2021, Volume 28, Issue 2, pages 41–80

2021, Volume 28, Issue 2, pages 41–80

Editorials Clinical articles News and views
Topics include:-
  • ECG changes in hospitalised patients with COVID-19
  • A national heart disease strategy for Scotland
  • Dapagliflozin in heart failure
  • Lipids and ACS


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June 2021 Br J Cardiol 2021;28:47–8 doi:10.5837/bjc.2021.025

A National Heart Disease Strategy for Scotland: the BHF proposal to Government

David McColgan, Dennis Sandeman, Adrian J B Brady


Heart disease remains a major cause of death and disability in Scotland, accounting for around 10,000 deaths each year.1 Ischaemic heart disease is still Scotland’s single biggest killer, responsible for 11.3% of all deaths in 2018, and accounts for 25,000 hospital admissions each year. While it is true that there have been improvements in survival from heart attacks and other acute events in Scotland over the last half century, it is also the case that significant challenges remain.

The reduction in deaths from heart attacks means that more people are living with heart disease as a long-term condition. On top of this, the population is getting older,2 and increasingly people are living with associated comorbidities, many requiring long-term support. The number of people living with cardiovascular risk factors in Scotland continues to increase, health inequalities persist and in some cases, have worsened.3

Beyond ischaemic heart disease, the incidence of conditions like heart failure,4 heart valve disease,5 and atrial fibrillation are increasing. There is also a need to consider the impact of less common, but no less important conditions, such as congenital heart disease and inherited heart conditions. Around 28,000 people in Scotland have an inherited heart condition, the most common of which is hypertrophic cardiomyopathy. Congenital heart disease is one of the most common birth defects in Scotland, affecting around one in every 150 births. Improved survival rates mean that a growing number of people are living into adulthood with congenital heart disease.

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April 2021 Br J Cardiol 2021;28:51–2 doi:10.5837/bjc.2021.022

Cardiorenal syndrome: a Bright idea with earlier roots

Xingping Dai, Bing Zhou, Stanley Fan, Han B Xiao


Cardiorenal syndrome has attracted an enormous amount of attention, particularly in the last decade. A lot of research has been conducted in pathophysiology, haemodynamic manifestations, therapeutic options, and clinical outcomes.1,2 In practice, however, cardiorenal syndrome remains clinically challenging for both cardiologists and nephrologists. Cardiorenal syndrome covers a wide range of structural and functional disorders of both the heart and kidneys. Typically, the acute or chronic dysfunction in one organ induces acute or chronic dysfunction in the other. The interaction between the two organs may well be in multiple interfaces, such as haemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, alterations in neurohormonal markers, as well as inflammatory molecular characteristics.2 Much of the credit for the initial description of cardiorenal syndrome is attributed to Robert Bright who, in 1836, described the interdependent relationship between the kidney and the heart based on his observations on significant cardiac structural changes seen in patients with advanced kidney disease.3 The formal definition of cardiorenal syndrome and its classifications were established more recently,1,2,4 although uncertainty remains still. The classification appears to be attractive and easily applicable in clinical practice, but its value in aiding treatment or prevention strategy has yet to be ascertained.4

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Clinical articles

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June 2021 Br J Cardiol 2021;28:55 doi:10.5837/bjc.2021.024

ECG changes in hospitalised patients with COVID-19 infection

Mengshi Yuan, Zafraan Zathar, Frantisek Nihaj, Stavros Apostolakis, Fairoz Abdul, Derek Connolly, Chetan Varma, Vinoda Sharma


The coronavirus disease 2019 (COVID-19) commonly involves the respiratory system but increasingly cardiovascular involvement is recognised. We assessed electrocardiogram (ECG) abnormalities in patients with COVID-19.

We performed retrospective analysis of the hospital’s COVID-19 database from April to May 2020. Any ECG abnormality was defined as: 1) new sinus bradycardia; 2) new/worsening bundle-branch block; 3) new/worsening heart block; 4) new ventricular or atrial bigeminy/trigeminy; 5) new-onset atrial fibrillation (AF)/atrial flutter or ventricular tachycardia (VT); and 6) new-onset ischaemic changes. Patients with and without any ECG change were compared.

