2026, Volume 33 (online first)

A 78-year-old man presented to the cancer assessment bay with a history of progressive fatigue, generalised muscle pain, and bilateral ptosis after completing two cycles of nivolumab/ipilimumab for metastatic renal cancer. Physical examination revealed mild bilateral ptosis (right > left), worsening with upward gaze, binocular diplopia, and fatigable weakness in the right shoulder. Electrocardiogram (ECG) showed a new right-bundle branch block (RBBB), with left-axis deviation, and left ventricular hypertrophy. Blood analyses showed elevated troponin I, brain natriuretic peptide, and creatine kinase with values of 221 ng/L, 114 ng/L, and 1,109 U/L, respectively. He was managed as immune checkpoint inhibitor-related severe myocarditis, myositis, and myasthenia gravis overlap (triple M) syndrome with high-dose steroids and pyridostigmine, resulting in clinical and biochemical improvement. However, immunotherapy was permanently discontinued, and follow-up imaging after three months showed evidence of disease progression. This case explores the importance of a multi-disciplinary approach in the effective management of a rare and severe immune-related toxicity and the impact of toxicities on treatment options and cancer progression....

Cardiovascular medicine is undergoing transformation driven by machine learning (ML) technologies.1 Algorithms now assist in imaging interpretation, electrocardiogram (ECG) analysis, and outcome prediction, with increasing sophistication.1,2 The adoption of ML-powered diagnostic tools in cardiology is growing, yet training programmes remain largely unchanged, creating a disconnect between skills taught and those required in contemporary practice.1–4 Despite rigorous clinical preparation, many cardiology trainees complete their education with insufficient knowledge of the ML technologies increasingly present in clinical workflows.5,6 As these applications become more prevalent, training programmes must integrate relevant ML education to ensure cardiologists can effectively evaluate, implement, and collaborate with artificial intelligence (AI) systems, rather than merely function as passive end-users of increasingly sophisticated technology....

Immune checkpoint inhibitors (ICIs) have revolutionised cancer care, but can cause serious cardiac immune-related adverse events (irAEs), particularly myocarditis, which carries up to 50% mortality. This study explores patient pathways to improve early recognition and management of ICI myocarditis in acute settings. This was a retrospective, single-centre case series from a UK tertiary hospital with a specialist cardio-oncology multi-disciplinary team (MDT). Ten patients referred to the cardio-oncology MDT between March and August 2024 were included if diagnosed with myocarditis, pericarditis, or arrhythmias linked to ICI treatment. Clinical pathways were described using structured vignettes. Seven patients had myocarditis, two pericarditis, and one bradyarrhythmia. Fatigue (57%) was the most common presenting symptom in myocarditis. Echocardiography was unremarkable in 86% of cases, while cardiac magnetic resonance imaging (MRI) confirmed myocarditis in 57%. N-terminal pro-B-type natriuretic protein (NT-proBNP) rose 17-fold from baseline compared with a four-fold rise in troponin T. Early MDT referral facilitated prompt diagnosis and treatment, while delayed recognition was associated with worse outcomes. This case series highlights the importance of early MDT involvement, and the utility of additional cardiac biomarkers, such as NT-proBNP. It provides practical guidance to improve the acute care pathway for patients developing ICI-associated cardiac toxicities....

Risk stratification for sudden cardiac death (SCD) and the selection of patients for prophylactic implantable cardiac defibrillator (ICD) in hypertrophic cardiomyopathy (HCM) are still evolving and far from ideal. I present a historical case of HCM that did not have recognised SCD risk factors. This case highlights the deficiency of the present risk-stratification strategy for HCM and European Society of Cardiology (ESC) risk-scoring system....

Conventional management of out-of-hospital cardiac arrest (OOHCA) in patients with unusual cardiac anatomy may result in inferior outcomes. It is important that appropriate consideration of these patients is made when developing OOHCA resuscitation guidelines. Initiatives to improve outcomes following OOHCA, such as community training of resuscitation techniques, should take patients with unusual cardiac anatomy into account. We present a male in his twenties with heterotaxy syndrome, a congenital defect with abnormally arranged intrathoracic and intra-abdominal organs. He experienced an unwitnessed OOHCA with a downtime of approximately 20 minutes. He had complex congenital heart disease and had undergone previous palliative cardiac surgery resulting in a Fontan circulation. Despite maximal inotropic and vasopressor support, he developed multi-organ failure with diffuse hypoxic brain injury warranting care withdrawal. In this case report we discuss the important roles of appropriate community resuscitation in patients with unusual cardiac anatomy and of mechanical circulatory support in patients with single ventricle physiology....

