2018, Volume 25 (online first)

2018, Volume 25, Issue 4, pages 121–160

Editorials Clinical articles News and views
Topics include:-
  • Cardiovascular outcomes and diabetes drugs
  • Quality of life in PoTS sufferers
  • ECG shared by multiple pathologies
  • Thrombus aspiration and PPCI


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April 2018 Br J Cardiol 2018;25:48–9 doi:10.5837/bjc.2018.009

Implications of Brexit for medical research

Chloe Watson


On 23 June 2016, the UK public took to the polls and voted to leave the European Union (EU). Since that vote, everyone – from the farming community to the financial sector – has been trying to digest the result and understand what it might mean for them. The science community has been no exception, and with good reason. Scientific research is widely acknowledged as an international endeavour and, until now, EU membership has played a role in this. Science is also a real UK strength – UK institutions, when compared internationally, are ranked second in the world for the quality of their research,1 and the UK has one of the largest drug development pipelines globally – making it all the more important that we secure a positive future for UK science post-Brexit.

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April 2018 Br J Cardiol 2018;25:50 doi:10.5837/bjc.2018.010

Celebrating 25 years of the Scottish Cardiac Society

Hany Eteiba


In September last year, the Scottish Cardiac Society (SCS) celebrated its 25th anniversary with a two-day symposium held in Crieff – the same venue where the inaugural meeting took place in 1992.

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Clinical articles

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October 2018 Br J Cardiol 2018;25:147–9 doi:10.5837/bjc.2018.026

Transitions of an open-heart surgery support lab in a resource-limited setting: effect on turnaround time

Ijeoma Angela Meka, Williams Uchenna Agu, Martha Chidinma Ndubuisi, Chinenye Frances Onyemeh


Open-heart surgery is a major surgical procedure that requires intensive patient monitoring. Clinicians require prompt laboratory test results to assist them in this monitoring. Timeliness of result delivery is of great importance in taking prompt clinical decisions. We set out to evaluate the performance of the support laboratory before and after domiciliation at the cardiac centre using turnaround time (TAT) of electrolytes and liver function tests as benchmarks.

This hospital-based descriptive study was carried out at the University of Nigeria Teaching Hospital (UNTH), Enugu. The authors conducted a desk review of laboratory records for electrolytes and liver function tests from March 2013 to July 2017. Relevant laboratory personnel were also interviewed to ascertain types of equipment used and possible causes of delay at different stages of transition during the period under review. The TAT was calculated as the time from sample reception to time of dispatch of results.

Between 2013 and 2014, TAT for electrolytes and liver function tests were ~2 and ~6 hours, respectively. In 2015, TAT reduced to ~1 hour for electrolytes and ~1½ hours for liver function tests. Between 2016 and July 2017, TAT further reduced to ~10 minutes for electrolytes and ~30 minutes for liver function tests.

In conclusion, we were able to demonstrate improvement in performance of the support laboratory as shown by a reduction in TAT following the transition from the main laboratory to being domiciled in the cardiac centre.

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October 2018 Br J Cardiol 2018;25:150–1 doi:10.5837/bjc.2018.027

Utility of MPS in AAA repair and prognostication of cardiovascular events and mortality

Mark G MacGregor, Neil Donald, Ayesha Rahim, Zara Kwan, Simon Wong, Hannah Sharp, Hannah Burkey, Mark Fellows, David Fluck, Pankaj Sharma, Vineet Prakash, Thang S Han


