2012, Volume 19, Issue 1, pages 01-48

In-hospital mortality from infective endocarditis remains high, ranging from 9.6 to 26%, and relates to many factors including associated co-morbidities (including previous valve replacement), the complications of endocarditis present, the micro-organism involved, and a number of echocardiographic features.¹ Currently, echocardiography remains the mainstay of imaging for diagnosis and evaluation of complications, monitoring of response to therapy, intra-operative evaluation (where relevant), and follow-up.^1,2 Indeed, three echocardiographic features are considered major criteria in the diagnosis: vegetation, abscess and new dehiscence of a prosthetic valve. Although the limitations of echocardiography are well recognised, the use of other imaging modalities for evaluation of endocarditis remains limited. Indeed, 2009 European Society of Cardiology (ESC) guidelines state that “Other advances in imaging technology have had minimal impact in routine clinical practice … alternative modes of imaging (computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET], and radionuclide scanning) have yet to be evaluated in infective endocarditis”.¹ 

The importance of heart rate reduction in chronic stable heart failure (HF) has been highlighted in the recently published Systolic Heart Failure Treatment with I_f Inhibitor Ivabradine Trial (SHIFT). Patients with an elevated resting heart rate (HR) benefited from additional HR control despite optimal doses of beta blockers. The aim of this study was to define the prescribing patterns of beta blockers and the scope for additional HR control in a ‘real life’ HF population.

We conducted a retrospective analysis of two HF clinics, where patients were referred for protocol-guided, up-titration of HF medications. At each assessment we documented: HR, blood pressure, and HF medications including potential side effects. The primary objective was to identify the proportion of patients who had suboptimal HR control (HR ≥70 bpm) despite optimal conventional HF therapy.

From 172 patient records, 145 (84.3%)could tolerate long-term beta blockade with 57 (33.1%) prescribed the maximum recommended dose. Overall, 101 patients were in sinus rhythm with 31/101 (30.7% having an ejection fraction ≤35% and a resting HR ≥70 bpm.

In conclusion, suboptimal HR control is evident in approximately one in three HF patients in sinus rhythm despite aggressive optimisation of beta blocker therapy. This cohort may benefit from additional HR control.

National Institute for Health and Clinical Excellence (NICE) guideline CG67 recommends that acute coronary syndrome (ACS) cases are treated with high-intensity statins (defined as statins used in doses that produce greater cholesterol lowering than simvastatin 40 mg). The objective of this study was to describe current UK prescribing of statins following ACS. This study used data from linkage between the Myocardial Ischaemia National Audit Project (MINAP) database and the General Practice Research Database (GPRD). The study included adults aged 40+ with a discharge diagnosis in MINAP of myocardial infarction, troponin positive or negative ACS discharged alive to home. A total of 6,138 ACS cases were included. Most ACS cases were prescribed both a statin at hospital discharge and by their GP, however, 340 of the 6,138 ACS cases (5.5%) had no record of statin prescription from either source. Of the ACS cases prescribed a statin by their GP, 30.1% received a high-intensity statin dose. At year four, 43% (95% confidence interval [CI] 41–45%) of ACS cases prescribed a statin remained on treatment (42% for those starting low and 45% for high intensity). In conclusion, statin therapy is provided to most ACS cases in the UK but duration and dosage is shorter and lower than recommended.

Although morbidity and mortality are the most commonly used end points in clinical trials of heart failure treatments, it is also important to consider how patients experience their illness when assessing treatment efficacy. The goal of this study was to use qualitative interviews to identify key experiences that may be targeted as end points in future heart failure trials. 

Interviews were conducted with 63 chronic heart failure patients. Interview responses were coded using ATLAS.ti software. Code frequency and bother ratings were used to identify salient patient experiences. Key symptoms included shortness of breath, tiredness, swelling of the lower extremities, and pain (chest and other). Shortness of breath and tiredness were often described as being related to physical activities. Key areas impacted by heart failure included physical activity and mobility limitations, and a variety of emotional effects.

In conclusion, patients report a number of symptoms and impacts related to heart failure. Although some experiences are already widely captured in clinical and patient-reported heart failure assessments, others, such as pain, are not. These findings support the use of patient-reported outcome instruments as end points when assessing the efficacy of heart failure treatments.  

SGLT2 inhibitors are a new class of oral drugs for the treatment of type 2 diabetes mellitus currently in phase III studies. They inhibit glucose re-absorption in the proximal renal tubules providing an insulin independent mechanism to lower blood glucose. Their use in clinical practice is associated with improved glycaemic control, weight loss and a low risk of hypoglycaemia. Phase III cardiovascular safety studies are ongoing.

