2015, Volume 22, Issue 1, pages 1–40

2015, Volume 22, Issue 1, pages 1–40

Editorials Clinical articles News and views
Topics include:-
  • Smartphones and ECG screening
  • Self-management of chronic pain after cardiac surgery
  • End-of-life care – trainee views
  • Cannabinoids and cardiovascular risk


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March 2015 Br J Cardiol 2015;22:7–9 doi:10.5837/bjc.2015.006

Synthetic and natural cannabinoids: the cardiovascular risk

Ethan B Russo


Cannabis has been employed medicinally and recreationally for thousands of years,1,2 but it was not until the 1960s that the structure and pharmacology of its primary phytocannabinoid components, cannabidiol (CBD)3 and tetrahydrocannabinol (THC)4 were identified, and another generation before the nature and function of the endocannabinoid system (ECS) were elucidated (see reference 5 for a comprehensive review). The ECS consists of endogenous cannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), their biosynthetic and catabolic enzymes, and their receptors: CB1, which is psychoactive, analgesic, neuromodulatory and the most abundant G-protein coupled receptor in the brain, and CB2, which is non-psychoactive, immunomodulatory and anti-inflammatory. The ECS may be thought of as a grand homeostatic regulator of chordate physiological functions, whose roles have been summarised as: “relax, eat, sleep, forget and protect”.6 Those actions closely describe the effects of THC and AEA, which are both weak partial agonists at CB1 and CB2. 

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March 2015 Br J Cardiol 2015;22:10–11 doi:10.5837/bjc.2015.007

Breaking the deadlock

Miriam J Johnson


We know that people with advanced heart failure have unmet supportive and palliative care needs, and the burden of these concerns is comparable with people with cancer.1–2 Palliative care services in the UK and elsewhere have grown up around oncology services. Randomised controlled trials (RCTs) have confirmed that early integration of palliative care, alongside cancer treatment, improves patient outcomes.3–7 In contrast, experience of and the evidence base for integration of palliative care alongside heart failure treatment has been slow to develop. However, this is changing. A pilot RCT comparing the addition of a palliative care intervention to usual care for people with advanced heart failure has reported benefit in health-related quality of life, symptom control and health service utilisation (reduced hospital admission)8 and several phase three RCTs are ongoing. 

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Clinical articles

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March 2015 Br J Cardiol 2015;22:40 doi:10.5837/bjc.2015.012

MI with multiple distal occlusions associated with use of the synthetic cannabinoid 5F-AKB48

Jason L Walsh, Benjamin H L Harris, Nicholas Ossei-Gerning


A 26-year-old man presented to the emergency department with central chest pain radiating to the left arm. An electrocardiogram (ECG) revealed inferior ST elevation. He had no major risk factors for cardiovascular disease, but habitually used synthetic cannabinoids (AKB48 and 5F-AKB48). A subsequent coronary angiogram showed occlusions in four obtuse marginal branches of the left circumflex artery and a large clot in the distal right coronary artery. The patient was treated with aspirin, ticagrelor, rivaroxaban and tirofiban infusion, and these occlusions were demonstrated to have resolved on a follow-up angiogram. The patient admitted smoking 5F-AKB48 four hours before the onset of chest pain. This case further strengthens the association between the use of synthetic cannabinoids and embolic-appearing myocardial infarction. This is the first report of myocardial infarction associated with the currently ‘legal-high’ 5F-AKB48, and may indicate the need for tighter regulation of this compound.

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March 2015 Br J Cardiol 2015;22:26 doi:10.5837/bjc.2015.008

Trainee experiences of delivering end-of-life care in heart failure: key findings of a national survey 

Yasmin Ismail, Kate Shorthose, Angus K Nightingale


It is widely accepted that end-of-life care for non-cancer conditions has lagged behind that for cancer. The purpose of this survey was to evaluate the confidence of trainees in managing end-of-life issues. An online questionnaire was distributed to all registrar-grade British Junior Cardiac Association members in the UK.

