2022, Volume 29, Issue 4, pages 121–160

Acute coronary syndrome (ACS) is one of the leading causes for morbidity and mortality in the world despite advances in treatment as shown by both short- and long-term studies.¹ Studies demonstrate that factors responsible for increased risk of future cardiovascular events are often ignored resulting in increased morbidity and mortality.^1,2 Despite the significant reduction of in-hospital mortality in patients with ACS, the overall mortality and morbidity remains high due to missed opportunities to optimise treatment.³ The Global Registry of Acute Coronary Events (GRACE) conducted in centres in Belgium and the United Kingdom (UK) shows a long-term signal of recurrent events, such that in-hospital mortality was 3%, 4% and 5% at five-year follow up and that mortality was 15% and 18% for Belgium and UK patients, respectively.⁴ The GRACE study showed that patients with a higher GRACE score were at higher risk compared to low and moderate scores, and 68%, 86% and 97% deaths occurred in patients with ST-elevation myocardial infarction (STEMI), ACS and unstable angina, respectively, after initial hospital discharge. Patients with non-ST segment elevated myocardial infarction (NSTEMI) were found to have poor prognosis at six-month follow up, compared to STEMI patients, which was most likely due to patients being on less-than-optimal treatment. Medication compliance among patients is highest in the first month after ACS and Cheng et al., reported that from patients discharged on aspirin, beta blocker and statins, 34% patients had stopped at least one medicine and 12% had stopped all three medications a month after ACS.⁵ Only 40–45% patients were adherent with beta blocker or statins one to two years following ACS.

Some healthcare professionals may see the idea of ‘joint working’ between NHS Trusts and pharmaceutical companies as anathema – a bridge too far in the direction of private interests perhaps? However, when the needs of patients, the health system and the company are aligned, it can bring significant benefits for everyone.

At the Leeds Teaching Hospitals NHS Trust (LTHT), we have recently entered into a joint working partnership with Boehringer Ingelheim.¹ This arrangement is helping us to develop a patient-centred clinic specifically focused on reducing cardiovascular (CV) risk in individuals with diabetes recently discharged from LTHT following a myocardial infarction (MI). Initiated in September 2021, the clinic is run jointly by the cardiology department at Leeds General Infirmary and the diabetes services at the Trust. It is shared funded by the Trust and by Boehringer Ingelheim.

Nutrition is underrepresented in the medical curriculum; this has always been the case, but recently there has been a focus on trying to change this. A ‘call for action’ by the independent organisation Nutritank CIC and the Nutrition Implementation Coalition has led the way for this. New recommendations for curriculum changes have been proposed, but no mandatory changes are yet in place.

Acute heart failure (AHF) is associated with 9.3% mortality. Depression and hopelessness are prevalent. We conducted an online survey using Survey Monkey, via the UK Heart Failure (HF) Investigators Research Network of 309 cardiologists, in 2021, to determine: what proportion of UK centres offer outpatient-based management (OPM) for AHF including the use of parenteral diuretics; and what proportion of HF services have clinical psychology support.

There were 51 services that responded, and an estimated 25,135 patients with AHF receive inpatient care per year (median 600 per site). There are 2,631 patients (median 50 per site) treated per year with OPM (9.7% of the population of AHF patients). While 65% of centres provided access to OPM, only 20% have a clinical psychology service.

In conclusion, nearly 10% of patients with AHF receive outpatient-based intravenous diuretic therapy. Only 20% of hospitals have a clinical psychology service for patients who suffer from HF.

Atrial fibrillation (AF) and diabetes are increasingly prevalent worldwide, both increasing stroke risk. AF can be detected by patient-led electrocardiogram (ECG) screening applications. Understanding patients’ views around AF screening is important when considering recommendations, and this study explores these views where there is an existing diagnosis of diabetes.

Nine semi-structured qualitative interviews were conducted with participants from a previous screening study (using a mobile ECG device), who were identified with AF. Thematic analysis was completed using NVivo 12 Plus software and themes were identified within each research question for clarity.

Themes were identified in four groups:

1. patients’ understanding of AF – the ‘concept of irregularity’ and ‘consideration of consequence’;
2. views on screening – ‘screening as a resource-intensive initiative’, ‘fear of outcomes from screening’ and ‘expectations of screening reliability’;
3. views on incorporating screening into routine care – ‘importance of screening convenience’; and
4. views on the screening tool – ‘technology as a barrier’ and ‘feasibility of the mobile ECG recording device for screening’.

