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Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide, causing around 17.9 million deaths annually, a third of whom are adults aged <70 years.¹ In addition to genetic and behavioural risk factors (unhealthy diet, physical inactivity, and tobacco and alcohol abuse), inhaling airborne pollutants, such as fine particulate matter (<2.5 µm [PM_2.5] and <10 µm [PM₁₀]), ultrafine particles (UFPs; <100 nm), nitrogen dioxide (NO₂), ozone (O₃), and sulphur dioxide (SO₂), are associated with ASCVD among adults.²

Air pollution has been referred to as “the single most important environmental factor presenting a risk to health and represents a greater disease burden than polluted water, soil contamination and occupational exposures combined”.³ Air pollution is a silent killer and was highlighted as a significant public health concern in the recently published European Society of Cardiology (ESC) guidelines.⁴

The impact of urbanisation on air pollution levels is a critical concern for countries like Malta, which have adopted a city model to bolster their economies. Despite efforts to stimulate economic growth, the rise in urbanisation can pose risks to air quality. In London, mean PM_2.5 concentrations stood at approximately 12.7 µg/m³ in 2017, 12.0 µg/m³ in 2018, and 11.4 µg/m³ in 2019.⁵ Conversely, Valletta, Malta’s capital, recorded mean PM_2.5 concentrations of about 14 µg/m³ in 2017, 14.4 µg/m³ in 2018, and 14 µg/m³ in 2019.⁶ While both have seen improvements in their aggregated annual mean PM_2.5 concentrations compared with the concentration levels recorded in the past decade, they still exceed the World Health Organisation (WHO) annual air quality guideline value by approximately 1.14 to 1.4 times, highlighting the persistent challenge of air pollution in urban environments.

Our objective was to compare the efficacy of atrial fibrillation (AF) ablation versus permanent pacemaker (PPM) with atrioventricular node ablation (AVNA) versus direct current cardioversion (DCCV) for persistent AF in patients ≥65 years old.

Seventy-seven patients (aged 66–86, mean 75.4 years) with persistent AF were randomised (1:1:1) to AF ablation + amiodarone (± DCCV), PPM with AVNA (+DCCV) or DCCV + amiodarone. The primary end point was persistent AF recurrence, measured with an implanted cardiac monitor or PPM. Cardiopulmonary exercise testing (CPET) was performed at baseline and six months. Symptom questionnaires were completed monthly. Follow-up was 12 months.

The primary end point occurred in fewer patients following AF ablation + amiodarone than DCCV + amiodarone (seven patients, 28% vs. 15 patients, 60%; hazard ratio [HR] 0.559, 95% confidence interval [CI] 0.293 to 1.065, p=0.073) with no differences between DCCV + amiodarone and PPM with AVNA (HR 0.990, 95%CI 0.539 to 1.818, p=0.973). AF ablation + amiodarone resulted in a lower AF burden at 12 months compared with DCCV + amiodarone (17.0 ± 37.9% vs. 61.7 ± 48.6%, p<0.0001). Modified European Heart Rhythm Association (EHRA) symptom class improved in all patients (baseline 2.4 ± 0.495 vs. 12-month follow-up 1.84 ± 0.081, p=0.00001). Six-month CPET demonstrated a higher VO₂ peak in sinus rhythm (SR) compared with baseline in AF (12.1 ± 4.2 ml/kg/min at baseline to 15.3 ± 4.2 ml/kg/min at six months, p=0.013).

In conclusion, in older patients with persistent AF, ablation + amiodarone resulted in a lower AF burden at 12 months than DCCV + amiodarone. There was a non-significant trend toward reduced recurrence of device-detected persistent AF episodes. All therapies improved symptoms despite DCCV restoring SR in <50% of patients at 12 months. CPET demonstrated improved VO₂ peak with SR restoration.

Artificial intelligence (AI) will revolutionise cardiology practices over the next decade, from optimising diagnostics to individualising treatment strategies. Moreover, it can play an important role in combating gender inequalities in cardiovascular disease outcomes. There is growing evidence that AI algorithms can match humans at echocardiography analysis, while also being able to extract subtle differences that the human eye cannot detect. Similar promise is evident in the analysis of electrocardiograms, creating a new layer of interpretation. From big data, AI can produce algorithms that individualise cardiac risk factors and prevent perpetuating gender biases in diagnosis. Nonetheless, AI implementation requires caution. To avoid worsening health inequalities, it must be trained across diverse populations, and when errors arise, a robust regulatory framework must be in place to ensure safety and accountability. AI is perfectly positioned to capitalise on the growth of big data, but to proceed we require a generation of physicians who understand its fundamentals.

