2016, Volume 23, Issue 4, pages 121–160

Following Brexit, like many other people with Irish parents, I started the process of applying for an Irish passport. The Irish embassy website informed me, to my surprise, that I had become an Irish citizen on the day I was born. Despite that status, and despite owning a home in County Kerry, I have to admit I know very little about the Irish healthcare system. In fact, having worked my entire life in English healthcare, I do not fully understand the systems in the other three constituent countries of the UK either. My career has mostly involved both primary and secondary care, so I do understand the issues and difficulties of communication between hospitals and general practitioners (GPs).

Ischaemic heart disease (IHD) is the leading cause of mortality worldwide.¹ It is a debilitating, life-changing illness that can reduce quality of life and life-expectancy. While surgical, percutaneous and optimal medical interventions can significantly improve the clinical course of the disease, our understanding of the biopsychosocial mechanisms promoting survival following an acute IHD event, such as an acute coronary syndrome (ACS), is still limited. 

Over and over we hear the message that healthcare spending is out of control, the National Health Service (NHS) needs to save £20 billion and that is before the baby boom* generation fully enters the most expensive part of their healthcare journey...

The rationale behind secondary prevention post-ST-elevation myocardial infarction (STEMI) is well established. Guidelines recommend titration of several medications for secondary prevention up to a maximally tolerated dose in order to confer maximum benefit. Due to decreasing duration of inpatient stays post-myocardial infarction (MI), this up-titration must often take place in primary care. Guidelines also recommend clearly informing GPs regarding duration of dual antiplatelet therapy and monitoring cardiovascular risk factors. Clear communication between secondary/tertiary and primary healthcare practitioners is essential in order to ensure our patients are receiving optimum care. 

We examined all discharge summaries for patients discharged post-STEMI in our tertiary referral centre. This encompassed rates of prescribing of the National Institute for Health and Care Excellence (NICE) recommended medications post-MI, rates of therapeutic prescribing of these medications and communication with GPs regarding duration of dual antiplatelet therapy, up-titration of medications and repeat checking of fasting lipid profiles. In order to improve compliance with guidelines, incoming junior staff were educated on guidelines for communication post-STEMI at our journal club. We then re-audited our practice in order to see if compliance with the guidelines improved. 

Our results showed that, while the majority of our patients were discharged on the correct medications post-MI, most were receiving subtherapeutic doses of angiotensin-converting enzyme (ACE) inhibitors and beta blockers. In addition, we exhibited poor communication with primary healthcare practitioners. Compliance with the NICE guidelines on communication significantly improved after our intervention. 

In conclusion, education of junior staff can significantly improve communication with GPs. This, in turn, could help optimise secondary prevention strategies post-MI.

Postural tachycardia syndrome (PoTS) is a form of dysautonomia, a term used to describe dysfunction of the autonomic nervous system. The condition can cause marked physical and cognitive impairment that can significantly impact upon activity. Although the exact UK prevalence is unknown, its frequency has stimulated an increase in studies. Occupational therapy services should place themselves in a position to respond to the potential need. 

This study aimed to determine how PoTS impacts upon activity, in order for occupational therapists to understand the implications of this condition and develop appropriate interventions. 

We recruited 201 adults (aged 18–70 years) via two patient support charities to participate in an online quantitative survey. Participants rated their experiences pre-symptoms versus present day in relation to their occupations, producing ordinal data under self-care, leisure and productivity domains, including their physical ability, motivation and fatigue levels.

The pre-symptom versus present day probability scores of <0.001 can be viewed as ‘very significant’ and confirm that PoTS has a significant negative impact across all three occupational domains.

In conclusion, PoTS has a significant negative impact upon occupation and is associated with considerable morbidity. With their understanding of the central role of occupation in wellbeing, occupational therapists may need to support people with PoTS in achieving a satisfying balance of occupations that will support their health.

National Institute for Health and Care Excellence (NICE) clinical guideline 95 (CG95) was introduced to rapid-access chest pain clinics (RACPC) to aid investigation of possible stable angina based on pretest probability of coronary artery disease (CAD). Following a six-month audit of its implementation we introduced a modified version: patients with low/moderate risk of CAD were referred for computed tomography coronary angiography (CTCA), while those at high/very high risk were referred for invasive angiography.

Patient records of 546 patients referred to our RACPC over a six-month period were retrospectively analysed. Pretest probability of CAD, referral for initial investigation, and outcomes at a minimum follow-up time of six months were documented.