A total of 219 trainees responded. Overall, 73% of trainees feel the care they provide patients with advanced heart failure is poor/adequate. Over 50% of trainees do not feel equipped to discuss advanced-care planning and end-of-life issues. There are 45% who report receiving no training in palliation of advanced heart failure symptoms, while 57% are unhappy with current provision of training. Trainees’ suggestions include more workplace-based supervision with additional regional and national training days, closer links with local hospices, and fellowships for cardiology trainees in palliative care.

Despite being part of the national curriculum for training in cardiology since 2010, trainees’ level of confidence in delivering end-of-life care in advanced heart failure and discussing prognosis is poor. This could be rectified by closer links with palliative care and formal teaching programmes.

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March 2015 Br J Cardiol 2015;22:31–3 doi:10.5837/bjc.2015.009

The efficacy of a smartphone ECG application for cardiac screening in an unselected island population

Pierre Le Page, Hamish MacLachlan, Lisa Anderson, Lee-Ann Penn, Angela Moss, Andrew R J Mitchell; from the Jersey International Centre for Advanced Studies


Cardiac screening in the community is limited by time, resources and cost. We evaluated the efficacy of a novel smartphone application to provide a rapid electrocardiogram (ECG) screening method on the Island of Jersey, population 98,000.

Members of the general public were invited to attend a free heart screening event, held over three days, in the foyer of Jersey General Hospital. Participants filled out dedicated questionnaires, had their blood pressure checked and an ECG recorded using the AliveCor (CA, USA) device attached to an Apple (CA, USA) iPhone 4 or 5. 

There were 989 participants aged 12–99 years evaluated: 954 were screened with the ECG application. There were 54 (5.6%) people noted to have a potential abnormality, including suspected conduction defects, increased voltages or a rhythm abnormality requiring further evaluation with a 12-lead ECG. Of these, 23 (43%) were abnormal with two confirming atrial fibrillation and two showing atrial flutter. Other abnormalities detected included atrial and ventricular ectopy, bundle branch block and ST-segment abnormalities. In addition, increased voltages meeting criteria for left ventricular hypertrophy (LVH) on 12-lead ECG were detected in four patients leading to one diagnosis of hypertrophic cardiomyopathy.

In conclusion, this novel ECG application was quick and easy to use and led to the new diagnoses of arrhythmia, bundle branch block, LVH and cardiomyopathy in 23 (2.4%) of the total patients screened. Due to its highly portable nature and ease of use, this application could be used as a rapid screening tool for cardiovascular abnormalities in the community.

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March 2015 Br J Cardiol 2015;22:37 doi:10.5837/bjc.2015.010

Long-term cardiac rehabilitation and cardioprotective changes in lifestyle

Wolfgang Mastnak


Sustainability of health benefits from cardiac rehabilitation (CR) requires adequate changes in lifestyles. Preventive medicine highlights a triadic guideline referring to cardioprotective behaviour, avoidance of associated polymorbid developments (e.g. depression), and improvement of life-quality. To assess the influence of long-term CR management (in Austria phase 4) offered by the Austrian Heart Association (ÖHV) on changes in lifestyles according to the INTERHEART CHD-risk parameters, a questionnaire measuring the extent of phase 4 influences on lifestyle modifications according to the INTERHEART parameters physical activity, stress, nutrition, body mass index (BMI), smoking, and alcohol was developed. Data were gained from a non-preselected sample of cardiac patients with various diagnoses (n=204; age 41–91, average 71.8; standard variation 7.8, 48% cardiovascular). 

ÖHV activities were found to exert a strong influence on health sports (various indoor and outdoor aerobic activities and mobility exercises), stress-reduction, and nutritional adjustment, contrasting low influence on the awareness of diabetes risks and alcohol/nicotine consumption. Social inclusion is considered an important life-quality factor supporting also the sense of security. 

Long-term CR management is an efficient instrument for cardioprotective lifestyle modification. The important influence on patients requires especially high sports cardiologic standards and psycho-educational competence. Close collaboration between different phases/stages of CR, as well as similar international organisation should be fostered. 

