2019, Volume 26 (online first)

2019, Volume 26, Issue 3, pages 81–120

Editorials Clinical articles News and views
Topics include:-
  • Identifying CAD in end-stage renal disease
  • Heart failure specialist nurses: what is the national picture?
  • Focus on aortic stenosis: avoiding needless deaths
  • Managing GI in patients with PoTS

Editorials

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July 2019 Br J Cardiol 2019;26:86–7 doi:10.5837/bjc.2019.023

Heart failure specialist nurse care: more questions than answers!

Angela Graves, Nick Hartshorne-Evans

Abstract

The All-Party Parliamentary Inquiry1 into heart failure reported in September 2016. The inquiry’s aim was to understand what the key issues were in heart failure and what needs to happen to address deficiencies. Data presented to the inquiry highlighted the significant impact of the role played by the heart failure specialist nurse (HFSN). The evidence-base behind the role of the HFSN has shown that these highly skilled individuals have been able to reduce morbidity, mortality and provide patients and carers with holistic and effective care.2 The patients that contributed to the inquiry spoke of the immense support and care that they received from their HFSN. However, further data emphasised that access to a HFSN was inequitable, with anecdotal experience suggesting that services are being decommissioned as a result of reorganisation of services and nurse retirement.

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April 2019 Br J Cardiol 2019;26:46–7 doi:10.5837/bjc.2019.013

Should invasive coronary angiography be performed by non-cardiologist operators?

Tiffany Patterson, Simon R Redwood

Abstract

The concept of nurse-led angiography was first introduced in the UK just over two decades ago. This was in response to concerns raised following implementation of the Calman report.1 The Calman report recommended a structured training programme for cardiology registrars, thus, achieving clinical competence at a faster rate, with a view to filling anticipated consultant vacancies. However, it was presumed that this would negatively impact clinical service delivery. One particular concern was that there would be a reduced number of registrars available and able to perform coronary angiography. There was a fear that this shortfall would lead to reduced throughput within cardiology centres. Boulton et al. described a potential solution to this shortfall: the training of a clinical nurse specialist to perform coronary angiography.2 The aim was to teach the nurse-angiographer the technical skills to undertake coronary angiography, with a head-to-head comparison of procedural time, radiation exposure, and complication rate. The results were impressive with the nurse-angiographer demonstrating a numerical reduction in complication rate and fluoroscopy time. These results were similar to those of DeMots et al., who trained a physician assistant in Portland, Oregon to perform coronary angiography with a view to reducing the workload of trainee cardiologists.3

In this issue of the British Journal of Cardiology Yasin et al. describe the implementation of nurse-led angiography at Wycombe Hospital. Although not novel, the findings are certainly interesting. They performed a comparison of nurse-led coronary angiography with registrar-led angiography in an observational study of 200 patients. They examined procedural time, radiation exposure, contrast load and complication rates. Albeit small numbers, they demonstrated that nurse-led angiography was associated with a reduction in radiation and contrast load, concluding that a non-medical operator can be taught the technical skills required to perform coronary angiography safely. However, the observational nature of this study limits the conclusions that can be drawn. Although appropriate at an early level of training, the patients that underwent nurse-led angiography were a highly select ‘safe’ patient group, and, without baseline characteristics, it is not possible to determine if one arm of the study had more comorbidities than the other.

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April 2019 Br J Cardiol 2019;26:48–9 doi:10.5837/bjc.2019.014

Should we be targeting people with diabetes when screening for atrial fibrillation?

Angela Hall, Andrew Mitchell

Abstract

Atrial fibrillation (AF) and diabetes are chronic conditions, which are increasing in prevalence. Stroke is a recognised complication of both conditions and can often be prevented through detection and appropriate intervention. Screening for disease has also improved over the last few decades through a plethora of tools and advances in technology. AF impacts physically, psychologically, socially and economically, and does not always present with symptoms. AF can be detected through electrocardiogram (ECG) monitoring and pulse checks, with high-risk groups typically targeted. When AF is detected, medication to control heart rate and anticoagulation can be started to reduce subsequent risks. AF is underdiagnosed in the community, particularly in the elderly, and the condition lends itself to screening.1

A review of the evidence for AF screening demonstrates a lack of homogeneity, with different target populations. High-risk groups have varied and include those with hypertension, stroke, myocardial infarction, older age and diabetes. Although the pathophysiological relationship between AF and diabetes is not entirely understood, there is an acceptance that the coexistence imposes greater risk to the patient in terms of comorbidities including stroke.

