2023, Volume 30, Issue 4, pages 121–160

It is no secret that the National Health Service (NHS) is currently screaming along in fifth gear just to stay on a country lane: and we haven’t yet reached the motorway that lies ahead.

The NHS long-term plan couldn’t be more current, but it could perhaps have been more timely.¹ Successive governments have watched our population changing shape and ageing over the last 20 years, but a powerful response to that looming ‘motorway’ of healthcare demand has only now materialised. The backlash of COVID-19 and the realisation of the impact of Brexit on NHS staff has become the ‘speed camera’ the NHS needed.

In 2022, the British Society of Echocardiography (BSE) commissioned Professor Alison Leary, Chair of Workforce Modelling at London South Bank University, to design a workforce survey that would allow us to fully understand the challenges facing the echocardiography workforce. This report and the policy report, which models solutions onto these data, can be read in full through our website (bsecho.org).^2,3

This is my viewpoint on the messages contained within these gold-dust documents painted within the landscape of three years of fascinating conversations with many members of our profession and the national agencies we interact with.

Stroke is a major cause of mortality, morbidity and economic burden. Strokes can be thrombotic, embolic or haemorrhagic. The key risk factor for cardioembolic stroke is atrial fibrillation or flutter, and oral anticoagulation (OAC) is recommended in all but the lowest-risk patients with evidence of these arrhythmias. Risk factors for thrombotic stroke overlap strongly with those for other atherosclerotic cardiovascular diseases (ASCVDs). Antiplatelet therapy (APT) should be considered in patients with established ASCVD to reduce risk of cardiovascular events, including stroke. Intensification from single to dual APT or a combination of APT with low-dose OAC can reduce ischaemic stroke risk further, but increases bleeding risk. Blood pressure and lipid profile should be controlled appropriately to guideline targets. In patients with diabetes, good glycaemic control can reduce stroke risk. Inflammation is another emerging target for stroke prevention. Overall, comprehensive assessment and pharmacological modification of risk factors are central to stroke prevention.

To review the utility of cardiovascular magnetic resonance (CMR) in the management of hospital inpatients, we performed a retrospective review of all inpatient CMR scans performed over a six-month period at a tertiary referral cardiology centre. Patient demographics, indication for CMR imaging, results of the CMR scans and whether the results changed patient management were recorded. Change in management included medication changes, subsequent invasive procedures, or avoidance of such, and hospital discharge.

Overall, 169 patients were included in the study cohort, 66% were male, mean age was 57.1 years. The most common indication for inpatient CMR was to investigate for cardiomyopathy (53% of patients). The most prevalent diagnosis post-CMR in our cohort was ischaemic heart disease, including ischaemic cardiomyopathy and coronary artery disease. There was a complete change in diagnosis or additional diagnosis found in 29% of patients following CMR. Overall, inpatient CMR led to a change in management in 77% of patients; the most common being changes to medication regimen. CMR was well tolerated in 99% of patients and image quality was diagnostic in 93% of cine scans performed.

In conclusion, CMR is vital for the management of cardiology inpatients, having an impact that is at least as significant as in the management of outpatients.

Guidelines recommend decision-making using the heart team (HT) in complex patients considered for myocardial revascularisation, but there are little data on how this approach works in practice. We data-mined our electronic HT database and selected patients in whom the clinical question referred to revascularisation, and documented HT recommendations and their implementation.

We identified 154 patients (117 male), mean age 68.9 ± 11.4 years, discussed between February 2019 and December 2020. The clinical questions were coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) (141 cases, 91%), and medical treatment versus revascularisation by PCI (eight cases, 6%) or by CABG (five cases, 3%).

HT recommended CABG in 55 cases (35%), PCI in 43 (28%), medical treatment in 15 (10%), and equipoise in seven (5%) and further investigations in 34 (22%): non-invasive imaging for ischaemia in 11 (32%), invasive coronary physiology studies in eight (24%), further clinical assessment in seven (20%), structural imaging for five (15%), invasive coronary angiography in two (6%), and an electrophysiology opinion in one case (3%).

Decisions were implemented in 135 cases (89%). The average time between the HT and the implementation of its decision was 80.5 ± 129.3 days. There were 17 deaths: 10 cardiac, six non-cardiac and one of unknown cause. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p = 0.03).

In conclusion, almost 90% of the decisions of the HT on myocardial revascularisation are implemented, while ischaemia testing is the main investigation required for decision-making. Recent data on the futility of such an approach have not yet permeated clinical practice.