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March 2015 Br J Cardiol 2015;22:38 doi:10.5837/bjc.2015.011

Optimising self-management to reduce chronic pain and disability after cardiac surgery

Michael Hugh McGillion, Andrew Turner, Sandra L Carroll, Gill Furze, Jason W Busse, Andre Lamy


While the primary aims of cardiac surgical procedures are to improve survival and ameliorate symptoms, chronic post-surgical pain (CPSP) is a prevalent problem requiring focused attention. Recent years have seen a global emphasis on the development and implementation of self-management (SM) interventions to combat the negative consequences of multiple chronic conditions, including chronic pain. This short report makes recommendations for optimising SM following cardiac surgery to improve pain and related functional outcomes and reduce the risk and impact of CPSP.

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February 2015 Br J Cardiol 2015;22:36 doi:10.5837/bjc.2015.004

Experiences from a non-medical, non-catheter laboratory implantable loop recorder (ILR) service

Alun Roebuck, Cara Mercer, Joanne Denman, Andrew R Houghton, Richard Andrews


This paper describes the experiences of developing a non-medical, non-catheter laboratory (cath lab) based implantable loop recorder (ILR) service. ILRs are small subcutaneous single-lead electrocardiogram (ECG) monitoring devices that are placed in a left pectoral pocket under local analgesia. Traditionally, devices have been implanted by medical staff in the cath lab. Each implant can take between 30 and 45 minutes depending on operator skill and patient anatomy. The development of this service has had several major patient and organisational benefits that include shorter waiting times, less cancellations and increased flexibility to implant ‘urgent’ devices in transient loss of consciousness (TLOC). The latter has reduced length of stay within our emergency assessment unit (EAU). Moreover, this service means that the department has been able to undertake more procedures in the cath lab. Data from 2013–14 suggest that an additional 32 × four-hour cath lab sessions were made available for alternative use. Adverse events (infection/erosion) are comparable with published data at less than 1%. To conclude, non-medical, non-cath lab based implantation is safe, cost-effective and has the potential to improve patient experience while increasing both cardiologist and cath lab capacity. 

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February 2015 Br J Cardiol 2015;22:34 doi:10.5837/bjc.2015.001

Contrast-induced nephropathy in PCI: an evidence-based approach to prevention

Asad Shabbir, Jamie Kitt, Omar Ali


Contrast-induced nephropathy is the third most common cause of in-hospital acute kidney injury and accounts for 10% of total cases. It is commonly encountered following coronary angiography and this systematic review aims to use current evidence to ascertain which treatment modalities are most effective in the prevention of the disease. 

A PubMed literature search was conducted in March 2014 using search terms, ‘contrast nephropathy and coronary angiography’. The data analysed included 15 trials and two meta-analyses in order to determine whether patients given N-acetylcysteine (NAC), sodium chloride or sodium bicarbonate had better clinical outcomes. Study data were reviewed and quality of data discussed. 

Current data indicate that sodium bicarbonate is as effective as sodium chloride when used in patients with estimated glomerular filtration rate (eGFR) <60 ml/min. NAC adds no statistically significant benefit in mild-to-moderate renal disease regardless of whether it is used in isolation or as an adjunct therapy with fluid.

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February 2015 Br J Cardiol 2015;22:35 doi:10.5837/bjc.2015.002

An arrhythmia specialist nurse improves patient care in arrhythmias treated with dronedarone

Moira Allison, Robert T Gerber, Steve S Furniss, Conn Sugihara, A Neil Sulke


The European Medicines Agency (EMA) has mandated that patients treated with dronedarone have regular monitoring. An arrhythmia specialist nurse (ASN) took over the care of patients on dronedarone in 2012.

Patients on dronedarone were identified from hospital notes and pharmacy records. Adherence to EMA guidelines on monitoring before and after the appointment of an ASN were compared. In 112 patients on dronedarone in the year prior to the appointment of an ASN, only 478 of the 1,275 (37%) required tests were actually done. With the ASN, 382 of 422 (92%) tests in 53 patients were performed. This was significantly better (p<0.001). Dronedarone was more likely to be stopped due to contraindications (p<0.017) prior to the appointment of ASN, but afterwards was more likely to be stopped due to side effects (p<0.001).

