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Clinical articles

June 2018 Br J Cardiol 2018;25:73–6 doi :10.5837/bjc.2018.016

Prescribing glucose-lowering drugs for patients with cardiac disease

Miles Fisher, Emma Johns, Gerry McKay

Abstract

The past decade has seen the emergence of several new classes of drugs for the treatment of type 2 diabetes mellitus (T2DM). Despite the increasing use of these agents, metformin and sulfonylureas remain the most commonly prescribed glucose-lowering drugs in people with T2DM. This reflects the National Institute for Health and Care Excellence (NICE) guideline from 2015 and the Scottish Intercollegiate Guidelines Network (SIGN) guideline from 2010, which recommended metformin as first-line treatment and sulfonylureas as the ‘usual’ second-line treatment for patients with T2DM. SIGN has recently provided an updated guideline on the pharmacological management of glycaemic control in people with T2DM. For the first time in UK guidelines, this recommends that in individuals with diabetes and cardiovascular disease, sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists with proven cardiovascular benefit (currently empagliflozin, canagliflozin and liraglutide) should be considered. It is anticipated that implementation of these new guidelines will lead to increased prescribing of these drugs in people with diabetes and cardiac disease, with reductions in prescribing of dipeptidyl peptidase-4 (DPP-4) inhibitors and other drugs in the GLP-1 receptor agonist class, where cardiovascular benefits have not been clearly demonstrated.

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June 2018 Br J Cardiol 2018;25:77–80 doi :10.5837/bjc.2018.017

‘Normal’ blood pressure: too good to be true? Case series on postural syncope and the ‘white-coat’ effect

Haqeel A Jamil, Noman Ali, Mohammad Waleed, Yvonne Blackburn, Caroline Moyles, Christopher Morley

Abstract

Ambulatory blood pressure monitoring (ABPM) can confirm diagnosis in essential hypertension (HTN) and mitigate the ‘white-coat’ effect, preventing erroneous antihypertensive therapy. We aimed to collect a case series of over-treated hypertension in the context of ‘white-coat’ effect, resulting in pre-syncopal or syncopal episodes. We collected data retrospectively from patients presenting to syncope clinic between January 2016 and March 2017. ABPM was used at baseline and repeated at three months, following withdrawal of one or more antihypertensive agents.

There were 39 patients with orthostatic symptoms of syncope/pre-syncope, previous HTN diagnosis and ‘white-coat’ effect included. Reducing antihypertensive therapy increased daytime ABPM (baseline vs. three months: systolic 119 ± 11 vs. 128 ± 8 mmHg, p<0.05; diastolic 70 ± 9 vs. 76 ± 9 mmHg, p<0.05) and resolved symptoms.

In conclusion, some patients exhibit pre-syncope or syncope due to over/erroneous HTN treatment resulting in orthostatic hypotension. Our findings suggest that reducing antihypertensive medications may resolve symptoms, without rendering them hypertensive.

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May 2018 Br J Cardiol 2018;25:63–8 doi :10.5837/bjc.2018.014 Online First

3D echocardiography: benefits and steps to wider implementation

Kevin Cheng, Mark J Monaghan, Antoinette Kenny, Bushra Rana, Rick Steeds, Claire Mackay, DeWet van der Westhuizen

Abstract

Advancements in computer and transducer technologies over the past two decades have allowed the development of three-dimensional (3D) echocardiography (3DE), which offers significant additional clinical information to traditional two-dimensional (2D) echocardiography (2DE). However, the majority of departmental studies today remain 2D, and adoption of 3DE as a complementary tool into mainstream clinical practice has not been without its difficulties. Although cardiologists have a range of alternative imaging modalities at their disposal to investigate cardiovascular structure and function, given the pace of technological innovation and improvements in data analysis, the field of 3DE is one of great expectation and is likely to be of increasing clinical importance. In this review, we discuss the role of 3DE, its advantages and limitations, and how novel technology will help workflow and expand its routine use.

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April 2018 Br J Cardiol 2018;25:69–72 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 Br J Cardiol 2018;25:54–7 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 Br J Cardiol 2018;25:58–62 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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