There were 455 patients included of whom 59 patients (12.8%) met criteria for any ECG abnormality. Patients were older (any ECG abnormality 77.8 ± 12 years vs. no ECG abnormality 67.4 ± 18.2 years, p<0.001) and more likely to die in-hospital (any ECG abnormality 44.1% vs. no ECG abnormality 27.8%, p=0.011). Cox-proportional hazard analysis demonstrated any ECG abnormality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.12 to 3.47, p=0.019), age (HR 1.03, 95%CI 1.01 to 1.05, p=0.0009), raised high sensitivity troponin I (HR 2.22, 95%CI 1.27 to 3.90, p=0.006) and low estimated glomerular filtration rate (eGFR) (HR 1.73, 95%CI 1.04 to 2.88, p=0.036) were independent predictors of in-hospital mortality.

In conclusion, any new ECG abnormality is a significant predictor of in-hospital mortality.

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June 2021 Br J Cardiol 2021;28:67–9 doi:10.5837/bjc.2021.026

Reducing antithrombotic-related bleeding risk in urgent and emergency cardiac surgery

Amer Harky, Abdul Badran


This review focuses on the role of CytoSorb® (CytoSorbents Corporation, Monmouth Junction, New Jersey, USA), a technology for purifying extracorporeal blood. The technology is designed for several indications to prevent bleeding complications during on-pump cardiac surgery, including removal of the antiplatelet agent, ticagrelor, and the oral anticoagulant, rivaroxaban, from the blood. Recent clinical studies are briefly reviewed.

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June 2021 Br J Cardiol 2021;28:73–6 doi:10.5837/bjc.2021.027

The effect of a standardised protocol for CIED insertion on complications and infection rates in a DGH

Eliza Foster, Guy Furniss, Mark Dayer


Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period.

An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIED-related infection in the two years post-implementation. This was not statistically significant (p=0.093).

In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

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April 2021 Br J Cardiol 2021;28:62–6 doi:10.5837/bjc.2021.017

Management of hyperlipidaemia following acute coronary syndrome: a retrospective audit

Handi Yuwono Salim, Kaung Lwin, Chee Khoo, David Wilson


Control of hypercholesterolaemia is an effective way of reducing cardiovascular events in patients at elevated risk of cardiovascular disease. Repeat cholesterol measurement is a good practice, but is rarely performed, with clinicians often adopting a ‘fire and forget’ policy.

A retrospective audit at two cardiac centres in the West Midlands was performed to evaluate performance in lipid measurement following initiation of lipid therapy, and to evaluate whether all patients with an indication for a proprotein convertase subtisilin/kexin 9 inhibitor (PCSK9i) following acute coronary syndrome (ACS) were identified according to National Institute for Health and Care Excellence (NICE) recommendations.

We identified 167/7,048 patients with a total cholesterol of ≥7.2 mmol/L, of which 33 patients had previous vascular disease affecting more than one territory (polyvascular disease). Total cholesterol threshold ≥7.2 mmol/L was chosen in order to achieve a sufficient number of samples for the audit to be completed successfully. Low-density lipoprotein (LDL) level was performed in 93 patients on admission and repeated within three months in 20 patients (13%). Overall, 48 patients (30%) had any repeat LDL recorded. Of this group, 10 patients met the NICE criteria for PCSK9i.

Failure to repeat LDL levels in patients following hospital discharge with a diagnosis of ACS, is likely to explain the small number of patients identified as being eligible for PCSK9i. Underreporting of comorbid vascular disease also prevents the identification of patients at very high risk. We advocate re-establishing the practice of routine repeat fasting lipids measurement following discharge from hospital in order to correctly identify patients who may be eligible for optimal lipid-lowering therapy.

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April 2021 Br J Cardiol 2021;28:56–61 doi:10.5837/bjc.2021.018

Eligibility for dapagliflozin in unselected patients hospitalised with decompensated heart failure

Hibba Kurdi, Parin Shah, Simon Barker, Daniel Harris, Benjamin Dicken, Carey Edwards, Geraint Jenkins


Patients with heart failure with reduced ejection fraction (HFrEF) who received the sodium-glucose co-transport 2 inhibitor, dapagliflozin, in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) study have a significant reduction in worsening heart failure (HF) and cardiovascular death. It is uncertain what proportion of patients admitted to a large regional cardiac centre with decompensated heart failure would be eligible for dapagliflozin post-discharge based on their characteristics at discharge.

The DAPA-HF study criteria were retrospectively applied to a cohort of 521 consecutive patients referred to the inpatient HF service in a tertiary cardiac centre in South West Wales between April 2017 and April 2018. Inclusion criteria: left ventricular ejection fraction (LVEF) <40%, New York Heart Association (NYHA) class II–IV symptoms and an elevated N-terminal pro-B-type naturietic peptide (NT-proBNP). Exclusion criteria: systolic blood pressure (SBP) <95 mmHg, estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m2 or type 1 diabetes mellitus. We did not have complete NT-proBNP data for the cohort, as it was not routinely measured at the time in our institute.