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January 2019 Br J Cardiol 2019;26(1) doi:10.5837/bjc.2019.001

Manage frailty effectively or manage decline – your choice and responsibility!

Srikanth Bellary, Alan J Sinclair

Abstract

Over the last few decades there has been a steady increase in life-expectancy leading to an increase in the ageing population, placing significant demands on health and social care.1 Among the several healthcare issues that confront older people, frailty has emerged as an important entity, and tackling frailty has assumed greater significance.2 There is currently no single agreed definition of frailty, but it is widely accepted as a condition characterised by reduced response to stressors consequent to decline in multiple physiological systems associated with ageing. Prevalence of frailty in community-dwelling older adults is estimated to be around 10–14%, but figures between 4% and 49% have been quoted in various populations.3,4 Prevalence also varies with age, with around 7% in adults over 65 years, increasing up to 25% in those aged 80 years and above.5 There are a number of tools to detect frailty, and the most commonly used tool is the criteria proposed by Fried and colleagues based on data from the Cardiovascular Health Study, which assesses five domains, namely weight loss (≥5% weight loss in the past year), exhaustion (effort required for activities), slow walking speed (>6–7 s per 15 feet), weakness as measured by grip strength and decreased physical activity (kilocalories/week: male <383, female <270), with the presence of three or more of these fulfilling the criteria for frailty.5

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Clinical articles

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July 2019 Br J Cardiol 2019;26:110–3 doi:10.5837/bjc.2019.024

A simple technique for IMA graft angiography and PCI using contralateral radial access

Matthew E Li Kam Wa, Pitt O Lim

Abstract

Angiography of internal mammary artery (IMA) grafts continues to be a common indication for upfront femoral access. This is particularly the case for bilateral pedicled IMAs, or when the left radial artery has been grafted. While the right radial artery is ideally suited in these situations for cannulation of the right IMA, accessing the left IMA (LIMA) by this route is often perceived as challenging and for ‘radial evangelists’ only. We describe a case series showing a simple technique for selective cannulation of the LIMA from the right radial artery using a single catheter that provides sufficient backup for percutaneous coronary intervention (PCI).

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July 2019 Br J Cardiol 2019;26:101–4 doi:10.5837/bjc.2019.025

Managing gastrointestinal manifestations in patients with PoTS: a UK DGH experience

Jeremy S Nayagam, Viral A Sagar, Maxwell Asante

Abstract

Gastrointestinal (GI) symptoms are common in patients with postural orthostatic tachycardia syndrome (PoTS). Our understanding of managing GI symptoms in PoTS is very limited. Our objectives were to evaluate common GI symptoms, diagnostic work-up, diagnosis and management strategy in patients with PoTS.

We retrospectively reviewed medical records of all patients referred to the gastroenterology clinic (2014 to 2017) with GI symptoms and known or suspected PoTS: 85 patients with PoTS and GI symptoms were seen in our clinic. Bloating (75%), constipation (74%) and abdominal pain (60%) were the most common GI symptoms. Endoscopy, high-resolution manometry, gastric-emptying studies and colonic-transit studies were commonly performed investigations. Over two-thirds of patients had confirmed or suspected GI dysmotility, 5.9% had organic GI disease (e.g. inflammatory and acid peptic disorders).

In conclusion, the majority of patients with PoTS have a functional disturbance and reduced GI motility, however, a small proportion have organic disease that needs systematic evaluation. Dietary modifications and laxatives are the main modalities of therapy.

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July 2019 Br J Cardiol 2019;26:92–6 doi:10.5837/bjc.2019.026

Identifying prognostically significant CAD in end-stage renal disease patients

Subodh R Devabhaktuni, Ali O Malik, Ji Won Yoo, Xibei Liu, Vipul Shah, Syed I Shah, John M Ham, Bejon T Maneckshana, Jimmy Diep, Chowdhury H Ahsan

Abstract

False-negative results either from balanced ischaemia or from failure to induce optimal hyperaemia is a known limitation of vasodilator myocardial perfusion imaging (MPI). We sought to identify the prevalence of false-negative results in the kidney transplant population and to identify the risk factors predictive of false-negative MPI results at our institution.

We retrospectively studied 133 consecutive patients who were referred to us for pre-operative evaluation. Mean age was 56 years and 70% of the subjects were males. All patients who underwent vasodilator MPI and computed tomography coronary angiography (CTCA) were included.

