2024, Volume 31, Issue 4, pages 121–160

The arrival of sodium-glucose cotransporter type 2 (SGLT2) inhibitors has ushered in a new era in the management of cardiometabolic diseases. These innovative agents, initially developed for glycaemic control in type 2 diabetes, have unexpectedly demonstrated significant cardiovascular benefits, revolutionising cardiologists’ approach to the prevention and treatment of heart failure and cardiovascular events.¹

Cardiovascular disease remains the leading cause of death for women, responsible for over a third of all deaths.¹ In contrast, women remain widely under-represented in cardiovascular trials,² as well as in their roles as physicians and trialists.³

The scarcity of female representation in cardiology carries broad consequences, affecting patient care quality, workplace diversity, and the inclusion of women in clinical trials. Engaging more women in academia and industry collaborations can boost their professional visibility, career opportunities, and increases the likelihood of female patients to receive guideline-based therapies, all of which highlights the need for gender diversity in cardiology.⁴

A quiet revolution without fanfare took place at a meeting, witnessed by over 1,000 people both in London and live streamed across the globe on 31 January 2024. It was unprecedented, going against received wisdom. That, it was possible to treat atherosclerotic coronary artery disease with an updated Andreas Grüntzig’s balloon alone, without the safety net and comfort of implanting a single stent. Three interactive cases were treated with the drug-coated balloon and all patients were same-day discharged. Seemingly a show of simplicity, parsimony and bravado, but dive a little deeper, the skill set for stent-free coronary intervention has been meticulously studied over the last 20 years by pioneers and early adopters alike. The sacred cow slayed on this historic day was that balloon-inflicted coronary dissection rarely leads to occlusion, having effective antiplatelet therapy on board. And, potentially occlusive dissection is, not only predictable, but this method can be used in the ambulatory care setting. Thus, saving hospital bed stays. This event will be remembered as the tipping point at which a paradigm shift has occurred, but going back to embracing Grüntzig’s lessons. This is timely too, considering that two decades of systematic stenting has led to stent failures comprising nearly a third of daily interventional workload.

This study aimed to understand the national echocardiography assessment pathway in heart donation. We carried out a prospective national specialist nurses in organ donation (SNOD) audit of UK donor offers between 20 August and 31 November 2022, and a prospective national recipient transplant centre audit of all donor offers between 22 September and 19 December 2022.

The SNOD audit identified median time delay between requesting and performing an echocardiogram of 17.9 hours (interquartile range [IQR] 13.9–33.2). The staff group performing the echo were a cardiac physiologist in 57% (17/30) of cases and a medical doctor in 43% (13/30) of cases. Only 30% (9/30) of providers held comprehensive accreditation, 13% (4/30) were focused accredited, 33% (10/30) had no accreditation, and 23% (7/30) were unknown. Only 50% (15/30) of images were transferred for review to the transplant centre. Images were transferred via email (10/15, 67%), WhatsApp (4/15, 27%) and a standard picture archiving system (PACS) (1/15, 3%).

The transplant centre audit revealed that in 21% of donors, the transplant team felt that the echo performed at the referring centre contained inadequate information, and in 11% of donors, no echo was performed at all. Only 52% of potential donors had echo images available for direct review by the transplant centre. In 17% of cases, the transplant team felt that if good quality echo data and imaging had been available, the decision regarding mobilising the retrieval team may have been altered.

In conclusion, to improve donor heart utilisation rates we believe there is a need to recognise the contribution of focused echo and improve guidance for echo image acquisition. There is also a need for a robust system for image transfer to transplant centres.

Protection against the increased risk of sudden cardiac death (SCD) due to ventricular arrhythmias is offered by the implantation of cardiac defibrillators. A life-expectancy of less than one year is usually a contraindication to the implantation of these devices. We evaluated the outcomes of all those who received defibrillator implantation for any clinical indication at our centre in the same year that early (<12 months) death notifications occurred.

This is a single-centre retrospective study on the outcomes of all patients who had a transvenous defibrillator implant in 2015. All transvenous defibrillator devices implanted for both primary and secondary prevention of SCD were included. Patient demographic data and device data were studied.