Often considered benign, Takotsubo syndrome (TTS) could be life threatening. We present a 54-year-old female patient with a history of heterozygous beta-thalassaemia and Graves’ disease who came to the emergency department complaining of dizziness, atypical chest pain and an episode of collapse. The patient developed cardiac arrest due to ventricular fibrillation. After 45 minutes of cardiopulmonary resuscitation, return of spontaneous circulation was achieved. A transthoracic echocardiography revealed hypokinetic mid and apical left ventricular (LV) segments. Her coronary angiography showed significant stenosis in the left anterior descending coronary artery, for which she underwent percutaneous coronary intervention. In the subacute phase, she had episodes of polymorphic ventricular tachycardia in the context of QT-interval prolongation. Cardiac magnetic resonance imaging demonstrated diffuse myocardial oedema in the mid and apical segments of the LV. Finally, after 60 days of hospitalisation, an implantable cardioverter-defibrillator was implanted for secondary prevention of sudden cardiac death. This case study demonstrates some of the serious complications of TTS and the medical decisions that may need to be made regarding its treatment course....

A man in his eighties presented with a two-week history of left-arm swelling and bruising. Twelve years earlier, he had undergone dual-chamber pacemaker implantation for bradycardia and syncope. His past medical history included hypertension, paroxysmal atrial fibrillation (pAF), and coronary artery bypass grafting (CABG) 15 years prior. Upon further investigation with ultrasound Doppler, and computerised tomography (CT) of his chest, a thrombus was confirmed in the left subclavian vein, associated with a pacing lead. He was initiated on a three-week course of low molecular weight heparin (LMWH). Although his symptoms initially improved, traces of the thrombus remained on his follow-up CT after commencing treatment, and he was continued on lifelong direct oral anticoagulant (DOAC). Pathogenesis, incidence, investigations and management of pacemaker-induced thrombosis are discussed. This case illustrates a rare, delayed presentation of pacemaker-induced thrombosis in the context of a symptomatic presentation and highlights the potential need for prolonged anticoagulation....

We present a patient with medication-refractory inappropriate sinus tachycardia (IST) who was hospital-bound and successfully treated with hybrid thoracoscopic ablation....

A 61-year-old man with Brugada syndrome (BrS) (SCN5A mutation) presented with chest pain to a district general hospital (DGH). There was no history of syncope or ventricular arrhythmias. A subcutaneous implantable cardioverter-defibrillator (S-ICD) was in situ for primary prevention following extraction of a previous transvenous ICD due to infection. Investigations suggested a non-ST-elevation myocardial infarction. While awaiting coronary angiography, he developed a ventricular tachycardia (VT) storm with recurrent cardiac arrests over 30 minutes due to polymorphic VT, receiving seven S-ICD shocks. Defibrillation, isoprenaline and quinidine were employed to manage the polymorphic VT storm, permitting transfer to a tertiary centre for further investigations. Coronary angiography demonstrated an occluded marginal artery, which was managed medically. Isoprenaline was weaned following quinidine initiation, the S-ICD reactivated, and he was discharged. A year later, there have been no further ventricular arrhythmias while on quinidine. This case report demonstrates the effectiveness of isoprenaline, which is easily accessible and readily available in DGHs, in stabilising an acute Brugada storm. Quinidine allowed successful weaning from isoprenaline, but lack of availability limits its use. Finally, this case report highlights both the benefits and risks of primary prevention ICDs in BrS....

An 18-year-old woman with truncus arteriosus presented with septic shock due to methicillin-sensitive Staphylococcus aureus infective endocarditis of her right-ventricle-to-pulmonary-artery (RV-PA) conduit requiring urgent conduit replacement and a prolonged admission complicated by acute respiratory distress syndrome and significant deconditioning. She had three separate presentations to external medical practitioners in the week preceding admission. This case underscores the complexity of managing infective endocarditis in patients with congenital heart disease and the importance of early referral to a specialist congenital centre....

Rate-related left-bundle branch block (LBBB) is an uncommon conduction abnormality that can mimic ventricular tachycardia or myocardial ischaemia, and in prolonged cases may contribute to cardiomyopathy. We describe the case of a 49-year-old woman with a previous history of mitral valve annuloplasty, anomalous pulmonary vein correction, and atrial fibrillation ablation who presented with recurrent palpitations and exertional chest pain. Despite normal echocardiograms and negative investigations for ischaemia, initially; a subsequent repeat exercise-tolerance test in 2024 revealed tachycardia-induced LBBB. Tachycardia-induced LBBB may cause haemodynamic instability, chest pain (‘painful LBBB syndrome’), or long-term ventricular dysfunction. Early recognition is important for avoiding misdiagnosis as ventricular tachycardia or acute coronary syndrome. Clinical management focuses on rate control, exclusion of coronary disease, and the use of implantable cardiac device therapy in refractory or cardiomyopathic cases. This case highlights the diagnostic challenges in patients with recurrent tachycardia-induced LBBB, the importance of excluding coronary artery disease, and the role of timely electrophysiology assessment to guide long-term management....

