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November 2016 Br J Cardiol 2016;23:127 doi: 10.5837/bjc.2016.035

Cut out the middleman

Terry McCormack

Abstract

Following Brexit, like many other people with Irish parents, I started the process of applying for an Irish passport. The Irish embassy website informed me, to my surprise, that I had become an Irish citizen on the day I was born. Despite that status, and despite owning a home in County Kerry, I have to admit I know very little about the Irish healthcare system. In fact, having worked my entire life in English healthcare, I do not fully understand the systems in the other three constituent countries of the UK either. My career has mostly involved both primary and secondary care, so I do understand the issues and difficulties of communication between hospitals and general practitioners (GPs).

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November 2016 Br J Cardiol 2016;23:130–1 doi: 10.5837/bjc.2016.036

Can marriage mend a broken heart (and save the National Health Service)?

Nicholas D Gollop

Abstract

Ischaemic heart disease (IHD) is the leading cause of mortality worldwide.1 It is a debilitating, life-changing illness that can reduce quality of life and life-expectancy. While surgical, percutaneous and optimal medical interventions can significantly improve the clinical course of the disease, our understanding of the biopsychosocial mechanisms promoting survival following an acute IHD event, such as an acute coronary syndrome (ACS), is still limited. 

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November 2016 Br J Cardiol 2016;23:141–4 doi: 10.5837/bjc.2016.038

Postural tachycardia syndrome: a UK occupational therapy perspective

Jenny Welford, Christopher McKenna

Abstract

Postural tachycardia syndrome (PoTS) is a form of dysautonomia, a term used to describe dysfunction of the autonomic nervous system. The condition can cause marked physical and cognitive impairment that can significantly impact upon activity. Although the exact UK prevalence is unknown, its frequency has stimulated an increase in studies. Occupational therapy services should place themselves in a position to respond to the potential need. 

This study aimed to determine how PoTS impacts upon activity, in order for occupational therapists to understand the implications of this condition and develop appropriate interventions. 

We recruited 201 adults (aged 18–70 years) via two patient support charities to participate in an online quantitative survey. Participants rated their experiences pre-symptoms versus present day in relation to their occupations, producing ordinal data under self-care, leisure and productivity domains, including their physical ability, motivation and fatigue levels.

The pre-symptom versus present day probability scores of <0.001 can be viewed as ‘very significant’ and confirm that PoTS has a significant negative impact across all three occupational domains.

In conclusion, PoTS has a significant negative impact upon occupation and is associated with considerable morbidity. With their understanding of the central role of occupation in wellbeing, occupational therapists may need to support people with PoTS in achieving a satisfying balance of occupations that will support their health.

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November 2016 Br J Cardiol 2016;23:151–4 doi: 10.5837/bjc.2016.039

Implementation of a modified version of NICE CG95 on chest pain of recent onset: experience in a DGH

Peregrine Green, Stephanie Jordan, Julian O M Ormerod, Douglas Haynes, Iwan Harries, Steve Ramcharitar, Paul Foley, William McCrea, Andy Beale, Badri Chandrasekaran, Edward Barnes

Abstract

National Institute for Health and Care Excellence (NICE) clinical guideline 95 (CG95) was introduced to rapid-access chest pain clinics (RACPC) to aid investigation of possible stable angina based on pretest probability of coronary artery disease (CAD). Following a six-month audit of its implementation we introduced a modified version: patients with low/moderate risk of CAD were referred for computed tomography coronary angiography (CTCA), while those at high/very high risk were referred for invasive angiography.

Patient records of 546 patients referred to our RACPC over a six-month period were retrospectively analysed. Pretest probability of CAD, referral for initial investigation, and outcomes at a minimum follow-up time of six months were documented.

Incidence of CAD correlated well with pretest probability. Moderate-risk patients had a low incidence of CAD and revascularisation. High/very high-risk patients had a high incidence of revascularisation, and this was predominantly for prognostically significant disease.

In conclusion, low rates of CAD in low- and moderate-risk groups justifies the use of CTCA as a first-line investigation in these patients. Routine investigation of very high-risk patients allows a high proportion to undergo revascularisation for prognostically significant disease. Strict adherence to NICE CG95 could lead to these patients being missed. 

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November 2016 Br J Cardiol 2016;23:155–8 doi: 10.5837/bjc.2016.040

Risk factors for femoral arterial complications and management

Shabnam Rashid, Stephanie Hughes

Abstract

Bleeding is one of the complications associated with percutaneous coronary intervention from the femoral route due to the use of potent antiplatelet therapies including adenosine diphosphate receptor blockers and glycoprotein IIb/IIIa inhibitors. Complications include haematoma, retroperitoneal haemorrhage, pseudoaneurysm, arteriovenous fistula, arterial occlusion, femoral neuropathy and infection. Complications for diagnostic procedures are lower due to the lack of antiplatelet therapies on board. Often, incorrect location of the femoral artery puncture site results in complications. Puncturing below the femoral bifurcation can result in psedoaneurysm, haematoma and arteriovenous fistulas, whereas retroperitoneal haemorrhage is caused by high femoral punctures. Identification of bleeding and vascular complications is paramount as bleeding is associated with adverse events. Techniques to reduce the risk of femoral arterial complications include the use of ultrasound scan or fluoroscopy guided femoral punctures. Furthermore, the micropuncture technique has been shown to reduce complications but is not widely adopted. Ultimately, the radial route is preferable to the femoral route as vascular complications are significantly lower.

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