2018, Volume 25, Issue 1, pages 1–40

Physicians use tests to inform decision-making. Whether this is a bedside test using a stethoscope, the seemingly ancient technology of recording an electrocardiogram (ECG), or the most advanced imaging modalities and biochemical panels available – all pursue diagnostic clarity. But, more frequently than we might like to admit, the results do not illuminate a clear path of treatment.

Rhythm disturbances in healthy subjects undergoing Holter recording are well described. The purpose of this study has been to determine the frequency of rhythm disturbances, in particular of multi-focal atrial rhythm, on the 12-lead ECG of patients complaining of palpitation presenting to their GP.

There were 500 electrocardiograms (ECGs) studied. Rhythms were categorised as supraventricular rhythm disturbances, ventricular rhythm disturbances, multi-focal atrial rhythm, sinus arrhythmia and sinus rhythm. Multi-focal atrial rhythm was diagnosed either if there were a minimum of two complexes of each of three or more distinct P-wave shapes, none of which were obvious atrial ectopics, or if an ectopic atrial rhythm morphed into an ectopic atrial rhythm from another atrial focus.

Supraventricular rhythm disturbances (8.6%) were more common than ventricular rhythm disturbances (5.2%). Multi-focal atrial rhythm was found in 12.7% of ECGs and sinus arrhythmia in 4.0%. The relative frequency of the rhythms varied significantly with age, but not by gender or by ethnicity.

In conclusion, a quarter of the subjects with palpitation had a rhythm disturbance on a 10-second 12-lead ECG. Multi-focal atrial rhythm should be considered as a potential cause of palpitation.

Palpitations are a common symptom leading to primary care consultation. Establishing a symptom-rhythm correlation is important for providing a diagnosis. The Kardia Mobile personalised smartphone electrocardiogram (ECG) can provide patient-driven real-time ECG recording over extended periods. We investigated if this device might provide an effective alternative to conventional ECG recorders as the first-line investigation of low-risk palpitations.

Patients referred to our institution for investigation of intermittent palpitations but without syncope were supplied with a Kardia Mobile device if they had access to a compatible smartphone. Patients were asked to record an ECG when symptomatic.

Between March 2015 and June 2016, 148 patients were issued with a Kardia Mobile: 113 (76.4%) patients made symptomatic recordings during this period. A symptom-rhythm correlation was possible for all patients who submitted downloads. Median time to diagnosis was nine days (1–287 days). Diagnoses were: sinus rhythm n=47 (41.6%), sinus tachycardia n=21 (18.6%), supraventricular/ventricular ectopics n=31 (27.4%), atrial fibrillation n=8 (7.1%), and supraventricular tachycardia n=6 (5.3%).

In conclusion, the Kardia Mobile diagnosed the cause of intermittent palpitations in the majority of patients referred for specialist evaluation. Use of the Kardia Mobile may permit patients with palpitations to be evaluated in primary care.

In this article we review the latest cardiovascular outcomes trials performed using older diabetes drugs.

We present a patient with progressive aortic regurgitation that developed following successful implantation of a left ventricular assist device (LVAD). We were able to correct this known complication of LVAD by occluding the aortic valve percutaneously with an Amplatzer^TM multi-fenestrated septal occluder – Cribriform. This is the first such case to be reported in the UK.

This review aims to summarise the cardiovascular complications from cancer treatments and the methods used to prevent, identify, and treat them. 

While the field of cardio-oncology is relatively new, it is developing rapidly in the UK. There is a need to develop services to care for the patients with current cardiac problems, to undertake research and education to identify those patients at higher risk of complications, and to apply modern imaging methods and biomarkers to detect problems early and implement prevention strategies. An evidence-based approach is required to enhance delivery of care and prevent cardiovascular toxicity in this patient population.

Despite guidelines on the treatment of acute heart failure (AHF), treatment remains heterogeneous, particularly regarding intravenous (IV) nitrate use. This clinical decision-making study assessed the use of IV nitrates and diuretics by 40 UK hospital physicians, each ‘treating’ the same 10 virtual patients. Semi-structured interviews were performed to investigate participants’ decision-making rationale.

IV nitrates were prescribed in 37% of clinical decisions. Considerable variability was seen in the administration of IV nitrates among physicians. Interview data revealed polarised opinions regarding the efficacy of IV nitrates and the evidence base supporting their use. Physicians’ treatment decisions were more heavily influenced by their perceptions and beliefs regarding IV nitrates than by consideration of the evidence. In contrast, diuretics were prescribed more frequently (78%) and more consistently.

In conclusion, where there is a limited evidence base and no strong recommendation from clinical guidelines, prescribing behaviour for AHF therapies such as IV nitrates are likely to reflect variability in physicians’ beliefs, experiences, and decision-making styles.

Identification of ST elevation on the electrocardiogram (ECG) is the cornerstone of diagnosis of ST-elevation myocardial infarction (STEMI). While lesion localisation can usually be achieved by regional ST-elevation patterns on ECG, clinicians often neglect changes in the ST segment of lead aVR, possibly contributing to delayed recognition and poorer outcomes for these patients.

This study compared the ‘door-to-balloon time’ and peak troponins – as a surrogate marker of infarct size – for patients presenting with STEMI with ST-segment elevation in aVR compared with those patients without elevation in aVR. A total of 179 patients, including 17 patients presenting with ST-elevation in aVR, were included in this study. Patients presenting with elevation in aVR had significantly longer door-to-balloon times than those patients presenting with ‘traditional’ patterns of ST-elevation. There was, however, no significant difference in peak troponin as a marker of infarct size. While patients presenting with ST-elevation in lead aVR may have a delayed time to intervention, the present study does not suggest the use of aVR elevation as an indication for urgent angiography.