- Implantable devices - using physical activity data better
- Nephrilysin inhibition, angiotensin and COVID-19
- Anticoagulation and cancer
- Women not in cardiology: where are we going wrong?
EditorialsBack to top
October 2020 Br J Cardiol 2020;27:109–11 doi:10.5837/bjc.2020.031
Nathalie Esser, Sakeneh Zraika
The renin–angiotensin system (RAS) has been at the forefront of research aimed at mitigating the infectivity and mortality associated with the coronavirus disease 2019 (COVID-19) pandemic. This stems from the observation that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen that causes COVID-19, utilises angiotensin-converting enzyme 2 (ACE2) as its receptor to invade host cells. Since emergence of COVID-19, conflicting guidance has been published on the use of medications that may increase ACE2 levels. Specifically, initial reports suggested that ACE inhibitors and angiotensin II type 1 receptor blockers (ARBs) may result in increased virulence of COVID-19 due to elevated ACE2. Thus, discontinuation of these RAS blockers was advised. However, the data on ACE2 expression with use of RAS blockers in humans without COVID-19 are not clear, and for humans with COVID-19 are not yet available. Moreover, discontinuation of these medications may be deleterious in some patients for whom they are prescribed to treat heart failure, hypertension and ischaemic heart disease. For this reason, professional organisations, including the American College of Cardiology, American Heart Association, Heart Failure Society of America and the European Society of Cardiology, have issued statements advising against discontinuation of any RAS-related treatments in patients during the COVID-19 crisis.
October 2020 Br J Cardiol 2020;27:112–4 doi:10.5837/bjc.2020.033
Telal Mudawi, Darar Al-Khdair, Muath Al-Anbaei, Asmaa Ali, Ahmed Amin, Dalia Besada, Waleed Alenezi
The benefit of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) is undisputed. Clinical trials like DANAMI-2 (DANish Acute Myocardial Infarction 2),1-3 PRAGUE-2 (Primary Angioplasty in AMI Patients from General Community Hospitals Transported to PTCA Units vs Emergency Thrombolysis),4,5 STAT (Stenting Versus Thrombolysis in Acute Myocardial Infarction),6 AIR PAMI (Air Primary Angioplasty in Myocardial Infarction),7 Stent Versus Thrombolysis for Occluded Coronary Arteries in Patients With Acute Myocardial Infarction (STOPAMI)-1,8 and STOPAMI-29 have demonstrated better outcomes with primary PCI over fibrinolysis. Other clinical trials10-14 have demonstrated superiority of PCI over sole medical therapy for non-ST elevation myocardial infarction (NSTEMI) and unstable angina.
In contrast, there is ambiguity surrounding the benefit of elective PCI in stable coronary disease. The available evidence suggests no prognostic advantage over optimum medical therapy but deeper data scrutiny indicates that this remains uncertain. COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation),15 BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes),16 and ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary Disease)17 are the main trials that examined this issue, all concluding against the prognostic usefulness of elective PCI. We argue that those studies contained inherent flaws that impacted on their results, thereby rendering their final conclusions unreliable. We suggest an alternative design for a new trial so the question can be answered decisively, once and for all.
Clinical articlesBack to top
December 2020 Br J Cardiol 2020;27:115–8 doi:10.5837/bjc.2020.035
Kara Callum, David J Muggeridge, Oonagh M Giggins, Daniel R Crabtree, Trish Gorely, Stephen J Leslie
Regular physical activity for secondary prevention in cardiovascular disease has many well-recognised benefits, with declines in physical activity being associated with worsening cardiovascular disease, suboptimal treatment or worsening comorbidities that might be rectified by early intervention. Most cardiovascular implantable electronic devices (CIED) now have the ability to detect, analyse and interpret physical activity data through an inbuilt accelerometer. Currently, these data are not being utilised to their full potential. We present three cases that demonstrate some of the possible uses of CIED-collected physical-activity data. These data have the potential to detect a deteriorating patient, to monitor the effects of an intervention, and/or provide motivational feedback to a patient. However, for the data to be used in this manner in the future, greater transparency from manufacturers and robust validation studies will be needed.
December 2020 Br J Cardiol 2020;27:124–5 doi:10.5837/bjc.2020.036
Dipal Mehta, Avirup Guha, Peter K MacCallum, Amitava Banerjee, Charlotte Manisty, Thomas Crake, Mark Westwood, Daniel M Jones, Arjun K Ghosh
Stroke prophylaxis in atrial fibrillation is an important consideration in patients with cancer. However, there is little consensus on the choice of anticoagulation, due to the numerous difficulties associated with active cancer. Direct oral anticoagulants (DOACs) have been shown to be a promising option. Here, we conduct a simple cross-sectional analysis of 29 cancer patients receiving DOACs for stroke prophylaxis in atrial fibrillation at a tertiary-care institution in London. Our study demonstrates an encouraging efficacy and safety profile of DOACs used in this setting. We conclude by suggesting that, while DOACs may be useful, anticoagulation in cancer patients should continue to be individualised.
