2025, Volume 32 (online first)

Wellens’ syndrome, characterised by specific T-wave changes on electrocardiogram (ECG), indicates critical proximal left anterior descending (LAD) stenosis and high acute myocardial infarction risk. While revascularisation is the standard treatment, it may be unsuitable for elderly patients with comorbidities. We present a case of successful medical management of Wellens’ syndrome type B in a 94-year-old woman deemed unfit for invasive interventions. The patient was treated with dual antiplatelet therapy, high-intensity statin, and anti-anginal medications. Symptom control was achieved, and serial ECGs and cardiac biomarkers remained stable. This case demonstrates that aggressive medical management can be a viable alternative in elderly patients with Wellens’ syndrome type B, unsuitable for invasive procedures....

Though a rare condition, acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality; hence, timely diagnosis and surgery are important to reduce the risk of mortality. If the dissection extends into the aortic arch branches, ensuring adequate cerebral perfusion during surgery is crucial to preventing stroke. A 50-year-old man presented to the emergency department with symptoms of acute chest pain, dizziness, and headache. His blood pressure was 180/110 mmHg and heart rate was 100 bpm. He had a high blood pressure and heart rate and was initially treated with glyceryl trinitrate. Initial investigations ruled out acute coronary syndrome. Further investigations revealed ATAAD with the involvement of arch branches, an incomplete (open) circle of Willis and cerebral malperfusion. He was prepared for a branch-first total aortic arch replacement. Due to the high risk of stroke in this patient, off-pump axillo-axillary bypass (adaptive perfusion technique) was used to ensure bihemispheric cerebral perfusion throughout the surgery. The surgery was uneventful, and the patient was discharged 12 days later. Postoperative follow-up at six months was normal. In conclusion, ATAAD is a surgical emergency that can mimic other acute thoracic conditions, such as pulmonary embolism and acute coronary syndrome; therefore, a judicious approach should be applied in the diagnosis and early management of symptoms. The reconstruction technique should be tailored to the patient’s needs; as this patient had a poorly functioning circle of Willis and cerebral hypoperfusion, continuous bilateral cerebral perfusion was essential to prevent irreversible cerebral ischaemic insult. The adaptive technique is easy to learn for surgeons who are already proficient in aortic dissection procedures, it is reproducible and requires only minor changes to the surgical setup without any substantial increase in operative time. Adoption of this technique in other surgical centres could be beneficial in increasing the success rate for the treatment of ATAAD....

Pericardial cyst is a rare diagnosis, mainly considered a congenital condition. Most patients with pericardial cysts present without symptoms. Symptomatic presentation often relates to the size and location of the pericardial cyst. We report a case of a 49-year-old man who presented with subacute breathlessness in which the diagnosis of a pericardial cyst was made following various investigations – from transthoracic echocardiography and computed tomography scan to video-assisted thoracoscopic surgery biopsy, upon which a histological diagnosis was made. This case report reviews and discusses the available literature on the epidemiology and potential presenting features of a pericardial cyst, and the current recommended assessment and management strategies thereof. This case highlights the importance of effective multidisciplinary communication and joint input towards clinical decision-making, particularly in complex scenarios, to achieve optimal patient outcomes....

Coronary artery spasm (CAS), or Prinzmetal angina, is a recognised cause of myocardial ischaemia in non-obstructed coronary arteries which typically presents with anginal chest pain. This case report describes an atypical presentation of CAS in a 68-year-old white British male with cardiovascular risk factors. The patient presented with recurrent palpitations and pre-syncope, with no chest pain. Ambulatory electrocardiography (ECG) monitoring revealed recurrent polymorphic ventricular tachycardia (PMVT). Coronary angiography identified moderate stenosis of the right coronary artery (RCA), without significant flow restriction by invasive pressure wire interrogation. Inpatient monitoring revealed episodes of recurrent PMVT coinciding with transient inferior ST elevation and a distinct ‘shark fin’ waveform, indicating dynamic RCA occlusion. The arrhythmias persisted despite initial medical management, including calcium channel blockers and intravenous glyceryl trinitrate. Percutaneous coronary intervention to the moderate RCA lesion was performed, which definitively treated the arrhythmias. This case emphasises the importance of recognising plaque-associated CAS as a potential trigger for life-threatening arrhythmias, even in the absence of chest pain. While medical therapy remains first-line treatment, life-threatening presentations may necessitate invasive interventions to stabilise the patient and prevent recurrence....

