Clinical articles

The UK cardiology specialist training programme utilises the National Health Service (NHS) e-Portfolio to ensure adequate progression is being made during a trainees’ career. The NHS e-portfolio has been used for 15 years, but many questions remain regarding its perceived learning value and usefulness for trainees and trainers. This qualitative study in the recent pre-COVID era explored the perceived benefits of the NHS e-Portfolio with cardiology trainees and trainers in two UK training deaneries. Questionnaires were sent to 66 trainees and to 50 trainers. 50% of trainees felt that their development had benefited from use of the ePortfolio. 61% of trainees found it an effective educational tool, and 25% of trainees and 39% of trainers found the ePortfolio useful for highlighting their strengths and weaknesses. 75% of trainees viewed workplace based assessments as a means to passing the ARCP. The results show that the NHS ePortfolio and workplace based assessments were perceived negatively by some trainees and trainers alike, with many feeling that significant improvements need to be made. In light of the progress and acceptance of digital technology and communication in the current COVID-19 era, it is likely to be the time for the development of a new optimal digital training platform for cardiology trainees and trainers. The specialist societies could help develop a more speciality specific learning and development tool.

Selexipag is an oral selective prostacyclin-receptor agonist that was approved for use in patients with World Health Organisation (WHO) functional class II–III pulmonary arterial hypertension (PAH). Treatment with individualised doses of selexipag resulted in significant reductions in the composite end point of death or a complication related to PAH in the phase III GRIPHON (Prostacyclin [PGI2] Receptor Agonist In Pulmonary Arterial Hypertension) study. In order to better understand the real-world approach to selexipag titration and to establish the individualised maintenance regimens used in our centre, we performed this retrospective study of the first 20 patients prescribed selexipag. Baseline characteristics differed from the GRIPHON study, with more combination therapy and comorbidities at drug initiation. Maintenance doses were stratified as low-dose in 10% (n=2), medium-dose in 70% (n=14) and high-dose in 20% (n=4). This study highlights that selexipag can be safely initiated, titrated and transitioned in an outpatient setting to achieve an individualised dosing regimen.

A 52-year-old woman, referred for transoesophageal echocardiography, developed acute Takotsubo cardiomyopathy during the examination as a result of emotional distress beforehand. Asymptomatic left ventricular apical ballooning with severe systolic dysfunction within minutes of the emotional trigger was the first sign of any abnormality.

This is an interesting case of wide complex tachycardia in a patient on flecainide for paroxysmal atrial fibrillation. Diagnostic possibilities were discussed, actual diagnosis revealed, and explanation provided.

The coronavirus disease 2019 (COVID-19) commonly involves the respiratory system but increasingly cardiovascular involvement is recognised. We assessed electrocardiogram (ECG) abnormalities in patients with COVID-19.

We performed retrospective analysis of the hospital’s COVID-19 database from April to May 2020. Any ECG abnormality was defined as: 1) new sinus bradycardia; 2) new/worsening bundle-branch block; 3) new/worsening heart block; 4) new ventricular or atrial bigeminy/trigeminy; 5) new-onset atrial fibrillation (AF)/atrial flutter or ventricular tachycardia (VT); and 6) new-onset ischaemic changes. Patients with and without any ECG change were compared.

There were 455 patients included of whom 59 patients (12.8%) met criteria for any ECG abnormality. Patients were older (any ECG abnormality 77.8 ± 12 years vs. no ECG abnormality 67.4 ± 18.2 years, p<0.001) and more likely to die in-hospital (any ECG abnormality 44.1% vs. no ECG abnormality 27.8%, p=0.011). Cox-proportional hazard analysis demonstrated any ECG abnormality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.12 to 3.47, p=0.019), age (HR 1.03, 95%CI 1.01 to 1.05, p=0.0009), raised high sensitivity troponin I (HR 2.22, 95%CI 1.27 to 3.90, p=0.006) and low estimated glomerular filtration rate (eGFR) (HR 1.73, 95%CI 1.04 to 2.88, p=0.036) were independent predictors of in-hospital mortality.

In conclusion, any new ECG abnormality is a significant predictor of in-hospital mortality.

