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Carcinoid heart disease (CHD) is a serious complication of metastatic neuroendocrine tumours (NETs) and a key driver of symptom burden, functional limitation, and overall prognosis. Up to 20% of patients with carcinoid syndrome have CHD at diagnosis, and approximately 50% develop cardiac involvement over the course of the disease.^1,2 Beyond highlighting the prognostic burden of CHD, the case report from this issue, Hickson et al. https://doi.org/10.5837/bjc.2026.054, presents an opportunity to reflect on how developments in CHD management and adjunct tumour-directed therapies have contributed to improved outcomes in the last few decades.

We present a case of carcinoid heart disease as a consequence of a metastatic neuroendocrine tumour. The importance of recognising carcinoid syndrome as a cause of tricuspid and pulmonary valve pathology, as well as potential treatment, are discussed.

Although international guidelines for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) have recently been updated, uncertainty remains about the optimal timing of an invasive strategy (IS). Further randomised trial data comparing such strategies have been published and merit inclusion in an updated analysis. We conducted a systematic review and meta-analysis to consolidate the current evidence-base.

A systematic review of randomised-controlled trials (RCTs) comparing early versus delayed IS was performed by searching MEDLINE, Embase and the Cochrane Central Register for Clinical Trials. Meta-analysis was performed by pooling the relative risks using a random-effects model. The primary outcome was all-cause mortality, while secondary end points included myocardial infarction (MI), recurrent ischaemia, admission for heart failure (HF), repeat revascularisation, major bleeding and stroke. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42024578335).

Data from 18 RCTs were included in the analysis. There was no statistically significant difference in all-cause mortality (relative risk [RR] 0.89, 95% confidence interval [CI] 0.77 to 1.03), MI (RR 0.86, 95%CI 0.65 to 1.15), repeat revascularisation (RR 1.05, 95%CI 0.89 to 1.22), major bleeding (RR 0.89, 95%CI 0.70 to 1.12) or stroke (RR 0.93, 95%CI 0.58 to 1.48) between the groups. However, early IS was associated with a reduction in recurrent ischaemia (RR 0.54, 95%CI 0.38 to 0.78) and admission for HF (RR 0.76, 95%CI 0.60 to 0.95).

In conclusion, in patients admitted with NSTE-ACS, early IS was not associated with a reduction in all-cause mortality, repeat revascularisation, MI, major bleeding or stroke. Early IS reduced the risk of recurrent ischaemia and admission for HF.

Hypertension is the leading modifiable cardiovascular risk factor worldwide.¹ Effective and inexpensive treatments are available, yet blood pressure control remains suboptimal in many countries.² In Sweden, as in many other healthcare systems, hypertension management is largely delivered through primary care. This creates a major challenge, as the increasing number of patients with hypertension places additional pressure on a primary care already strained by workforce shortages and the growing healthcare needs of an ageing population.

Coronary artery anomalies (CAAs) are typically discovered by accident during imaging. We describe a 57-year-old man who presented with chest pain suggestive of acute coronary syndrome. Invasive angiography revealed unobstructed coronaries with an anomalous left anterior descending (LAD) artery originating from the right coronary sinus. Computed tomography coronary angiography confirmed its anomalous nature and revealed a trans-septal (intramuscular) course between the aortic root and right ventricular outflow tract. This configuration is regarded as benign, unlike inter-arterial forms associated with ischaemia or sudden cardiac death. The patient remained asymptomatic on follow up. This case highlights the value of multimodal imaging in accurately assessing coronary anatomy, avoiding misdiagnosis and directing the appropriate course of treatment.

The 2026 European Society of Cardiology (ESC) heart failure guidelines represent an important shift in how we think about this disease.¹ Heart failure (HF) is no longer simply a syndrome treated once symptoms develop; it is a continuum from cardiovascular risk to cardiac change and overt disease. The greatest gains may come from identifying patients earlier, before irreversible changes occur. The question is no longer simply, “How should we treat HF?”, but “How early should we intervene, and can we prevent it?”