We present the cumulative percutaneous coronary intervention (PCI) data of all comers (stable angina and acute coronary syndromes [ACS]) who presented to Hadi Clinic between January 2018 and December 2020. As a low-volume PCI centre in the Middle East, we wanted to find out if the outcomes of our PCI procedures are different from those of high-volume PCI centres in the UK and the Western world.

Prospectively collected data of all comers for PCI (urgent and elective) were retrospectively analysed. Pre-procedural data included patients’ baseline characteristics (age, gender, clinical presentation and comorbidities). Intra-procedural data included access route, coronary anatomy, lesion complexity, number of stents deployed, door-to-balloon time for primary PCI, and any intra-procedural complications. Post-procedural data included average length of in-hospital stay, intra-hospital morbidity and mortality, and mortality or admission with ACS 12–36 months after the index procedure.

A total of 567 patients underwent coronary catheterisation for the three-year period between January 2018 and December 2020. Mean age was 60.9 ± 9.4 years, and 459/567 (81.0%) were male. Comorbidities included dyslipidaemia 515/567 (90.9%), hypertension 460/567 (81.2%), diabetes 346/567 (61%), known prior coronary disease 250/567 (44.2%), and smoking 188/567 (33.1%). Clinical presentation was stable angina 130/567 (22.9%), non-ST-elevation acute coronary syndrome (NSTEACS) 312/567 (55%), ST-elevation myocardial infarction (STEMI) 125/567 (22.0%), and STEMI with cardiogenic shock 13/125 (10.4%). The radial approach was used in 544/567 (95.94%), the average SYNTAX score was 34.8 ± 9.6, and the average number of stents 2.6. The total number of PCI was 367 (122.3 annually) with PCI procedural complete success in 349/367 (95.1%), partial success 5/367 (1.36%), PCI procedural complications 3/367 (0.82%), PCI in-hospital mortality 1/367 (0.27%), door-to-balloon time for primary PCI 31.8 ± 12.2 minutes, subsequent admission with ACS after 12–36 months 2/367 (0.54%), and post-discharge mortality after 12–36 months 1/367 (0.27%).

In conclusion, our patient population have more comorbidities and more complex coronary disease in comparison to their western counterparts. Our annual PCI numbers have been significantly lower than the recommended 400 minimum cut-off figure, yet we have achieved comparable outcomes to those of larger institutions of the western world.

Cardiac pathology contributes to a significant proportion of emergency department (ED) attendances. Many could be managed as urgent outpatients and avoid hospital admission. We evaluated a novel rapid-access general cardiology clinic to achieve this, implemented during the COVID-19 pandemic.

We performed a retrospective review of baseline characteristics, investigations, final diagnoses, and 90-day safety (readmission, major adverse cardiovascular events [MACE], mortality) from electronic records and conducted a patient experience survey.

There were 216 ED referrals made between 1 June and 30 October 2020. The median time to review was two days (interquartile range 1–5). At 90 days, there were three (1.4%) re-presentations requiring admission, two (0.9%) MACE, and no deaths. There were 205 (95%) successfully managed without hospital admission. Among surveyed patients, 96% felt they had concerns adequately addressed in a timely manner.

In conclusion, our rapid-access cardiology clinic is a safe model for outpatient management of a range of cardiovascular presentations to the ED.

The National Institute for Health and Care Excellence (NICE) advise against routine testing for coronary artery disease (CAD) in patients with non-anginal chest pain (NACP). This clinical audit sought to establish the prevalence of significant CAD in this cohort using computed tomography angiography (CTCA) and evaluate differences in the prevalence of cardiovascular risk factors between those with and without obstructive coronary disease.

