2022, Volume 29, Issue 1, pages 1–40

2022, Volume 29, Issue 1, pages 1–40

Editorials Clinical articles News and views
Topics include:-
  • Transforming heart failure care pathways for earlier diagnosis
  • Rapid sequencing for heart failure drugs
  • PoTS and long COVID
  • New agents for anticoagulation reversal


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March 2022 Br J Cardiol 2022;29:5–7 doi:10.5837/bjc.2022.007

Pipedreams, the pandemic and PoTS: is the post-COVID-19 era a turning point for PoTS services?

Morwenna Opie, Michaela Nuttall


The paper by Gall et al., published in this issue (see https://doi.org/10.5837/bjc.2022.003), is timely and important; the largest case series from the UK, and among the largest globally detailing the clinical characteristics of patients affected with postural tachycardia syndrome (PoTS) developing after a COVID-19 infection. It brings empirical stature to the anecdotal reports of PoTS developing post-COVID-19. It articulates that this presents in a form indistinguishable from PoTS precipitated by other events.

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Clinical articles

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March 2022 Br J Cardiol 2022;29:21–5 doi:10.5837/bjc.2022.008

Atrial fibrillation prevalence and predictors in patients with diabetes: a cross-sectional screening study

Angela Hall, Andrew Robert John Mitchell, Lisa Ashmore, Carol Holland


Prevalence of atrial fibrillation (AF) and diabetes is increasing worldwide. Diabetes is a risk factor for AF and both increase stroke risk. Previous AF screening studies have recruited high-risk patient groups, but not with diabetes as the target group. This study aims to determine whether people with diabetes have a higher prevalence of AF than the general population and investigate whether determinants, such as diabetes duration or diabetes control, add to AF risk.

In a cross-sectional screening study, patients with diabetes were recruited via their GP surgeries or a diabetes centre. A 30-second single-lead electrocardiogram (ECG) was recorded using the Kardia® device, along with physiological measurements and details relating to risk factor variables.

There were 300 participants recruited and 16 patients identified with AF (5.3% prevalence). This demonstrated a significantly greater likelihood of AF than the background population (p=0.043). People with diabetes and AF were significantly older than those who only had diabetes. More people with type 2 diabetes had AF than people with type 1. Prediction of AF diagnosis by age, sex, diabetes type, diabetes duration and level of control revealed only age as a significant predictor.

In conclusion, these findings add to existing data around the association of these chronic conditions, supporting AF screening in this high-risk group, particularly in those of older age. This can contribute to appropriate management of both conditions in combination, not least with regards to stroke prevention.

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March 2022 Br J Cardiol 2022;29:31–5 doi:10.5837/bjc.2022.009

Dermatological manifestations of cardiac conditions

Arnav Katira, Ravish Katira


Various cardiac disorders seen in general and acute medicine have dermatological manifestations that may provide critical clues to the underlying disease. This review will discuss the important dermatological signs seen in cardiac conditions. We believe greater interdisciplinary liaison will improve our understanding of the link between the dermatological and cardiovascular systems and the underlying disease processes.

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January 2022 Br J Cardiol 2022;29:16–20 doi:10.5837/bjc.2022.003

Observational case series of postural tachycardia syndrome (PoTS) in post-COVID-19 patients

Nicholas P Gall, Stephen James, Lesley Kavi


There is emerging evidence that a proportion of patients who develop long (post)-COVID-19 have abnormalities in the regulation of their autonomic nervous system manifesting as postural tachycardia syndrome (PoTS). We report a series of 14 patients who developed symptoms and signs compatible with PoTS following clinically diagnosed COVID-19 infection. Their symptoms and clinical findings were consistent with those of patients with non-COVID-related PoTS. The authors recommend an active stand test for patients who present after COVID-19 infection with cardiovascular symptoms including chest pain, palpitations, light-headedness and breathlessness that are worse with the upright posture. They further recommend training of clinicians and investment in health services to provide for the anticipated significant increase in patients presenting with PoTS and other forms of autonomic dysfunction due to the COVID-19 pandemic.

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January 2022 Br J Cardiol 2022;29:36–40 doi:10.5837/bjc.2022.004

Effect of the COVID-19 pandemic on ST-elevation myocardial infarction presentation and survival

Sachintha Perera, Sudhir Rathore, Joanne Shannon, Peter Clarkson, Matthew Faircloth, Vinod Achan


Presentation and outcomes of patients with ST-elevation myocardial infarction (STEMI) may change during viral pandemics. We compared symptom-to-call (STC), call-to-balloon (CTB), door-to-balloon (DTB) times; high-sensitivity troponin (hs-cTnI) levels; and survival of patients (n=39) during the first wave of the COVID-19 pandemic (defined as a ‘COVID period’ starting four weeks before lockdown) to historical controls from a ‘pre-COVID period’ (n=45).