In this study, we evaluated the change in left ventricular end-diastolic pressure (LVEDP) after primary percutaneous coronary intervention (PCI) and its impact on in-hospital outcomes and 30-day and three-month quality of life (SAQ-7), ejection fraction (EF), and major adverse cardiovascular events (MACE). LVEDP ≥19 mmHg was taken as elevated LVEDP. In a sample of 318 patients, 18.9% (n=60) were females and mean age was 55.7 ± 10.52 years. Post-procedure elevated LVEDP was observed in 20.8% (n=66) with a mean reduction of 1.65 ± 4.35 mmHg. LVEDP declined in 39% (n=124) and increased in 10.7% (n=34). In-hospital mortality rate (9.1% vs. 2.4%, p=0.011), 30-day MACE (9.1% vs. 4.0%), and three-month MACE (21.2% vs. 5.6%) were found to be significantly higher among patients with elevated LVEDP, respectively. Elevated LVEDP was found to be associated with a reduced SAQ-7 score (89.84 ± 8.09 vs. 92.29 ± 3.03, p<0.001) and reduced (25–40%) EF (55.6% vs. 22.6%) at three-month follow-up. LVEDP declined acutely in a significant number of patients after primary PCI. Post-procedure elevated LVEDP was found to be associated with poor quality of life and an increased risk of immediate and short-term MACE.

Despite widespread use of statins and other lipid-lowering therapies for hypercholesterolaemia, cardiovascular (CV) mortality and morbidity remains high. The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, have been approved for use in patients with familial hypercholesterolaemia and high CV risk in the UK. We reviewed the records of patients at a large health board in Scotland, who were prescribed these agents, to determine their real-world efficacy and tolerability in routine clinical care.

Primary percutaneous coronary intervention (PPCI) remains the gold-standard treatment for ST-elevation myocardial infarction (STEMI). Femoral arterial access for the procedure may be an ideal option in patients who are haemodynamically unwell. However, it is associated with rare, but life-threatening, complications such as perforation, leading to retroperitoneal haemorrhage. We present the case of a man in his 50s, admitted with cardiac arrest secondary to inferolateral STEMI. Successful PPCI was performed via right femoral artery, with access gained under ultrasound guidance. However, the patient deteriorated and was diagnosed to have a retroperitoneal haematoma secondary to femoral artery perforation. Additional arterial access via left brachial artery was obtained, and a covered stent was deployed successfully in the right femoral artery with satisfactory haemostasis. The patient recovered successfully and was discharged two weeks later. Early recognition of such complications is imperative to adequate management and percutaneous treatment is a viable option for such situations, in comparison with open surgical repair.

Persistent cardiac arrhythmias are readily amenable to detection by performing a standard electrocardiogram (ECG), but detection of transient (paroxysmal) arrhythmias has long been a significant cause of frustration to both doctors and patients. Often a significantly symptomatic arrhythmia is experienced by the patient but terminates before an ECG can be recorded to allow diagnosis. Prognostically important treatment is often delayed, and recurrent symptomatic attacks represent a high morbidity in patients’ lives and result in a burden on emergency services, who often arrive after the arrhythmia has terminated with no resultant progress in making a diagnosis.

Another area of concern has been the presence of asymptomatic, but clinically important, arrhythmias that can go unnoticed by people experiencing them and may result in permanent harm; asymptomatic paroxysmal atrial fibrillation in patients with high CHA₂DS₂-VASc scores being the most common example.

Both these issues are now being importantly addressed by the widespread availability of portable ECG recording devices, which patients can either manually activate themselves or program to automatically detect abnormal arrhythmias. Information on the range of devices available and their strengths and weaknesses is limited. This article aims to provide a helpful overview for patients and doctors advising them.

Andreas Grüntzig, an ardent angiologist crafted an indeflatable sausage-shaped dual-lumen balloon-catheter, designed its delivery to the heart, launched minimally invasive coronary intervention and taught by beaming live demonstration. Subsequent advances are just incremental tweaks and tinkers around this fully formed framework from 1978. The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug-eluting stent, drug-coated balloon, or both in different combinations and permutations. Now with Grüntzig’s balloon armed with an antiproliferative drug, it could dominate the field once more, as he originally envisaged.

Thrombus is the main finding in most patients with acute coronary syndrome (ACS), the type of which potentially impacts the end result of the interventional procedure in terms of no reflow and edge dissection. Optical coherence tomography (OCT) is considered a precise intra-vascular tool to image thrombi and characterise its properties. We aimed to study the impact of thrombus type, as defined by OCT, on procedural outcome in ACS patients. In this retrospective study we enrolled 100 patients who were treated by percutaneous coronary intervention (PCI) with the guidance of OCT. We recorded demographic and clinical data of the whole studied cohort. Angiographic details and procedural data were noted. Baseline OCT study was performed before intervention and repeated post-intervention. Plaque characterisation was identified, and thrombi were defined as red or white thrombi. Acute angiographic outcome was defined with special emphasis on no reflow.

Male patients and ST-elevation myocardial infarction (STEMI) patients more often had white thrombi (58.1% and 71.2%, respectively). Cases with red thrombi had longer pain duration, which was statistically significant. Edge dissection was more frequent with red thrombus, 44.7% versus 32.1% with white thrombus, but the difference is not statistically significant, while 17% of patients with white thrombi were complicated by no-reflow phenomenon versus only 4.3% in patients with red thrombi, and this difference was statistically significant.

