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Cardiorenal syndrome is a complex condition associated with significant morbidity in the form of symptoms secondary to fluid overload, leading to hospitalisations, and portends increased mortality. Both the diagnosis and management of the conditions are complicated by the fact that there is dysfunction of the heart as well as the kidney, usually with uncertainty with regards to the timing of the first insult. Management in primary care, or in the emergency setting, tends to be predominantly focused on short-term improvement in function of one organ, leading to deleterious effects on the other. A consensus multi-disciplinary approach involving both cardiologists and nephrologists has been advocated in order to devise a unified management plan. Our report presents findings of monthly cardio-nephrology multi-disciplinary team meetings and illustrates that this can be an efficacious approach both in terms of avoiding unnecessary outpatient clinic visits, as well as consensus decision-making.

Ventriculophasic arrhythmia (VPA) is an intriguing electrocardiogram (ECG) phenomenon, often seen in patients with complete heart block, and could sometimes pose a challenging diagnostic dilemma for physicians. By definition, in VPA, the P–P intervals that contain a QRS complex are shorter than the P–P intervals that do not have a QRS complex. VPA is often a tell-tale ECG finding of complete heart block. We describe a case in which paroxysmal VPA led us to diagnose complete heart block.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibro-inflammatory immune-mediated disease, which has been defined in the past few years. IgG4-RD affects various organs and leads to a variety of clinical manifestations. As it is a relatively newly defined entity, new manifestations are now being recognised and reported. We describe a case involving the cardiovascular system.

In 2015 one of my patients in the Fourier PCSK9 inhibitor trial asked me if I would like to attend his ‘bespoke’ total knee replacement operation. I said yes and witnessed an amazing procedure.

This article is available as a BJC Learning CPD activity

Coronary lithotripsy is a novel approach to percutaneous coronary intervention (PCI). It is based on well-established technology dating back to 1980 when lithotripsy was first used to treat renal calculi. Its application in cardiovascular medicine is a more recent development that involves using a low-pressure lithotripsy balloon to deliver unfocused acoustic pulse waves in a circumferential mechanical energy distribution. This causes fracturing of calcification within the surrounding vasculature, facilitating optimal stent deployment.

This article aims to review recent clinical experience and the published data regarding intravascular lithotripsy (IVL). All relevant articles were identified via PubMed using keywords including “intravascular lithotripsy”, “shockwave” and “coronary”. All studies that contained published datasets regarding IVL with patient numbers >50 were included for review. There were 116 results found. After reviewing all the publications, articles were then tabulated and 17 were found to be relevant, including only four clinical studies.

In this review we found that intracoronary lithotripsy for heavily calcified arteries appears to be a safe, effective, easy-to-use method of dealing with an otherwise technically-challenging and high-risk scenario. It appears to carry low risk, uses low pressures, and exerts its effects on both superficial and deep intravascular calcium. Further prospective data with long-term follow-up will be required to explore both the off-label uses of IVL (such as post-stent dilatation), and the long-term patency of these vessels.