A 24-year-old male bodybuilder presented with cardiac symptoms following long-term performance-enhancing drug (PED) use. He was diagnosed with heart failure with reduced ejection fraction and body dysmorphic disorder. Treatment included cardiac medical therapy and psychiatric support. After PED discontinuation and ongoing psychological care, symptoms improved and relapse was prevented. This case highlights the potential severe cardiovascular consequences of PED abuse in young, healthy individuals. It emphasises the importance of early recognition, multidisciplinary intervention addressing both physical and psychological aspects, and increased awareness about PED risks, particularly among those with body image disorders....

A 79-year-old woman presents to the hospital with dyspnoea, fever, and hypotension, and is diagnosed with community-acquired pneumonia and septic shock. Resuscitation is initiated with fluids and vasopressors, and a central venous catheter is placed. However, during the procedure, the guide experiences resistance and cannot be removed, becoming trapped. This is confirmed with tomography and reconstruction, demonstrating intravascular position. The patient is then sent to interventional cardiology for extraction, which is successfully performed using the EN Snare (Merit Medical). The significance of this case lies in the complications of not guiding procedures with ultrasound and how to resolve them, such as the guide being trapped in this patient....

Severe mitral regurgitation (MR), when complicated by a co-existing lung abscess, is a management challenge, as both conventional cardiac and thoracic surgical interventions may be contraindicated. In the case described below, transcatheter edge-to-edge mitral valve repair (TEER) was utilised to achieve haemodynamic stability, permitting subsequent thoracic surgical lung abscess resection. We report the case of a 60-year-old man with torrential MR secondary to chordal rupture presenting with recurrent pulmonary oedema, complicated by lung sepsis and abscess formation resistant to antibiotic therapy and precluding open valvular repair. The presence of a lung abscess contraindicated open mitral valve repair, and the severity of MR precluded thoracic surgical treatment of the lung abscess, precluding any form of surgical intervention. A successful TEER procedure resulted in a reduction of MR from severe to no more than mild-to-moderate, enabling haemodynamic stabilisation and permitting subsequent thoracic surgical treatment of the lung abscess. Our case demonstrates the possibility of treating severe MR with TEER in the presence of a lung sepsis and abscess, when both conventional cardiac and thoracic surgical interventions were considered contraindicated. This later enabled thoracic surgery and treatment of the lung abscess....

This case report describes a young man in his early thirties with insulin-dependent diabetes mellitus and ulcerative colitis, who developed acute myocardial infarction (AMI) during an acute flare-up of ulcerative colitis. The case highlights the diagnostic and therapeutic challenges involved in managing AMI in patients with systemic inflammatory diseases and metabolic conditions. The patient was successfully treated with a combination of thrombectomy and a drug-eluting balloon procedure for coronary occlusion, along with pharmacotherapy consisting of intravenous steroids, intravenous glycoprotein IIb/IIIa inhibitor and the involvement of a multi-disciplinary team of cardiologists and gastroenterology specialists. This case underscores the need for an integrated care approach, aggressive cardiovascular risk management, and interdisciplinary collaboration to optimise outcomes in complex clinical scenarios where systemic inflammation intersects with cardiovascular events....

A 32-year-old man presented to the emergency department with shortness of breath and altered mental status. He reported a two-day history of epigastric pain, nausea, and vomiting. His past medical and family history were unremarkable. He was haemodynamically unstable, and his initial electrocardiogram (ECG) revealed a Brugada type 1 ECG pattern. The initial diagnostic assessment revealed significant metabolic derangements consistent with diabetic ketoacidosis, accompanied by hyperkalaemia. Notably, the prompt and effective management of hyperkalaemia resolved the Brugada type 1 ECG pattern, confirming the diagnosis of Brugada phenocopy....

Platypnea-orthodeoxia syndrome (POS) is a rare condition which presents with positional dyspnoea and deoxygenation on an orthopneic position which resolves when supine. We present a rare presentation of POS in a 75-year-old man, who initially presented with mixed symptomology including dyspnoea on exertion and syncope. He was found to have intermittent symptomatic hypoxia and initial investigations ruled out infection, pulmonary embolism and interstitial lung disease. Pulse oximetry confirmed positional variations in oxygenation. A transthoracic echocardiogram and a transoesophageal bubble echocardiogram with positional manoeuvres confirmed the presence of a large patent foramen ovale (PFO) with shunting. The patient was referred to the tertiary centre for PFO closure which resulted in resolution of his symptoms. This case report highlights the importance of recognising POS as a rare differential in causes of unexplained dyspnoea and utilising multiple imaging techniques to confirm the diagnosis....