It is impossible to cover every change within such comprehensive guidelines in a single opinion piece. We, therefore, focus on four clinically important developments: the prevention-focused stages A–D, revised left ventricular ejection fraction (LVEF) classification, replacement of guideline-directed medical therapy (GDMT) with more precise terminology, and earlier referral in stage D.

Cardiovascular–kidney–metabolic (CVKM) care is increasingly recognised as a more realistic way to understand and manage chronic disease. Cardiovascular disease, chronic kidney disease (CKD), type 2 diabetes, obesity, and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently co-exist, share major risk factors, and influence one another biologically and clinically. Yet care delivery across the National Health Service (NHS) remains largely organised around separate pathways, disease-specific targets, and professional silos. This creates a practical mismatch between integrated disease biology and fragmented service delivery.^1–3

A coherent CVKM approach is, therefore, not simply a new label for existing practice. It is a shift in clinical reasoning and system design: away from isolated disease management and towards integrated risk reduction, prioritisation, and patient-centred decision-making.^4,5 The challenge is no longer only to identify effective therapies, but to deliver them in ways that are meaningful, equitable, and sustainable across real-world primary and secondary care.^6–8

To pace or not to pace? Clinical decision-making for older people with frailty and bradycardia is often challenging. For ambulatory, symptomatic patients a pacing strategy is clearly recommended, however, for those patients with severe frailty or limited mobility with an absence of clearcut symptoms, management strategies usually take a shared decision-making approach. How are clinicians expected to provide patients and carers with an objective picture of things to come in such an evidence-light space? The featured publication by Warraich et al., entitled “Outcomes of bradyarrhythmia device implantation: a single-centre retrospective cohort study”, from this issue at https://doi.org/10.5837/bjc.2026.052, is a call to arms to aid clinicians by providing some metrics around the likelihood of benefit. Bradycardia and bradyarrhythmias are common in older people reaching the end of their natural life, and patients, families and clinicians are reluctant to implant a pacemaker device when impact on quality of life is doubtful. This said, syncope can have devastating consequences, particularly hip fractures and head injuries, so there is a risk either way. Geriatricians are heavily invested in falls prevention, and the promotion of physical activity to improve health and wellbeing in the latter stages of life, so implantation is usually the preferred choice in the majority of cases, but where should we draw the line?

There is growing evidence for mortality with increasing age and comorbidities in implantable cardiac defibrillator receivers. We aimed to characterise how frailty and comorbidities impact mortality in patients receiving simple bradyarrhythmia device implants.

A retrospective cohort of 700 consecutive individuals who underwent novel bradyarrhythmia devices in a single centre were studied. Results were analysed using a multi-variate Cox regression model hazard ratios (HR) and Kaplan-Meier curves.

Mean implant age was 78.4 ± 10.3 years; 53.9% inpatient implants. All-cause mortality rate was 12.4% at one year. Mild-to-severe frailty measured by Rockwood frailty score (RFS) 5–9 was associated with mortality overall (HR 1.70, 95% confidence interval [CI] 1.30 to 2.21). Both inpatient (HR 1.57, 95%CI 1.19 to 2.08) and single-lead implants (HR 1.63, 95%CI 1.20 to 2.21) were associated with mortality.

Patient characteristics include male gender (HR 1.49, 95%CI 1.15 to 1.92) and age per 10-year increment (HR 1.75, 95%CI 1.46 to 2.09), heart failure syndrome (HR 1.52, 95%CI 1.13 to 2.05), valvular heart disease (HR 1.88, 95%CI 1.33 to 2.65), obesity (HR 2.97, 95%CI 1.42 to 6.21), chronic kidney disease (HR 1.34, 95%CI 1.00 to 1.79) and malignancy (HR 1.55, 95%CI 1.09 to 2.19) were associated with mortality.

In conclusion, higher RFS, male gender, heart failure syndrome, valvular heart disease, chronic kidney disease, obesity and malignancy were associated with mortality. Although advanced age does not preclude pacing, consideration should be given to frailty, which may detract from any perceived benefit bradyarrhythmia correction may offer.