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March 2024 Br J Cardiol 2024;31:36 doi: 10.5837/bjc.2024.009

The prevalence of coronary artery disease in patients presenting with ‘non-anginal chest pain’

William Chick, Anita Macnab

Abstract

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.

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March 2024 Br J Cardiol 2024;31:27 doi: 10.5837/bjc.2024.010

Comparison between early and late dapagliflozin administration for decompensated heart failure

Takahiro Tokuda, Yoriyasu Suzuki, Ai Kagase, Hiroaki Matsuda, Akira Murata, Tatsuya Ito

Abstract

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.

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March 2024 Br J Cardiol 2024;31:32–5 doi: 10.5837/bjc.2024.011

Navigating the research landscape in cardiology. Part 2: finding the right research

Hibba Kurdi, Jessica Artico, Freya Lodge, C Fielder Camm

Abstract

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.

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March 2024 Br J Cardiol 2024;31:31 doi: 10.5837/bjc.2024.012

Mitral valvular surgery outcomes in a centre with a dedicated mitral multi-disciplinary team

Ishtiaq Rahman, Cristina Ruiz Segria, Jason Trevis, Sharareh Vahabi, Richard Graham, Jeet Thambyrajah, Ralph White, Andrew Goodwin, Simon Kendall, Enoch Akowuah

Abstract

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.

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February 2024 Br J Cardiol 2024;31:7–8 doi: 10.5837/bjc.2024.005

Rewriting the heart failure pillars toward less burdensome heart failure care pathways

Rosalynn C Austin

Abstract

At the Association of Cardiovascular Nursing & Allied Professions conference in June, Professor Tiny Jaarsma called for a pillar of self-care to be added to heart failure (HF) care guidelines.1 Taylor et al.2 agree that HF care needs an additional pillar and suggest cardiac rehabilitation. Currently, the HF pillars are focused on medications shown to improve the outcomes of people with heart failure with reduced ejection fraction (HFrEF),3 but other key non-pharmacological interventions are not considered. Also, the pillars of care do not provide guidance for people with heart failure with preserved ejection fraction (HFpEF), which represent 50% of the HF population.4 While these pillars focus on a single important aspect of care, they do not capture the totality of HF management or illness types. A focus on interventions to improve HF management is welcome but can obscure the challenges that treatment – as well as illness – impose on patients and their carers.

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February 2024 Br J Cardiol 2024;31:13–6 doi: 10.5837/bjc.2024.006

A retrospective single-centre study on determinants of high-risk coronary artery calcium (CAC) score in women

Saskia D Handari, Naesilla, Annisya Dinda Paramitha

Abstract

One of the assessments for coronary atherosclerosis during cardiac computed tomography (CT) is coronary artery calcium (CAC) scoring. We conducted analysis on the determinants of high-risk coronary calcification, represented by CAC score, among women as a step to improve their outcomes and prognosis. This study involved a total of 1,129 female patients from a single centre. There were 127 patients (11.2%) classified as high risk (CAC ≥400). We found that a history of hypertension and diabetes are independent determinants of having a high-risk CAC score. Furthermore, this study demonstrated protective effects associated with physical activity and diastolic blood pressure. In conclusion, a history of hypertension, diabetes, and high uncontrolled systolic blood pressure might be used as cues for physicians to prioritise CAC assessment in women, despite the absence of chest pain or atypical symptoms.

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February 2024 Br J Cardiol 2024;31:28–30 doi: 10.5837/bjc.2024.007

Transcatheter versus surgical valve replacement in patients with bicuspid aortic valves: an updated meta-analysis

Peter S Giannaris, Viren S Sehgal, Branden Tejada, Kenzy H Ismail, Roshan Pandey, Eamon Vega, Kathryn Varghese, Ahmed K Awad, Adham Ahmed, Irbaz Hameed

Abstract

Patients with bicuspid aortic valves (BAV) are predisposed to the development of aortic stenosis. We performed a pairwise meta-analysis, comparing the efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with BAV.

Medical databases were queried to pool comparative studies of interest. Single-arm studies, conference presentations, animal studies, and studies that involved patients with tricuspid aortic morphology were excluded. Outcomes were pooled as risk ratios (RRs) with their 95% confidence intervals (CI) using the random effects model in R.

There were 60,858 patients with BAV (7,565 TAVR, 53,293 SAVR) included. Compared with SAVR, TAVR was associated with a significantly lower risk of 30-day major bleeding (RR 0.29, 95%CI 0.13 to 0.63, p=0.01) but a higher risk of new permanent pacemaker placement (RR 2.17, 95%CI 1.03 to 4.58, p=0.04). No significant differences were seen with other explored outcomes, including 30-day/mid-term mortality, stroke, acute kidney injury, major vascular complications, paravalvular leak, and conduction abnormalities.

In conclusion, in patients with BAV, TAVR is associated with a lower risk of 30-day major bleeding but has an increased risk for permanent pacemaker implantation when compared with SAVR. Future large-scale randomised trials comparing both the short- and long-term outcomes of SAVR and TAVR in patients with BAV are needed to assess the efficacy of each modality in a controlled population across long follow-up durations.

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February 2024 Br J Cardiol 2024;31:40 doi: 10.5837/bjc.2024.008

Solving problems at the cath lab

Rita Caldeira da Rocha, Alejandro Diego Nieto, Jesus Garibi, Ignacio Cruz-Gonzalez

Abstract

We describe a case of aortic rupture following transcatheter aortic valve implantation that was managed percutaneously.

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January 2024 Br J Cardiol 2024;31:4–6 doi: 10.5837/bjc.2024.001

Dishing out the meds

David Mulcahy, Palwasha Khan

Abstract

Twenty years ago, Wald and Law1 hypothesised that, if a combination pill could be made including aspirin, folic acid, a statin, and a low-dose diuretic, beta blocker and angiotensin-converting enzyme (ACE) inhibitor (thus, allowing for the simultaneous modification of four different risk factors: low-density lipoprotein [LDL]-cholesterol, blood pressure, homocysteine, and platelet function), and administered to everyone with existing cardiovascular disease and everyone over 55 years old, there would be an 88% reduction in ischaemic heart disease events, and an 80% reduction in stroke. One third of people over the age of 55 years would benefit by gaining an average of 11 years free from a cardiac event or stroke (subsequently termed the vaccination approach). They called this pill the ‘Polypill’, and concluded that treatment would be acceptably safe and, with widespread use, would have a greater impact on the prevention of disease in the Western world than any other single intervention. They noted that, while such a preventative strategy was radical, if such a formulation existed that prevented cancer and was safe, it would be widely used. “It is time to discard the view that risk factors need to be measured and treated individually if found to be abnormal. There is much to gain and little to lose by the widespread use of these drugs.” While subsequent works have shown that folic acid is not prognostically beneficial in preventing cardiovascular disease,2 and that aspirin may not be beneficial overall in primary prevention settings,3 the concept of the combination pill was awakened in the public eye.

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