Saphenous vein grafts (SVGs) are frequently used for coronary artery bypass grafting (CABG) of severe coronary artery disease; however, re-stenosis is common. Restoration of blood flow to the SVG is uncommonly achieved via revascularisation of the native vessel. A man in his 70s with previous CABGs presented with prolonged chest pain at rest. The left anterior descending (LAD) and left circumflex arteries had chronic total occlusions (CTO), and the SVG and left internal mammary artery, previously used to bypass the LAD, were severely diseased with sluggish flow and an inability to pass a balloon or microcatheter. Rotational atherectomy was successfully performed to cross the LAD CTO, with good flow post-stenting. He remained asymptomatic one year later. Where management of calcified venous grafts precludes passage with balloon or microcatheter, rotational atherectomy of the native coronary may represent an alternative method of restoring blood flow....

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management....

Temporary epicardial pacing is a cornerstone of postoperative cardiac care, but improper management, particularly of atrial pacing, may contribute to the onset of postoperative atrial fibrillation (POAF). In this article we review the challenges involved in identifying atrial lead malfunction and the associated arrhythmogenic risk. As well as implementing strategies to reduce risk, the development of advanced technology capable of detecting and correcting atrial pacing dysfunction in real time should be a priority....

Adults with Fontan palliation face variable risks of thrombosis and bleeding. The optimal thromboprophylaxis strategy remains unclear. There is a balance between the risk of thromboembolism and bleeding with thromboprophylaxis. Recent studies suggest direct oral anticoagulants (DOACs) may provide effective thromboembolism prevention, but concerns regarding bleeding risk, hepatic impairment, and lack of robust data persist. This study investigates thromboprophylaxis practices among UK adult congenital heart disease (ACHD) specialists, focusing on the use of DOACs in Fontan patients. An electronic survey was distributed to UK National ACHD Consultant Group members from February to March 2023. Based on hypothetical clinical scenarios, the survey collected demographic data, familiarity with DOACs, and preferred thromboprophylaxis strategies. Responses were analysed using descriptive statistics to identify patterns in practice. There was a maximum response rate of 42%, with 32 respondents participating, primarily consultants from level 1 ACHD centres. Thromboprophylaxis strategies varied significantly: DOACs, warfarin, and aspirin were used with varying frequency, depending on clinical factors, such as arrhythmias, thrombosis history, and patient-specific challenges. While 35% of respondents were comfortable prescribing DOACs, 42% expressed reservations, citing limited evidence and concerns about risks. This study highlights wide variability in thromboprophylaxis strategies for Fontan patients in the NHS, underscoring significant gaps in evidence. Hepatic considerations, patient-specific challenges, and the lack of DOAC licensing for certain scenarios contribute to the complexity of clinical decision-making. Prospective studies are essential to guide practice, and patient involvement in shared decision-making is critical in the interim....

Cardiotoxicity, including left ventricular (LV) dysfunction, is a dreaded side-effect of selected drugs that are widely used in oncology. Guidelines recommend the assessment of LV systolic function, primarily by echocardiography, before and during exposure to cardiotoxic medications. However, apart from LV ejection fraction (LVEF), echocardiography reports include dozens of numerical data points and other detailed information familiar to cardiologists, but which may not be familiar to other specialties. With a rising need for echo in oncology patients, and with no cardio-oncology service within our hospital, we assessed what is understood by oncologists regarding the information provided within an echocardiographic report, and what action they take subsequent to the report. Morriston Cardiac Centre provides tertiary care to a population of 1.2 million and conducts 12,000 transthoracic echocardiograms (TTE) annually. We ran a survey of all consultant clinical oncologists in Wales, using a set of multiple-choice questions via Google Forms. We presented the responders to our questionnaire with a set of hypothetical echocardiographic findings, drawn from common clinical scenarios, and asked what they would do if they received a report containing such a finding. Our questionnaire was completed by 14 of 19 (74%) oncology consultants. Only a little better than half reported low-to-moderate confidence in interpreting the findings that echo reported. Oncologists varied in their level of confidence and understanding of what TTE findings meant, and the responses to commonly reported echocardiographic findings (e.g. actions they would take if echo report stated low-normal ejection fraction) had inhomogeneity. Our work supports the utility of a dedicated cardio-oncology clinical pathway or service, which would assist with these queries, and may even obviate them, by providing the echo report directly to a cardio-oncologist....