In conclusion, eliciting patients’ views has demonstrated the need for clear and concise information around the delivery of an AF diagnosis. Screening initiatives should factor in location, convenience, personnel, and cost, all of which were important for promoting screening inclusion.

The COVID-19 pandemic required a radical change in healthcare delivery methods, including the remote delivery of many outpatient services. We aimed to understand patient satisfaction with telephone consultations.

Patients who had undergone a cardiology telephone consultation between 24 February and 19 July 2021 were asked to complete a survey. The survey assessed their satisfaction with the consultation and their preference between remote and face-to-face consultation. The 56 responses demonstrated high levels of satisfaction with 56% agreeing they were “completely satisfied” with the consultation compared with 5% who disagreed. However, 63% would have preferred a face-to-face appointment compared with 22% preferring a telephone consultation.

No patterns were observed that might help to guide who should be offered the different modalities of consultation; to maximise patient satisfaction a flexible and individualised approach is likely to be required.

Elevated cholesterol/lipid levels, especially low-density lipoprotein cholesterol (LDL-C) are known to contribute to the development of atherosclerotic cardiovascular disease (ASCVD). The attainment of lipid targets is known to be suboptimal both globally and locally. This study aimed to evaluate the effectiveness of a lipid management pathway (LMP) in supporting attainment of lipid targets following an acute coronary syndrome (ACS) in a local cohort of cardiac rehabilitation (CR) patients.

Quantitative data were retrospectively collected from 54 CR patient records. Local lipid target attainment was benchmarked against national guidelines and pre-pathway implementation audit results.

The number of admission lipid profiles increased by 24.8% to 79.6% following implementation of the LMP. There was a 31% improvement in the number of patients achieving either a 50% reduction in LDL-C or an LDL-C level of <1.4 mmol/L. In conclusion, the LMP had a significant positive impact upon the attainment of lipid goals.

We report the case of a 45-year-old man presenting with worsening shortness of breath and chest tightness on a background of type 2 diabetes mellitus, hypertension and stable angina. He felt generally unwell and had a productive cough two weeks prior to presentation. Initial examination found quiet heart sounds and reduced air entry bi-basally on auscultation. Electrocardiography (ECG) demonstrating lateral T-wave flattening and ongoing chest tightness directed management towards an acute coronary syndrome (ACS). However, negative troponin I and positive D-dimer prompted investigation with computed tomography pulmonary angiogram (CTPA) identifying a 3.5 cm thickness pericardial effusion and no pulmonary embolism. Initial COVID-19 nasopharyngeal swabs were negative for SARS-CoV-2. Echocardiography identified features consistent with cardiac tamponade prompting pericardiocentesis. Over 1,000 ml of straw-coloured aspirate was drained with significant clinical improvement, and the patient was discharged with plans for urgent outpatient cardiac magnetic resonance imaging (MRI). Interestingly, despite multiple negative nasopharyngeal swabs for COVID-19, serum antibodies to SARS-CoV-2 were detected.

Dual antiplatelet therapy is recommended for secondary prevention of ischaemic events in coronary artery disease. Some patients, who may be at high bleed risk if other factors are present, should be considered for gastroprotection. In our survey, we assessed whether gastroprotection was prescribed for hospital inpatients, especially high-risk patients, who were receiving dual antiplatelet therapy at discharge, and the type of gastroprotection prescribed. We found that over 13 months, a total of 1,693 patient episodes were prescribed dual antiplatelet therapy at discharge, of which 71% also received gastroprotection. Of the patient episodes who were not prescribed gastroprotection, 46% (223/483) met the criterion of age as a risk factor for gastroprotection. A further 30 episodes met other risk criteria of certain concomitant drugs or prior comorbidity. There is a need among clinicians and pharmacy teams within the hospital for recognition and management of this opportunity to improve the care of these patients.

We report the case of an elderly woman with recent hip replacement surgery that presented with cardiogenic shock. The initial echocardiogram was suggestive of mid-ventricular Takotsubo cardiomyopathy, which was later confirmed due to absence of severe coronary artery disease and complete resolution of the patient’s cardiac systolic dysfunction. Fluid and inotrope administration in the acute phase, and guideline-directed medical therapy for heart failure, thereafter, led to full recovery.