Data from 235 patients were analysed. In a follow-up period of 66.2 ± 3.8 months, 77 (32.8%) of the study cohort died; 20 (8.5%) of these patients died less than 12 months post-implant. None of the deaths were directly arrhythmia related. Factors that were significant in predicting mortality included age and ejection fraction <35% (p<0.01). From a pre-procedure biomarker perspective, an increased red cell distribution width (RDW) was strongly associated with early mortality risk on univariate and multi-variate analysis (p<0.001). Receiver operator characteristics (ROC) curve analysis found that the optimal cut-off for RDW was 14.75% (area under curve 0.75; sensitivity 0.69; specificity 0.77; p<0.001).

In conclusion, there are limitations in fully assessing patient prognosis despite current guidance. Universal clinical frailty scores that incorporate biomarkers may be helpful in enhancing this pre-assessment process to improve the evaluation of the risk of early non-arrhythmic-related death for implantable cardioverter defibrillator candidates.

Atrioventricular nodal (AVN) ablation with permanent pacemaker implantation – ‘pace and ablate’ – may be considered for patients with symptomatic atrial fibrillation (AF) for whom rhythm control has been unsuccessful. This creates concerns about inducing pacemaker dependence and potential pacemaker-induced cardiomyopathy (PICM). Conduction-system pacing mitigates PICM, so we expect a greater uptake of AVN ablation going forward.

We conducted a retrospective multi-centre review of our patients who underwent AVN ablation over a one-year period. AVN ablation was successful with durable lesions at one year. Radiofrequency energy was utilised in all patients, with a median application time of 2.67 minutes. Median procedure time was found to be 55.5 minutes and fluoroscopy median of 3.5 minutes. Median radiation dose was 11 mGy. We found no acute or subacute complications up to three months.

In conclusion, our right-sided approach for ablation, staged post-device insertion demonstrated results in keeping with other centres in the UK and Europe. We expect our current practice to become more widespread, given the increased risk of lead-related complications or failures associated with physiological pacing compared with standard pacing methods.

The combination of atrioventricular (AV) block – specifically high-grade AV block– within the setting of myocarditis, is a rarely encountered clinical phenomenon. It is commonly encountered in infiltrative cardiomyopathies but may be associated with myocarditis.

Beyond conventional investigation and consideration of endomyocardial biopsy, there is a paucity of data to guide clinicians with regards to the issue of heart rhythm disorder. Options include a ‘watch-and-wait’ policy, anti-arrhythmic drugs, consideration of a permanent pacemaker or, alternatively, a wearable or implantable cardioverter-defibrillator (ICD).

The case encapsulates the difficulties facing clinicians with such pathology and the need to further investigate and risk stratify such patients.

Endomyocardial fibrosis is a common cause of restrictive cardiomyopathy worldwide, but rarely occurs in patients living outside tropical regions.¹ Herein is the first published case report of a 48-year-old woman with endomyocardial fibrosis due to hypereosinophilia secondary to a rare chromosome 8 and 9 PCM1-JAK2 translocation.

A 74-year-old man with a heterotopic heart transplant experienced alternating episodes of sustained native heart ventricular tachycardia and prolonged asystole. These were managed with cardioversion, drug therapy and pacemaker insertion. The unique physiology in such patients lends itself to numerous clinical considerations that would otherwise be routine management for most.

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) have demonstrated efficacy in reducing cardiovascular deaths and hospitalisations associated with heart failure patients. Despite well-established benefits observed in clinical trials, their real-world application remains underexplored. The purpose of this quality improvement project was to investigate and address the gap between evidence-based guidelines and the practical application of SGLT2i therapy in patients with heart failure with reduced ejection fraction (HFrEF).

The medical records were assessed in retrospect for HFrEF-related admissions at our cardiac centre. The main target of assessment was the dapagliflozin prescriptions in eligible patients. After the first cycle of data collection and analysis, several interventions, in the form of targeted teaching, empowering pharmacists, and utilising digital tools, were employed to improve compliance with prescriptions. After the implementation of our measures, a further cycle of data collection and analysis was carried out.

