- Cardiac surgery in the very elderly
- Cancer immunotherapy and cardiac complications
- Will heart failure become the first cyber-specialty?
- CVD prevention with aspirin in the older patient
EditorialsBack to top
March 2020 Br J Cardiol 2020;27:5–7 doi:10.5837/bjc.2020.005
Ishtiaq Ali Rahman, Simon Kendall
Cardiac surgery for adults became widely available around 50 years ago, due mainly to the introduction of relatively safe cardiopulmonary bypass. Initially, mortality rates were quite high, even for relatively young and fit patients, and, therefore, patients and carers focused on this outcome measure. Moreover, it was easy to define and record. Local and national registries developed into databases that allowed comparison of mortality rates and were then further refined with risk modelling.
As the odds of survival after cardiac surgery improved, sicker and older patients were offered cardiac surgery, including octogenarians and extending to nonagenarians.
Clearly, surviving cardiac surgery is very important – but is survival the top priority for the 92-year old after bypass surgery who becomes unable to live independently again and who’s quality of life is insufferable? Should quality of life be the main factor driving therapeutic decisions for the frail and elderly?
January 2020 Br J Cardiol 2020;27:8–10 doi:10.5837/bjc.2020.001
Cardiovascular complications of anti-cancer immune checkpoint inhibitor therapy and their combinations: are we ready for challenges ahead?
Alexandros Georgiou, Nadia Yousaf
The use of immune checkpoint inhibitors (ICIs) has transformed the treatment landscape for a number of tumour types over the past decade. Targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4; ipilimumab), programmed cell death protein 1 (PD1; nivolumab, pembrolizumab), and programmed death-ligand 1 (PD-L1; atezolizumab, avelumab, or durvalumab), as monotherapy or in combination, activates the immune system to recognise and target cancer cells via a T-cell-mediated immune response and can lead to improved survival in the metastatic setting in a number of malignancies, as well as improved recurrence-free survival when utilised in multi-modality radical treatment paradigms in melanoma and non-small cell lung cancer (NSCLC).1,2 The systemic activation of T-cells can also lead to auto-immune toxicity, affecting any body system; most commonly skin, gastrointestinal, liver and endocrine toxicities.3
Clinical articlesBack to top
March 2020 Br J Cardiol 2020;27:27–30 doi:10.5837/bjc.2020.006
Digital healthcare is being introduced to the management of heart failure as a consequence of innovations in information technology. Advancement in technology enables remote symptom and device monitoring, and facilitates early detection and treatment of heart failure exacerbation, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems. Although promising, there is, as yet, insufficient evidence to support the widespread implementation of digital healthcare. Patient-related barriers include user characteristics and health status; privacy and security concerns; financial costs and lack of accessibility of digital resources. Physician-related barriers include the lack of infrastructure, incentive, knowledge and training. There are also a multitude of technical challenges in maintaining system efficiency and data quality. Furthermore, the lack of regulation and legislation regarding digital healthcare also prevents its large-scale deployment. Further education and support and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure.
March 2020 Br J Cardiol 2020;27:31–3 doi:10.5837/bjc.2020.007
Primary prevention aspirin among the elderly: challenges in translating trial evidence to the clinic
J William McEvoy, Michael Keane, Justin Ng
The ASPirin in Reducing Events in the Elderly trial (ASPREE) contributed important knowledge about primary cardiovascular disease (CVD) prevention among healthy older adults. The finding that daily low-dose aspirin (LDA) does not statistically prevent disability or CVD among adults aged over 70 years when compared with placebo, but does significantly increase risk of haemorrhage, immediately influenced clinical practice guidelines. In this article, we discuss nuances of the trial that may impact the extrapolation of the ASPREE trial results to the everyday individual clinical care of older adults.
March 2020 Br J Cardiol 2020;27:40 doi:10.5837/bjc.2020.008
Grace Lydia Goss, Tarik Salem Ahmed Salim, John Huish, Gethin Ellis
A 78-year-old man presented to the emergency department with recurrent episodes of syncope precipitated by a variety of strong aromas. He denied chest pain, breathlessness or palpitations. There were no headaches, no blurred vision or limb weakness or seizure-like activity. On recovery, he had no post-ictal symptoms. He was initially discharged after initial investigations, including electrocardiogram (ECG), were normal. On the way to the main entrance, while passing cleaning equipment (which included strongly smelling bleach), he experienced a further syncopal episode. He was taken into the resuscitation bay, attached to cardiac monitoring and referred to the medical on-call team. When approached by the medical registrar on call (who was wearing ‘powerful’ aftershave), the patient commented the scent was precipitating a further attack. The registrar reviewed the cardiac monitor captured in figure 1 and witnessed a prolonged pause followed by asystole. Cardiopulmonary resuscitation (CPR) was commenced for approximately one minute, at which point there was a spontaneous recovery of cardiac output and a quick recovery to baseline.
