2024, Volume 31, Issue 2, pages 41–80

“Seek simplicity and distrust it.”
Alfred North Whitehead (1861–1947), English philosopher and mathematician

The metric ejection fraction (EF) is widely employed to evaluate ventricular pumping performance, used for heart failure (HF) classification, and its calculation is simple.^1–3 For example, with end-systolic volume (ESV) =50 ml and end-diastolic volume (EDV) =100 ml, the EF=50%. Unfortunately, its correct interpretation received insufficient attention. As EF is a ratio-based number (or percentage) without physical unit(s), it cannot provide unique information. The underlying problem, and also a logical solution, can be shown by the ventricular volume domain representation (figure 1A) that relates ESV to EDV. Volumes may be indexed (i) for body surface area, if appropriate. Focusing on ESVi and EDVi is important, as this combination is associated with the familiar pressure–volume (PV) loop description, which, in turn, connects with clinically relevant characteristics, such as stroke work and myocardial oxygen consumption (MVO₂).¹

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide, causing around 17.9 million deaths annually, a third of whom are adults aged <70 years.¹ In addition to genetic and behavioural risk factors (unhealthy diet, physical inactivity, and tobacco and alcohol abuse), inhaling airborne pollutants, such as fine particulate matter (<2.5 µm [PM_2.5] and <10 µm [PM₁₀]), ultrafine particles (UFPs; <100 nm), nitrogen dioxide (NO₂), ozone (O₃), and sulphur dioxide (SO₂), are associated with ASCVD among adults.²

Air pollution has been referred to as “the single most important environmental factor presenting a risk to health and represents a greater disease burden than polluted water, soil contamination and occupational exposures combined”.³ Air pollution is a silent killer and was highlighted as a significant public health concern in the recently published European Society of Cardiology (ESC) guidelines.⁴

The impact of urbanisation on air pollution levels is a critical concern for countries like Malta, which have adopted a city model to bolster their economies. Despite efforts to stimulate economic growth, the rise in urbanisation can pose risks to air quality. In London, mean PM_2.5 concentrations stood at approximately 12.7 µg/m³ in 2017, 12.0 µg/m³ in 2018, and 11.4 µg/m³ in 2019.⁵ Conversely, Valletta, Malta’s capital, recorded mean PM_2.5 concentrations of about 14 µg/m³ in 2017, 14.4 µg/m³ in 2018, and 14 µg/m³ in 2019.⁶ While both have seen improvements in their aggregated annual mean PM_2.5 concentrations compared with the concentration levels recorded in the past decade, they still exceed the World Health Organisation (WHO) annual air quality guideline value by approximately 1.14 to 1.4 times, highlighting the persistent challenge of air pollution in urban environments.

Heart failure (HF) is a major cause of morbidity and mortality in older people, and 80% of people with HF are aged over 60 years. HF is the end point for almost all common cardiovascular diseases, as well as many non-cardiovascular diseases. Despite this, HF remains underdetected and undertreated. Detection and treatment of HF has improved significantly in recent years, with several novel treatments developed in the last decade improving outcomes for patients. Therefore, earlier detection and improved treatment of HF has the potential to reduce morbidity and mortality for older people, particularly given the shift in ageing demographics anticipated over the coming decades. The British Geriatrics Society Cardiovascular Specialist Interest Group recently participated in the British Society for Heart Failure (BSH) ‘25in25’ Heart Failure Summit, which aims to reduce deaths due to HF by 25% in the next 25 years. The 2023 summit comprised experts from over 45 top health organisations across Europe, Canada and the US. The summit brought together cross-disciplinary expertise to support the implementation of strategies to improve outcomes for people living with HF, and, in this commentary, we reflect upon the priorities identified. We discuss the current barriers to the early detection and management of HF, and the particular challenges and complexity of managing HF in older people. Finally, we discuss the role of patient empowerment and how this can lead to improved care for older people living with HF.

In this article we focus on areas of the European Society for Cardiology (ESC) heart failure guideline 2023 update that will be most relevant in the day-to-day management of patients with heart failure. These include an expanded indication for sodium-glucose cotransporter 2 (SGLT2) inhibitors and intravenous iron, together with rapid optimisation of foundation therapies. With important outcomes for patients, there will undoubtedly need to be modifications to service delivery to ensure that they are widely available for patient benefit.

In ambulatory patients with complete heart block (CHB), dual-chamber (DDD) pacing confers physiological benefits versus single-chamber (VVI) pacing, however, the impact on mortality is disputed. Nonagenarians constitute an expanding proportion of pacemaker recipients, yet data on device selection and outcomes are limited, especially in emergency situations.

In nonagenarians with emergent CHB, we compared the clinical characteristics and outcomes of patients receiving VVI versus DDD pacemakers. Cox proportional-hazards analysis examined all-cause mortality and death from congestive cardiac failure (CCF).