In the first cycle, 31% of 225 HFrEF patients, aged 74 ± 15 years, received dapagliflozin or had plans for its initiation. Prescription rates were influenced by age (mean 69 vs. 76 years, p<0.001) and admission under cardiology (70% vs. other specialties, p<0.001), while gender and diabetes had no impact. In the second cycle, 52% of 172 HFrEF, aged 74 ± 14 years, received dapagliflozin or had plans for its initiation. Prescription rates correlated with age (71 vs. 79 years, p<0.001) and admission under cardiology (59% vs. other specialties, p=0.002), with male patients more likely to be initiated on dapagliflozin (p=0.005).

Our quality improvement project sheds light on the challenges and opportunities in implementing dapagliflozin therapy for patients with HFrEF in a real-world clinical setting. The interventions introduced led to a substantial improvement in prescription rates, indicating the potential for positive change. There is a need for ongoing efforts to bridge the gap between evidence-based guidelines and clinical practice.

Traditionally, radial artery access (RAA) has been an exclusively ‘physician-delivered’ service, but with adequate training, nurse-led arterial cannulation can become widely adopted. In this clinical audit, senior nursing practitioners with at least two years of catheter lab experience, were offered RAA training. In phase 1 of training, two nurses were initially familiarised with a well-structured training protocol. Each of the two nurses carried out the first 50 RAA procedures under supervision on elective patients. In phase 2, candidates independently performed 100 procedures. The success and complication rates of these procedures were evaluated prior to their sign-off as competent. The procedural efficacy of nurses was compared with medical registrars of the department to assess the measures of patient satisfaction and time elapsed prior to the insertion of sheath.

During the first 100 directly observed RAA procedures, nurse 1 and nurse 2 achieved success rates of 84% (42/50 procedures) and 86% (43/50 procedures), respectively. During the second phase, nurse 1 achieved a success rate of 82% (82/100 procedures), whereas nurse 2 achieved a success rate of 97% (97/100 procedures). Overall, a success rate of 88% was achieved in the first 300 patients. No significant complications were noted. In contrast to medical registrars, nurse-led cannulation was associated with a greater extent of patient satisfaction, reduced pain intensity (p<0.001), and decreased patient-on-table to sheath insertion intervals (p<0.001). During embedding of the programme, the two nursing practitioners trained additional nurses. Of the five nurses that subsequently entered into training, two have successfully completed both training phases while a further three have completed phase 1. To date, an overall success rate of 91.1% (1,307/1,435 procedures) has been documented.

In conclusion, a nurse-led RAA program is feasible, with satisfactory success rates, no significant complications, and improved rates of patient satisfaction.

Sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are established glucose-lowering and weight-lowering agents used in the management of type 2 diabetes mellitus and obesity. Several recent clinical trials have provided evidence that these agents can decrease the risk of, and slow progression of, cardiovascular and renal diseases independently of their glucose-lowering and weight-lowering effects. In clinical trials and ‘real-world’ observational studies in people with and without diabetes, SGLT2 inhibitors have offered protection against heart failure and chronic kidney disease, while GLP-1 receptor agonists have been associated with reductions in atherosclerotic cardiovascular events and albuminuria. Based on this evidence, SGLT2 inhibitors and GLP-1 receptor agonists can now be considered for use beyond diabetes and obesity as new treatment options in the management of cardiorenal disease.

Clinical trials and observational studies have demonstrated that long-term systolic blood pressure variability derived from repeated measurements of visit-to-visit clinic blood pressure is an important predictor of cardiovascular outcomes, independent of average levels of systolic pressure. Even in patients with well-controlled blood pressure (<140/90 mmHg), high systolic blood pressure variability confers an increased risk of cardiovascular events. Systolic blood pressure variability is currently derived from several measurements of visit-to-visit clinic blood pressure and expressed as the standard deviation of systolic pressure. Values in excess of 12 are indicative of high systolic blood pressure variability. Ongoing studies aim to determine whether home blood pressure monitoring may be an alternative way of measuring blood pressure variability. Evidence from several clinical trials shows that long-acting calcium-channel blockers, such as amlodipine, and thiazide-like diuretics are the only antihypertensive drugs that reduce long-term systolic blood pressure variability, and should be used preferentially in patients with high variability.