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Acute coronary syndromes (ACS) are common in patients with end-stage renal disease (ESRD). Diagnosis may be challenging given diverse symptomatology, absence of classical symptoms on presentation, and difficulties in the interpretation of biomarkers. Morbidity and mortality in this patient population remain high compared with patients with normal renal function, partly due to a lack of evidence for optimal management. This review presents a summary of the diagnostic features and early management of ACS in patients with ESRD on haemodialysis.

Acute coronary syndrome (ACS) events in people receiving long-term haemodialysis (HD) are common, present atypically and are associated with poor outcomes.^1–3 Diagnosis is challenging, and treatment even more so. The complexity of this population drives their exclusion from clinical trials, resulting in a scarcity of evidence supporting any ‘optimal’ treatment strategy.⁴ Guidelines are, as a result, vague and, to a degree, contradictory.^5–7 These are some of the reasons that the combination of cardiac and renal disease strike fear into even the most seasoned clinicians. Is it this fear that underlies the observed conservatism in treatment of those with advanced chronic kidney disease (CKD), and are we, therefore, contributing inadvertently to the adverse outcomes we are simultaneously striving to avoid? I commend Muhammad Haider and colleagues for tackling this challenging area, and attempting to summarise our knowledge in their review: “Diagnosis and management of ACS in patients with ESRD on haemodialysis: a comprehensive review”.⁸

This review provides information about the current evidence-base for screening for atrial fibrillation (AF). The current burden of AF and recommendations related to AF screening are discussed, and randomised-controlled trial evidence for AF detection, clinical outcomes, harms and cost-effectiveness of population-based AF screening are reviewed. Finally, novel methods to refine the population to whom AF screening should be offered, which may improve clinical and cost-effectiveness, are considered.

Coronary artery spasm (CAS), or Prinzmetal angina, is a recognised cause of myocardial ischaemia in non-obstructed coronary arteries which typically presents with anginal chest pain. This case report describes an atypical presentation of CAS in a 68-year-old white British male with cardiovascular risk factors. The patient presented with recurrent palpitations and pre-syncope, with no chest pain. Ambulatory electrocardiography (ECG) monitoring revealed recurrent polymorphic ventricular tachycardia (PMVT). Coronary angiography identified moderate stenosis of the right coronary artery (RCA), without significant flow restriction by invasive pressure wire interrogation.

Inpatient monitoring revealed episodes of recurrent PMVT coinciding with transient inferior ST elevation and a distinct ‘shark fin’ waveform, indicating dynamic RCA occlusion. The arrhythmias persisted despite initial medical management, including calcium channel blockers and intravenous glyceryl trinitrate. Percutaneous coronary intervention to the moderate RCA lesion was performed, which definitively treated the arrhythmias.

This case emphasises the importance of recognising plaque-associated CAS as a potential trigger for life-threatening arrhythmias, even in the absence of chest pain. While medical therapy remains first-line treatment, life-threatening presentations may necessitate invasive interventions to stabilise the patient and prevent recurrence.

Pericardial cyst is a rare diagnosis, mainly considered a congenital condition. Most patients with pericardial cysts present without symptoms. Symptomatic presentation often relates to the size and location of the pericardial cyst. We report a case of a 49-year-old man who presented with subacute breathlessness in which the diagnosis of a pericardial cyst was made following various investigations – from transthoracic echocardiography and computed tomography scan to video-assisted thoracoscopic surgery biopsy, upon which a histological diagnosis was made. This case report reviews and discusses the available literature on the epidemiology and potential presenting features of a pericardial cyst, and the current recommended assessment and management strategies thereof. This case highlights the importance of effective multidisciplinary communication and joint input towards clinical decision-making, particularly in complex scenarios, to achieve optimal patient outcomes.

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

Though a rare condition, acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality; hence, timely diagnosis and surgery are important to reduce the risk of mortality. If the dissection extends into the aortic arch branches, ensuring adequate cerebral perfusion during surgery is crucial to preventing stroke.