The ASN significantly improved adherence to EMA-mandated monitoring in patients on dronedarone. Involvement of an ASN had no overall impact on the likelihood of dronedarone being stopped. Patients were more likely to have the drug stopped due to side effects, and were less likely to stop for safety reasons. ASN care is superior to conventional follow-up, and is the gold standard for patients treated with dronedarone.

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February 2015 Br J Cardiol 2015;22:27–30 doi:10.5837/bjc.2015.003

Incidence of cardiac surgery following PCI: insights from a high-volume, non-surgical, UK centre

Andrew Whittaker, Peregrine Green, Giles Coverdale, Omar Rana, Terry Levy


Percutaneous coronary intervention (PCI) has established itself as an effective alternative to coronary artery bypass graft surgery (CABG) in appropriate patients. However, the proportion of patients that undergo CABG and/or valve surgery (VS) following PCI in the short and long term is currently unknown.

We conducted a single-centre, retrospective study examining the indications and number of patients requiring CABG and or VS following successful PCI between 2009 and 2012. The surgical procedure was categorised as early (referred within <1 month of the index PCI), mid-term (referred 1–12 months after index PCI) and remote (referred >1 year and up to four years following the index PCI). 

During each three-year period (2008–2010, 2009–2011), 5,244 PCIs were performed at our centre. The total number of patients referred for cardiac surgery post-PCI was 63 (1.2%). The number of patients referred for early, mid-term and remote cardiac surgery was 21 (0.4%), 14 (0.26%) and 28 (0.53%), respectively. Within the early group, eight patients had extensive three-vessel disease stabilised with emergency/urgent PCI to allow subsequent CABG, while 10 patients had failed PCI to a chronic total occlusion. In the mid-term group, the main reason for surgery was rapid progression in coronary disease. In the remote group, the majority of patients underwent surgery for progression of valve disease. 

Our data suggest that the number of patients requiring CABG and/or VS following PCI is small, and the indications differ with time following the index PCI. We hope that these results will provide reassurance and interest to our interventional colleagues. 

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February 2015 Br J Cardiol 2015;22:39 doi:10.5837/bjc.2015.005

Anomalous coronary artery origin: all three arising from right coronary cusp from separate ostia

Vickram Singh, Jeffrey Khoo


A 53-year-old woman presented with history of exertional chest pain. A coronary angiogram subsequently showed an unusual and rare coronary artery anatomy: all of her coronary arteries originate from the right coronary cusp, with separate ostia. In addition, the left anterior descending (LAD) artery was hypoplastic resulting in ischaemia.

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News and views

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March 2015 Br J Cardiol 2015;22:(1)

Where there’s life, there’s hope: debating the Saatchi Bill

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March 2015 Br J Cardiol 2015;22:20–1

A significant collapse?

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March 2015 Br J Cardiol 2015;22:22–4

Vive la différence?

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March 2015 Br J Cardiol 2015;22:17

News from the Cardiorenal Forum 9th Annual Scientific Meeting – embracing the future, not forgetting the past

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March 2015 Br J Cardiol 2015;22:19

In brief

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February 2015 Br J Cardiol 2015;22:18

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February 2015 Br J Cardiol 2015;22:11

Correspondence: accurate classification of chest pain

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February 2015 Br J Cardiol 2015;22:11

Correspondence: don’t see their heart broken

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February 2015 Br J Cardiol 2015;22:11

Correspondence: mortality due to rheumatic heart disease

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February 2015 Br J Cardiol 2015;22:25

Book review

The antibody molecule: from antitoxins to therapeutic...

January 2015 Br J Cardiol 2015;22:12–13

News from the American Heart Association Scientific Sessions 2014

The latest mega trial − IMPROVE-IT − dominated discussion at the recent American Heart Association (AHA) Scientific Sessions, with ezetimibe becoming the first non-statin...