2020, Volume 27, Issue 2, pages 41–72

2020, Volume 27, Issue 2, pages 41–72

Editorials Clinical articles News and views
Topics include:-
  • COVID-19 and the heart
  • The quest for a vaccine
  • Hypertrophic cardiomyopathy and exercise restrictions
  • Improving outlook in refractory angina


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June 2020 Br J Cardiol 2020;27:49 doi:10.5837/bjc.2020.016

Catheter lab activity and COVID-19: damned if you do and…

Nick Curzen


When the extent of the coronavirus threat became clear, it was an obvious imperative to close down elective catheter lab work for all cases except for patients at the highest level of clinical urgency. The effect of this action is illustrated by the national survey reported by Adlan and colleagues.1

Above and beyond the immediate, unarguable imperative to limit elective work, a range of other equally immediate challenges relating to patient care were apparent, and generated strong but divergent opinion within the interventional cardiology community. Firstly, the optimal treatment plan for patients presenting with ST-elevation myocardial infarction (STEMI)… should primary percutaneous coronary intervention (PCI) remain the default strategy, or should it now be to adopt thrombolysis as a default, as recommended by hastily constructed care pathways in other countries which were affected by COVID-19 earlier than the UK? Secondly, what level of personal protective equipment (PPE) should cardiologists and cath lab staff wear for the cases who did make it to the lab? Finally, how should patients admitted to hospital with severe symptomatic aortic stenosis be treated?

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May 2020 Br J Cardiol 2020;27:45–6 doi:10.5837/bjc.2020.010

Cardiac complications in end-stage renal disease: a shared care challenge

Xenophon Kassianides, Adil Hazara, Sunil Bhandari


The current President of the United States once stated that “the kidney has a very special place in the heart”; despite the questionable anatomical reference, the truth is that the kidneys and heart are intertwined, affected by common pathophysiological processes and sharing many of the same disease-causing risk factors. Ronco and colleagues have previously classified the complex array of inter-related derangements that simultaneously involve both organs, and this serves as a useful starting point in understanding their important physiological and pathophysiological inter-dependence.1

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Clinical articles

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June 2020 Br J Cardiol 2020;27:51–54 doi:10.5837/bjc.2020.017

Impact of COVID-19 on primary percutaneous coronary intervention centres in the UK: a survey

Ahmed M Adlan, Ven G Lim, Gurpreet Dhillon, Hibba Kurdi, Gemina Doolub, Nadir Elamin, Amir Aziz, Sanjay Sastry, Gershan Davis


During the coronavirus disease (COVID-19) pandemic, the British Cardiovascular Society/British Cardiovascular Intervention Society and the British Heart Rhythm Society recommended to postpone non-urgent elective work and that primary percutaneous coronary intervention (PCI) should remain the treatment of choice for patients with ST-segment elevation myocardial infarction (STEMI). We sought to determine the impact of COVID-19 on the primary PCI service within the United Kingdom (UK).

A survey of 43 UK primary PCI centres was performed and a significant reduction in the number of cath labs open was found (pre-COVID 3.6±1.8 vs. post-COVID 2.1±0.8; p<0.001) with only 64% of cath labs remained open during the COVID-19 pandemic. Primary PCI remained first-line treatment for STEMI in all centres surveyed.

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June 2020 Br J Cardiol 2020;27:55–9 doi:10.5837/bjc.2020.018

COVID-19: the heart and other issues

Cormac T O’Connor, David Mulcahy


From the time that the first cases were reported from Wuhan, China on the 31st December 2019,1 our knowledge of the clinical and virological associations of the novel coronavirus (COVID-19) has been evolving at a rapid pace. On 18th May 2020, COVID-19 had caused over 4.82 million cases worldwide and resulted in 316,959 deaths.2 Whilst the primary focus of management for patients with COVID-19 remains close monitoring of respiratory function, there have been high levels of cardiac dysfunction in emerging cross-sectional and observational analyses, suggesting the need for heightened awareness in patients who may require cardiac input as part of a multidisciplinary approach. We review the current data on the association of COVID-19 and the heart.

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June 2020 Br J Cardiol 2020;27:67–70 doi:10.5837/bjc.2020.020

An exercise-based cardiac rehabilitation programme for AF patients in the NHS: a feasibility study

Mark Mills, Elizabeth Johnson, Hamza Zafar, Andrew Horwood, Nicola Lax, Sarah Charlesworth, Anna Gregory, Justin Lee, Jonathan Sahu, Graeme Kirkwood, Nicholas Kelland, Andreas Kyriacou


There is increasing evidence for the role of exercise-based cardiac rehabilitation in the management of patients with atrial fibrillation (AF). However, this intervention has not yet been widely adopted within the National Health Service (NHS).

We performed a feasibility study on the utilisation of an established NHS cardiac rehabilitation programme in the management of AF, and examined the effects of this intervention on exercise capacity, weight, and psychological health. We then identified factors that might prevent patients from enrolling on our programme.

Patients with symptomatic AF were invited to participate in an established six-week exercise-based cardiac rehabilitation programme, composed of physical activity and education sessions. At the start of the programme, patients were weighed and measured, performed the six-minute walk test (6MWT), completed the Generalised Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9). Measurements were repeated on completion of the programme.