Drug-eluting stents (DES) are a common treatment for acute coronary syndrome (ACS) but pose risks like bleeding, re-stenosis, stent thrombosis, and neo-atherosclerosis. Drug-coated balloons (DCB) may mitigate these risks. This study compares DCB therapy’s effectiveness with DES in ACS patients with de novo lesions. A retrospective observational study was conducted on ACS patients undergoing percutaneous coronary intervention (PCI) with either DES or DCB from May 2019 to August 2022 at a single tertiary centre. Patients with left central trunk lesions were excluded. The primary end point was a composite of major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, and target lesion revascularisation, evaluated 12 months post-intervention. Statistical analysis was performed using R software with significance set at a two-tailed p value <0.05. Of 168 patients, 101 received DES and 67 received DCB. The DCB group had a mean age of 61.9 years, while the DES group averaged 63 years. The DCB group had more prior PCIs and myocardial infarctions. Baseline characteristics, including target and number of lesions, were comparable. MACE occurred in eight (11.9%) DCB patients and 11 (10.9%) DES patients, showing no significant difference (p=0.64). In conclusion, this study suggests that DCB therapy may be an effective alternative to DES for ACS. However, limitations, including a single-centre setting and short follow-up, warrant the need for more extensive, randomised trials to validate these findings....

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) represent major global health burdens, collectively affecting hundreds of millions worldwide.1 COPD is projected to become the third leading cause of death globally by 2030, while CVD remains the primary cause of mortality worldwide.2 Historically viewed as distinct entities, a paradigm shift is underway as mounting evidence reveals a complex, bi-directional relationship between these conditions.3,4 This growing recognition extends beyond shared risk factors like smoking, encompassing common pathophysiological mechanisms, such as systemic inflammation and oxidative stress.5 The interplay between COPD and CVD presents unique challenges and opportunities, necessitating a re-evaluation of traditional management approaches and calling for more integrated, multi-disciplinary care strategies....

This article explores using artificial intelligence (AI) to detect atrial fibrillation (AF) early, highlighting its potential to revolutionise cardiology. It reviews numerous studies demonstrating AI’s superior accuracy to traditional methods, particularly in leveraging electrocardiography data from various sources like smart devices and chest radiographs. A key concern addressed is the ‘black box’ nature of some AI algorithms, emphasising the critical need for transparency to build clinician confidence and ensure ethical patient care. It concludes by advocating for policy changes and further research to enhance AI algorithm transparency and integration into clinical practice....

Cardiovascular disease (CVD) is one of the leading causes of death and disability in the UK. The implications for the NHS are profound, as increasing hospital admissions strain resources and escalate wait times. Currently, people with one or more long-term conditions use 50% of all general practitioner (GP) appointments, 64% of all outpatient appointments, and 70% of hospital beds.1 With CVD now the cause of one in four premature deaths2 in the UK, transforming the way CVD is prevented and care is provided, is becoming increasingly crucial. With National Health Service England (NHSE) recently publishing their 2025/26 priorities and operational planning guidance,3 there is a need for systems to address inequalities and shift towards prevention. To address this challenge in the West Midlands, a transformative approach to CVD prevention and management was taken that included early diagnosis, effective management and comprehensive education. The work was led by Health Innovation West Midlands (HIWM) and colleagues from primary and secondary care across all six integrated care systems (ICSs)....

Most cardiologists view themselves as strong, hardened clinicians with a broad knowledge-base, alongside (sometimes very) specialist expertise. As clinicians we are seen to embody the quintessential type A stereotype, impervious to most emotional traumas, managing and coping with frequent, both sudden and slow, demises and challenging, complex and often time-pressured, scenarios. I am no stranger to the demands of a profession that requires precision, composure, and resilience. Yet, behind the façade of clinical and academic competence, lies a reality that many of us, including myself, are reluctant to confront: the personal and professional toll that psychiatric illness can take on physicians....

Sudden cardiac death (SCD) in young athletes is a rare but devastating event, most often caused by structural or electrical abnormalities of the heart. Although athletes are generally among the healthiest individuals, the occurrence of SCD in this group attracts significant public attention, particularly as exercise may trigger fatal events in those with underlying disease. This has driven debate around the role of pre-participation screening (PPS) as a strategy to identify at-risk individuals before they compete. Several international sporting and scientific organisations have issued recommendations, but screening protocols vary, and the balance between benefit, feasibility, cost, and potential harm remains controversial. While evidence suggests that screening may detect otherwise silent cardiovascular disease, limitations include false-positives, false-negatives, interpretation challenges, and the ethical implications of disqualification. This review explores the benefits and potential challenges of cardiac screening in athletes, and the implications for protecting athlete health and ensuring safe participation in sport....