Over 23 months, 866 patients with NACP underwent CTCA. Patients were separated into three groups for analysis depending on the degree of CAD on CTCA using the CAD-RADS (Coronary Artery Disease Reporting and Data System) scoring system; no evidence of CAD (group 1), a degree of CAD requiring medical therapy only (group 2), significant CAD defined as a CAD-RADS score 4A/B or 5 (group 3). Cardiovascular risk factors were compared between the groups.

We found 11.5% had significant CAD (group 3), 58.3% required medical therapy (group 2) and 30.1% had no CAD (group 1). There were 32 patients who required coronary revascularisation. Patients in group 2 and 3 were more likely to be male (p<0.001) and older (p<0.001) when compared to patients in group 1. Patients in group 3 were more likely to be hypertensive (p=0.008) and have higher Qrisk2 scores (p<0.001) when compared with those in group 1.

In conclusion, NICE guidelines for NACP may result in a significant proportion of patients with CAD being underdiagnosed, including some with severe disease requiring revascularisation. This analysis suggests age, male gender, Qrisk2 score and hypertension are predictors of CAD in this cohort.

Sodium-glucose cotransporter 2 inhibitors have demonstrated positive effects in heart failure (HF) patients. However, the effects of dapagliflozin in patients with decompensated HF remain unclear. This study aimed to compare the efficacy and safety of early and late dapagliflozin administration for decompensated HF. Data regarding dapagliflozin administration from 70 patients diagnosed with HF between December 2020 and November 2021 at a Japanese heart centre were analysed retrospectively. Propensity score matching was performed to compare the clinical outcomes of early and late dapagliflozin administration for decompensated HF. The primary end point was HF admission one year after dapagliflozin administration. The secondary end points were evaluated based on 24-hour urine volume, cardiac death, changes in ejection fraction (EF), blood pressure, glomerular filtration rate (GFR), haemoglobin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and side effects within one year of treatment. Fifteen matched pairs of patients were analysed. Admission rate within one year was significantly lower in the early administration group than in the late administration group (0 vs. 20%, p=0.03). Secondary end points were not significantly different between the two groups. In conclusion, early dapagliflozin administration significantly reduced HF admission within one year of treatment, although no differences were observed in 24-hour urine volume, cardiac death, EF, GFR, haemoglobin and NT-proBNP levels, and side effects.

This editorial series provides an in-depth exploration of research avenues in UK cardiology. It underscores the pivotal role of research in cardiology training and addresses the challenges faced by trainees in identifying apt research opportunities. This second article categorises available research roles, weighing their pros and cons, and outlines various supervisory styles to guide trainees in finding the optimal fit. It also summarises the primary research degrees, namely MPhil, MSc, MD, and PhD, tailored to diverse research goals.

International guidelines recommend ‘heart teams’ as the preferred method for decision-making. Heart team processes, mandatory attendees and investigations vary significantly between hospitals. We assessed outcomes following mitral valvular surgery in a tertiary referral centre with a dedicated mitral multi-disciplinary team (MDT).

This was a single-centre retrospective review of prospectively collected data within the ‘mitral database’ of mitral valvular disease patients. The ‘mitral MDT’ meeting involved pre-operative imaging and clinical data review, including mandatory transoesophageal echocardiography; recommendation for planned procedure, as well as an appropriate surgeon; and review of echocardiography images and clinical outcomes after surgery had been performed.

Between 2016 and 2020, 395 patients with mitral valvular disease were discussed at MDT. Of these, 310 patients underwent surgery. During the same time interval, 75 patients had surgery without MDT discussion: 84% of patients not discussed were urgent or emergent procedures and, in these, the most common pathology was degenerative mitral regurgitation (DMR, 46%) followed by infective endocarditis (30%). Of those discussed at MDT the pathology was: DMR 65%; mitral stenosis 14%; functional mitral regurgitation (MR) 5%; rheumatic MR 4%; endocarditis 4%; ischaemic MR 4%; and other pathologies 4%. For patients with DMR having elective surgery, the repair rate was 93% with mortality 2% and median (IQR) length of stay 5 (4–6) days. Postoperative transthoracic echocardiography demonstrated 99% of elective DMR patients had ≤2+ MR and <1% severe (3+) MR.

In conclusion, a dedicated ‘mitral MDT’ can enhance the safe delivery of care with consistently high repair rates for DMR patients with excellent outcomes.