Clinical articles

Ejection fraction (EF) offers a remarkable approach to assess ventricular and atrial pumping capacity. Its value can easily be calculated, and it seems to reflect performance. However, EF is a non-preferred candidate from a conceptual point of view. To fully understand the weakness of the EF metric, it is necessary to appreciate that its numerical value (by its definition) solely depends on end-systolic volume (ESV) and end-diastolic volume (EDV). This tight mathematical connection can best be graphically represented in the ventricular volume domain while relating ESV to EDV, leading to straight conclusions about EF.

No previous paper has addressed the curious tradition of applying EF in cardiology in terms of the indirect reasons for its popularity, as well as the intrinsic shortcomings, alongside the statistical irregularities involved. This review highlights the misleading attractiveness of EF, while also offering logical alternatives without invoking the need for relying on additional data beyond standard measurements.

Cardiovascular disease incidence is increasing worldwide, rendering it the most common cause of death worldwide. As such, nanomedicine has emerged in the context of overcoming these biological barriers. In this review, novel technologies are illustrated on two levels: molecular imaging and nanotechnology in atherosclerosis and therapeutic options in atherosclerosis. The former includes many diagnostic techniques, such as fluorescence imaging, computed tomography angiography (CTA), magnetic resonance imaging (MRI), photoacoustic imaging, contrast-enhanced ultrasound (CEUS), and multi-modality imaging. The latter is divided into two main subgroups: the first group includes inflammation-targeted therapies involving the endothelial cells and macrophages, and the second group includes nanoparticle transporters, like liposomes, micelles, dendrimers, polymeric nanoparticles (NPs), gel-like NPs, carbon nanotube, magnetic NPs, iron oxide NPs and gold NPs, and nanocoating (stent polymeric coatings to nanotextured ceramic coatings). In conclusion, nanoparticles show promise in enhancing the early diagnosis and targeted treatment of coronary artery disease. While several imaging and therapeutic techniques have demonstrated efficacy in preclinical models, only a few have progressed to human trials or clinical use.

Systemic inflammatory diseases (SIDs) can present with a wide range of cardiac manifestations, which, although uncommon, are frequently associated with significant morbidity and poor prognosis. Behçet’s disease and antiphospholipid syndrome (APS) are two distinct immune-mediated disorders encompassed within this spectrum, both capable of causing intracardiac thrombi and systemic embolisation, which causes diagnostic and therapeutic challenges. While Behçet’s disease is a classic systemic inflammatory vasculitis, APS primarily represents a prothrombotic autoimmune disorder with variable inflammatory features. This case series highlights two patients with cardiac involvement in SIDs, emphasising the importance of early recognition, individualised treatment strategies, and a multi-disciplinary approach to optimise outcomes in these complex clinical scenarios.

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and another structure. This rare condition has an incidence in the general population of 0.002%. A 57-year-old woman presented with angina, a normal electrocardiogram (ECG) and a peak troponin I of 0.22 µg/L (normal <0.04 µg/L). She was treated with a standard medical regimen for non-ST-elevation myocardial infarction. Coronary angiography revealed non-obstructed coronary arteries, with fistulae arising from the left anterior descending, left circumflex and right coronary arteries, all terminating in the pulmonary artery. Cardiac magnetic resonance (CMR) imaging was performed to investigate coronary steal syndrome. This confirmed there was no significant shunt or evidence of infarction. There was a small concentric pericardial effusion with a focal region of inferolateral epicardial fibrosis, suggesting a diagnosis of myopericarditis. The patient was treated with colchicine for three months.

CAF can cause patients to present with a variety of symptoms or potentially life-threatening complications, including fistula rupture and myocardial infarction. Early recognition, characterisation and shunt analysis are imperative to facilitate management. Although left/right heart catheterisation is considered the gold standard, CMR proved to be a useful diagnostic tool in our case, ruling out significant shunting and helping to identify a differential diagnosis.

This case report highlights the clinical course of a young patient with a history of ischaemic cardiomyopathy and severely impaired left ventricular (LV) systolic function following a delayed anterior myocardial infarction, which was further complicated by the presence of large LV thrombus. The patient subsequently presented with persistent ventricular tachycardia (VT) refractory to multiple anti-arrhythmic medications and antitachycardia pacing (ATP). VT ablation was contraindicated due to the LV thrombus, and the failure of conventional medical therapy. Heart transplantation was considered as the final viable management strategy. This case highlights the complexity of managing patients with advanced heart failure and ventricular arrhythmias, emphasising the importance of timely consideration of advanced therapeutic options in refractory scenarios.

Sudden cardiac death (SCD) in young athletes is a rare but devastating event, most often caused by structural or electrical abnormalities of the heart. Although athletes are generally among the healthiest individuals, the occurrence of SCD in this group attracts significant public attention, particularly as exercise may trigger fatal events in those with underlying disease. This has driven debate around the role of pre-participation screening (PPS) as a strategy to identify at-risk individuals before they compete. Several international sporting and scientific organisations have issued recommendations, but screening protocols vary, and the balance between benefit, feasibility, cost, and potential harm remains controversial. While evidence suggests that screening may detect otherwise silent cardiovascular disease, limitations include false-positives, false-negatives, interpretation challenges, and the ethical implications of disqualification. This review explores the benefits and potential challenges of cardiac screening in athletes, and the implications for protecting athlete health and ensuring safe participation in sport.

