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Clinical articles

October 2017 Br J Cardiol 2017;24:(4) doi :10.5837/bjc.2017.025 Online First

Heart rate monitors and fitness trackers: friend or foe?

Edward Doris, Iain Matthews, Honey Thomas

Abstract

Wearable and smartphone-based activity and heart rate (HR) monitors are becoming increasingly common, with around 80 million devices in use in 2017. Wearable and smartphone-based devices may be dedicated HR monitors or part of an activity tracker system. One of the main aims of these devices is to encourage exercise and increase fitness, which is clearly desirable in a society with high levels of inactivity and obesity. These devices provide individuals with large amounts of data including HR information. This may, therefore, give an opportunity to document or diagnose arrhythmias. Undiagnosed atrial fibrillation is a common problem and is associated with a huge burden of potentially preventable stroke. Wearable HR monitors may provide the opportunity to identify these individuals and allow them to receive stroke prevention treatment. However, the consumer fitness market is unregulated and the manufacturers emphasise that their devices are not intended to be used for detecting heart rhythm problems. The reliability, sampling frequency and algorithms for the HR data these devices provide are hugely variable. Detected ‘abnormalities’ may inform clinical decision making but it may also trigger unnecessary anxiety and costly investigations in healthy people.

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October 2017 Br J Cardiol 2017;24:(4) doi :10.5837/bjc.2017.026 Online First

How hard do we look for atrial fibrillation?

Ioannis Merinopoulos, Sajid Alam, David Bloore

Abstract

Atrial fibrillation (AF) is one of the most common arrhythmias, affecting approximately 2% of the general population. Identifying AF after an ischaemic stroke is particularly important as it changes the recommended antithrombotic therapy from antiplatelets to anticoagulation. Currently, there is no clear consensus with regards to the duration of rhythm monitoring post-stroke. In our study, we aim to review some of the pivotal studies regarding rhythm monitoring after an ischaemic stroke and identify the percentage of patients who get referred for prolonged rhythm monitoring after a stroke by providing real-world data from the Ipswich hospital. To our surprise, we did not identify any patients who got referred for prolonged rhythm monitoring (ILR) and the proportion of patients who did not have a 24-hour tape was unexpectedly high. In addition, there was a clear tendency for patients with lacunar strokes not to get investigated with 24-hour tape.

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October 2017 Br J Cardiol 2017;24:(4) doi :10.5837/bjc.2017.027 Online First

The PACI survey: Patient adherence to cardioprotective lifestyle interventions in myocardial infarction patients treated with primary percutaneous coronary intervention

Justin L Mifsud

Abstract

Despite documented evidence of benefits of lifestyle cardioprotective interventions in reducing recurrent coronary heart disease (CHD) events, many patients still fail to adhere to proposed lifestyle interventions. To determine the percentage adherence rate and to identify the perceived barriers influencing adherence rate to cardioprotective lifestyle interventions among patients treated with primary percutaneous coronary intervention (PPCI) a cross-sectional survey was designed.

A total of 193 consecutive patients, with a clinical diagnosis of CHD who had a PPCI, were identified retrospectively between 2008 and 2013, and were subsequently telephone surveyed. Data were analysed using chi-square tests and Fisher’s exact tests. At survey, 21.8% of patients smoked cigarettes, 30.6% were adhering to physical activities as per guidelines, 36.3% were consuming five portions of fruits and vegetables per day, and 9.8% were consuming three portions of oily fish per week. Negative stress, low mood, advanced age, poor health, lack of enjoyment from physical activities, low expectations from physical activity benefits, obesity and diabetes, were associated with non-adherence to physical activities as per guidelines.

In conclusion, risk factor targets for secondary prevention were not reached by a large proportion of patients. Several barriers exist among these individuals. Thus, there is still considerable potential for cardiac rehabilitation clinicians to improve standards of preventive cardiology by clearly identifying barriers and ways to overcome them. 

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October 2017 Br J Cardiol 2017;24:(4) doi :10.5837/bjc.2017.028 Online First

Current diagnostic yield of invasive coronary angiography at a district general hospital

Ali Rauf, Sarah Denny, Floyd Pierres, Alice Jackson, Nikolaos Papamichail, Antonis Pavlidis, Khaled Alfakih

Abstract

Invasive coronary angiography (ICA) is an important diagnostic test in the diagnosis of coronary artery disease (CAD). However, it is associated with a small risk and is a relatively expensive procedure. National Institute for Health and Care Excellence (NICE) 2010 guidelines on stable chest pain recommended that patients with stable chest pain and high probability of CAD should be investigated with ICA.

We audited our own practice at a district general hospital (DGH), with a single catheter lab, to assess the yield of significant CAD at ICA in patients presenting with stable chest pain and acute coronary syndromes (ACS). There were 457 patients who were referrals for ICA with stable chest pain and 250 were inpatients undergoing ICA for ACS. The incidence of severe CAD in the whole cohort was 41%, with a further 20% found to have moderate CAD. The prevalence was higher in the ACS subgroup with 55% of patients having severe CAD compared with 33% in the stable chest pain sub-group. Of the patients having ICA for stable chest pain, 72% were direct referrals, with 30% found to have severe CAD. Our data show that overall detection rate of severe CAD in patients presenting with stable chest pain, at ICA, is relatively low.

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August 2017 Br J Cardiol 2017;24:117 doi :10.5837/bjc.2017.023

Brugada syndrome in the context of a fever: a case study and review of current knowledge

Saad Ahmad, Irfan Ahmed

Abstract

Brugada syndrome is a distinct arrhythmogenic disorder widely recognised as a sudden cause of death in the young. It is identified by a classical ST-segment elevation on electrocardiogram (ECG) that may be provoked in the context of a fever or vagal stimulation. The pathophysiology and genetic basis have been elucidated as an abnormality in ion channels. Diagnosis takes into account, not only the ECG, but clinical features and modulating factors; the inducibility of a suspect ECG when febrile is one such observation. Anti-arrhythmic drugs like ajmaline can also induce Brugada syndrome and have a role in its work-up. Electrophysiology studies may be useful in assessment and risk stratification of select cases. The management is centred around device therapy with the implantable cardioverter defibrillator (ICD), though pharmacological treatments are being actively pursued.

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August 2017 Br J Cardiol 2017;24:120 doi :10.5837/bjc.2017.024

Multiple left atrial masses in a patient with breast cancer

Debjit Chatterjee

Abstract

This is a rare case with dramatic image of multiple clot formation in the left atrium in a patient with mitral stenosis when anticoagulation was stopped for a few days before cancer surgery.

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July 2017 Br J Cardiol 2017;24:105–7 doi :http://doi.org/10.5837/bjc.2017.017 Online First

The age of diagnostic coronary angiography is over

Andrew J M Lewis

Abstract

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. 

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July 2017 Br J Cardiol 2017;24:100–4 doi :http://doi.org/10.5837/bjc.2017.020 Online First

Randomised clinical trial comparing transradial catheterisation with or without prophylactic nitroglycerin

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

Abstract

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.

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July 2017 Br J Cardiol 2017;24:108–12 doi :http://doi.org/10.5837/bjc.2017.019 Online First

A review of endomyocardial biopsy and current practice in England: out of date or underutilised?

Alex Asher

Abstract

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.

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July 2017 Br J Cardiol 2017;24:113–16 doi :http://doi.org/10.5837/bjc.2017.018 Online First

Glitazones (thiazolidinediones)

Emma Johns, Gerry McKay, Miles Fisher

Abstract

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.

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