December 2020 Br J Cardiol 2020;27:126–8 doi:10.5837/bjc.2020.037
Timely discharge of low-risk STEMI patients admitted for primary PCI in an Essex cardiothoracic centre
Izza Arif, Rajender Singh
Data for low-risk ST-elevation myocardial infarction (STEMI) patients in the Essex cardiothoracic centre (CTC) during a three-month period were evaluated and the average duration of admission was calculated to be 67.2 hours. The data were sifted by applying Second Primary Angioplasty in Myocardial Infarction (PAMI-II) criteria for low-risk STEMI patients who could be safely discharged after 48 hours. After application of a proforma as a quality improvement intervention tool, data were re-assessed and the average time of admission observed for a similar cohort of patients dropped down to an average of 55.2 hours. Overall, there was a 13% average increase in rate of early discharge for low-risk STEMI patients.
December 2020 Br J Cardiol 2020;27:129–31 doi:10.5837/bjc.2020.038
Is there a need to measure pre- and post-capillary blood glucose following a cardiac exercise class?
Tim P Grove, Neil E Hill
Exercise training is associated with positive health outcomes in people with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). However, fear of hypoglycaemia is a potential barrier to participants attending a cardiac exercise class. Therefore, we assessed the capillary blood glucose (CBG) responses to the Imperial NHS Trust cardiac exercise class.
Forty patients (median age 66 years, interquartile range [IQR] 57–74 years) with CVD and T2DM treated with insulin and/or sulfonylureas completed a cardiac exercise class. CBG was measured immediately before and after the exercise class. Subgroup analysis assessed CBG levels in patients who had consumed food <2 and ≥2 hours and had taken their insulin and/or sulfonylureas <4 and ≥4 hours before the exercise class.
Overall, post-exercise CBG had significantly decreased (–3.0 mmol/L, p≤0.0001). Subgroup analyses demonstrated significant reductions in CBG in both food consumption groups (<2 hours –2.9 mmol/L, p≤0.0001, and ≥2 hours –3.1 mmol/L, p≤0.0001) and medication groups (<4 hours –3.4 mmol/L, p≤0.0002, and ≥4 hours –2.7 mmol/L, p≤0.0001). However, there were no significant differences in CBG between the food consumption groups and the medication groups, respectively (p=0.7 and p=0.3).
Cardiac exercise classes resulted in significant reductions in CBG levels. However, the timing of food consumption or medication intake did not influence the magnitude of CBG decline after the cardiac exercise class.
December 2020 Br J Cardiol 2020;27:141–2 doi:10.5837/bjc.2020.039
Jordan Faulkner, Francis A Kalu
The inflammatory component of ischaemic heart disease (IHD) is well recognised. An elderly male, following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI), had, otherwise unexplained, severely elevated C-reactive protein (CRP) prior to sudden cardiac death (SCD). Post-mortem showed only old infarct, no re-stenosis, and no evidence of inflammation elsewhere. The levels of CRP in this case are much higher than those documented previously in IHD. Current guidelines advocate for implantable cardioverter defibrillator (ICD) implantation after acute coronary syndrome (ACS) only in the context of left ventricular ejection fraction <35%, therefore, this patient would not qualify. Multiple risk-stratification tools have been developed to widen ICD prescription after ACS, but have not yet been integrated into the National Institute for Health and Care Excellence (NICE) guidelines. This case is a poignant reminder that we must widen ICD prescription, and CRP should be considered as a likely predictor.
December 2020 Br J Cardiol 2020;27:143–4 doi:10.5837/bjc.2020.040
Nicholas Cereceda-Monteoliva, Massimo Capoccia, Kwabena Mensah, Ruediger Stenz, Mario Petrou
Quadricuspid aortic valve (QAV) is a rare congenital anomaly that can present as aortic insufficiency later in life. We report a case of aortic regurgitation associated with a QAV, treated by aortic valve replacement. The patient presented with breathlessness, lethargy and peripheral oedema. Echocardiography and cardiac magnetic resonance revealed abnormal aortic valve morphology and coronary angiography was normal. The presence of a quadricuspid aortic valve was confirmed intra-operatively. This was excised and replaced with a bioprosthetic valve and the patient recovered well postoperatively. Importantly, the literature indicates that specific QAV morphology and associated structural abnormalities can lead to complications. Hence, early detection and diagnosis of QAV allows effective treatment. Aortic valve surgery is the definitive treatment strategy in patients with aortic valve regurgitation secondary to QAV. However, the long-term effects and complications of treatment of this condition remain largely unknown.