In conculsion, OCT-guided PCI is feasible and safe in ACS settings. OCT-guided intra-procedural differentiation of thrombus type is potentially beneficial in predicting acute procedural outcome.

Remote delivery of cardiovascular rehabilitation (CR) has been vital during the COVID pandemic when restrictions have been placed on face-to-face services. In the future, CR services are likely to offer alternatives to centre-based CR, including digital options. However, little is known about the digital access and confidence of CR service users, or their CR delivery preferences.

A telephone survey was conducted of those referred for CR in the London boroughs of Lambeth and Southwark (n=60) in which questions were asked about digital access and confidence, as well as current and future delivery preferences for their CR.

Between March and July 2021, 60 service-users met the inclusion criteria and were recruited for a telephone survey (mean age 60 ± 11.2 years). Of those, 82% had regular access to a smartphone, 60% to a computer or laptop and 43% to a tablet device. A high proportion of service users perceived themselves to be ‘extremely’ or ‘somewhat’ confident to use their devices. Thirty-nine (65%) service users would currently prefer a face-to-face assessment, rising to 82% once the perceived COVID-19 threat and restrictions are less. Preferences for accessing exercise were equally split between face-to-face and remotely supported independent exercise, with low interest in digital options. Delivery preferences for education, relaxation and peer support were more heterogeneous with interest in all delivery options.

In conclusion, digital access and confidence in CR service users was good. Redesigning CR services to offer more rehabilitation delivery options, aligned with patient choice may increase uptake and further trials are needed to assess the impact.

Transthoracic echocardiography (TTE) is used to assess for evidence of infective endocarditis (IE). Inappropriate patient selection leads to significant burden on healthcare services. We aimed to assess effectiveness of cardiology consultant vetting of TTE requests for suspected IE in reduction of unnecessary scans. All inpatient TTE requests querying IE over a six-month period were vetted. Clinical information and pathology results were reviewed, and requests were either accepted, deferred, or rejected. A total of 103 patients had TTE requested: 39 (38%) were accepted for scan; four cases of IE were confirmed on TTE. There were 62% of patient requests rejected and not scanned, and no cases of IE subsequently diagnosed. Thus, consultant vetting of TTE requests for suspected IE is an effective way to safely reduce unnecessary scans and enables cost-effective streamlining of echocardiography services.

This paper summarises ‘Share The Pressure’, a project that developed and piloted a scalable model for engaging patients on the benefits of risk factor control for healthy ageing; training healthcare professionals (HCPs) in cardiovascular disease (CVD) risk communication; and improving the shared decision-making process between nurses, pharmacists and patients. The study features the use of a CVD risk tool called Heart Age, which has been shown to effectively motivate risk factor reduction in individuals.

The study team engaged virtually with patients and HCPs through established relationships within the community, third sector, charities, and social media. In addition, patients living with high blood pressure (hypertension) participated via online focus groups and surveys, which provided insight into patients’ preferences for conveying CVD risk, quantification of intervention benefits, side effects and processes to facilitate shared decision-making.

This insight gained from the focus group and survey data informed adaptations made to the Heart Age tool to provide ‘years off’ – or lowering of heart age – benefits for different aspects of blood pressure lowering, focusing on the independent and joint benefits of medication management and lifestyle.

The study piloted a training programme for nurses and pharmacists to support them in communicating and framing risk and intervention benefits.

The study trained 1,148 HCPs from 37 countries over 17 sessions. Post-training survey results of HCPs indicated an increase in self-rated knowledge and a strong likelihood of applying information learned to their clinical practice. In addition, the Heart Age users found the personalised report and Heart Age test results very motivating for patients with high blood pressure.

Transcatheter edge-to-edge repair (TEER) was first performed in 2003, and is now established across the developed world as an effective, minimally invasive treatment option for patients with mitral regurgitation (MR). Multiple large registries have established the efficacy of mitral TEER in patients with primary or degenerative MR in whom surgery is considered prohibitive or high risk, while ongoing randomised-controlled trials will determine its role in younger and lower-risk patients. In patients with secondary or functional MR, in whom mitral valve surgery is not routinely recommended, the pivotal COAPT trial showed a profound reduction in both mortality and heart failure hospitalisation in carefully selected patients.

NHS England approved the routine commissioning of mitral TEER in 2019, and following a substantial delay, due in large part to the COVID pandemic, the procedure is now widely available across the UK. This review article describes the TEER procedure, currently available devices, the underlying evidence base, and the key facts needed for clinicians to understand who, how, and where to refer patients for consideration of mitral TEER. The emerging role of TEER in patients with severe symptomatic tricuspid regurgitation is also considered.