This review focuses on the role of CytoSorb® (CytoSorbents Corporation, Monmouth Junction, New Jersey, USA), a technology for purifying extracorporeal blood. The technology is designed for several indications to prevent bleeding complications during on-pump cardiac surgery, including removal of the antiplatelet agent, ticagrelor, and the oral anticoagulant, rivaroxaban, from the blood. Recent clinical studies are briefly reviewed.

Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period.

An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIED-related infection in the two years post-implementation. This was not statistically significant (p=0.093).

In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

The Fontan procedure provides a palliative surgical repair for complex congenital heart disease, but it is associated with many long-term problems, including liver cirrhosis, and hepatocellular carcinoma. The current suggestion from international guidance is that end-organ surveillance should be carried out, with a particular focus on regular blood tests and imaging for liver function.

In this study, retrospective analysis was performed on adult patients who had previously had a Fontan operation performed to determine the regularity of end-organ surveillance in regards to their liver function covering the three calendar years from 2016 to 2018, and the first six months of 2019.

Eighty-six patients were identified in South Wales monitored by the adult congenital heart disease unit. We found that the number of investigations performed in the first six months of 2019 was comparable to other calendar years in their entirety. Liver function tests had been performed in 57% of patients throughout 2018, with only 8% having had an alpha-fetoprotein taken, and only 9% having had imaging of the liver performed. Over the course of their lifetime, 97% of patients had had a liver function blood test performed at some point, with 17% having had an alpha-fetoprotein taken, and 49% having their liver imaged.

In conclusion, end-organ surveillance is an important follow-up for patients with a Fontan circulation, with guidelines proposing yearly blood test and imaging investigations. This study shows the opportunities to improve surveillance in this group of patients to highlight the development of liver cirrhosis, and/or hepatocellular carcinoma.

Exercise prevents and aids treatment of coronary heart disease, hypertension, heart failure, diabetes mellitus, obesity and depression, reduces cardiac events and improves survival. However, evidence suggests that the relationship between exercise and mortality may be curvilinear, with modest additional benefit at higher levels. Intensive exercise has also been associated with increased atrial fibrillation risk, although its clinical implications are not well understood. Other proposed adverse effects of exercise on the heart, including reduced right ventricular function, elevated cardiac biomarkers, myocardial fibrosis and coronary artery calcification, are less substantiated. Current evidence cannot affirm that extreme exercise is dangerous and future studies should combine large cohorts to obtain a statistically reliable limit. Associations between features of the athlete’s heart and cardiovascular morbidity and mortality should also be explored.

Control of hypercholesterolaemia is an effective way of reducing cardiovascular events in patients at elevated risk of cardiovascular disease. Repeat cholesterol measurement is a good practice, but is rarely performed, with clinicians often adopting a ‘fire and forget’ policy.

A retrospective audit at two cardiac centres in the West Midlands was performed to evaluate performance in lipid measurement following initiation of lipid therapy, and to evaluate whether all patients with an indication for a proprotein convertase subtisilin/kexin 9 inhibitor (PCSK9i) following acute coronary syndrome (ACS) were identified according to National Institute for Health and Care Excellence (NICE) recommendations.

We identified 167/7,048 patients with a total cholesterol of ≥7.2 mmol/L, of which 33 patients had previous vascular disease affecting more than one territory (polyvascular disease). Total cholesterol threshold ≥7.2 mmol/L was chosen in order to achieve a sufficient number of samples for the audit to be completed successfully. Low-density lipoprotein (LDL) level was performed in 93 patients on admission and repeated within three months in 20 patients (13%). Overall, 48 patients (30%) had any repeat LDL recorded. Of this group, 10 patients met the NICE criteria for PCSK9i.

Failure to repeat LDL levels in patients following hospital discharge with a diagnosis of ACS, is likely to explain the small number of patients identified as being eligible for PCSK9i. Underreporting of comorbid vascular disease also prevents the identification of patients at very high risk. We advocate re-establishing the practice of routine repeat fasting lipids measurement following discharge from hospital in order to correctly identify patients who may be eligible for optimal lipid-lowering therapy.