Myocardial perfusion scintigraphy (MPS) is a non-invasive method that can be used to assess reversible left ventricular myocardial perfusion defect (<20% indicates limited and ≥20% indicates extensive ischaemia), and left ventricular ejection fraction (LVEF) at rest and at stress. Data on the utility of MPS used to stratify cardiac risk prior to abdominal aortic aneurysm (AAA) repairs are limited. We evaluated MPS as a stratification tool for patients scheduled for endovascular aneurysm repair (EVAR) or open repair, between 2013 and 2016 at Ashford and St Peter’s NHS Foundation Trust, and 4.9 years (median 2.8 years, interquartile range [IQR] 2.1–3.8) cardiovascular events (n=15, 17.9%) all-cause mortality (n=17, 22.6%). Of the 84 patients recruited (median age 75.7 years, IQR 69.4–79.6), 57 (67.9%) had limited and 27 (32.1%) extensive ischaemia, 62 (73.8%) underwent EVAR and 22 (26.2%) open repair. Compared with open repair patients, EVAR patients were older (median age 70.6 years vs. 76.4 years, p=0.015), had higher rates of extensive ischaemia (13.6% vs. 38.7%, p=0.025), and abnormal LVEF reserve (LVEF at stress minus LVEF at rest ≤0: 40.0% vs. 76.6%, p=0.011), while having lower rates of 30-day postoperative major adverse cardiac events (13.6% vs. 3.3%, p=0.040) but no difference for cardiovascular events (p=0.179) or 4.9 year all-cause mortality (22.7% vs. 22.6%, adjusted hazard ratio 0.80, 95% confidence interval [CI] 0.22 to 3.20, p=0.799). Our findings indicate that MPS provides valuable information for AAA repair procedure.

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October 2018 Br J Cardiol 2018;25:143–6 doi:10.5837/bjc.2018.028

New-onset giant T-wave inversion with prolonged QT interval: shared by multiple pathologies

Debjit Chatterjee, Priya Philip, Kay Teck Ling


This is a case series of 10 patients who presented with the same electrocardiogram (ECG) manifestation of new-onset giant T-wave inversion and QT prolongation over a period of 24 months in a district general hospital. This unique ECG manifestation has been described with several cardiac and non-cardiac conditions.

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October 2018 Br J Cardiol 2018;25:157–8 doi:10.5837/bjc.2018.029

A case report of transient acute left ventricular dysfunction

Allam Harfoush


Stunned myocardium is a rare, but serious, medical condition, and requires emergency intervention. Short periods of hypoperfusion may lead to a prolonged cardiac hypokinesia (hours to days), even though the perfusion is retained eventually. In other words, although the coronary circulation is retained, the hypokinesia remains. It might be considered as a case of prolonged post-ischaemic dysfunction.

In this case, a 60-year-old woman, visiting her siblings, presented with severe dyspnoea and cyanosis to the emergency department. Pulmonary oedema was diagnosed, and transthoracic echocardiography (TTE) showed general hypokinesia and reduced ejection fraction (15%), nevertheless, sequential TTE monitoring after the required medical intervention revealed a continuous improvement, with a 45% ejection fraction three days later and a specific anterior wall hypokinesia, solely.

In conclusion, rapid diagnosis and treatment are essential for stunned myocardium, as these could change the progress of the clinical condition.

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July 2018 Br J Cardiol 2018;25:115–7 doi:10.5837/bjc.2018.018

A pulmonary triad in a patient with a giant left atrial myxoma

Andrea Calo, Madeleine Openshaw, Timothy J Bowker, Han B Xiao


A 55-year-old man with suspected community-acquired pneumonia and atrial fibrillation was found to have a very large left atrial myxoma complicated with a pulmonary triad – pulmonary hypertension, pulmonary infarction, and pulmonary lymphadenopathy. The myxoma was successfully removed and complete resolution of all three pulmonary complications followed. He re-presented two weeks post-surgery with atrial flutter, which was medically treated and considered for ablation. We have taken the opportunity to undergo a mini-literature review on myxoma and its pulmonary complications.