Incidence of CAD correlated well with pretest probability. Moderate-risk patients had a low incidence of CAD and revascularisation. High/very high-risk patients had a high incidence of revascularisation, and this was predominantly for prognostically significant disease.

In conclusion, low rates of CAD in low- and moderate-risk groups justifies the use of CTCA as a first-line investigation in these patients. Routine investigation of very high-risk patients allows a high proportion to undergo revascularisation for prognostically significant disease. Strict adherence to NICE CG95 could lead to these patients being missed. 

Bleeding is one of the complications associated with percutaneous coronary intervention from the femoral route due to the use of potent antiplatelet therapies including adenosine diphosphate receptor blockers and glycoprotein IIb/IIIa inhibitors. Complications include haematoma, retroperitoneal haemorrhage, pseudoaneurysm, arteriovenous fistula, arterial occlusion, femoral neuropathy and infection. Complications for diagnostic procedures are lower due to the lack of antiplatelet therapies on board. Often, incorrect location of the femoral artery puncture site results in complications. Puncturing below the femoral bifurcation can result in psedoaneurysm, haematoma and arteriovenous fistulas, whereas retroperitoneal haemorrhage is caused by high femoral punctures. Identification of bleeding and vascular complications is paramount as bleeding is associated with adverse events. Techniques to reduce the risk of femoral arterial complications include the use of ultrasound scan or fluoroscopy guided femoral punctures. Furthermore, the micropuncture technique has been shown to reduce complications but is not widely adopted. Ultimately, the radial route is preferable to the femoral route as vascular complications are significantly lower.

National Institute for Health and Care Excellence (NICE) guidance supports the introduction of sacubitril/valsartan under the supervision of a heart failure specialist with access to a multi-disciplinary heart failure team. Clinical information was obtained retrospectively on all patients with a primary coded diagnosis of heart failure discharged from the Conquest Hospital, Hastings, UK during the calendar year 2015. We recorded the proportion of patients meeting the NICE recommendation and those patients meeting the additional PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) study inclusion criteria. 

In a total of 205 assessable patients discharged with a primary diagnosis of heart failure during the calendar year 2015, inpatient mortality was 11%, with a crude readmission rate during the year of 17%. The number of patients meeting the NICE criteria was 26 (13%). In hierarchical analysis taking the major PARADIGM-HF inclusion criteria, 20 patients (10%) patients met the inclusion criteria. 

In conclusion, the findings from this audit suggest that the number of patients potentially suitable for sacubitril/valsartan therapy is low. Given the PARADIGM-HF study run-in design, the optimal dose and stability of angiotensin-converting enzyme (ACE) inhibitor and angiotensin-receptor blocker medication may need to be clarified if sacubitril/valsartan is to be commenced during or shortly after hospitalisation.

The first-in-class drug sacubitril/valsartan (Entresto^TM) has been recommended for use in the UK by the National Institute for Health and Care Excellence (NICE) following evidence from the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial. To qualify, patients should have severe left ventricular dysfunction (ejection fraction ≤35%), New York Heart Association (NYHA) grade II–IV symptomatic heart failure, and be on a stable dose of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB). We evaluated all patients seen in our nurse-led heart failure clinics over a six-month period to assess suitability for sacubitril/valsartan and the resulting cost implication. 

Of 553 patients seen, more than two thirds (69%) were unsuitable, of whom most had an ejection fraction greater than 35%. Other reasons included hypotension, NYHA class I, renal dysfunction, intolerance of ACEi/ARB and compliance concerns. There were 49 patients who died within nine months of the study period end. Of these, most (84%) were unsuitable for sacubitril/valsartan. Compared with current local use of ACEi and ARB, switching the 174 suitable patients to sacubitril/valsartan would cost £171,816 per year.

In our real-world experience, 31–37% of patients attending a specialist nurse-led heart failure clinic may be suitable for sacubitril/valsartan therapy. While the clinical benefits of this treatment are well proven and a recent NICE technology assessment has demonstrated cost-effectiveness, the medication has significant upfront cost implications for healthcare commissioners.

Drug-eluting stents (DES) have revolutionised the treatment of acute coronary syndrome, resulting in improvement in mortality and morbidity. However, there have been safety concerns, mainly involving a small, but long-term, risk of stent thrombosis (ST) and in-stent restenosis (ISR). Stent fracture (SF) is a lesser-known complication that can predispose to both ST and ISR and for which there is no general consensus for treatment. We present an interesting case and a new approach to treating this complex problem.