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Clinical articles

April 2022 Br J Cardiol 2022;29:55–9 doi :10.5837/bjc.2022.011

Marijuana: cardiovascular effects and legal considerations. A clinical case-based review

Saad Ahmad, Shwe Win Hlaing, Muhammad Haris, Nadeem Attar

Abstract

Though coronary artery disease primarily occurs in those over the age of 40 years, younger individuals who use recreational drugs may be afflicted with coronary events. Cannabis is one such perilous agent that can cause myocardial infarction (MI) and is one of the most common psychoactive drugs used worldwide. Cannabis (also known as marijuana, weed, pot, dope or grass) is the most widely used illegal drug in the UK. The desired euphoric effects are immediate, as are life-threatening hazardous ones.

In this article, we briefly describe a case series of two unique but similar cases of cannabis-induced ST-elevation MI witnessed at our hospital in quick succession. We will analyse the composite pathophysiology in acute coronary syndromes provoked by cannabis and discuss the evolving legality around the use of the drug.

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April 2022 Br J Cardiol 2022;29:52–4 doi :10.5837/bjc.2022.012

Drive-by collection and self-fitting of ambulatory electrocardiogram monitoring

Mark T Mills, Sarah Ritzmann, Maisie Danson, Gillian E Payne, David R Warriner

Abstract

Ambulatory electrocardiogram (AECG) monitoring is a common cardiovascular investigation. Traditionally, this requires a face-to-face appointment. In order to reduce contact during the COVID-19 pandemic, we investigated whether drive-by collection and self-fitting of the device by the patient represents an acceptable alternative.

A prospective, observational study of consecutive patients requiring AECG monitoring over a period of one month at three hospitals was performed. Half underwent standard (face-to-face) fitting, and half attended a drive-by service to collect their monitor, fitting their device at home. Outcome measures were quality of the recordings (determined as good, acceptable or poor), and patient satisfaction.

A total of 375 patients were included (192 face-to-face, 183 drive-by). Mean patient age was similar between the two groups. The quality of the AECG recordings was similar in both groups (52.6% good in face-to-face vs. 53.0% in drive-by; 34.9% acceptable in face-to-face vs. 32.2% in drive-by; 12.5% poor in face-to-face vs. 14.8% in drive-by; Chi-square statistic 0.55, p=0.76). Patient satisfaction rates were high, with all patients in both groups satisfied with the care they received.

In conclusion, drive-by collection and self-fitting of AECG monitoring yields similar AECG quality to conventional face-to-face fitting, with high levels of patient satisfaction.

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April 2022 Br J Cardiol 2022;29:67–72 doi :10.5837/bjc.2022.013

Angina with coronary microvascular dysfunction and its physiological assessment: a review with cases

Pitt O Lim

Abstract

Imagine that it is possible to know, the actual coronary blood flow. Would this not remove any doubt, if a chest pain is the heart’s fault?

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April 2022 Br J Cardiol 2022;29:77–8 doi :10.5837/bjc.2022.014

Iatrogenic aortic dissection of the descending aorta after percutaneous coronary intervention

Kristen Westenfield, Shannon Mackey-Bojack, Yale L Wang, Kevin M Harris

Abstract

Aortic dissection is a rare and potentially fatal complication of coronary angiography. We report a case of a woman in her late 80s who underwent a left femoral approach coronary angiogram for evaluation of a transcatheter aortic valve replacement (TAVR). Following the procedure, she had a cardiac arrest and was found to have a descending aortic dissection on transoesophageal echocardiogram. Autopsy showed an acute intimal tear of the descending aorta, most likely related to catheter manipulation. Patients undergoing evaluation for TAVR, who tend to be elderly with concomitant atherosclerosis, are at risk for complications following cardiac catheterisation including aortic dissection.

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March 2022 Br J Cardiol 2022;29:21–5 doi :10.5837/bjc.2022.008

Atrial fibrillation prevalence and predictors in patients with diabetes: a cross-sectional screening study

Angela Hall, Andrew Robert John Mitchell, Lisa Ashmore, Carol Holland

Abstract

Prevalence of atrial fibrillation (AF) and diabetes is increasing worldwide. Diabetes is a risk factor for AF and both increase stroke risk. Previous AF screening studies have recruited high-risk patient groups, but not with diabetes as the target group. This study aims to determine whether people with diabetes have a higher prevalence of AF than the general population and investigate whether determinants, such as diabetes duration or diabetes control, add to AF risk.

In a cross-sectional screening study, patients with diabetes were recruited via their GP surgeries or a diabetes centre. A 30-second single-lead electrocardiogram (ECG) was recorded using the Kardia® device, along with physiological measurements and details relating to risk factor variables.

