Clinical articles

There is a high prevalence of frailty in people with heart failure, chronic kidney disease, type 2 diabetes, and multiple long-term conditions. These groups are eligible for treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i), with numerous large-scale trials demonstrating favourable clinical outcomes spanning disease states. There are now increasing data that the benefits of these agents are consistent across all frailty severities and are well tolerated. However, real-world data suggest a hesitancy in SGLT2i use in those with frailty. As a result, SGLT2i are either not initiated or discontinued inappropriately in people with frailty who are likely to derive benefit from these agents. This review critically evaluates current evidence and clinical guidelines for SGLT2i use in people with frailty, addressing safety concerns and offering practical recommendations for clinical practice.

Pulmonary hypertension (PH) is common in patients with severe aortic stenosis (AS). Severe PH has been associated with mortality up to two years following transcatheter aortic valve implantation (TAVI). Data on longer-term outcomes in TAVI patients with severe PH are limited. We aimed to compare all-cause mortality at five years post-TAVI in patients with and without severe PH and to identify any patient factors associated with reduced long-term survival.

TAVI patients meeting our inclusion criteria between January 2013 and October 2017 at a specialist cardiac centre in the UK were retrospectively analysed. Severe PH was defined as a systolic pulmonary arterial pressure >40 mmHg, estimated on transthoracic echocardiography. Data on patient demographics, comorbidities and mortality were obtained from routinely collected registry data. Kaplan-Meier and Cox-proportional hazards analyses were performed.

The median ages of the patients were 84 and 83 years in the group without severe PH and the group with severe PH, respectively. Severe PH was present in 95 out of 219 patients (43%). Patients with severe PH had higher levels of disability, left ventricular impairment and serum creatinine. On multi-variate analysis, the presence of severe PH was not associated with an increased mortality (adjusted hazard ratio [HR]=1.23, p=0.29). Peripheral vascular disease (PVD) was associated with a significantly increased risk of death at five years’ follow-up (adjusted HR=2.24, p=0.002). A lower body mass index (BMI) was also independently associated with reduced survival (adjusted HR=0.96, for an increase of 1 kg/m², p=0.038).

In conclusion, our data show that severe PH in patients with AS did not affect five-year survival post-TAVI. Reduced BMI and PVD were significantly associated with long-term all-cause mortality in patients undergoing TAVI.

Anticoagulation with vitamin K antagonists is recommended for prevention of thromboembolism in patients with mechanical heart valves. However, this treatment carries a notable risk of bleeding. We performed a retrospective analysis of patients with mechanical heart valves who were anticoagulated with warfarin, extracting the number and type of mechanical heart valves and their time in therapeutic range (TTR) for various recommended international normalised ratio (INR) ranges. Following this, we carried out a prospective study, over two separate six-month periods, identifying those with mechanical heart valves who sustained a bleeding or thromboembolic event.

We identified 409 patients with mechanical heart valves with an overall TTR of 68%. Over 12 months, we recorded 32 possible bleeding incidents in 22 patients. There was one thromboembolic event during this period, specifically a cerebrovascular event.

In conclusion, while our data indicate an elevated risk of bleeding, additional larger studies are needed to better understand bleeding risks across different demographic groups.

A 78-year-old man presented to the cancer assessment bay with a history of progressive fatigue, generalised muscle pain, and bilateral ptosis after completing two cycles of nivolumab/ipilimumab for metastatic renal cancer. Physical examination revealed mild bilateral ptosis (right > left), worsening with upward gaze, binocular diplopia, and fatigable weakness in the right shoulder. Electrocardiogram (ECG) showed a new right-bundle branch block (RBBB), with left-axis deviation, and left ventricular hypertrophy. Blood analyses showed elevated troponin I, brain natriuretic peptide, and creatine kinase with values of 221 ng/L, 114 ng/L, and 1,109 U/L, respectively. He was managed as immune checkpoint inhibitor-related severe myocarditis, myositis, and myasthenia gravis overlap (triple M) syndrome with high-dose steroids and pyridostigmine, resulting in clinical and biochemical improvement. However, immunotherapy was permanently discontinued, and follow-up imaging after three months showed evidence of disease progression. This case explores the importance of a multi-disciplinary approach in the effective management of a rare and severe immune-related toxicity and the impact of toxicities on treatment options and cancer progression.

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.