There were 478 patients, mean age 78 ± 13 years, 57% male and 91% NYHA class II–IV symptoms, were included in the analysis. Of these, 247 patients had HFrEF, 219 (46%) patients met the inclusion criteria, 231 (48%) were excluded as LVEF was >40%, and 48 (10%) were excluded with NYHA class I symptoms. Of the 219 patients who met the inclusion criteria, 13 (5.9%) had a SBP <95 mmHg, 48 (22%) had eGFR <30 ml/min/1.73 m2, leaving 136 (28.5% of total and 55% of those with HFrEF) who met DAPA-HF study criteria.

In our study, 28.5% of all heart failure admissions and 55% of patients with HFrEF would be eligible for dapagliflozin post-discharge according to the DAPA–HF study entry criteria.

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April 2021 Br J Cardiol 2021;28:77–8 doi:10.5837/bjc.2021.019

When Blades broke my heart

Nadir Elamin, Izhar Hashmi, Martin Tilney, Ever Grech


Takotsubo cardiomyopathy (TCM) was first described about 30 years ago. It has been attributed to the sudden catecholamine surge in relation to severe stress, which can cause multi-vessel coronary spasms and myocardial apical ballooning. Football supporters are prone to develop severe stress due to sudden changes in match results. This case presents a football supporter of Sheffield United (the Blades) who was admitted to the hospital with cardiac sounding chest pain following a last minute goal by the opposing team. The necessary investigations were carried out including coronary angiogram and echocardiogram. He was diagnosed with TCM following a left ventricular angiogram demonstrating the typical appearance of the octopus pot.

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April 2021 Br J Cardiol 2021;28:70–2 doi:10.5837/bjc.2021.020

Minimising permanent pacemaker implantation (PPI) after TAVI

Philip MacCarthy, Azfar Zaman, Neal Uren, James Cockburn, Stephen Dorman, Iqbal Malik, Douglas Muir, Muhiddin (Mick) Ozkor, David Smith, Sarah Shield


Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.

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April 2021 Br J Cardiol 2021;28:54 doi:10.5837/bjc.2021.021

The primary prevention implantable cardioverter-defibrillator (ICD) during the COVID-19 pandemic

Christopher J Cassidy, Khalid Abozguia, Michael J Brack, Angelic Goode, Grahame K Goode, Alison Seed


During the recent ‘first wave’ of the COVID-19 pandemic, the National Health Service (NHS) has triaged planned services to create surge capacity. The primary prevention implantable cardioverter-defibrillator (ICD) was in a grey area of triage guidance, but it was suggested as a procedure that could be reasonably stopped. Recent reports have highlighted deaths of patients awaiting ICDs who may have been deferred during the pandemic. In our trust we reorganised our device service and continued to implant primary prevention ICDs during the ‘first wave’ and, here, report that most patients wished to proceed and underwent uncomplicated implantations. One patient later died from COVID-19, although the transmission site cannot be definitively concluded. With strict adherence to public health guidance and infection prevention strategies, we believe that ICD implantation can be performed safely during the pandemic, and this should be standard practice during subsequent surges.

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April 2021 Br J Cardiol 2021;28:79–80 doi:10.5837/bjc.2021.023

TAVR for severe aortic stenosis and papillary fibroelastoma in a high-risk setting

Ishtiaq Rahman, Ammar Alibrahim, Mohammad Zahrani, Joji Ito, Kim Connelly, Chris Buller, Mark Peterson, David Latter


Papillary fibroelastomas (PFE) are rare benign cardiac tumours mainly originating on aortic and mitral valvular surfaces. Management is individualised, but most recommend surgical excision due to thromboembolic risk. We report a 75-year-old man with symptomatic severe aortic stenosis compounded by PFE. Redo sternotomy aortic valve replacement was deferred in favour of the trans-apical (TAVR) approach. This report highlights, for the first time, the application of TAVR as a strategy for aortic valve stenosis and PFE to mitigate risk posed by injury to patent internal mammary arterial graft in close proximity to the manubrium, and complications due to the patient’s multiple comorbidities.

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News and views

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June 2021

Freedom from failure campaign aims to raise awareness of heart failure

The British Journal of Cardiology is pleased to support the British Society of Heart Failure’s (BSH’s) important new campaign ‘Freedom from failure’. Its aim,...

April 2021 Br J Cardiol 2021;28:53

Dr John Pittard

We report, with great sadness that our friend, Dr John Pittard, has died peacefully at home after a long illness, borne with incredible...