We present a case of malignancy-induced thromboembolism resulting in global ST-elevation myocardial infarction and complete heart block....

There is growing evidence for mortality with increasing age and comorbidities in implantable cardiac defibrillator receivers. We aimed to characterise how frailty and comorbidities impact mortality in patients receiving simple bradyarrhythmia device implants. A retrospective cohort of 700 consecutive individuals who underwent novel bradyarrhythmia devices in a single centre were studied. Results were analysed using a multi-variate Cox regression model hazard ratios (HR) and Kaplan-Meier curves. Mean implant age was 78.4 ± 10.3 years; 53.9% inpatient implants. All-cause mortality rate was 12.4% at one year. Mild-to-severe frailty measured by Rockwood frailty score (RFS) 5–9 was associated with mortality overall (HR 1.70, 95% confidence interval [CI] 1.30 to 2.21). Both inpatient (HR 1.57, 95%CI 1.19 to 2.08) and single-lead implants (HR 1.63, 95%CI 1.20 to 2.21) were associated with mortality. Patient characteristics include male gender (HR 1.49, 95%CI 1.15 to 1.92) and age per 10-year increment (HR 1.75, 95%CI 1.46 to 2.09), heart failure syndrome (HR 1.52, 95%CI 1.13 to 2.05), valvular heart disease (HR 1.88, 95%CI 1.33 to 2.65), obesity (HR 2.97, 95%CI 1.42 to 6.21), chronic kidney disease (HR 1.34, 95%CI 1.00 to 1.79) and malignancy (HR 1.55, 95%CI 1.09 to 2.19) were associated with mortality. In conclusion, higher RFS, male gender, heart failure syndrome, valvular heart disease, chronic kidney disease, obesity and malignancy were associated with mortality. Although advanced age does not preclude pacing, consideration should be given to frailty, which may detract from any perceived benefit bradyarrhythmia correction may offer....

To pace or not to pace? Clinical decision-making for older people with frailty and bradycardia is often challenging. For ambulatory, symptomatic patients a pacing strategy is clearly recommended, however, for those patients with severe frailty or limited mobility with an absence of clearcut symptoms, management strategies usually take a shared decision-making approach. How are clinicians expected to provide patients and carers with an objective picture of things to come in such an evidence-light space? The featured publication by Warraich et al., entitled “Outcomes of bradyarrhythmia device implantation: a single-centre retrospective cohort study”, from this issue at https://doi.org/10.5837/bjc.2026.052, is a call to arms to aid clinicians by providing some metrics around the likelihood of benefit. Bradycardia and bradyarrhythmias are common in older people reaching the end of their natural life, and patients, families and clinicians are reluctant to implant a pacemaker device when impact on quality of life is doubtful. This said, syncope can have devastating consequences, particularly hip fractures and head injuries, so there is a risk either way. Geriatricians are heavily invested in falls prevention, and the promotion of physical activity to improve health and wellbeing in the latter stages of life, so implantation is usually the preferred choice in the majority of cases, but where should we draw the line?...

Cardiovascular–kidney–metabolic (CVKM) care is increasingly recognised as a more realistic way to understand and manage chronic disease. Cardiovascular disease, chronic kidney disease (CKD), type 2 diabetes, obesity, and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently co-exist, share major risk factors, and influence one another biologically and clinically. Yet care delivery across the National Health Service (NHS) remains largely organised around separate pathways, disease-specific targets, and professional silos. This creates a practical mismatch between integrated disease biology and fragmented service delivery.1–3 A coherent CVKM approach is, therefore, not simply a new label for existing practice. It is a shift in clinical reasoning and system design: away from isolated disease management and towards integrated risk reduction, prioritisation, and patient-centred decision-making.4,5 The challenge is no longer only to identify effective therapies, but to deliver them in ways that are meaningful, equitable, and sustainable across real-world primary and secondary care.6–8...

The 2026 European Society of Cardiology (ESC) heart failure guidelines represent an important shift in how we think about this disease.1 Heart failure (HF) is no longer simply a syndrome treated once symptoms develop; it is a continuum from cardiovascular risk to cardiac change and overt disease. The greatest gains may come from identifying patients earlier, before irreversible changes occur. The question is no longer simply, “How should we treat HF?”, but “How early should we intervene, and can we prevent it?” It is impossible to cover every change within such comprehensive guidelines in a single opinion piece. We, therefore, focus on four clinically important developments: the prevention-focused stages A–D, revised left ventricular ejection fraction (LVEF) classification, replacement of guideline-directed medical therapy (GDMT) with more precise terminology, and earlier referral in stage D....