July 2017 Br J Cardiol 2017;24:(3) doi :http://doi.org/10.5837/bjc.2017.017 Online First
Andrew J M Lewis
This article won first prize in the recent British Junior Cardiologists’ Association (BJCA) essay competition.
Coronary angiography stubbornly bucks the hospital-wide trend to non-invasive diagnostic tests. New imaging technologies offer paths to better ways to investigate and manage ischaemic heart disease.
July 2017 Br J Cardiol 2017;24:(3) doi :http://doi.org/10.5837/bjc.2017.020 Online First
Roberto Léo da Silva, Luis Sérgio Carvalho Luciano, Daniel Medeiros Moreira, Tammuz Fattah, Ana Paula Trombetta, Luciano Panata, Leandro Waldrich, Luiz Eduardo Koenig São Thiago, Luiz Carlos Giuliano
Spasm after transradial approach for catheterisation decreases procedural success and offers discomfort to the patient. Nitroglycerin is one of the drugs applied prophylactically to prevent spasm. The aim of this study was to assess the effect of preventive nitroglycerin on the comfort of patients during cardiac catheterisation.
A total of 328 patients were randomly assigned to receive either 200 µg nitroglycerin (n=164) or placebo (n=164). The main outcome was the evaluation of spasm using a visual analogue scale to measure the pain of the patient, and procedural time and radiation used to measure the operator difficulty during the examination.
The pain evaluation was equal in both groups (nitroglycerin 24.74 vs. placebo 24.75, p=0.72). Using the operator’s impression, there was a higher incidence of spasm in the placebo group (9.1% grade 3 or 4 vs. 2.4% in the nitroglycerin group, p=0.004), while procedural time (21.36 minutes vs. 22.24 minutes, p=0.23) and radiation exposure (655.61 mGy vs. 660.92 mGy, p=0.63) were comparable in both arms.
In conclusion, the prophylactic use of nitroglycerin offers no advantage in terms of comfort to the patient during cardiac catheterisation by a transradial approach. Although there was difference in operators’ perception of spasm, omission of vasodilator does not cause any objective difficulty to operators.
July 2017 Br J Cardiol 2017;24:(3) doi :http://doi.org/10.5837/bjc.2017.019 Online First
Endomyocardial biopsy (EMB) has been long established as a diagnostic tool in myocardial disease. EMB surveillance for rejection of cardiac allografts continues to be routinely performed. However, the use of EMB beyond transplant monitoring is controversial. In recent years, the procedure has fallen out of favour. This is most likely due to the growing capabilities of non-invasive imaging modalities and the questionable impact of EMB findings on treatment.
This article aims to examine current practice of EMB in England, discuss the utility of EMB in myocardial diseases and compare prominent society guidelines from recent years. Information gained from freedom of information requests shows just 18% of NHS trusts reported performing EMB, and only 46% referred to other centres for EMB in England in 2014–2015. Despite the limitations of EMB, it remains the only procedure capable of obtaining a histological diagnosis of cardiac disease.
July 2017 Br J Cardiol 2017;24:(3) doi :http://doi.org/10.5837/bjc.2017.018 Online First
Emma Johns, Gerry McKay, Miles Fisher
Glitazones improve glycaemic control in type 2 diabetes mellitus (T2DM) by increasing whole-body insulin sensitivity. They can cause fluid retention and are, therefore, contraindicated in heart failure. A 2007 meta-analysis linked rosiglitazone with an increased risk of myocardial infarction, leading to its European marketing authorisation being suspended in 2010. Pioglitazone has demonstrated cardiovascular safety for atherosclerotic events in a large, randomised, placebo-controlled trial. A 2016 study in patients with insulin resistance and recent cerebrovascular event showed pioglitazone was associated with reduced risk of further stroke or transient ischaemic attack when compared with placebo, as well as reduced diabetes incidence.
July 2017 Br J Cardiol 2017;24:(3) doi :http://doi.org/10.5837/bjc.2017.016 Online First
Deidre F Waterhouse, Theodore M Murphy, Charles McCreery, Rory O’Hanlon
A sixty-two-year-old asymptomatic man presented for a routine insurance medical. He had no previous cardiac history, nor any significant cardiac risk factors. His examination was normal. His electrocardiogram (ECG), however, was noted to be significantly abnormal, with deep anterior T-wave inversion in the precordial leads (figure 1). Given this abnormality and the potential differential diagnoses, a cardiovascular magnetic resonance (CMR) (Siemens Aera 1.5 T) with regadenosine stress perfusion was performed and images analysed using CMR 42 software (Circle CVI, Calgary).
June 2017 Br J Cardiol 2017;24:62-5 doi :http://doi.org/10.5837/bjc.2017.013
Blackouts are common, affecting up to 50% of the population. However, little is known about the incidence and initial management of blackouts in primary care. A retrospective computerised search of the medical records of 16,911 patients in two UK practices found the incidence of first presentation with blackout to the GP to be 3.4/1,000 patients/year. Affected patients’ records were then individually reviewed to assess whether key aspects of National Institute of Health and Care Excellence (NICE) blackouts and European Society of Cardiology syncope guidelines had been followed during that initial consultation. GPs were generally better at enquiring about features that differentiate between vasovagal syncope and epilepsy. They were not as good at detecting syncope red flags, which help to identify the cardiac causes of syncope that are associated with higher mortality. Raising awareness of these red flags in primary care was recommended.