There were 168 consecutive patients followed-up for 30.6 ± 15.5 months. Of these, 22 patients (13.1%) received VVI pacemakers; when compared with DDD recipients, these patients had similar median age (93 vs. 91 years, p=0.15) and left ventricular (LV) systolic function (LV ejection fraction [EF] 49.2% ± 9.7 vs. 50.7% ± 10.1, p=0.71), but were more frail (Rockwood scale 5.2 ± 1.8 vs. 4.3 ± 1.1, p=0.004) and more likely to have dementia (27.3% vs. 8.9%, p=0.011). Post-implant, device interrogation demonstrated that VVI recipients had higher respiratory rates (21.3 ± 2.4 vs. 17.5 ± 2.6 breaths per minute, p=0.002), lower mean heart rates (65.5 ± 10.1 vs. 71.9 ± 8.6 bpm, p=0.002), and lower daily activity levels (0.57 ± 0.3 vs. 1.5 ± 1.1 hours of activity, p=0.016) than DDD recipients. Adjusting for age, frailty and dementia, VVI pacing was associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.08 to 4.1, p=0.03) and death from CCF (adjusted HR 7.1, 95%CI 2.5 to 20.6, p<0.001).

In conclusion, in nonagenarians with emergent CHB, dual-chamber pacing was associated with improved symptomatic and prognostic outcomes versus single-chamber pacing.

This editorial series explores research in UK cardiology and acts as a practical guide to trainees interested in pursuing early career research. Two earlier entries in the series have explored the rationale for pursuing research and how to identify a project and supervisor. We now take a closer look at navigating the application processes, including funding opportunities and regulatory approvals, to get your research off the ground.

Cardiovascular diseases (CVDs) have been reported to occur in a significant number of patients diagnosed with coronavirus disease 2019 (COVID-19). We report our experience regarding the occurrence of symptomatic and asymptomatic CVDs in COVID-19 patients. In this cross-sectional study, 690 COVID-19 patients were included. Cardiovascular consultation had been requested for all of the patients based on their primary clinical examination, vital signs, and electrocardiogram (ECG). Additionally, 2D transthoracic echocardiography (TTE), and myocardial injury serum biomarkers assays (creatine phosphokinase-MB [CPK-MB] and cardiac troponins [cTn]) were measured once. Manifestations of CVDs, such as chest pain, abnormal serum markers, unstable angina, myocardial infarction (MI), myocarditis, and new-onset hypertension, were documented. The most common symptom was left hemithorax and interscapular pain (317 patients, 46%). New-onset high systolic and diastolic blood pressures were seen in 67 patients (10%). Unstable angina, MI, and myocarditis were, respectively, diagnosed in 20 (2.8%), five (0.7%), and 12 (1.7%) patients. On TTE, pericardial effusion was diagnosed in 139 patients (31.1%). The most common abnormal ECG changes seen were regarding the T-wave, including flat T-wave (148 cases, 21.4%) and inverted T-wave (141 cases, 20.4%). Serum cTn levels were positive or weekly positive in 17 cases (7.4%). The incidence rate of cardiovascular involvements was high in COVID-19 patients.

Factor (F) XI or XIa inhibition has attracted interest due to the protection from thrombotic events and minimal bleeding tendency observed in FXI-deficient individuals. The prospect of uncoupling the management of thrombosis from the bleeding risk inadvertently associated with current therapy inspired the development of agents directed towards this step in the coagulation process. This review describes the physiological rationale behind FXI/FXIa inhibition and the pharmacological properties of existing FXI/FXIa inhibitors. It also explores the potential clinical use of these agents in various thromboembolic pathologies, predominantly through the phase II clinical trials conducted so far comparing them to current anticoagulant therapy or placebo.

The use of simvastatin 40 mg with various interacting medicines may lead to an increased risk of myopathy. We examined the extent to which hospital inpatients were prescribed simvastatin 40 mg with amiodarone, amlodipine, diltiazem, or verapamil, and assessed if any action was taken by prescribers or the pharmacy team to avoid this interaction. We found 56 patients on a combination of interest during their stay. Of the 20 (36%) patients not discharged on the combination, in six instances this was due to pharmacy intervention, while the remaining instances when simvastatin 40 mg or the interacting drug was amended or ceased were due to other clinical reasons. There is a need among clinicians and pharmacy teams within the hospital for recognition and management of these particular interactions.

Our objective was to compare the efficacy of atrial fibrillation (AF) ablation versus permanent pacemaker (PPM) with atrioventricular node ablation (AVNA) versus direct current cardioversion (DCCV) for persistent AF in patients ≥65 years old.

Seventy-seven patients (aged 66–86, mean 75.4 years) with persistent AF were randomised (1:1:1) to AF ablation + amiodarone (± DCCV), PPM with AVNA (+DCCV) or DCCV + amiodarone. The primary end point was persistent AF recurrence, measured with an implanted cardiac monitor or PPM. Cardiopulmonary exercise testing (CPET) was performed at baseline and six months. Symptom questionnaires were completed monthly. Follow-up was 12 months.

