’ Association (BJCA). The BJCA has undertaken commendable work exploring challenges and proposing potential solutions: much of the data discussed in this article are from their annual survey or was reported at BCS 2019.