This article explores using artificial intelligence (AI) to detect atrial fibrillation (AF) early, highlighting its potential to revolutionise cardiology. It reviews numerous studies demonstrating AI’s superior accuracy to traditional methods, particularly in leveraging electrocardiography data from various sources like smart devices and chest radiographs. A key concern addressed is the ‘black box’ nature of some AI algorithms, emphasising the critical need for transparency to build clinician confidence and ensure ethical patient care. It concludes by advocating for policy changes and further research to enhance AI algorithm transparency and integration into clinical practice.

Drug-eluting stents (DES) are a common treatment for acute coronary syndrome (ACS) but pose risks like bleeding, re-stenosis, stent thrombosis, and neo-atherosclerosis. Drug-coated balloons (DCB) may mitigate these risks. This study compares DCB therapy’s effectiveness with DES in ACS patients with de novo lesions.

A retrospective observational study was conducted on ACS patients undergoing percutaneous coronary intervention (PCI) with either DES or DCB from May 2019 to August 2022 at a single tertiary centre. Patients with left central trunk lesions were excluded. The primary end point was a composite of major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, and target lesion revascularisation, evaluated 12 months post-intervention. Statistical analysis was performed using R software with significance set at a two-tailed p value <0.05.

Of 168 patients, 101 received DES and 67 received DCB. The DCB group had a mean age of 61.9 years, while the DES group averaged 63 years. The DCB group had more prior PCIs and myocardial infarctions. Baseline characteristics, including target and number of lesions, were comparable. MACE occurred in eight (11.9%) DCB patients and 11 (10.9%) DES patients, showing no significant difference (p=0.64).

In conclusion, this study suggests that DCB therapy may be an effective alternative to DES for ACS. However, limitations, including a single-centre setting and short follow-up, warrant the need for more extensive, randomised trials to validate these findings.

Cardiotoxicity, including left ventricular (LV) dysfunction, is a dreaded side-effect of selected drugs that are widely used in oncology. Guidelines recommend the assessment of LV systolic function, primarily by echocardiography, before and during exposure to cardiotoxic medications. However, apart from LV ejection fraction (LVEF), echocardiography reports include dozens of numerical data points and other detailed information familiar to cardiologists, but which may not be familiar to other specialties.

With a rising need for echo in oncology patients, and with no cardio-oncology service within our hospital, we assessed what is understood by oncologists regarding the information provided within an echocardiographic report, and what action they take subsequent to the report. Morriston Cardiac Centre provides tertiary care to a population of 1.2 million and conducts 12,000 transthoracic echocardiograms (TTE) annually.

We ran a survey of all consultant clinical oncologists in Wales, using a set of multiple-choice questions via Google Forms. We presented the responders to our questionnaire with a set of hypothetical echocardiographic findings, drawn from common clinical scenarios, and asked what they would do if they received a report containing such a finding. Our questionnaire was completed by 14 of 19 (74%) oncology consultants.

Only a little better than half reported low-to-moderate confidence in interpreting the findings that echo reported. Oncologists varied in their level of confidence and understanding of what TTE findings meant, and the responses to commonly reported echocardiographic findings (e.g. actions they would take if echo report stated low-normal ejection fraction) had inhomogeneity.

Our work supports the utility of a dedicated cardio-oncology clinical pathway or service, which would assist with these queries, and may even obviate them, by providing the echo report directly to a cardio-oncologist.

Adults with Fontan palliation face variable risks of thrombosis and bleeding. The optimal thromboprophylaxis strategy remains unclear. There is a balance between the risk of thromboembolism and bleeding with thromboprophylaxis. Recent studies suggest direct oral anticoagulants (DOACs) may provide effective thromboembolism prevention, but concerns regarding bleeding risk, hepatic impairment, and lack of robust data persist. This study investigates thromboprophylaxis practices among UK adult congenital heart disease (ACHD) specialists, focusing on the use of DOACs in Fontan patients.

An electronic survey was distributed to UK National ACHD Consultant Group members from February to March 2023. Based on hypothetical clinical scenarios, the survey collected demographic data, familiarity with DOACs, and preferred thromboprophylaxis strategies. Responses were analysed using descriptive statistics to identify patterns in practice.

There was a maximum response rate of 42%, with 32 respondents participating, primarily consultants from level 1 ACHD centres. Thromboprophylaxis strategies varied significantly: DOACs, warfarin, and aspirin were used with varying frequency, depending on clinical factors, such as arrhythmias, thrombosis history, and patient-specific challenges. While 35% of respondents were comfortable prescribing DOACs, 42% expressed reservations, citing limited evidence and concerns about risks.

This study highlights wide variability in thromboprophylaxis strategies for Fontan patients in the NHS, underscoring significant gaps in evidence. Hepatic considerations, patient-specific challenges, and the lack of DOAC licensing for certain scenarios contribute to the complexity of clinical decision-making. Prospective studies are essential to guide practice, and patient involvement in shared decision-making is critical in the interim.