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January 2018 doi: 10.5837/bjc.2018.002 Online First

Variability in use of IV nitrates and diuretics in acute HF: a ‘virtual patient’ clinical decision-making study

Alison Carr, Fosca De Iorio, Martin R Cowie

Abstract

Despite guidelines on the treatment of acute heart failure (AHF), treatment remains heterogeneous, particularly regarding intravenous (IV) nitrate use. This clinical decision-making study assessed the use of IV nitrates and diuretics by 40 UK hospital physicians, each ‘treating’ the same 10 virtual patients. Semi-structured interviews were performed to investigate participants’ decision-making rationale.

IV nitrates were prescribed in 37% of clinical decisions. Considerable variability was seen in the administration of IV nitrates among physicians. Interview data revealed polarised opinions regarding the efficacy of IV nitrates and the evidence base supporting their use. Physicians’ treatment decisions were more heavily influenced by their perceptions and beliefs regarding IV nitrates than by consideration of the evidence. In contrast, diuretics were prescribed more frequently (78%) and more consistently.

In conclusion, where there is a limited evidence base and no strong recommendation from clinical guidelines, prescribing behaviour for AHF therapies such as IV nitrates are likely to reflect variability in physicians’ beliefs, experiences, and decision-making styles.

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January 2018 doi: 10.5837/bjc.2018.003 Online First

What next for troponin? When diagnostic precision muddies the water for the physician

Thomas E Kaier

Abstract

Physicians use tests to inform decision-making. Whether this is a bedside test using a stethoscope, the seemingly ancient technology of recording an electrocardiogram (ECG), or the most advanced imaging modalities and biochemical panels available – all pursue diagnostic clarity. But, more frequently than we might like to admit, the results do not illuminate a clear path of treatment.

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January 2018 doi: 10.5837/bjc.2018.004 Online First

Recognition and management of aVR STEMI: a retrospective cohort study

Ruan Vlok, Joshua Wall, Hannah Kempton, Thomas Melhuish, Astin Lee, Leigh White

Abstract

Identification of ST elevation on the electrocardiogram (ECG) is the cornerstone of diagnosis of ST-elevation myocardial infarction (STEMI). While lesion localisation can usually be achieved by regional ST-elevation patterns on ECG, clinicians often neglect changes in the ST segment of lead aVR, possibly contributing to delayed recognition and poorer outcomes for these patients.

This study compared the ‘door-to-balloon time’ and peak troponins – as a surrogate marker of infarct size – for patients presenting with STEMI with ST-segment elevation in aVR compared with those patients without elevation in aVR. A total of 179 patients, including 17 patients presenting with ST-elevation in aVR, were included in this study. Patients presenting with elevation in aVR had significantly longer door-to-balloon times than those patients presenting with ‘traditional’ patterns of ST-elevation. There was, however, no significant difference in peak troponin as a marker of infarct size. While patients presenting with ST-elevation in lead aVR may have a delayed time to intervention, the present study does not suggest the use of aVR elevation as an indication for urgent angiography.

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November 2017 Br J Cardiol 2017;24:152–5 doi: 10.5837/bjc.2017.030

Glucagon-like peptide-1 (GLP-1) receptor agonists

Emma Johns, Gerry McKay, Miles Fisher

Abstract

Glucagon-like peptide-1 (GLP-1) receptor agonists are an injectable glucose-lowering therapy used in the treatment of type 2 diabetes mellitus (T2DM). Alongside dipeptidyl peptidase-4 (DPP-4) inhibitors, they exert their effect by augmenting the incretin pathway. GLP-1 receptor agonists offer reductions in glycosylated haemoglobin (HbA1c) and weight alongside a low risk of hypoglycaemia. The cardiovascular safety of GLP-1 receptor agonists in patients at elevated cardiovascular risk has been examined in large double-blind, placebo-controlled cardiovascular safety trials. Liraglutide demonstrated superiority over placebo with reduced major adverse cardiovascular events (MACE) in the treatment group. Exenatide, lixisenatide and semaglutide have shown non-inferiority versus placebo for MACE. These trials demonstrated no association between GLP-1 agonist therapy and hospitalisation for heart failure.

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November 2017 Br J Cardiol 2017;24:127 doi: 10.5837/bjc.2017.029

Controlled hypertension: a forgotten diagnosis

Aaron Koshy, Anet Gregory Toms, Sharon Koshy, Raj Mohindra

Abstract
We believe that controlled systemic hypertension should be considered as an important clinical entity (figure 1). We know that cardiovascular risks increase with rising blood pressure, each 2 mmHg increase in systolic blood pressure is associated with a 7% and 10% rise in mortality from ischaemic heart disease and stroke, respectively.1 However, the converse proposition would also seem to be true. Meta-analyses have found significant reductions in stroke and coronary events associated with blood pressure control,2 even in grade 1 hypertension. Furthermore, large studies such as SPRINT (Systolic Blood Pressure Intervention Trial)3 have shown that patients with tighter blood pressure control (mean systolic 121.4 mmHg) have significantly lower rates of major cardiovascular events and heart failure in addition to reduced mortality compared with the standard therapy cohort (mean systolic 136.2 mmHg). With reduction of blood pressure the associated risks are reduced.
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