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Clinical articles

April 2017 Br J Cardiol 2017;24:(2) doi :http://doi.org/10.5837/bjc.2017.009 Online First

Does CTCA improve the diagnostic yield from conventional coronary angiography? A DGH experience

Colin Reid, Mark Tanner, Hatef Mansoubi, Conrad Murphy

Abstract

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.

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April 2017 Br J Cardiol 2017;24:(2) doi :10.5837/bjc.2017.010 Online First

SGLT2 inhibitors

Emma Johns, Gerry McKay, Miles Fisher

Abstract

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.  

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April 2017 Br J Cardiol 2017;24:(2) doi :10.5837/bjc.2017.011 Online First

Recognition and management of posterior myocardial infarction: a retrospective cohort study

Leigh D White, Joshua Wall, Thomas M Melhuish, Ruan Vlok, Astin Lee

Abstract

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.

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April 2017 Br J Cardiol 2017;24:(2) doi :10.5837/bjc.2017.012 Online First

Dedicated side-branch stent: what could go wrong?

Usha Rao, Simon C Eccleshall

Abstract

Bifurcation lesions are complex, technically difficult, have a higher rate of adverse events and lower success rates. This has led to the introduction of dedicated bifurcation stents, generally deployed along with main-vessel stent. Cappella Sideguard® is a dedicated bifurcation stent for treatment of bifurcation lesions, which otherwise could be technically challenging and may have low success rates. We report a very interesting case that resulted in a unique complication following the use of a dedicated bifurcation stent.

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Cardiorespiratory fitness, oxygen pulse and heart rate response following the MyAction programme 

March 2017 Br J Cardiol 2017;24:25–9 doi :10.5837/bjc.2017.006

Cardiorespiratory fitness, oxygen pulse and heart rate response following the MyAction programme 

Tim P Grove, Jennifer L Jones, Susan B Connolly

Abstract

Improvements in cardiorespiratory fitness (CRF) are associated with better health outcomes. The Chester step test (CST) is used to assess the changes in CRF following a protocol-driven cardiovascular prevention and rehabilitation programme (CPRP) entitled MyAction. CRF expressed as predicted VO2max, can be influenced by physiological adaptations and/or retest familiarity-efficiency. Therefore, we employed an index ratio between oxygen uptake and heart rate (O2 pulse) to determine if the improvement in CRF is related to a true physiological adaptation.

In total, 169 patients, mean age 66.8 ± 7.3 years attended a 12-week MyAction CPRP. All were assessed using the CST on the initial and end-of-programme assessment. O2 pulse was estimated from the CST and was calculated by dividing VO2 into the exercise heart rate multiplied by 100. 

Following the CPRP, VO2max increased by 2.8 ml/kg/min. These changes were associated with an overall increase in O2 pulse by 0.6 ml/beat (p≤0.001) and a 4.1 beats/min (p≤0.001) reduction in the exercise heart rate response on the CST.

In conclusion, O2 pulse provides transparency on the physiological adaptations following a CPRP and can be used to help patients recognise the benefits of exercise training. For example, the average patient increased his/her O2 pulse by 0.6 ml/beats and saved 4–7 heart-beats on the CST.

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March 2017 Br J Cardiol 2017;24:30–4 doi :10.5837/bjc.2017.007

Impact of HF on HRQoL in patients and their caregivers in England: results from the ASSESS study

Iain Squire, Jason Glover, Jacqueline Corp, Rola Haroun, David Kuzan, Vera Gielen

Abstract

Heart failure (HF) is a chronic, symptomatic and progressive disease associated with reduced health-related quality of life (HRQoL) in both patients and their caregivers. This study assessed the HRQoL of HF patients (n=191; mean age 70 [range 21–95] years; New York Heart Association [NYHA] class II–IV) and their caregivers (n=72; mean age 69 [range 43–88] years) in England. Patients had poor HRQoL assessed by the EQ-5D-5L weighted index (mean ± standard deviation [SD] 0.60 ± 0.25 [normal 0.78 ± 0.26 for people aged 65–74 years]). The impact of HF on patients’ HRQoL varied markedly; importantly, the extent of comorbidity most influenced the reduction in patients’ HRQoL, as well as disease-related symptoms. The impact on HRQoL on caregivers of patients with HF was on average limited, with the EQ-5D-5L index for caregivers (0.75 ± 0.18) in-line with the normal values for their age range. However, as with the patients, the impact on HRQoL varied markedly, with some caregivers having a bad caregiving experience as measured by the Carer Experience Scale weighted index. This study provides important information on the impact on HRQoL and burden of HF for patients and their caregivers.

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Reperfusion, conditioning and the ongoing search for the holy grail

March 2017 Br J Cardiol 2017;24:35–8 doi :10.5837/bjc.2017.008

Reperfusion, conditioning and the ongoing search for the holy grail

Robert L Yellon, Rob M Bell

Abstract

Ischaemic conditioning is the phenomenon of protection against reperfusion injury via the application of brief, repeated episodes of non-lethal ischaemia. This review has three aims: 1) to briefly explain the various categories of ischaemic conditioning; 2) to explore past clinical trials and their failures; 3) to explore the future of clinical trials in the realm of ischaemic conditioning. 

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Dipeptidyl peptidase-4 (DPP-4) inhibitors

January 2017 Br J Cardiol 2017;24:(1) doi :10.5837/bjc.2017.001 Online First

Dipeptidyl peptidase-4 (DPP-4) inhibitors

Emma Johns, Gerry McKay, Miles Fisher

Abstract

Dipeptidyl peptidase-4 (DPP-4) inhibitors are one of two classes of antidiabetes drugs that mediate their glucose-lowering effect through the incretin pathway. They are administered orally and offer significant glucose-lowering with a neutral weight profile and a low risk of hypoglycaemia. Three large randomised-controlled trials have demonstrated cardiovascular safety, with no increase in major adverse cardiovascular events comparing DPP-4 inhibitors (saxagliptin, alogliptin and sitagliptin) with placebo. An increase in heart failure hospitalisation was noted with saxagliptin compared with placebo, and a similar increase was also noted in one subgroup receiving alogliptin compared with placebo. Further cardiovascular safety trials with DPP-4 inhibitors are ongoing, including a trial comparing the DPP-4 inhibitor linagliptin with the sulphonylurea glimepiride.

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Setting up cardio-oncology services

January 2017 Br j Cardiol 2017;24(1) doi :10.5837/bjc.2017.003 Online First

Setting up cardio-oncology services

Arjun K Ghosh, Charlotte Manisty, Simon Woldman, Tom Crake, Mark Westwood, J Malcolm Walker

Abstract

In this article, we explain the clinical requirement for cardio-oncology services and reflect on our experiences in setting these up at Barts Heart Centre and at University College London Hospital.

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Multiple coronary cameral fistulae

January 2017 Br J Cardiol 2017;24:39–40 doi :10.5837/bjc.2017.004 Online First

Multiple coronary cameral fistulae

Hasan Kadhim, Anita Radomski

Abstract

A 61-year-old East European woman was admitted with atypical chest pain. Risk factors: smoker of 5–10 cigarettes per day, hypertension, hypercholesterolaemia and family history of ischaemic heart disease. Highly sensitive troponin-T, electrocardiogram (ECG) and exercise stress test were normal.

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