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This article is available as a 'Learning with reflection' CPD activity

In November 2016, the National Institute for Health and Care Excellence (NICE) published an update of its guideline for the investigation of chest pain of recent onset (CG95), bringing computed tomography coronary angiography (CTCA) to the forefront as the first-line investigation. CTCA has a high negative-predictive value for the identification of obstructive coronary artery disease (CAD), but its positive-predictive value may be as low as 48%. Moreover, until recently it was unable to determine the functional significance of stenoses identified by CTCA. Using advanced computational fluid dynamics (CFD), HeartFlow® has pioneered a system that can predict the invasive fractional flow reserve (FFR) from a standard CTCA acquisition (FFR_CT). The PLATFORM study has demonstrated that the use of CTCA with FFR_CT was associated with equivalent clinical outcomes in terms of major adverse cardiovascular events (MACE) and quality of life at one year compared with usual testing. The global ADVANCE registry, and other long-term follow-up studies in over 9,000 patients, have demonstrated extremely good long-term outcomes when patients with CAD but negative FFR_CT are managed conservatively without invasive testing. In a technology appraisal (MTG32), NICE projected that the adoption of this technology within the NHS in England could save at least £9.1 million by 2022. While it is accepted that the HeartFlow® FFR_CT shows a lot of promise, there are a number of limitations that need to be considered.

Radial artery access coronary angiography is associated with high procedural success and lower rates of complications, compared with femoral access, in patients without prior coronary artery bypass surgery (CABG). Whether or not this applies to patients who have undergone CABG is not known.

We retrospectively examined hospital records of 5,993 consecutive patients undergoing coronary angiography to identify patients with previous CABG undergoing the procedure by the radial or femoral access routes. We compared clinical characteristics, procedural success and complications up to 30 days, adjusting for significant baseline differences.

Among the 5,993 patients undergoing angiography, 471 (8%) had previous CABG; 164 (35%) underwent angiography by the radial and 307 (65%) by the femoral artery. Procedural success was lower in the radial than femoral groups; 28/164 (17%) radial versus 1/307 (0.3%) femoral patients required access-site cross-over (p<0.001) and 254/347 (73%) versus 496/594 (84%) bypass grafts were selectively identified without the need for further imaging investigations (p=0.008), respectively. Access-site bleeding requiring compression affected 1/164 (0.6%) in the radial group and 12/307 (3.9%) in the femoral group (p=0.04 for difference) with no significant differences in other major complications.

About one in 12 patients undergoing coronary angiography have had previous CABG surgery. In such patients, the radial access route was associated with lower procedural success than the femoral route but also a lower rate of bleeding complications.

We describe a case of primary meningococcal Y effusive pericarditis in a previously fit and well 35-year-old man who presented with a rapidly developing pericardial effusion resulting in cardiac tamponade. This is a rare, but important, cause of primary pericardial disease, and only the fourth documented case of primary meningococcal pericarditis due to Neisseria meningitidis serotype Y. Our patient was successfully treated with a pericardial drain and intravenous ceftriaxone. Our case highlights the importance of adverse clinical features such as temperature >38°C, subacute course, large effusion or tamponade, and non-steroidal anti-inflammatory drug (NSAID)/aspirin failure, which can identify patients who require close observation as they are at higher risk of complications.

The All-Party Parliamentary Inquiry¹ into heart failure reported in September 2016. The inquiry’s aim was to understand what the key issues were in heart failure and what needs to happen to address deficiencies. Data presented to the inquiry highlighted the significant impact of the role played by the heart failure specialist nurse (HFSN). The evidence-base behind the role of the HFSN has shown that these highly skilled individuals have been able to reduce morbidity, mortality and provide patients and carers with holistic and effective care.² The patients that contributed to the inquiry spoke of the immense support and care that they received from their HFSN. However, further data emphasised that access to a HFSN was inequitable, with anecdotal experience suggesting that services are being decommissioned as a result of reorganisation of services and nurse retirement.

Angiography of internal mammary artery (IMA) grafts continues to be a common indication for upfront femoral access. This is particularly the case for bilateral pedicled IMAs, or when the left radial artery has been grafted. While the right radial artery is ideally suited in these situations for cannulation of the right IMA, accessing the left IMA (LIMA) by this route is often perceived as challenging and for ‘radial evangelists’ only. We describe a case series showing a simple technique for selective cannulation of the LIMA from the right radial artery using a single catheter that provides sufficient backup for percutaneous coronary intervention (PCI).