March 2020 Br J Cardiol 2020;27:37–40 doi:10.5837/bjc.2020.009
Alexander Birkinshaw, Pankaj Sharma, Thang S Han
Aldosterone/renin ratio (ARR) is commonly used to screen for primary hyperaldosteronism (Conn’s disease). A number of drugs can alter ARR measurements, thus requiring omission before testing. However, hormonal agents such as the combined oral contraceptive (COCP) or progestogen-only pill (POP) are not listed for omission. A 20-year-old woman was referred to the endocrinology team, following investigations for syncope by her cardiologist, when ARR was found to be elevated. She was taking POP (Cerelle®) while having ARR measured. After omitting POP for four weeks, plasma aldosterone concentration was reduced by 52% (from 560 pmol/L to 271 pmol/L, reference range: 100–450 pmol/L), plasma renin concentration increased by 253% (from 3.6 mU/L to 12.7 mU/L, reference range: 5.4–30 mU/L) and ARR reduced from 156 to 21 (–86.5%) (reference range: <80 suggests Conn’s unlikely). To the best of our knowledge, this is the first reported case of POP-related false-positive ARR screening for primary hyperaldosteronism. Omission of POP should, therefore, be considered in women undergoing ARR measurement.
January 2020 Br J Cardiol 2020;27:19–23 doi:10.5837/bjc.2020.002
Simon G Findlay, Ruth Plummer, Chris Plummer
Recent advances in immune therapy for cancer have significantly improved the clinical outcomes of patients with advanced cancers, where prognosis has historically been very poor. With these new treatments have come new toxicities and, as the use of immunotherapy increases, we will see an increasing incidence of immune-related adverse events, with patients presenting as an emergency. It is important that all cardiologists, and other physicians who see these patients, are aware of life-threatening immune-related toxicities, in addition to their recommended investigation and treatment.
We describe a patient with acute cardiotoxicity secondary to immune therapy to illustrate the complexity of these adverse cardiovascular events, providing recommendations for screening, diagnosis and management.
January 2020 Br J Cardiol 2020;27:24–5 doi:10.5837/bjc.2020.003
Amaliya A Arakelyanz, Tatiana E Morozova, Anna V Vlasova, Roman Lischke
This short review of cardiac tumours presents a case that clearly demonstrates the manifestation of embolic and cardiac symptoms of an intracardiac mass. Acute onset and rapid progression of a neoplastic process in the heart leading to arrhythmia, cardiac conduction disorders and heart failure combined with highly mobile fragments of tumour, which can cause emboli in cerebral vessels, are characteristic signs of an intracardiac mass. Early diagnosis and immediate treatment may improve the long-term prognosis, but overall the prognosis is poor. Cardiac tumours present to the cardiologist when the patient presents with cardiac symptoms, and the neurologist when there are cerebral symptoms. Most cardiac masses are not amenable to percutaneous biopsy; therefore, definitive diagnosis often awaits surgical excision.
January 2020 Br J Cardiol 2020;27:34–6 doi:10.5837/bjc.2020.004
Successful treatment of ischaemic ventricular septal defect and acute right ventricular failure: a challenging case in the modern NHS
Renata Greco, Andrew Johnson, Xy Jin, Rajesh K Kharabanda, Adrian P Banning, Mario Petrou
A 52-year-old man, previously fit and well, presented with myocardial infarction complicated by ischaemic ventricular septal defect (VSD) and acute right ventricular failure, was successfully treated with early percutaneous coronary reperfusion, surgical VSD repair and temporary right ventricular assist device (VAD) support.
This case is an example of how a modern healthcare system can successfully manage complex emergency cases, combining high levels of clinical care and medical technology. Access to temporary mechanical support played a vital role in this case. We believe that wider access to VADs may contribute to improvement in the, widely recognised, poor outcome of ischaemic VSD.
News and viewsBack to top
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