There were 300 participants recruited and 16 patients identified with AF (5.3% prevalence). This demonstrated a significantly greater likelihood of AF than the background population (p=0.043). People with diabetes and AF were significantly older than those who only had diabetes. More people with type 2 diabetes had AF than people with type 1. Prediction of AF diagnosis by age, sex, diabetes type, diabetes duration and level of control revealed only age as a significant predictor.

In conclusion, these findings add to existing data around the association of these chronic conditions, supporting AF screening in this high-risk group, particularly in those of older age. This can contribute to appropriate management of both conditions in combination, not least with regards to stroke prevention.

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March 2022 Br J Cardiol 2022;29:31–5 doi :10.5837/bjc.2022.009

Dermatological manifestations of cardiac conditions

Arnav Katira, Ravish Katira

Abstract

Various cardiac disorders seen in general and acute medicine have dermatological manifestations that may provide critical clues to the underlying disease. This review will discuss the important dermatological signs seen in cardiac conditions. We believe greater interdisciplinary liaison will improve our understanding of the link between the dermatological and cardiovascular systems and the underlying disease processes.

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January 2022 Br J Cardiol 2022;29:16–20 doi :10.5837/bjc.2022.003

Observational case series of postural tachycardia syndrome (PoTS) in post-COVID-19 patients

Nicholas P Gall, Stephen James, Lesley Kavi

Abstract

There is emerging evidence that a proportion of patients who develop long (post)-COVID-19 have abnormalities in the regulation of their autonomic nervous system manifesting as postural tachycardia syndrome (PoTS). We report a series of 14 patients who developed symptoms and signs compatible with PoTS following clinically diagnosed COVID-19 infection. Their symptoms and clinical findings were consistent with those of patients with non-COVID-related PoTS. The authors recommend an active stand test for patients who present after COVID-19 infection with cardiovascular symptoms including chest pain, palpitations, light-headedness and breathlessness that are worse with the upright posture. They further recommend training of clinicians and investment in health services to provide for the anticipated significant increase in patients presenting with PoTS and other forms of autonomic dysfunction due to the COVID-19 pandemic.

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January 2022 Br J Cardiol 2022;29:36–40 doi :10.5837/bjc.2022.004

Effect of the COVID-19 pandemic on ST-elevation myocardial infarction presentation and survival

Sachintha Perera, Sudhir Rathore, Joanne Shannon, Peter Clarkson, Matthew Faircloth, Vinod Achan

Abstract

Presentation and outcomes of patients with ST-elevation myocardial infarction (STEMI) may change during viral pandemics. We compared symptom-to-call (STC), call-to-balloon (CTB), door-to-balloon (DTB) times; high-sensitivity troponin (hs-cTnI) levels; and survival of patients (n=39) during the first wave of the COVID-19 pandemic (defined as a ‘COVID period’ starting four weeks before lockdown) to historical controls from a ‘pre-COVID period’ (n=45).

STEMI admissions fell one week before lockdown by 29%. Median STC times began to rise one month before lockdown (54 vs. 25 min, p=0.06), with peak increases between 9 March and 5 April (166 vs. 59 min, p=0.04). Median CTB and DTB times were unchanged. Mean peak hs-cTnI increased during COVID-19 (15,225 vs. 8,852 ng/ml, p=0.004). Six-month survival following all STEMI reduced (82.1% vs. 95.6%, p<0.05).

STC times are the earliest indicator that STEMI-patient behaviour changed four weeks before lockdown, correlating with higher troponin levels and reduced survival. These early signals could guide public health interventions during future pandemics.

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January 2022 Br J Cardiol 2022;29:9–11 doi :10.5837/bjc.2022.005

Heart failure care pathways: the power of collaboration and marginal gains

Carys Barton, Simon Gordon, Afsana Safa, Carla M Plymen

Abstract

Heart failure (HF) is increasingly common and incurs a substantial cost, both in terms of quality and length of life, but also in terms of societal and economic impact. While significant gains are being made in the therapeutic management of HF, we continue to diagnose most patients when they are acutely unwell in hospital, often with advanced disease.

This article presents our experience in working collaboratively with primary care colleagues to redesign our HF pathway with the aim of facilitating earlier, community, diagnosis of HF. In so doing, and, thus, starting prognostic therapy much earlier in the course of the disease, we seek to avoid both the cost of emergency hospitalisation and the cost of poorer outcomes.

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January 2022 Br J Cardiol 2022;29:26–30 doi :10.5837/bjc.2022.001

New agents for DOAC reversal: a practical management review

Katie White, Uzma Faruqi, Alexander (Ander) T Cohen

Abstract

Bleeding is the commonest and most concerning adverse event associated with anticoagulants. Bleeding, depending on the severity, is managed in various ways, and for severe or life-threatening bleeding, specific antidotes are indicated and recommended. This review provides guidance relating to specific direct oral anticoagulant (DOAC) reversal agents, the antidotes. We discuss their indications for use, dosing, and potential side effects.

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