2012, Volume 19, Issue 4, pages 145-184

2012, Volume 19, Issue 4, pages 145-184

Editorials Clinical articles News and views
Topics include:-
  • Preventing a second heart attack
  • Physician assistant: a new role
  • Atrial fibrillation in Scotland
  • News from ESC and HRC


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November 2012 Br J Cardiol 2012;19:151 doi:10.5837/bjc.2012.028

BHS call for more primary care and cardiologist members

Tony Heagerty, Terry McCormack


The British Hypertension Society (BHS) was established in 1980 by a group of physicians interested primarily in research. Over the years it has broadened its remit to encompass teaching and the development of best practice in hypertension management and cardiovascular risk prevention. Originally membership was restricted to people actively involved in research, but recently we have opened our doors to welcome other healthcare professionals (resident in the UK and Ireland) who are interested in the wider field. The majority of hypertension management in the UK is carried out by primary care physicians and nurses with increasing input from pharmacists. Many referrals to secondary care involve cardiologists. These practitioners are not sufficiently represented in the Society and, hence, we are keen for primary care health workers and cardiologists to apply for membership.

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Clinical articles

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November 2012 Br J Cardiol 2012;19:167–9 doi:10.5837/bjc.2012.029

Secondary prevention regimens and risk factors are not optimised in patients re-admitted with ACS

Krishnaraj S Rathod, Shoaib Siddiqui, Barron Sin, John Hogan, Sandy Gupta


An observational study was conducted on patients with pre-existing coronary heart disease who were re-admitted to an acute district general hospital with a further acute coronary event. Their demographics, admission drug therapies and cardiovascular risk factor parameters were recorded and analysed. Of the 100 patients admitted over a nine-month period, more than a quarter of them were taking suboptimal secondary prevention drug therapies. Furthermore, a proportion of patients were not achieving adequate cholesterol, blood pressure and heart rate targets, which, in turn, may be a major contributory factor for their re-presentation to hospital. 

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November 2012 Br J Cardiol 2012;19:170–2 doi:10.5837/bjc.2012.030

Incidence screening for primary prevention ICDs based on UK guidelines following STEMI

Ellen Berry, Helen Padgett, Melanie Doyle, Arif J Ahsan, Andrew D Staniforth


We conducted an observational study within a cardiology tertiary centre with the aim of increasing the primary prevention implantable cardioverter defibrillator (ICD) implantation rate in line with Heart Rhythm UK (HRUK) national target.

A total of 326 patients experienced ST-elevation myocardial infarction (STEMI) over a 14-month time period and were offered incidence screening for implantation of a primary prevention ICD at six weeks according to National Institute for Health and Clinical Excellence (NICE) guidelines (TA095). There were 273 (84%) patients who completed the screening process; 26 (8%) had an ejection fraction (EF) of <35%. Two patients had an EF of <30% with a QRS duration >120 msec. Two of 22 subjects had evidence of non-sustained ventricular tachycardia on 24-hour Holter monitoring; one had a positive ventricular tachycardia stimulation test. Overall, three patients received an ICD (0.9%).

In conclusion, this process was labour intensive and had a lower than expected yield.

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November 2012 Br J Cardiol 2012;19:173–7 doi:10.5837/bjc.2012.031

Trends in atrial fibrillation hospitalisation in Scotland: an increasing cost burden

Martin Keech, Yogesh Punekar, Anna-Maria Choy


The objective of our study was to evaluate the impact of atrial fibrillation (AF) on secondary care costs in Scotland. Patient hospitalisation data from the Information and Statistics Division (ISD) of the Scottish National Health Service (NHS) from 2004 to 2008 were analysed to estimate trends in hospital episodes in the 5.2 million population of Scotland. The associated costs were estimated using the tariff prices in Scotland for the respective years. 

Over the five-year period, AF-related hospital discharges increased by 33% compared with 20% for all cardiovascular discharges (29 and 37 per 1,000 population respectively). There were increases of: 21% in number of patients hospitalised; 27% in AF-related hospital admissions; and 15% in total patient bed days. Despite decreasing trends, mean length of inpatient stay for AF remained higher than for total cardiovascular conditions (10.9 vs. 8.7 days), as did inpatient cost per patient (£6,009 vs. £5,586). AF-related hospital costs increased from £138.9 million in 2004 to £162.5 million in 2008, accounting for 24% of all cardiovascular hospital costs. Overall, the burden of AF was higher among women and increased progressively with age. 

In conclusion, AF presents a significant and increasing burden on hospital care in Scotland. At 25% of the total cardiovascular burden, AF costs are increasing relatively faster. 