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July 2018 Br J Cardiol 2018;25:107–9 doi:10.5837/bjc.2018.019

Opinions on the expanding role of CTCA in patients with stable chest pain and beyond: a UK survey

Saad Fyyaz, Alexandros Papachristidis, Jonathan Byrne, Khaled Alfakih


The National Institute for Health and Care Excellence (NICE) released an updated guideline on stable chest pain in 2016. They recommended that all patients with chest pain, typical or atypical, should be investigated with computed tomography coronary angiography (CTCA) in the first instance. Functional imaging tests were reserved for the assessment of patients with chest pain and known coronary artery disease (CAD) and for patients where the CTCA is equivocal or has shown CAD of uncertain significance. The European Society of Cardiology (ESC) guidelines on stable chest pain, however, recommend functional imaging tests for all stable chest pain patients, with CTCA as an alternative in patients with low-to-intermediate likelihood of CAD. The ESC guidelines also allow for the use of the exercise electrocardiogram (ECG) as an alternative to functional imaging tests in patients with low-to-intermediate likelihood of CAD, if functional imaging tests are not available.

Furthermore, traditionally, the aetiology of heart failure or left ventricular (LV) dysfunction was investigated with diagnostic invasive coronary angiography. More recently, cardiac magnetic resonance imaging (MRI) tissue characterisation was proposed as an effective alternative test. We conducted a survey of UK cardiologists’ opinions on the use of CTCA in patients with stable chest pain and in the investigation of the aetiology of heart failure.

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July 2018 Br J Cardiol 2018;25:110 doi:10.5837/bjc.2018.020

Comprehensive study of routine clinical use of cardiac MRI in a district general hospital setting

George Abraham, Aamir Shamsi, Yousef Daryani


The study sought to evaluate the indications, image quality, safety and impact on patient management of cardiac magnetic resonance imaging (CMR) in a district general hospital setting.  The database was developed using retrospective analysis of patient records from the start of the local CMR service in January 2014 until January 2017. All 791 consecutive patients were included in the dataset.

The most important indications were the investigation of myocarditis/cardiomyopathies (54.5%), work-up of suspected coronary artery disease (CAD)/ischaemia (27.1%), and assessment of viability (9.1%). Image quality was diagnostic in 99.9% of cases. Mild adverse effects were reported for 3.8% of patients for stress CMR and in 1.1% of non-stress CMR. No serious adverse events were reported in this study population. In 26.5% of cases, CMR findings resulted in therapeutic modifications. In 18.1%, the final diagnosis based on CMR was different to that suspected before the CMR.

In conclusion, the findings of this study emphasise that CMR is a safe procedure with high image quality. In many cases, CMR can be shown to change a patient’s management plan.

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July 2018 Br J Cardiol 2018;25:111–4 doi:10.5837/bjc.2018.021

Hypertension in pregnancy as the most influential risk factor for PPCM

Hawani Sasmaya Prameswari, Triwedya Indra Dewi, Melawati Hasan, Erwan Martanto, Toni M Aprami


Peri-partum cardiomyopathy (PPCM) is one of the leading causes of maternal mortality worldwide, but the exact cause of PPCM is still unknown. PPCM is often associated with many risk factors, especially hypertension in pregnancy. This study aimed to evaluate the most influential risk factors of PPCM in Javanese ethnic patients.

The study was a case-control study involving 96 PPCM patients and 96 healthy non-PPCM parturients (control group) in the Hasan Sadikin Central General Hospital, West Java, Indonesia in the period from 2011 to 2014. A multiple logistic regression analysis was performed to evaluate the most influential risk factors for PPCM.

There were four significant and independent risk factors in this study, which were low socioeconomic status (adjusted odds ratio [OR] 3.312; confidence interval [CI] 1.383, 7.932), history of hypertension in previous pregnancy (adjusted OR 4.862; CI 1.245, 8.988), hypertension in current pregnancy (adjusted OR 2.311; CI 1.164, 4.590), and multi-foetal pregnancy (adjusted OR 7.057; CI 0.777, 64.097). Multiple logistic regression analysis showed the history of hypertension in previous pregnancy or hypertension in current pregnancy were the most influential independent risk factors of PPCM based on the narrowest confidence interval range, and after adjustment for other significant risk factors.

