Clinical articles

Lipid management is a key component of secondary prevention after acute coronary syndrome (ACS), but guideline adherence is variable. Adjunctive lipid-lowering therapies (LLTs) beyond statins are available, yet eligibility in the real-world setting is not well-described. We aimed to improve local post-ACS lipid management, and evaluate eligibility for LLTs.

Consecutive admissions of patients with ACS to a district general hospital from April to June 2022 were assessed for: inpatient lipid-profile assessment, inpatient LLT management, and outpatient repeat lipid profiles. A structured intervention, including updating blood testing panels, education, and reference resources, was implemented. We re-audited admissions in April–June 2024, where eligibility for adjunctive LLTs was assessed.

There were 97 (cycle 1) and 102 (cycle 2) patients identified. While performance was suboptimal in cycle 1, we observed improvements in cycle 2 (baseline full lipid profile testing from 10% to 75%; appropriate LLT management 65% to 78%; post-discharge repeat testing 37% to 63%). At one year post-ACS, 35% of patients remained subtherapeutic, but medication changes were rare.

In conclusion, through use of a structured intervention, we were able to improve post-ACS lipid management. Many patients fail to achieve therapeutic lipid lowering. Strategies to address this are urgently required.

Infective endocarditis (IE) carries significant morbidity and mortality, with reported in-hospital mortality ranging from 15 to 30%. Timely echocardiography is crucial for early diagnosis and optimal management. Current UK and European Society of Cardiology (ESC) guidelines recommend echocardiography within 24 hours for suspected IE, particularly in high-risk cases. We aimed to evaluate adherence to these guidelines at a UK district general hospital (DGH), to assess the relationship between delayed echocardiography and patient outcomes, and to assess the reasons why it may be delayed.

We performed a retrospective audit of 78 patients who were inpatients, undergoing echocardiography for suspected IE. Patient demographics, clinical features, day of the week and timing of echocardiography from initial clinical suspicion, and outcomes (30-day mortality, IE diagnosis per modified Duke criteria) were recorded. Echocardiography delays were defined as imaging beyond 24 hours from the echo being requested. Primary outcome was adherence to imaging timing. Secondary outcome was 30-day mortality.

Among the 78 patients audited, delays exceeded on-time scans (47/78, 60.3%, p=0.044, 95% confidence interval [CI] 48.5 to 71.2%). Day-of-week was associated with <24-hour breach on logistic modelling (p=0.031), worst on Thursday/weekends (100% delayed) vs. Wednesday (60%). Using modified Duke criteria, 32% of patients were deemed to have definite or possible IE. The overall 30-day mortality rate in the audit population was 20.5%. However, echocardiography delays alone did not significantly impact mortality (p=0.594).

In conclusion, despite clear guidelines, delays in echocardiography were prevalent. While delayed imaging alone did not significantly predict mortality, patients diagnosed with IE had significantly higher mortality. The day of the week of the echo request had a statistically significant impact on delays. These results highlight the importance of timely echocardiography to confirm IE diagnosis promptly, and potentially improve outcomes.

A man in his eighties presented with a two-week history of left-arm swelling and bruising. Twelve years earlier, he had undergone dual-chamber pacemaker implantation for bradycardia and syncope. His past medical history included hypertension, paroxysmal atrial fibrillation (pAF), and coronary artery bypass grafting (CABG) 15 years prior.

Upon further investigation with ultrasound Doppler, and computerised tomography (CT) of his chest, a thrombus was confirmed in the left subclavian vein, associated with a pacing lead. He was initiated on a three-week course of low molecular weight heparin (LMWH). Although his symptoms initially improved, traces of the thrombus remained on his follow-up CT after commencing treatment, and he was continued on lifelong direct oral anticoagulant (DOAC).

Pathogenesis, incidence, investigations and management of pacemaker-induced thrombosis are discussed. This case illustrates a rare, delayed presentation of pacemaker-induced thrombosis in the context of a symptomatic presentation and highlights the potential need for prolonged anticoagulation.

In the UK, the majority (90%) of hypertension is managed in primary care. Yet, for the 10% who require secondary-care input, there is no specialist register for doctors who manage hypertension. There is a mismatch across the nations with regards to access to secondary care for management of complex hypertension cases. Heterogeneity exists in terms of local specialist services, referral pathways, and specialties overseeing care.

We polled across primary care in the UK to assess accessibility to a local specialist hypertension clinic, the clinical reasons for referral and the specialty referred to. Cardiology was by far and away the leading specialty for referrals. Yet the vast majority of cardiology trainees in the UK are receiving minimal, if any, specialist training in hypertension. A cardiology registrar is likely to spend substantially more days on-call for general medicine than the amount of specialist clinics they can attend in hypertension.

We are facing a major deficit in the specialist management of hypertension if the trainees of today are not ready to provide the required expertise and oversight for the complex cases of tomorrow.

Conduction system pacing (CSP) ― encompassing His-bundle pacing (HBP) and left bundle-branch area pacing (LBBAP) ― delivers more physiological ventricular pacing compared with traditional right ventricular (RV) pacing. It is gaining traction beyond tertiary centres, however, evidence from district general hospitals (DGHs) remains limited. We aimed to evaluate the feasibility, electrical performance, and early clinical outcomes of CSP implemented in a UK DGH.

We performed a retrospective single-centre study of consecutive patients who underwent successful CSP at Chesterfield Royal Hospital. HBP implants (n=20) were performed between June 2019 and August 2022; LBBAP implants (n=71) between January 2023 and May 2025. Baseline demographics, procedural metrics, pacing parameters, complications, heart-failure (HF) readmissions, and echocardiographic data to 12 months were obtained from electronic records.