The primary end point occurred in fewer patients following AF ablation + amiodarone than DCCV + amiodarone (seven patients, 28% vs. 15 patients, 60%; hazard ratio [HR] 0.559, 95% confidence interval [CI] 0.293 to 1.065, p=0.073) with no differences between DCCV + amiodarone and PPM with AVNA (HR 0.990, 95%CI 0.539 to 1.818, p=0.973). AF ablation + amiodarone resulted in a lower AF burden at 12 months compared with DCCV + amiodarone (17.0 ± 37.9% vs. 61.7 ± 48.6%, p<0.0001). Modified European Heart Rhythm Association (EHRA) symptom class improved in all patients (baseline 2.4 ± 0.495 vs. 12-month follow-up 1.84 ± 0.081, p=0.00001). Six-month CPET demonstrated a higher VO₂ peak in sinus rhythm (SR) compared with baseline in AF (12.1 ± 4.2 ml/kg/min at baseline to 15.3 ± 4.2 ml/kg/min at six months, p=0.013).

In conclusion, in older patients with persistent AF, ablation + amiodarone resulted in a lower AF burden at 12 months than DCCV + amiodarone. There was a non-significant trend toward reduced recurrence of device-detected persistent AF episodes. All therapies improved symptoms despite DCCV restoring SR in <50% of patients at 12 months. CPET demonstrated improved VO₂ peak with SR restoration.

Artificial intelligence (AI) will revolutionise cardiology practices over the next decade, from optimising diagnostics to individualising treatment strategies. Moreover, it can play an important role in combating gender inequalities in cardiovascular disease outcomes. There is growing evidence that AI algorithms can match humans at echocardiography analysis, while also being able to extract subtle differences that the human eye cannot detect. Similar promise is evident in the analysis of electrocardiograms, creating a new layer of interpretation. From big data, AI can produce algorithms that individualise cardiac risk factors and prevent perpetuating gender biases in diagnosis. Nonetheless, AI implementation requires caution. To avoid worsening health inequalities, it must be trained across diverse populations, and when errors arise, a robust regulatory framework must be in place to ensure safety and accountability. AI is perfectly positioned to capitalise on the growth of big data, but to proceed we require a generation of physicians who understand its fundamentals.

We present the cumulative percutaneous coronary intervention (PCI) data of all comers (stable angina and acute coronary syndromes [ACS]) who presented to Hadi Clinic between January 2018 and December 2020. As a low-volume PCI centre in the Middle East, we wanted to find out if the outcomes of our PCI procedures are different from those of high-volume PCI centres in the UK and the Western world.

Prospectively collected data of all comers for PCI (urgent and elective) were retrospectively analysed. Pre-procedural data included patients’ baseline characteristics (age, gender, clinical presentation and comorbidities). Intra-procedural data included access route, coronary anatomy, lesion complexity, number of stents deployed, door-to-balloon time for primary PCI, and any intra-procedural complications. Post-procedural data included average length of in-hospital stay, intra-hospital morbidity and mortality, and mortality or admission with ACS 12–36 months after the index procedure.

A total of 567 patients underwent coronary catheterisation for the three-year period between January 2018 and December 2020. Mean age was 60.9 ± 9.4 years, and 459/567 (81.0%) were male. Comorbidities included dyslipidaemia 515/567 (90.9%), hypertension 460/567 (81.2%), diabetes 346/567 (61%), known prior coronary disease 250/567 (44.2%), and smoking 188/567 (33.1%). Clinical presentation was stable angina 130/567 (22.9%), non-ST-elevation acute coronary syndrome (NSTEACS) 312/567 (55%), ST-elevation myocardial infarction (STEMI) 125/567 (22.0%), and STEMI with cardiogenic shock 13/125 (10.4%). The radial approach was used in 544/567 (95.94%), the average SYNTAX score was 34.8 ± 9.6, and the average number of stents 2.6. The total number of PCI was 367 (122.3 annually) with PCI procedural complete success in 349/367 (95.1%), partial success 5/367 (1.36%), PCI procedural complications 3/367 (0.82%), PCI in-hospital mortality 1/367 (0.27%), door-to-balloon time for primary PCI 31.8 ± 12.2 minutes, subsequent admission with ACS after 12–36 months 2/367 (0.54%), and post-discharge mortality after 12–36 months 1/367 (0.27%).

In conclusion, our patient population have more comorbidities and more complex coronary disease in comparison to their western counterparts. Our annual PCI numbers have been significantly lower than the recommended 400 minimum cut-off figure, yet we have achieved comparable outcomes to those of larger institutions of the western world.

Cardiac pathology contributes to a significant proportion of emergency department (ED) attendances. Many could be managed as urgent outpatients and avoid hospital admission. We evaluated a novel rapid-access general cardiology clinic to achieve this, implemented during the COVID-19 pandemic.

We performed a retrospective review of baseline characteristics, investigations, final diagnoses, and 90-day safety (readmission, major adverse cardiovascular events [MACE], mortality) from electronic records and conducted a patient experience survey.

There were 216 ED referrals made between 1 June and 30 October 2020. The median time to review was two days (interquartile range 1–5). At 90 days, there were three (1.4%) re-presentations requiring admission, two (0.9%) MACE, and no deaths. There were 205 (95%) successfully managed without hospital admission. Among surveyed patients, 96% felt they had concerns adequately addressed in a timely manner.

In conclusion, our rapid-access cardiology clinic is a safe model for outpatient management of a range of cardiovascular presentations to the ED.