2024, Volume 31, Issue 3, pages 81–120

There is little doubt that demand on the National Health Service (NHS) has exceeded supply. Given the rhetoric of no more money, no new workforce, and no new estates, it is incumbent on us all to make better and more efficient use of the limited resource we do have, improve how we work together as one integrated health, community and social care ecosystem, and increase the value of every action we take. Cardiovascular services are no exception.

Training and development of cardiology trainees in the UK at a local level, is usually delivered through senior supervision by a consultant cardiologist. This training is overseen by clinical and educational supervisors, whose role is to set goals in line with existing training curricula. This is crucial to ensuring trainee development and attainment of skills in line with a pre-determined ‘gold standard’ for independent practice.

“In spite of the accumulating evidence of their efficacy, established treatments for maintaining renal function remain woefully underutilized. Clinicians and health care systems must be encouraged to make use of these treatments.”¹

The above was written in an editorial by Thomas Hostetter¹ that accompanied three landmark nephrology trials published in 2001.^2–4 The studies will be well-known to nephrologists and demonstrated that angiotensin-receptor blockers (ARBs) had anti-proteinuric effects and/or slowed the decline of kidney function in patients with diabetic kidney disease. These trials added weight to the evidence that supported the use of both angiotensin-converting enzyme inhibitors (ACEi) or ARBs in diabetic kidney disease and chronic kidney disease (CKD), particularly in patients with proteinuria.⁵ The evidence-base supporting the use of these drugs for patients with heart failure and cardiovascular diseases is unquestioned, and given the inter-related nature of the heart and the kidneys, the hope and optimism around these drugs was understandable. Dr Hostetter, however, was right to be cautious in his appraisal of the impact these medications might have on outcomes for patients with CKD, not because of the quality or compelling nature of the trial data, but because of the difficulties overcoming clinical and systems-related inertia to achieve effective implementation of the drugs. His predictions have proved cogent.

Heart failure (HF) is a prevalent and complex condition that demands precise and efficient management. This paper delves into a critical, yet often under-recognised, challenge in HF care – the accurate coding of patients on HF registers. We explore how discrepancies in coding, including missing patients and incorrect HF type classifications, can significantly impact patient management. The experiences of our healthcare system’s staff are examined to shed light on the real-world implications of these issues.

Clinicians and administrative staff in primary care can play a pivotal role in identifying, monitoring, and ensuring the accuracy of patient coding. By sharing their insights, we uncover the intricacies of addressing coding discrepancies and strategies suggested to optimise patient management. Furthermore, we investigate the technology and systems in place to aid staff in this endeavour.

This paper aims to contribute to the broader healthcare community’s understanding of the challenges related to coding accuracy in HF registers and to offer insights into potential solutions. By rectifying these coding discrepancies, we can enhance patient care, minimise potential oversights, and ultimately improve outcomes for individuals living with HF. Our findings underscore the significance of ensuring that no HF patient is missed or misclassified, emphasising the need for continued improvement in this vital aspect of HF care.

In this four-part editorial series, we have looked at the significance of research within cardiology training in the UK. The first three instalments explored the impact of research on a career in cardiology, identified the diverse research avenues, and provided guidance on navigating the application process. In the final part of this series, our focus shifts to post-higher degree opportunities within the field, and discuss the skills developed in research that can be applied to clinical practice.

In recent years, artificial intelligence (AI) has been used to improve the precision of valvular heart disease diagnosis and treatment. It has the ability to identify and risk stratify patients with valvular heart disease and holds promise in improving the innovation of new treatments through shorter, safer and more effective clinical trials. AI can help to guide the treatment of patients with valvular heart disease, by aiding in optimal device selection for transcatheter valvular interventions and, potentially, predicting the risk of specific complications. This review article explores the various potential applications of AI in the diagnosis and treatment of valvular heart disease in more detail.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce cardiovascular rehospitalisation in heart failure with reduced ejection fraction (HFrEF) patients. However, it is unknown whether initiating SGLT2i during an inpatient stay for a HFrEF exacerbation results in better outcomes versus initiation post-discharge in a cohort of diabetic and non-diabetic patients. This study compares cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death between patients initiated on SGLT2i as an inpatient versus post-discharge.

A retrospective study of four hospitals in England involving 184 patients with HFrEF exacerbations between March 2021 and June 2022 was performed. Cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death were compared between the two groups using Cox regression. A Cox proportional-hazards model was fitted to determine predictors of cardiovascular rehospitalisation.

There were 148 (80.4%) individuals who received SGLT2i as an inpatient, while 36 (19.6%) individuals received SGLT2i post-discharge. Median follow-up was 6.5 months for inpatients and 7.5 months for post-discharge patients (p=0.522). SGLT2i inpatients had significantly reduced cardiovascular rehospitalisations (22.3%) versus post-discharge patients (44.4%) (p=0.005), and significantly reduced heart failure specific rehospitalisations (10.1%) versus post-discharge patients (27.8%) (p=0.018). There was no significant difference in all-cause death (p=0.743) and cardiovascular death (p=0.816) between the two groups. Initiating SGLT2i post-discharge was an independent predictor of cardiovascular rehospitalisation (hazard ratio 2.40, 95% confidence interval 1.31 to 4.41, p=0.005).

