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Clinical articles

April 2018 doi :10.5837/bjc.2018.011 Online First

The effect of EECP on functional exercise capacity and symptom burden in refractory angina

Noman Ali, Haqeel A Jamil, Mohammad Waleed, Osama Raheem, Peysh Patel, Paul Sainsbury, Christopher Morley

Abstract

Refractory angina (RA) is characterised by persistent anginal symptoms despite optimal medical therapy and revascularisation. Enhanced external counterpulsation (EECP) is a technique that has shown promise in the treatment of this condition but is poorly utilised in the UK. The aim of this study is to assess the effect of EECP on anginal symptoms in patients with RA from a UK centre.

This retrospective study assessed the effectiveness of EECP at improving exercise capacity, anginal symptom burden and anginal episode frequency using pre- and post-treatment six-minute walk test (6MWT) results, Canadian Cardiovascular Society (CCS) scores and symptom questionnaires, respectively.

Fifty patients with a median age of 67 years (interquartile range [IQR] 14) underwent EECP between 2004 and 2015. The majority had undergone prior revascularisation (84%; 42/50) via percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG). Significant improvements were noted in 6MWT result (282 vs. 357 m; p<0.01), CCS score (3.2 vs. 2.0; p<0.01) and weekly anginal episode frequency (20 vs. 4; p<0.01). No adverse outcomes related to EECP were noted.

Our study demonstrates use of EECP to be associated with significant improvements in exercise capacity and anginal symptom burden.

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April 2018 doi :10.5837/bjc.2018.012 Online First

A study in the diagnosis and management of syncope: a retrospective review

Joseph Wilson, Donna Dalgetty, Selda Ahmet, Nida Taher, Mehran Asgari

Abstract

A study of 500 patients was conducted to ascertain how syncope is managed at the Ipswich Hospital NHS Trust. This was based on the variation in approach across the country despite the guidance from the European Society of Cardiology (ESC), National Institute for Health and Care Excellence (NICE) and the Heart Rhythm Society. Similar studies in the UK have indicated a number of inconsistencies in both the management and diagnosis of patients with suspected syncope.

We discuss the role of a syncope pathway, the need for a separate syncope clinic and for syncope experts.

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April 2018 doi :10.5837/bjc.2018.013 Online First

A novel ambulatory syncope assessment unit is safe and cost-effective in a low-risk patient cohort

Hamish I MacLachlan, Christopher J Allen, Gothandaraman Balaji

Abstract

A retrospective analysis of 50 inpatients admitted with syncope was undertaken to evaluate the safety and cost-effectiveness of a novel outpatient syncope clinic recently introduced within an emergency ambulatory care unit at a northwest London hospital together with review of echocardiographic parameters in syncope. Outcome measures included length of inpatient admission, frequency of cardiology review, 30-day readmission and 90-day mortality rates. The same variables were assessed prospectively in 50 inpatients referred to the syncope assessment unit (SAU). All 100 patients were deemed low risk, as defined by the San Francisco syncope rule. Patients under the age of 18 years and those investigated for conditions other than syncope were excluded. Echocardiographic parameters such as E/A ratio, left atrial (LA) dimension, left ventricular (LV) ejection fraction and E/E ratio were statistically analysed for their association with episodes of syncope.

The standard-care group remained in hospital for a median four days at a cost of €582 (£512). Waiting time for an SAU appointment was a median two days. Inpatient waiting time for 24-hour Holter and transthoracic echocardiography (TTE) investigations were significantly longer for the standard-care group (p<0.05). There was no significant difference in the rates of cardiology review, diagnostic yield, hospital readmission and mortality between the two groups. The SAU will save a projected annual cost of €108,371 (£95,232) on inpatient bed days. The fractional cost of clinical assessment on the SAU is €35 (£31) per patient. Among the echocardiographic parameters analysed, increased E/E ratio was associated with syncope (p=0.001).

In conclusion, the introduction of a novel low-risk SAU promotes early discharge from hospital with prompt outpatient medical review and shorter inpatient waiting times for diagnostic investigations. Our data suggest this is both cost-effective and safe. E/E echo parameter was observed as a significant parameter in low-risk syncope.

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March 2018 doi :10.5837/bjc.2018.005

Rhythm analysis of direct access 12-lead ECGs in patients complaining of palpitation

Morgan A Hughes, Peter J Bourdillon

Abstract

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.

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March 2018 doi :10.5837/bjc.2018.006

Diagnostic utility of real-time smartphone ECG in the initial investigation of palpitations

Anthony D Dimarco, Eunice N Onwordi, Conrad F Murphy, Emma J Walters, Lorraine Willis, Nicola J Mullan, Nicholas S Peters, Mark A Tanner

Abstract

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.

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March 2018 doi :10.5837/bjc.2018.007

Older antidiabetic drugs

Emma Johns, Gerry McKay, Miles Fisher

Abstract

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

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March 2018 doi :10.5837/bjc.2018.008

Percutaneous transcatheter closure of the aortic valve to treat aortic insufficiency after LVAD implantation

Wala Mattar, Christopher Walker, Shelley Rahman Haley, Andre Simon, Charles Ilsley

Abstract

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 AmplatzerTM multi-fenestrated septal occluder – Cribriform. This is the first such case to be reported in the UK.

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January 2018 doi :10.5837/bjc.2018.001 Online First

Cardio-oncology: a new sub-specialty

Jonathan Bennett, Alexander R Lyon, Chris Plummer, Stuart D Rosen, Kai-Keen Shiu

Abstract

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.

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January 2018 doi :10.5837/bjc.2018.002 Online First

Variability in use of IV nitrates and diuretics in acute HF: a ‘virtual patient’ clinical decision-making study

Alison Carr, Fosca De Iorio, Martin R Cowie

Abstract

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.

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January 2018 doi :10.5837/bjc.2018.004 Online First

Recognition and management of aVR STEMI: a retrospective cohort study

Ruan Vlok, Joshua Wall, Hannah Kempton, Thomas Melhuish, Astin Lee, Leigh White

Abstract

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.

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