Patients with chronic heart failure (CHF) may have low pulse pressures (PP). This retrospective study was undertaken to analyse the relationship between PP and outcomes of a 12-week exercise training programme. Data analysed from 86 patients (69 male) aged 40 to 86 years, included: PP, functional capacity (metabolic equivalents [METS]) and quality of life (QoL) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).

Median pre-training PP was 54 ± 19 mmHg. Functional capacity for the same heart rate (estimated 60% heart rate reserve) and Borg rating of 13 increased from 3.6 ± 1.1 to 4.0 ± 1.2 METS (p=0.0005); MLHFQ scores improved from 26 ± 19 to 22 ± 20 (p=0.0005). There was a high correlation between PP and systolic blood pressure pre- and post-training (pre: r=0.77, p=0.0005; post: r=0.80, p=0.0005). Changes in all the above outcomes were independent of pre-training PP. 

In conclusion, low PP did not reduce the efficacy of an exercise training programme, indicating that CHF patients with low PP can benefit similarly to those with normal/raised PP.

Midodrine is a sympathomimetic agent used in the treatment of hypotension resulting from various aetiologies. Debate around the use of midodrine recently increased after it was threatened with a licence withdrawal in the USA. The reason cited was a failure of the manufacturing drug companies to provide previously agreed post-market studies. Conversely, midodrine has never received a licence from the UK regulatory authorities.

We provide a review of its current status and a brief description of our own experience with midodrine over the last 11 years.

Electrocardiogram (ECG) is the most common cardiac investigation provided in primary care and accepted as core medical practice, yet little research evidence exists. In order to gather information on ECG provision in primary care and provide a training and competence analysis, a postal survey of 395 general practices within the North of England Cardiovascular Network area was conducted.

A total of 119 practices responded (30.1%) of which 91 (76.5%) recorded ECGs in-house. An average of 34.7 ECGs per 1,000 patients were recorded within 12 months (1.4–114/1,000). Of practices recording ECGs, 86% also interpreted the results themselves. Of staff recording ECGs, 72% received training, which was carried out mostly in-house, and 52.9% of practitioners interpreting results had received some training. A low level of confidence to recognise 10 important ECG abnormalities was reported.

Our survey confirmed that the majority of GP practices record and interpret ECGs. Few received formalised training and assessment in recording and interpreting ECGs. This was reflected in a low level of confidence to recognise critical ECG abnormalities.

Anderson-Fabry disease is a rare X-linked recessive lysosomal storage disease that may cause a wide range of symptoms affecting multiple systems. It is due to a DNA mutation in the enzyme alpha-galactosidase A; this causes an accumulation of a glycolipid, globotriaosylceramide, within blood vessels, tissues, and organs, impairing their function.

Typically, males experience severe symptoms, but the impact on women is variable, with some being asymptomatic and others having severe symptoms. Although the diagnosis can often be readily made in males by measuring the blood level of alpha-galactosidase activity, in females, gene sequencing is preferred as enzyme activity may be within the normal range. However, the disease may not be suspected as many symptoms are shared with other disease processes. Important clues are multi-system symptoms that vary in age of onset, severity and manner of progression; early onset of kidney failure; and stroke or heart disease in the absence of conventional vascular risk factors. Enzyme replacement therapy is available. 

A 47-year-old man with known bicuspid aortic valve was admitted with a six-week history of night sweats and malaise. Clinically, aortic systolic and diastolic murmurs were present. Temperature was 38ºC, white cell count was elevated at 13.8 x 10⁹/L, erythrocyte sedimentation rate (ESR) was 44 mm/hr, and three consecutive blood cultures grew Streptococcus parasanguinis. Transthoracic (TTE), then transoesophageal (TOE) echocardiography was performed.

A 57-year-old woman presented with a six-week history of non-productive cough associated with sharp chest pain. Her past medical history included a metallic aortic valve replacement for aortic regurgitation, hypertension and hypercholesterolaemia. The patient had a blood pressure of 97/60 mmHg and was afebrile. On examination, the metallic valve was audible with no added heart sounds. Examination of other systems was normal. Electrocardiogram (ECG) showed a normal sinus rhythm with no ischaemic changes. Admission blood tests showed an elevated white cell count (11.4 x 10⁹ per litre) and a C-reactive protein of 225.8 mg/L. Her chest radiograph demonstrated a widened mediastinum, evidence of previous cardiac surgery and a metallic valve (figure 1). Transthoracic echocardiography showed a dilated aortic root measuring 62 mm at the level of the sinotubular junction. In addition, a thrombus was visualised in the ascending aorta with a dissection flap, which was confirmed by computed tomography (CT) scan (figure 2). The patient was transferred to a cardiothoracic unit to undergo surgical repair of the dissection and replacement of the metallic valve. The dissection was shown to arise from the suture line of the previous valve replacement.