In this study, history of hypertension in previous pregnancy and hypertension in current pregnancy were the most influential and independent risk factors for PPCM. This study may increase awareness of treatment required for patients with hypertension in pregnancy, and also supports the pathogenesis of hypertension in pregnancy associated with PPCM, especially pre-eclampsia.

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July 2018 Br J Cardiol 2018;25:118–20 doi:10.5837/bjc.2018.022

A transitory right bundle branch block

Cristina Aguilera Agudo, Silvia Vilches Soria, Jorge Enrique Toquero Ramos


The clinical presentation of patients with cardiac tamponade largely depends upon the length of time over which pericardial fluid accumulates and the clinical situation. It can result in a clinical picture ranging from cardiogenic shock to general malaise, including dyspnoea, chest discomfort or fullness, peripheral oedema and fatiguability.

Although cardiac tamponade is a clinical diagnosis, two-dimensional and Doppler echocardiography play major roles in the identification of pericardial effusion and in assessing its haemodynamic significance. Despite this, some other imaging techniques or diagnostic tools could also be used for diagnosis. With this case we want to highlight not only the role of the electrocardiogram (ECG), but also its utility in assessing the haemodynamic changes in this clinical entity.

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May 2018 Br J Cardiol 2018;25:63–8 doi:10.5837/bjc.2018.014

3D echocardiography: benefits and steps to wider implementation

Kevin Cheng, Mark J Monaghan, Antoinette Kenny, Bushra Rana, Rick Steeds, Claire Mackay, DeWet van der Westhuizen


Advancements in computer and transducer technologies over the past two decades have allowed the development of three-dimensional (3D) echocardiography (3DE), which offers significant additional clinical information to traditional two-dimensional (2D) echocardiography (2DE). However, the majority of departmental studies today remain 2D, and adoption of 3DE as a complementary tool into mainstream clinical practice has not been without its difficulties. Although cardiologists have a range of alternative imaging modalities at their disposal to investigate cardiovascular structure and function, given the pace of technological innovation and improvements in data analysis, the field of 3DE is one of great expectation and is likely to be of increasing clinical importance. In this review, we discuss the role of 3DE, its advantages and limitations, and how novel technology will help workflow and expand its routine use.

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April 2018 Br J Cardiol 2018;25:69–72 doi:10.5837/bjc.2018.011

The effect of EECP on functional exercise capacity and symptom burden in refractory angina

Noman Ali, Haqeel A Jamil, Mohammad Waleed, Osama Raheem, Peysh Patel, Paul Sainsbury, Christopher Morley


Refractory angina (RA) is characterised by persistent anginal symptoms despite optimal medical therapy and revascularisation. Enhanced external counterpulsation (EECP) is a technique that has shown promise in the treatment of this condition but is poorly utilised in the UK. The aim of this study is to assess the effect of EECP on anginal symptoms in patients with RA from a UK centre.

This retrospective study assessed the effectiveness of EECP at improving exercise capacity, anginal symptom burden and anginal episode frequency using pre- and post-treatment six-minute walk test (6MWT) results, Canadian Cardiovascular Society (CCS) scores and symptom questionnaires, respectively.

Fifty patients with a median age of 67 years (interquartile range [IQR] 14) underwent EECP between 2004 and 2015. The majority had undergone prior revascularisation (84%; 42/50) via percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG). Significant improvements were noted in 6MWT result (282 vs. 357 m; p<0.01), CCS score (3.2 vs. 2.0; p<0.01) and weekly anginal episode frequency (20 vs. 4; p<0.01). No adverse outcomes related to EECP were noted.

Our study demonstrates use of EECP to be associated with significant improvements in exercise capacity and anginal symptom burden.