In the studied population, false-negative vasodilator MPI test result prevalence was around 13%. In uni-variable and multi-variable analysis, diabetes and cardiovascular disease (CVD) were predictive of false-negative vasodilator MPI testing results. CTCA had a positive-predictive value (PPV) of 82%.

In conclusion, false-negative results, either from balanced ischaemia or from failure to induce optimal hyperaemia, are a major problem in the pre-operative evaluation of renal transplant patients when the vasodilator MPI test is used. CTCA could be a useful imaging modality in this patient population. We found that diabetes and CVD are significantly associated with false-negative MPI results.

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July 2019 Br J Cardiol 2019;26:120 doi:10.5837/bjc.2019.027

Congenital absence of the right pericardium: managing patients long term

Jenny McKeon, Richard Mansfield, Mark Hamilton, Benjamin J Hudson

Abstract

Absence of the pericardium is a rare defect that can be both congenital and acquired. Defects occur through abnormal development of the pleuro-pericardial membranes, which should fuse at the midline and separate the pericardial and pleural cavities.1 Congenital incidence is thought to be less than one in 10,000,2 however, prevalence is uncertain due to the incidental findings of many diagnoses. With increasing use of cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CT), diagnosis of pericardial absence is becoming more frequent, however, little is known about the long-term management of these patients.

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April 2019 Br J Cardiol 2019;26:53–8 doi:10.5837/bjc.2019.012

Safety, effectiveness and quality of nurse diagnostic coronary angiography

Ghazala Yasin, Mark Davies, Piers Clifford, Soroosh Firoozan

Abstract

Advanced nursing roles supported by competency-based training have been pioneered over the last 25 years, with emphasis on the development of specific medical skills. This has largely been influenced by increasingly complex medical needs, costs of healthcare and the significant reduction in available doctors. With this reduction of doctors in training and departmental support for expanding nursing roles, we devised a local initiative to train an experienced nurse to perform diagnostic coronary angiography. Our aim was to provide a safe and enhanced service and improve procedural efficiency within the cardiac day unit.

A prospective audit of 250 coronary angiography procedures was performed in the training period between 24 September 2014 and 9 October 2015. Post-training, 143 procedures were performed between 12 October 2015 and 20 July 2016. The prospective audit was performed to explore the safety, effectiveness and quality of nurse-delivered diagnostic coronary angiography. An audit form was created to assess each component of the procedure. This included, gaining patient consent, success in gaining arterial access, success in intubating the left and right coronary arteries, observation of haemodynamics, observation of complications and reporting the findings. Financial impact, patient satisfaction and staff perception outcomes were also audited.

When directly compared with contemporaries, nurse-delivered diagnostic coronary angiography resulted in successful and appropriate arterial access, successful intubation of both coronary arteries, safe monitoring throughout the procedure and correct reporting of each study, with a similar level of patient satisfaction.

In conclusion, this study demonstrates that nurses can, under the right supervision and governance, perform diagnostic coronary angiography to a safe, highly effective standard, which is equivalent to contemporaries.

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April 2019 Br J Cardiol 2019;26:97–8 doi:10.5837/bjc.2019.015

Avoiding needless deaths in aortic stenosis

John B Chambers

Abstract

Echocardiography is key for the assessment of aortic stenosis (AS), but taking a good history is also crucial and requires specialist competency. Symptomatic AS requires surgery and, if physicians miss the onset of symptoms, the risk of death rises from 1% per annum in patients without symptoms to 14% on a six-month surgical waiting list. A case is described illustrating the difficulty of obtaining the history in a patient with AS, and suggests how to take a careful history and questions to ask. Patients with a murmur suggesting AS should be considered for a specialist valve clinic.

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April 2019 Br J Cardiol 2019;26:76–8 doi:10.5837/bjc.2019.016

Fatal anaphylaxis following teicoplanin administration during pacemaker implantation

Michael Chapman, Andrew Turley, Thanh Phan, Nicholas Linker

Abstract

Over 50,000 cardiac implantable electronic device procedures are undertaken annually in the UK. Despite prophylactic measures, device infection still occurs. Anaphylaxis following teicoplanin is extremely rare with evidence limited to case reports and one case series. We present two fatal cases of anaphylaxis following teicoplanin administration. Both cases meet the World Allergy Organisation definition of anaphylaxis. These cases highlight the importance of anaphylaxis to teicoplanin as a procedural complication. Despite prompt treatment, this reaction was fatal. Operators should be aware of this risk in an era of increasing procedures and rising incidence of anaphylaxis.