A 50-year-old man presented to the emergency department with symptoms of acute chest pain, dizziness, and headache. His blood pressure was 180/110 mmHg and heart rate was 100 bpm. He had a high blood pressure and heart rate and was initially treated with glyceryl trinitrate. Initial investigations ruled out acute coronary syndrome. Further investigations revealed ATAAD with the involvement of arch branches, an incomplete (open) circle of Willis and cerebral malperfusion. He was prepared for a branch-first total aortic arch replacement. Due to the high risk of stroke in this patient, off-pump axillo-axillary bypass (adaptive perfusion technique) was used to ensure bihemispheric cerebral perfusion throughout the surgery. The surgery was uneventful, and the patient was discharged 12 days later. Postoperative follow-up at six months was normal.

In conclusion, ATAAD is a surgical emergency that can mimic other acute thoracic conditions, such as pulmonary embolism and acute coronary syndrome; therefore, a judicious approach should be applied in the diagnosis and early management of symptoms. The reconstruction technique should be tailored to the patient’s needs; as this patient had a poorly functioning circle of Willis and cerebral hypoperfusion, continuous bilateral cerebral perfusion was essential to prevent irreversible cerebral ischaemic insult. The adaptive technique is easy to learn for surgeons who are already proficient in aortic dissection procedures, it is reproducible and requires only minor changes to the surgical setup without any substantial increase in operative time. Adoption of this technique in other surgical centres could be beneficial in increasing the success rate for the treatment of ATAAD.

In heart failure patients with reduced ejection fraction (HFrEF) requiring a pacemaker, biventricular cardiac resynchronisation therapy (CRT) is preferred to right ventricular (RV) pacing. Moreover, HFrEF patients who already have a conventional pacemaker in situ should be considered for CRT ‘upgrade’ in the presence of worsening symptoms and a significant proportion of RV pacing. While international guidelines are clearly defined, the ‘real-world’ prevalence of upgrading to CRT in patients with a significant proportion of RV pacing remains unclear. We aim to report the prevalence and characteristics of CRT upgrades in a UK district general hospital over a 10-year period.

We performed a retrospective univariate analysis of consecutive adult patients who underwent pacemaker implantation for Mobitz type 2 and complete atrioventricular (AV) block from January 2009 to December 2018. Over the study period, 34 patients were upgraded to CRT (prevalence 4.6%). Male patients were more likely to receive CRT upgrade (p=0.027). There was no statistically significant difference in RV-pacing burden or RV-paced QRS duration between CRT upgrade and non-upgrade groups. Patients who received CRT had lower baseline left ventricular (LV) ejection fraction than the non-upgrade group (50% vs. 60%, p=0.049).

In conclusion, this real-world study supports the notion that patients with impaired LV function and likely high requirements for RV pacing should be informed of the possible future need for device CRT upgrade. CRT should be considered upfront in selected patients with lower baseline LV systolic function.

Retinal ischaemic perivascular lesions (RIPL) are characterised on spectral domain optical coherence tomography (SD-OCT) as focal thinning of the inner nuclear layer (INL) associated with outer nuclear layer (ONL) upward expansion. We present a small case series of 11 patients and reviewed all relevant original research on RIPL and its association with cardiovascular diseases (CVD). All 11 patients had RIPL incidentally identified on SD-OCT by two consultant ophthalmologists during a routine medical retina clinic. We obtained a thorough medical history to identify risk factors and CVD. The most common risk factor was type 2 diabetes mellitus (90.9%), followed by hypertension (81.9%). A diagnosis of arrhythmia was determined in 36.4% patients, coronary artery disease in 27.3%, cerebrovascular events in 36.4%, peripheral vascular disease in 27.3% and carotid artery stenosis in 8.3%. A literature search was conducted using PubMed, Google Scholar and Scopus, using all relevant key words. Seven pieces of original research were described in the literature. Six of these described a RIPL prevalence ranging from 34.62% to 91%. One paper described a case series with an incidence of 72.7% new diagnosis of CVD in their cohort who were identified to have RIPLs. The ophthalmologists’ role in detecting RIPLs could be used to assess cardiovascular risk status, supporting a multi-disciplinary approach in managing CVD.