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November 2012 Br J Cardiol 2012;19:178–9 doi:10.5837/bjc.2012.032

Cardiovascular innovations: role, impact and first-year experience of a physician assistant

Susan Collett, Devan Vaghela, Ameet Bakhai


Improving patient access and implementation of the European Working Time Directive has proved a challenge for the National Health Service (NHS), particularly adding to workforce pressures and reducing continuity of care for patients. Innovative service and workforce redesign led to the introduction of new and extended roles based on service need. This paper outlines the introduction of one such new role, physician assistant (PA), introduced in the NHS in 2006, based on the established US PA model. UK-trained PA graduates are taking up newly created posts in primary and acute healthcare trusts and the aim of this paper is to share the first-year experience of introducing a newly qualified UK-trained PA within a busy district general hospital cardiology department, describing the internship year, achievements, limitations and how the role has evolved in line with service need. We believe the role has ideal potential in a cardiology department and, in particular, in the management of long-term chronic conditions, such as heart failure, where the number of specialist contacts with the patient can directly impact admissions, re-admissions, length of stay, adherence to medications and protocols of care positively.

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November 2012 Br J Cardiol 2012;19:180–3 doi:10.5837/bjc.2012.033

Sheffield’s nurse-led heart failure clinic: the patients’ opinions

Kathryn Drewry, Louisa Yates, Andrew Birchall, Donna Barnett, Natalie Buckley, Meg Warriner, Laurence O’Toole, Abdallah Al-Mohammad


A new heart failure service was established in Sheffield in 2008. The service provides specialist advice on the management of inpatients with heart failure, and optimises their medical therapy in a heart failure clinic led by heart failure nurse specialists. We undertook a survey of patients’ perception of the service provided by these clinics.

A postal survey was sent to the patients who attended the nurse-led heart failure clinics more than once in the first two years of the service. There were two types of questions: multiple-choice questions and those allowing free text answers. We approached 228 patients. We received responses from 192 (84%). Of these patients, the majority (80–90%) responded positively to most of the questions. The vast majority of patients regarded the service as providing excellent care, that the staff were courteous and professional, and they were able to establish a good relationship. The negative remarks were related to facilities such as parking spaces in the hospital, and to the label of heart failure. The team endeavours to make improvements to the service. 

In conclusion, the nurse-led heart failure clinic was positively received by heart failure patients.

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November 2012 Br J Cardiol 2012;19:184 doi:10.5837/bjc.2012.034

Massive inferior venacavo-atrial thrombus following neoadjuvant chemotherapy

Pankaj Kaul, Robert George, Rodolfo Paniagua, Subbarayulu Balaji, Mohan Sivananthan, Rob Sapsford


A 26-year-old man presented with T4 adenocarcinoma of sigmoid colon, which was initially treated with a covering ileostomy and neoadjuvant chemotherapy with oxaliplatin and infusional 5-fluorouracil delivered through a right subclavian Hickman line. While receiving chemotherapy, he developed a massive right atrial thrombus, adherent to the inferior venacaval opening and the adjoining right atrial wall, mimicking a metastatic deposit, which was removed surgically on cardiopulmonary bypass. The patient subsequently underwent successful high anterior resection of the sigmoid cancer followed by adjuvant chemotherapy with oxaliplatin and capecitabine. The unusual features of this patient’s presentation include the extremely rapid growth of thrombus despite aggressive anticoagulation, the unusual site of thrombus on the inferior vena caval opening rather than around the Hickman line, and possible facilitation of thrombus formation by chemotherapeutic agents. We also discuss the diagnostic and therapeutic dilemmas in a patient with a concurrent malignancy and a right atrial mass.

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News and views

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November 2012 Br J Cardiol 2012;19:152

News from the ESC Congress 2012

Highlights of the European Society of Cardiology (ESC) 2012 Congress held in Munich, Germany on August 25th–29th included the first ever randomised trial addressing...

November 2012 Br J Cardiol 2012;19:155

Highlights from HRC 2012

This year's Heart Rhythm Congress (HRC 2012), held in Birmingham from 23rd-26th September, was the largest to date showing the growing interest in this...

November 2012 Br J Cardiol 2012;19:158–9

New diabetes guidelines stress individual patient needs

The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have published new guidelines on the treatment of type...

November 2012 Br J Cardiol 2012;19:158–9

KEEPS: reassurance on heart effects of HRT

Four years of hormone-replacement therapy (HRT) started soon after the onset of the menopause improved depression and anxiety in healthy women without promoting or...

November 2012 Br J Cardiol 2012;19:158–9

More on diabetes risk with statins

Another study has found a slight increase in fasting glucose levels in patients at increased risk of type 2 diabetes taking statins. The study...

November 2012 Br J Cardiol 2012;19:160

In brief

News in brief from the world of...

November 2012 Br J Cardiol 2012;19:161

Lessons learnt from a tragic loss

Correspondence from the world of...

November 2012 Br J Cardiol 2012;19:162-4

Decision by consensus: more political correctness or a genuine improvement in care?

We continue our series in which Consultant Interventionist Dr Michael Norell takes a sideways look at life in the cath lab…and beyond. In this...