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April 2019 Br J Cardiol 2019;26:79–80 doi:10.5837/bjc.2019.017

An unusual cause of pericardial tamponade in pregnancy

Bishav Mohan, Hasrat Sidhu, Rohit Tandon, Rajesh Arya

Abstract

Pericardial involvement is sporadic during pregnancy. We present the case of a young woman who presented to the emergency department with a short history of rapidly progressive dyspnoea in her 38th week of pregnancy. Coronary arteriovenous fistula (CAVF) has been uncommonly described as a cause of pericardial effusion. We believe this is a rare case of a CAVF presenting as cardiac tamponade in pregnancy.

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January 2019 Br J Cardiol 2019;26:14–8 doi:10.5837/bjc.2019.002

A survey of post-cardiac rhythm device implantation: movement and mobilisation advice in the UK

George Collins, Sarah Hamill, Catherine Laventure, Stuart Newell, Brian Gordon

Abstract

Movement restrictions are given to patients after cardiac rhythm device implantation, despite little consensus, or evidence that they reduce complications. We conducted a UK survey assessing the nature of the advice and if it varies between individuals and institutions. A survey was distributed to cardiac rhythm teams at UK implanting centres. Questions concerned the advice that is given, its source, and who is responsible for providing it.

There were 100 responses from 42 centres. Advice is given by physiologists, nurses, and cardiologists. Advice comes from local protocols, information leaflets, current hospital opinion, manufacturers, national leaflets, published research and audit data. Within and between centres there was little agreement on what the advice should be. Depending on who gives the advice, a number of leisure pursuits were either completely unrestricted or restricted indefinitely. Cardiologists were less restrictive than others.

In conclusion, this is the first UK survey to assess the movement and mobilisation advice given to patients after device implantation. There is variation in the source and nature of advice. Over-restriction could impact on patients’ quality of life. Contradictory advice could cause uncertainty. Further work should determine the impact of this variation and how the effects could be safely mitigated.

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January 2019 Br J Cardiol 2019;26:19–22 doi:10.5837/bjc.2019.003

ICMs can be routinely implanted in a non-theatre environment by a cardiac physiologist

Varun Sharnam, Stelios Iacovides, Luisa Cleverdon, Wasing Taggu, Philip Keeling

Abstract

Implantable cardiac monitors (ICMs), also known as implantable loop recorders (ILRs), are used for long-term heart rhythm monitoring of unexplained syncope or in the detection of arrhythmias. These devices are implanted by cardiologists within a cardiac catheter suite environment. The newer generation devices are miniaturised and inserted using a specific tool kit via a minimally invasive procedure. This paper describes the changes we have made to allow these devices to be implanted in a non-theatre environment by a cardiac physiologist and the benefits and cost reduction of this service redesign.

A cardiac physiologist (LC, Band 6) undertook specific training beginning in September 2015. A standard operating procedure (SOP) was developed and patient information videos were commissioned. The new service was introduced in September 2016 in the screening room of our critical care unit (CCU). Data were collected prospectively on the clinical outcome, patient satisfaction and costs.

Over a 13-month period LC independently performed 116 procedures (113 Medtronic Reveal LINQ™ ICMs and 3 St. Judes SJM CONFIRM™) with only one minor complication. Patients were highly satisfied with the redesigned service, which showed a reduction in cost of £241.27 per case.

ICMs/ILRs can be implanted safely and cost-effectively outside a cardiac catheter suite environment by a cardiac physiologist. This requires some specific training, a clinical SOP and is supported by use of dedicated patient information videos.

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January 2019 Br J Cardiol 2019;26:27–30 doi:10.5837/bjc.2019.004

Outcome of investigations into patients who attended the emergency department due to palpitations

Alexander J Gibbs, Andrew Potter

Abstract

Previous research estimates that up to 40% of palpitation presentations to the emergency department (ED) have cardiac aetiology. This study was performed to determine the proportion of patients referred on for cardiology investigations that consequentially had new significant pathology diagnosed; and the effect of follow-up investigation on patient re-attendance to the ED with the complaint of palpitations.

Patients referred to a community cardiology centre in 2016 for investigation into palpitations following an ED presentation were included. The diagnosis that each patient received from these investigations was analysed to see whether: (a) new underlying cardiac abnormality was identified and (b) that abnormality was significant, requiring follow-up.