Ninety-one patients (mean age 76 ± 10 years; 69% male) received CSP, most commonly for left ventricular systolic dysfunction (LVSD) (40%) or anticipated high right-ventricular pacing burden (42%). LBBAP demonstrated lower implant thresholds than HBP (0.92 ± 0.44 V vs. 1.50 ± 0.77 V) and remained stable to 12 months (0.68 ± 0.25 V). HBP thresholds rose to 2.11 ± 1.49 V at 12 months. Screening time was shorter with LBBAP (9.6 ± 5.9 min) than HBP (14.4 ± 6.8 min, p<0.01). No infections or septal haematomas occurred. Lead revision was required in two HBP recipients and none with LBBAP (hazard ratio 17.14, p=0.067). Nine patients (9.9%) were readmitted with HF, occurring between 56 and 1,500 days post-implant.

In conclusion, CSP can be implemented safely and effectively in a DGH setting. LBBAP offers superior electrical stability, shorter procedure time, and less lead revisions, supporting its preferential adoption as the default pacing strategy for CSP.

A nurse-led heart murmur clinic was introduced at Sheffield Children’s Hospital in 2023 to reduce waiting times, support the clinical nurse specialist (CNS) role development, and improve cost-efficiency. By triaging appropriate referrals to a CNS-led pathway with pre-arranged echocardiography and telephone follow-up, the clinic reduced wait times from 16 to 5–6 weeks and saved over £3,000 in its first year. The model demonstrates that nurse-led services can safely and effectively manage selected paediatric referrals, improve access to care, and deliver measurable service efficiencies.

Anxiety is common in people with coronary artery disease (CAD), particularly in association with invasive procedures and investigations. Effective provision of information for patients is crucial, but traditional methods may fail to adequately inform or engage some patients. We aimed to synthesise clinical trials evaluating the effectiveness of video animations provided to patients with CAD.

We performed a systematic review of Medline, CINAHL Plus, Cochrane Library and PsycINFO from January 2000 to January 2025. Conducted in accordance with PRISMA guidelines and presented with a narrative synthesis.

Five randomised-controlled trials met the inclusion criteria. Four included video animations, and one a ‘whiteboard animation’. Each evaluated the animations as an addition to standard care. Patient knowledge was improved in all four trials that assessed it, and anxiety was reduced in two out of four trials that assessed it. There was some evidence of beneficial effects of animations on satisfaction and health behaviours. The quality of evidence was not strong, with two trials having a high risk of bias.

In conclusion, video animations show potential for their effects on knowledge and anxiety in patients with CAD, but the evidence-base is small.

We present a case involving the discovery of an extracardiac mass during a routine ablation procedure for typical atrial flutter. Using multiple imaging modalities it was possible to assess the mass during the procedure, leading to successful completion of the ablation.

Historically, young people with genetic heart diseases were discouraged from active sport due to concerns about the increased risk of sudden cardiac death during competitive or intensive exercise. The shock resulting from the sudden death of a young athlete, an event often highly publicised, tends to generate concern in the general population, and fear of litigation in a low-evidence area: both influence decision-making by the medical profession when discussing ‘restrictions’, especially in patients with genetic heart diseases, who by definition, are at increased risk of sudden cardiac death. In recent years, however, we have moved to a point where many athletes with certain genetic heart diseases can, with optimal medical therapy, be considered for involvement in various sporting and athletic pursuits. We are cautiously moving away from the assumption that exercise is contraindicated; we are factoring in the wishes of the patient-athlete (shared decision-making), and we are encouraging optimal protection for these athletes during their sporting endeavours (easily available automated external defibrillators [AEDs], and club personnel trained in basic life support [BLS]), while ensuring regular medical assessment to identify alterations in risk status. With dedicated follow-up of all such patient-athletes, we can refine our understanding of how best to advise (and protect) them in terms of exercise for enhanced quality of life.

Cardiomyopathies are diseases of the heart muscle (ICD‑10 chapter IX, code I42). This study compared the health profiles of individuals with cardiomyopathy to age- and sex-matched controls in the UK Biobank prospective cohort to better understand health behaviours. Historical advice for patients to avoid exercise may have contributed to earlier heart failure; addressing these outdated perceptions could guide future recommendations to improve outcomes and reduce cardiovascular mortality.

Data from the UK Biobank were analysed, including physical activity behaviours, body mass index (BMI), waist circumference, body composition, hand-grip strength, and lifestyle factors, such as intake of fruit, processed/red meat, oily fish, alcohol and smoking, as well as PC-sitting and TV-viewing time. Linear and logistic regression assessed associations between these exposures and cardiomyopathy, adjusting for age, sex, and deprivation index.

The cohort comprised 442 individuals with cardiomyopathy and 173,429 matched controls. Significant differences were noted in age, deprivation index, alcohol intake, BMI, waist and hip circumference, physical activity levels, TV viewing, and sedentary time. Males had higher odds of cardiomyopathy than females (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.04 to 3.05, p<0.0001). Obesity was strongly associated with cardiomyopathy (OR 3.7, 95%CI 2.88 to 4.76, p<0.0001). Sleep risk scores and type of physical activity risk scores were also significantly associated with cardiomyopathy.

In conclusion, individuals with cardiomyopathy demonstrated poorer health profiles and more sedentary behaviours than controls. These findings highlight the need for targeted interventions and updated exercise advice to improve clinical outcomes and reduce cardiovascular mortality in this population.