June 2017 Br J Cardiol 2017;24:75-78 doi :http://doi.org/10.5837/bjc.2017.015
Neil Bodagh, Fahad Farooqi
A discharge summary is intended to communicate relevant clinical information to GPs after hospital admission. High-quality discharge summaries are especially important in complex clinical syndromes, such as chronic heart failure, where effective communication between multi-disciplinary teams is necessary to coordinate safe community care and reduce re-hospitalisation risk.
The aim of this study was to audit the existing quality of heart failure discharge summary documentation at our Trust and test whether a 10-point checklist poster could improve performance. All heart failure discharge summaries issued from Barking, Havering and Redbridge University Hospitals’ NHS Trust over a three-month period were assessed. The content of each heart-failure-verified discharge summary was objectively analysed using a points-based scoring technique. A single checklist poster providing guidance on composing heart failure discharge summaries was positioned in a medical ward. The scores from every summary issued by doctors exposed to the checklist poster (n=24) on that ward were compared against discharge summaries scores issued by doctors working on all other (non-exposed) wards (n=84).
Of discharge summaries with heart failure listed as a primary diagnosis, 28% were found to have an alternate cause for symptoms and no verifiable evidence to support a heart failure diagnosis. Discharge summaries issued by doctors working on the ward exposed to the checklist poster had a mean discharge summary score of 5.2 ± 0.59. Discharge summaries issued by doctors working on wards that were not exposed to the checklist poster had a mean score that was significantly poorer 1.7 ± 0.11 (p<0.001).
This study demonstrates that a primary heart failure diagnosis may be inaccurate in approximately a quarter of all discharge summaries. The provision of a 10-point checklist was associated with a statistically significant improvement in the quality of heart failure discharge summaries issued from our Trust. This intervention was simple to implement at minimal cost and helps junior doctors communicate more effectively with primary care.
April 2017 Br J Cardiol 2017;24:66-7 doi :http://doi.org/10.5837/bjc.2017.009 Online First
Colin Reid, Mark Tanner, Hatef Mansoubi, Conrad Murphy
Our objective was to determine whether the development of a computed tomography coronary angiogram (CTCA) service has improved the yield of significant coronary artery disease (CAD) and subsequent referral for revascularisation following conventional invasive coronary angiography (ICA).
A retrospective audit comparing angiographic findings in a cohort of 2,094 patients investigated between 2007 and 2012 with findings from a cohort of 554 patients investigated in 2014 and 2015 during which time a CTCA service had been established. Cases included were those patients undergoing elective angiography for the assessment of possible coronary disease without any history of previous revascularisation.
In the pre-CTCA and CTCA cohorts the rates of one-vessel, two-vessel, three-vessel and left main stem disease were 20% vs. 18%, 14% vs. 14%, 10% vs. 11%, 2% vs. 3%, respectively, with overall yield of obstructive CAD of 46% in both cohorts (p>0.05 for all groups).
In conclusion, the availability of a CTCA service has not had any significant effect on the diagnostic yield of ICA. We propose that, adherence to current guidelines, results in a potential underuse of CTCA in the investigation of suspected stable CAD because a sizeable proportion of patients undergoing ICA have non-significant disease.
April 2017 Br J Cardiol 2017;24:68-71 doi :10.5837/bjc.2017.010 Online First
Emma Johns, Gerry McKay, Miles Fisher
Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a novel insulin-independent therapy for type 2 diabetes mellitus (T2DM). By inhibiting renal glucose re-absorption, they improve glycaemic control and have beneficial effects on weight and blood pressure. Current guidance states that any new diabetes medication must be shown not to unacceptably increase cardiovascular risk. The landmark EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) trial demonstrated that treatment with the SGLT2 inhibitor empagliflozin compared with placebo showed a significant reduction in the risk of major cardiovascular end points and hospitalisation for heart failure for patients with T2DM and existing cardiovascular disease. A positive impact on several renal outcomes was also demonstrated in secondary analysis. These milestone results are set to have significant implications on prescribing practice in T2DM, with potential benefits for many patients with existing cardiovascular disease.
April 2017 Br J Cardiol 2017;24:72-4 doi :10.5837/bjc.2017.011 Online First
Leigh D White, Joshua Wall, Thomas M Melhuish, Ruan Vlok, Astin Lee
Characteristic electrocardiogram (ECG) features of posterior myocardial infarction (PMI) do not include typical ST-segment elevation and, therefore, carries the risk of delayed diagnosis and management. The aim of this study was to investigate how well PMIs are recognised and whether a lack of recognition translates to a larger infarction.
This was a retrospective cohort study of patients sourced from a cardiac catheterisation database. Based on ECG analysis, patients included in this study included those meeting PMI criteria and those meeting ST-elevation myocardial infarction (STEMI) criteria as the control group. Door-to-balloon times were used as an outcome measure for differences in recognition between PMIs and other STEMIs. Troponin was used as a surrogate marker to measure degree of myocardial damage.
There were 14 patients meeting PMI criteria and 162 meeting STEMI criteria. PMI patients had significantly longer door-to-balloon times. There was no statistically significant difference between PMI and STEMI group initial troponins t(169)=1.05, p=0.30, or peak 24-hour troponins t(174)=–1.73, p=0.09.
In conclusion, using door-to-balloon times as a marker for recognition, this study illustrated that patients suffering PMI experience delayed recognition and management compared with non-PMI STEMIs. This did not, however, result in a significantly larger size of infarction as shown by peak troponin levels.