There were 93 patients meeting criteria for analysis: 28% had a cardiac cause for their palpitations elicited, including 11% with new significant pathology identified. Rate of re-attendance to the ED was reduced once cardiology investigations were completed (0.11 presentations/patient; 95% confidence interval [CI] 0.04 to 0.18) compared with the investigation period (0.75 presentations/patient; 95%CI 0.3 to 1.2).

In conclusion, although only one tenth of patients referred for investigations had new significant cardiac pathology identified, completing cardiology investigations reduced ED re-attendance.

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January 2019 Br J Cardiol 2019;26:35 doi:10.5837/bjc.2019.005

Association of subclinical hypothyroidism in heart failure: a study from South India

Pramod Kumar Kuchulakanti, VCS Srinivasarao Bandaru, Anurag Kuchulakanti, Tallapaneni Lakshumaiah, Mehul Rathod, Rajeev Khare, Parsa Sairam, Poondru Rohit Reddy, Athuluri Ravikanth, Avvaru Guruprakash, Regalla Prasada Reddy, Banda Balaraju

Abstract

Recent studies have associated subclinical hypothyroidism with heart failure (HF) and increased mortality. To investigate the relationship between subclinical hypothyroidism and HF in Indian patients we prospectively recruited 350 HF patients between March 2013 and February 2017 at the department of cardiology Yashoda Hospital, Hyderabad, India. All patients underwent fasting serum glucose, lipid profile, N-terminal-pro-brain natriuretic peptide (NT-proBNP), and thyroid hormone levels. Risk factors and clinical evaluation were undertaken. We divided thyroid-stimulating hormone (TSH) levels into severity grade 1 (≤9.9 mIU/L) and grade 2 (≥10 mIU/L).

Out of 350 HF patients, 191 (54.5%) were men, mean age was 60.4 ± 10.2 years (range 36–85 years). The incidence of subclinical hypothyroidism was 18.5%, 69.4% had normal thyroid function, and 12% had overt hypothyroidism. Mean NT-proBNP levels were 3561 ± 5553 pg/mL and 10.5% suffered in-hospital mortality. Dyslipidaemia (p=0.004), elevated NT-proBNP levels (p<0.0001) and mortality (p<0.0001) were significantly associated with subclinical hypothyroidism compared with euthyroidism. After multi-variate analysis, hypertension (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.32, 3.8), dyslipidaemia (OR 1.7; 95%CI 1.12, 2.8), subclinical hypothyroidism (OR 1.39; 95%CI 0.99, 1.82) and NT-proBNP >600 pg/mL (OR 1.98; 95%CI 1.23, 2.04) were significantly associated with HF. Grade 2 TSH (OR 4.16; 95%CI 2.04, 8.48), elevated NT-proBNP >1800 pg/mL (OR 2.18; 95%CI 1.53, 4.82), and severe left ventricular dysfunction (OR 2.51; 95%CI 1.24, 2.07) were significantly associated with poor outcome.

In conclusion, our study has established that subclinical hypothyroidism is associated with HF and grade 2 TSH has an independent association with in-hospital mortality in Indian patients.

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January 2019 Br J Cardiol 2019;26:36–7 doi:10.5837/bjc.2019.006

Significant suppression of premature ventricular ectopics with ivabradine in dilated cardiomyopathy

Lal H Mughal, Andrew R Houghton, Jeffrey Khoo

Abstract

Ivabradine is an I(f)-channel blocker currently used for the treatment of angina and heart failure. Although these channels are known to be found within the sino-atrial node, recent studies have also found localisation within the ventricular myocardium, and there have been reports of ventricular arrhythmia suppression in animal models. We describe an unusual case of significant ventricular ectopy suppression in a patient with non-ischaemic dilated cardiomyopathy. This was accompanied by a significant improvement in percentage pacing from her cardiac resynchronisation device, with corresponding improvement in her functional status. This report suggests, first, that the morbidity and mortality benefit of ivabradine in heart failure may not be solely due to its sino-atrial heart-rate lowering effect, and, second, highlights a potential role for ivabradine in the management of ventricular arrhythmias, which requires further studies to substantiate.

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News and views

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December 2018

Cardiorenal Forum 2018: Updates and progress in cardiorenal medicine

This year’s fascinating and thought-provoking 13th Annual Scientific Meeting of the Cardiorenal Forum brought together experts from the closely linked specialties of nephrology, cardiology...