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April 2018 Br J Cardiol 2018;25:54–7 doi:10.5837/bjc.2018.012

A study in the diagnosis and management of syncope: a retrospective review

Joseph Wilson, Donna Dalgetty, Selda Ahmet, Nida Taher, Mehran Asgari


A study of 500 patients was conducted to ascertain how syncope is managed at the Ipswich Hospital NHS Trust. This was based on the variation in approach across the country despite the guidance from the European Society of Cardiology (ESC), National Institute for Health and Care Excellence (NICE) and the Heart Rhythm Society. Similar studies in the UK have indicated a number of inconsistencies in both the management and diagnosis of patients with suspected syncope.

We discuss the role of a syncope pathway, the need for a separate syncope clinic and for syncope experts.

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April 2018 Br J Cardiol 2018;25:58–62 doi:10.5837/bjc.2018.013

A novel ambulatory syncope assessment unit is safe and cost-effective in a low-risk patient cohort

Hamish I MacLachlan, Christopher J Allen, Gothandaraman Balaji


A retrospective analysis of 50 inpatients admitted with syncope was undertaken to evaluate the safety and cost-effectiveness of a novel outpatient syncope clinic recently introduced within an emergency ambulatory care unit at a northwest London hospital together with review of echocardiographic parameters in syncope. Outcome measures included length of inpatient admission, frequency of cardiology review, 30-day readmission and 90-day mortality rates. The same variables were assessed prospectively in 50 inpatients referred to the syncope assessment unit (SAU). All 100 patients were deemed low risk, as defined by the San Francisco syncope rule. Patients under the age of 18 years and those investigated for conditions other than syncope were excluded. Echocardiographic parameters such as E/A ratio, left atrial (LA) dimension, left ventricular (LV) ejection fraction and E/E ratio were statistically analysed for their association with episodes of syncope.

The standard-care group remained in hospital for a median four days at a cost of €582 (£512). Waiting time for an SAU appointment was a median two days. Inpatient waiting time for 24-hour Holter and transthoracic echocardiography (TTE) investigations were significantly longer for the standard-care group (p<0.05). There was no significant difference in the rates of cardiology review, diagnostic yield, hospital readmission and mortality between the two groups. The SAU will save a projected annual cost of €108,371 (£95,232) on inpatient bed days. The fractional cost of clinical assessment on the SAU is €35 (£31) per patient. Among the echocardiographic parameters analysed, increased E/E ratio was associated with syncope (p=0.001).

In conclusion, the introduction of a novel low-risk SAU promotes early discharge from hospital with prompt outpatient medical review and shorter inpatient waiting times for diagnostic investigations. Our data suggest this is both cost-effective and safe. E/E echo parameter was observed as a significant parameter in low-risk syncope.

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News and views

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October 2018 Br J Cardiol 2018;25:135–7

News from ESC 2018: Not all HDL cholesterol is cardioprotective

Very high levels of high-density lipoprotein (HDL), the lipid that has been considered ‘good’ cholesterol, may be associated with an increased risk of...

October 2018 Br J Cardiol 2018;25:135–7

News from ESC 2018: COMMANDER HF – rivaroxaban in heart failure…

Rivaroxaban, the direct oral, factor Xa inhibitor, does not reduce the risk of a composite end point of survival, myocardial infarction (MI) and...

October 2018 Br J Cardiol 2018;25:135–7

News from ESC 2018: …and in VTE in the MARINER trial

The use of the oral anticoagulant rivaroxaban in medically ill patients for 45 days following hospital discharge showed there was no significant difference...

October 2018 Br J Cardiol 2018;25:135–7

News from ESC 2018: Is it safe for women with heart disease to become pregnant?

“Usually”, appears to be the answer according to 10-year results from the Registry Of Pregnancy And Cardiac disease (ROPAC) a worldwide, prospective registry...

October 2018 Br J Cardiol 2018;25(4)

News from the 10th British Society for Heart Failure Day for revalidation and training

‘All you need to know about heart failure – in one day’ was the promise of the 10th British Society for Heart Failure...

October 2018 Br J Cardiol 2018;25:135–7

European Society of Cardiology 2018 Congress in briefs

This year’s meeting of the European Society of Cardiology (ESC) was held in Munich, Germany, from 25th–29th August...