STEMI admissions fell one week before lockdown by 29%. Median STC times began to rise one month before lockdown (54 vs. 25 min, p=0.06), with peak increases between 9 March and 5 April (166 vs. 59 min, p=0.04). Median CTB and DTB times were unchanged. Mean peak hs-cTnI increased during COVID-19 (15,225 vs. 8,852 ng/ml, p=0.004). Six-month survival following all STEMI reduced (82.1% vs. 95.6%, p<0.05).

STC times are the earliest indicator that STEMI-patient behaviour changed four weeks before lockdown, correlating with higher troponin levels and reduced survival. These early signals could guide public health interventions during future pandemics.

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January 2022 Br J Cardiol 2022;29:9–11 doi:10.5837/bjc.2022.005

Heart failure care pathways: the power of collaboration and marginal gains

Carys Barton, Simon Gordon, Afsana Safa, Carla M Plymen


Heart failure (HF) is increasingly common and incurs a substantial cost, both in terms of quality and length of life, but also in terms of societal and economic impact. While significant gains are being made in the therapeutic management of HF, we continue to diagnose most patients when they are acutely unwell in hospital, often with advanced disease.

This article presents our experience in working collaboratively with primary care colleagues to redesign our HF pathway with the aim of facilitating earlier, community, diagnosis of HF. In so doing, and, thus, starting prognostic therapy much earlier in the course of the disease, we seek to avoid both the cost of emergency hospitalisation and the cost of poorer outcomes.

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January 2022 Br J Cardiol 2022;29:26–30 doi:10.5837/bjc.2022.001

New agents for DOAC reversal: a practical management review

Katie White, Uzma Faruqi, Alexander (Ander) T Cohen


Bleeding is the commonest and most concerning adverse event associated with anticoagulants. Bleeding, depending on the severity, is managed in various ways, and for severe or life-threatening bleeding, specific antidotes are indicated and recommended. This review provides guidance relating to specific direct oral anticoagulant (DOAC) reversal agents, the antidotes. We discuss their indications for use, dosing, and potential side effects.

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January 2022 Br J Cardiol 2022;29:12–15 doi:10.5837/bjc.2022.002

Foundational drugs for HFrEF: the growing evidence for a rapid sequencing strategy

Kieran F Docherty, John J V McMurray


In randomised, placebo- or active-controlled trials in patients with heart failure with reduced ejection fraction (HFrEF), each of the combination of a neprilysin inhibitor and an angiotensin-receptor blocker (i.e. sacubitril/valsartan), a beta blocker, a mineralocorticoid-receptor antagonist and a sodium-glucose co-transporter 2 (SGLT2) inhibitor have been shown to reduce morbidity and mortality, firmly establishing the role of these five agents, prescribed as four pills, as foundational therapy for HFrEF. Traditionally, the guideline-advocated strategy for the initiation of these therapies was based on the historical order in which the landmark clinical trials were performed, and the requirement to up-titrate each individual drug to the target dose (or maximally tolerated dose below this) prior to initiation of another therapy. This process could take six months or more to complete, during which time patients would not be taking one or more of these life-saving drugs. Recently an alternative, evidence-based, rapid three-step sequencing strategy has been proposed with the aim of establishing HFrEF patients on low-doses of all four foundational treatments within four weeks. This strategy is based on the premise that the benefits of each of these therapies are independent and additive to the others, the benefits are apparent at low doses early following initiation, and a specific ordering of therapies may increase likelihood of tolerance of others. This article will outline this novel rapid-sequencing strategy and provide an evidence-based framework to support its adoption into clinical practice.

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News and views

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March 2022 Br J Cardiol 2022;29:40 doi:10.5837/bjc.2022.010

Correspondence – Obstructive sleep apnoea and atrial fibrillation: a key omission in guidelines

Obstructive sleep apnoea and atrial fibrillation: a key omission in guidelines Dear Sirs, The National Institute for Health and Care Excellence (NICE) guidelines...

February 2022

Dr Derek G Gibson

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January 2022 Br J Cardiol 2022;29:40 doi:10.5837/bjc.2022.006

Correspondence: Improving DVLA advice upon discharge after cardiac device implantation

Dear Sirs, Implantation of cardiac devices is increasing at a tremendous rate. Rate of implantation of permanent pacemakers (PPM) alone is rising at...

January 2022 Br J Cardiol 2022;29:8

Freedom from failure: The British Society for Heart Failure Annual Meeting highlights

This year’s 24th British Society for Heart Failure annual meeting successfully brought together experts in heart failure from all over the UK as well...