In conclusion, inpatient SGLT2i initiation for HFrEF exacerbations may reduce cardiovascular and heart failure specific rehospitalisation versus initiation post-discharge. In the absence of contraindications, clinicians should consider initiating SGLT2i once patients are clinically stable during inpatient HFrEF admissions.

Atrial fibrillation (AF) is responsible for significant patient morbidity, and obesity is a major contributor to AF incidence and symptom burden. Weight loss has been shown to positively modify AF symptoms, but weight loss in a real-world population is often only temporary. This randomised study set out to examine if smartphone-based app technology could increase weight loss in a patient population with obesity and AF.

Individuals were screened following outpatient referral to Leeds Teaching Hospitals NHS Trust for symptomatic AF. Block randomisation was performed to allocate the treatment groups to either clinical follow-up or app-based follow-up, with weight loss updates planned fortnightly. Patients randomised to clinical follow-up received nurse-led telephone calls every two weeks, while those in the app arm received automated reminder messages every two weeks. Final follow-up at six months included clinical and weight data and a quality-of-life questionnaire.

Sixty-four patients underwent randomisation. No significant difference in weight loss was seen between the groups. Patient engagement was far more consistent in the telephone follow-up group.

In conclusion, no significant difference in weight loss was seen between the two groups, despite patient education on the value of weight loss to improve their AF symptoms.

Obesity is a global pandemic and is a recognised risk factor for cardiovascular diseases. However, its impact on cardiac structure and function using echocardiography, as well as its association with anthropometric parameters in otherwise healthy individuals, requires further investigation. Therefore, we conducted an observational study with a cohort of 196 participants, comparing various echocardiographic parameters in normal weight individuals and those who were overweight or obese but had no other risk factors. Our findings revealed that obese participants had significant changes in echocardiographic measurements of the structure and functions of the left ventricle, left ventricular global longitudinal strain, left atrium, right ventricle and right ventricular global longitudinal strain compared with the control group. Body surface area and body mass index were important anthropometric features that correlated with the above echocardiographic changes, and should be routinely evaluated to assess cardiovascular risk in patients. Further larger studies are necessary to determine the clinical significance of the echocardiographic changes observed in obese individuals and their impact on health.

The purpose of this study was to determine the correlation between the simplified treadmill score (STS) and both the number of blood vessels with significant stenosis and the severity of the SYNTAX score in patients with coronary artery disease (CAD). This was an observational, cross-sectional study conducted at Dr. Soetomo General Hospital and Premier Surabaya Hospital in Indonesia from January 2011 to February 2012.

The results of the analysis using the Spearman correlation showed that there was a strong positive relationship between STS and the number of blood vessels with significant stenosis (r_s=0.616 and p<0.001). Similarly, the relationship between STS and SYNTAX score obtained (r_s=0.500 and p<0.001) indicates a fairly strong positive relationship.

In conclusion, there is a significant correlation between the STS as a clinical reference for estimating the probability of CAD through a weight-training test with the number of blood vessels experiencing significant stenosis.

A 59-year-old woman presented to the emergency room with sudden onset of retrosternal thoracic pain following emotional stress. The electrocardiogram (ECG) revealed T-wave inversions on precordial leads. Her blood analyses demonstrated elevation of myocardial necrosis markers (peak of troponin I of 3.4 ng/ml). Transthoracic echocardiogram (TTE) findings were consistent with Takotsubo syndrome, accompanied by mild left ventricular dysfunction. The patient underwent invasive coronary angiography revealing a spontaneous coronary artery dissection in the left anterior descending artery and left main artery. A repeat TTE one week later showed complete resolution of the segmental contractility with a full recovery of left ventricular function. Cardiac magnetic resonance imaging revealed no abnormalities. The patient was discharged on dual-antiplatelet therapy. A follow-up coronary angiography performed one month later confirmed complete resolution of the dissection. Takotsubo syndrome and spontaneous coronary artery dissection predominantly affect women and share common triggers. This case highlights the often misdiagnosed association and emphasises the specific diagnosis and treatment nuances associated with it.

Cardiac metastases normally reflect diffuse metastatic spread of the primary tumour and are rarely found in isolation. We present a case of a 71-year-old man with a history of completely resected high-grade spindle cell sarcoma of the left thigh, who presented with shortness of breath, and was found to have a large right ventricular mass, subsequently diagnosed as a metastasis of the prior sarcoma. It was deemed inoperable and incurable, and the patient was offered palliative chemotherapy. Unfortunately, the patient died within four months of his original presentation.