Over two years, 77 patients were invited to join the programme. Twenty-two patients (28.5%) declined participation prior to initial assessment and 22 (28.5%) accepted and attended the initial assessment, but subsequently withdrew from the programme. In total, 33 patients completed the entire programme (63.9 ± 1.7 years, 58% female). On completion, patients covered longer distances during the 6MWT, had lower GAD-7 scores, and lower PHQ-9 scores, compared with their baseline results. Compared with patients that completed the entire programme, those who withdrew from the study had, at baseline, a significantly higher body mass index (BMI), covered a shorter distance during the 6MWT, and had higher PHQ-9 and GAD-7 scores.

In conclusion, enrolling patients with AF into an NHS cardiac rehabilitation programme is feasible, with nearly half of those invited completing the programme. In this feasibility study, cardiac rehabilitation resulted in an improved 6MWT, and reduced anxiety and depression levels, in the short term. Severe obesity, higher anxiety and depression levels, and lower initial exercise capacity appear to be barriers to completing exercise-based cardiac rehabilitation. These results warrant further investigation in larger cohorts.

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May 2020 Br J Cardiol 2020;27:64–6 doi:10.5837/bjc.2020.011

Hypertrophic cardiomyopathy and exercise restrictions: time to let the shackles off?

Yuen W Liao, James Redfern, John D Somauroo, Robert M Cooper


The health benefits of physical activity are well documented. Patients with hypertrophic cardiomyopathy (HCM) are often discouraged from participating in physical activity due to a perceived increase in the risk of sudden cardiac death (SCD). As a result, only 45% of patients with HCM meet the minimum guidelines for physical activity, and many report an intentional reduction in exercise following diagnosis. Despite most SCD being unrelated to HCM, guidelines traditionally focused on the avoidance of potential risk through restriction of exercise, without clear recommendations on how to negate the negative health impact of inactivity. Retrospective reviews have demonstrated that the majority of cardiac arrests in patients with HCM occurred at rest or on mild exertion and that the overall incidence of HCM-related SCD is significantly lower than previously reported. We will discuss current international guidelines and recommendations and consider the outcomes of various studies that have investigated the effects of exercise of different intensities on patients with HCM. In light of the growing evidence suggesting that carefully guided exercise can be both beneficial and safe in patients with HCM, we ask whether it is time to let the shackles off exercise restriction in HCM.

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May 2020 Br J Cardiol 2020;27:60–3 doi:10.5837/bjc.2020.012

A multi-disciplinary care pathway improves symptoms, QoL and medication use in refractory angina

Kevin Cheng, Ranil de Silva


Refractory angina (RA) is a growing clinical problem. Long-term mortality is better than expected and focus has shifted to improving symptoms, quality of life and psychological morbidity. We established a dedicated multi-disciplinary care pathway for patients with RA and assessed its effect on psychological outcomes, quality of life and polypharmacy. We reviewed electronic health records to capture demographics, changes in medication use, and patient-related outcome measures (Seattle Angina Questionnaire [SAQ] and Hospital Anxiety and Depression Scale) before and after enrolment.

One hundred and ninety patients were referred to our service. Pre- and post-questionnaire data were available in 83 patients. Anxiety and depression scores significantly improved (p<0.05) as well as quality of life and all subcategories of the SAQ (p<0.0001). Patients were most commonly on three or four anti-anginal drugs. In patients with no demonstrable reversible ischaemia, there was a significant reduction in anti-anginal usage (mean reduction of two drugs) after completion of our pathway (p<0.025).

In conclusion, a dedicated multi-disciplinary pathway for RA is associated with improvements in quality of life, mental health and polypharmacy. An ischaemia-driven method to rationalise medication may reduce polypharmacy in patients with RA, particularly in patients with no demonstrable ischaemia.

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May 2020 Br J Cardiol 2020;27:71 doi:10.5837/bjc.2020.013

Ezekiel’s heart

JJ Coughlan, Max Waters, David Moore, David Mulcahy


“I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh” – Ezekiel 36:26

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May 2020 Br J Cardiol 2020;27:72–3 doi:10.5837/bjc.2020.014

Can a giant U-wave be innocent?

Sinead Curran, Waleed Arshad, Arvinder Kurbaan, Han B Xiao


The U-wave on electrocardiogram (ECG) is a small deflection following the T-wave, the sixth wave. It is 25% or less of the preceding T-wave in amplitude.1,2 While the genesis of the U-wave is uncertain, it is said to represent repolarisation of the Purkinje fibres.1,2 Disproportionally large U-waves may indicate underlying cardiac or non-cardiac pathology. A relatively frequent cause for a large U-wave is hypokalaemia. It is observed in patients with bradycardia, ventricular hypertrophy, hypothyroidism, hypocalcaemia, hypomagnesaemia, mitral valve prolapse, hypothermia, increased intracranial pressure, or patients on anti-arrhythmic medicine.2 A negative U-wave, on the other hand, may represent early myocardial ischaemia, specifically in the context of a lesion in the left main or proximal left anterior descending coronary artery.2,3

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News and views

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June 2020 doi:10.5837/bjc.2020.019

COVID-19 and cardiac rehabilitation

Joint BACPR/BCS/BHF statement on cardiac rehabilitation services The British Association for Cardiovascular Prevention and Rehabilitation (BACPR), the British Cardiovascular Society (BCS) and the British Heart...

May 2020 Br J Cardiol 2020;27:47–8 doi:10.5837/bjc.2020.015

COVID-19 and immunology

COVID-19 and vaccine development Trials in...