October 2020 Br J Cardiol 2020;27:119–23 doi:10.5837/bjc.2020.030
Women not in cardiology: where are we going wrong? A survey of the perceptions and barriers to training
Hibba Kurdi, Holly Morgan, Claire Williams
In the UK, there is a difference between the medical specialties and cardiology in recruitment of women. Research, thus far, has concentrated on women already in cardiology. Although invaluable in understanding barriers to training, these studies fail to provide insight into why other trainees chose an alternative. Therefore, we designed a survey aimed at medical personnel, evaluating why higher trainees in other specialties overlooked cardiology.
An online survey was distributed via email to non-cardiology higher trainees in Wales. Questions covered previous clinical experiences of cardiology, interactions with cardiologists, and tried to identify deterrent factors.
There were 227 responses received over six weeks: 61.7% (n=137) female respondents, 23.5% (n=52) less than full-time. Of these, 49% completed a cardiology placement previously. Bullying was witnessed and experienced equally among genders, females witnessed and experienced sexism, 24% (n=24) and 13% (n=13), respectively. In contrast, male trainees witnessed and experienced sexism 14% (n=7) and 0%. There were 62% (n=133) who felt cardiologists and registrars were unapproachable. Work-life balance ranked first (40%), as the most important factor influencing career choice. The negative attitudes of cardiologists and registrars was ranked top 3 for not pursuing cardiology.
In conclusion, many barriers exist to cardiology training including poor work-life balance, sexism and lack of less than full-time opportunities. However, this survey highlights that the behaviour of cardiologists and registrars has the potential to impact negatively on trainees. It is, therefore, our responsibility to be aware of this and encourage change.
October 2020 Br J Cardiol 2020;27:138–40 doi:10.5837/bjc.2020.032
Paula Finnegan, John Jefferies, Ronan Margey, Barry Hennigan
We provide the details of three cases utilising intravascular lithotripsy, a novel approach to percutaneous coronary intervention (PCI).
October 2020 Br J Cardiol 2020;27:132–7 doi:10.5837/bjc.2020.034
Iain T Parsons, Michael Hickman, Mark Ingram, Edward W Leatham
The utility of computed tomography (CT) coronary angiography (CTCA) is underpinned by its excellent sensitivity and negative-predictive value for coronary artery disease (CAD), although it lacks specificity. Invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR), are gold-standard investigations for coronary artery disease, however, they are resource intensive and associated with a small risk of serious complications. FFR-CT has been shown to have comparable performance to FFR measurements and has the potential to reduce unnecessary ICAs. The aim of this study is to briefly review FFR-CT, as an investigational modality for stable angina, and to share ‘real-world’ UK data, in consecutive patients, following the initial adoption of FFR-CT in our district general hospital in 2016.
A retrospective analysis was performed of a previously published consecutive series of 157 patients referred for CTCA by our group in a single, non-interventional, district general hospital. Our multi-disciplinary team (MDT) recorded the likely definitive outcome following CTCA, namely intervention or optimised medical management. FFR-CT analysis was performed on 24 consecutive patients where the MDT recommendation was for ICA. The CTCA + MDT findings, FFR-CT and ICA ± FFR were correlated along with the definitive outcome.
In comparing CTCA + MDT, FFR-CT and definitive outcome, in terms of whether a percutaneous coronary intervention was performed, FFR-CT was significantly correlated with definitive outcome (r=0.471, p=0.036) as opposed to CTCA + MDT (r=0.378, p=0.07). In five cases (21%, 5/24), FFR-CT could have altered the management plan by reclassification of coronary stenosis. FFR-CT of 60 coronary artery vessels (83%, 60/72) (mean FFR-CT ratio 0.82 ± 0.10) compared well with FFR performed on 18 coronary vessels (mean 0.80 ± 0.11) (r=0.758, p=0.0013).
In conclusion, FFR-CT potentially adds value to MDT outcome of CTCA, increasing the specificity and predictive accuracy of CTCA. FFR-CT may be best utilised to investigate CTCAs where there is potentially prognostically significant moderate disease or severe disease to maximise cost-effectiveness. These data could be used by other NHS trusts to best incorporate FFR-CT into their diagnostic pathways for the investigation of stable chest pain.