Clinical articles

Patients with heart failure with reduced ejection fraction (HFrEF) who received the sodium-glucose co-transport 2 inhibitor, dapagliflozin, in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) study have a significant reduction in worsening heart failure (HF) and cardiovascular death. It is uncertain what proportion of patients admitted to a large regional cardiac centre with decompensated heart failure would be eligible for dapagliflozin post-discharge based on their characteristics at discharge.

The DAPA-HF study criteria were retrospectively applied to a cohort of 521 consecutive patients referred to the inpatient HF service in a tertiary cardiac centre in South West Wales between April 2017 and April 2018. Inclusion criteria: left ventricular ejection fraction (LVEF) <40%, New York Heart Association (NYHA) class II–IV symptoms and an elevated N-terminal pro-B-type naturietic peptide (NT-proBNP). Exclusion criteria: systolic blood pressure (SBP) <95 mmHg, estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m² or type 1 diabetes mellitus. We did not have complete NT-proBNP data for the cohort, as it was not routinely measured at the time in our institute.

There were 478 patients, mean age 78 ± 13 years, 57% male and 91% NYHA class II–IV symptoms, were included in the analysis. Of these, 247 patients had HFrEF, 219 (46%) patients met the inclusion criteria, 231 (48%) were excluded as LVEF was >40%, and 48 (10%) were excluded with NYHA class I symptoms. Of the 219 patients who met the inclusion criteria, 13 (5.9%) had a SBP <95 mmHg, 48 (22%) had eGFR <30 ml/min/1.73 m², leaving 136 (28.5% of total and 55% of those with HFrEF) who met DAPA-HF study criteria.

In our study, 28.5% of all heart failure admissions and 55% of patients with HFrEF would be eligible for dapagliflozin post-discharge according to the DAPA–HF study entry criteria.

Takotsubo cardiomyopathy (TCM) was first described about 30 years ago. It has been attributed to the sudden catecholamine surge in relation to severe stress, which can cause multi-vessel coronary spasms and myocardial apical ballooning. Football supporters are prone to develop severe stress due to sudden changes in match results. This case presents a football supporter of Sheffield United (the Blades) who was admitted to the hospital with cardiac sounding chest pain following a last minute goal by the opposing team. The necessary investigations were carried out including coronary angiogram and echocardiogram. He was diagnosed with TCM following a left ventricular angiogram demonstrating the typical appearance of the octopus pot.

Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.

During the recent ‘first wave’ of the COVID-19 pandemic, the National Health Service (NHS) has triaged planned services to create surge capacity. The primary prevention implantable cardioverter-defibrillator (ICD) was in a grey area of triage guidance, but it was suggested as a procedure that could be reasonably stopped. Recent reports have highlighted deaths of patients awaiting ICDs who may have been deferred during the pandemic. In our trust we reorganised our device service and continued to implant primary prevention ICDs during the ‘first wave’ and, here, report that most patients wished to proceed and underwent uncomplicated implantations. One patient later died from COVID-19, although the transmission site cannot be definitively concluded. With strict adherence to public health guidance and infection prevention strategies, we believe that ICD implantation can be performed safely during the pandemic, and this should be standard practice during subsequent surges.

Papillary fibroelastomas (PFE) are rare benign cardiac tumours mainly originating on aortic and mitral valvular surfaces. Management is individualised, but most recommend surgical excision due to thromboembolic risk. We report a 75-year-old man with symptomatic severe aortic stenosis compounded by PFE. Redo sternotomy aortic valve replacement was deferred in favour of the trans-apical (TAVR) approach. This report highlights, for the first time, the application of TAVR as a strategy for aortic valve stenosis and PFE to mitigate risk posed by injury to patent internal mammary arterial graft in close proximity to the manubrium, and complications due to the patient’s multiple comorbidities.

This article is available as a ‘Standalone BJC Learning module’ CPD activity

Background

Cardiac amyloidosis (CA) is a disorder of protein misfolding with resultant accumulation within the myocardium ultimately leading to clinical heart failure. It is subcategorised, according to the type of misfolded protein, into primary light-chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). AL-CA is the result of cardiac infiltration of misfolded light-chain proteins; whereas ATTR-CA is caused by cardiac deposition of the misfolded thyroid hormone transport protein, transthyretin. ATTR-CA can be further subcategorised into hereditary (hATTR) versus wild-type (wtATTR).^1,2 Although the exact prevalence of ATTR-CA is unknown, it has become increasingly accepted as a common cause of heart failure, particularly in the elderly. Despite this knowledge, ATTR-CA remains a widely underdiagnosed cause of heart failure, and there are frequently delays to achieving the accurate diagnosis. Prompt recognition and early diagnosis of ATTR-CA is critical to decreasing morbidity and mortality, particularly as disease-modifying therapies emerge in the treatment of ATTR-CA. We present a case of ATTR-CA that remained undiagnosed until later disease stages and we will subsequently review the diagnostic evaluation of patients with suspected ATTR-CA.

This article is available as a ‘Standalone BJC Learning module’ CPD activity

Transthyretin amyloidosis (ATTR) is a progressive, fatal disease in which deposition of amyloid derived from either mutant or wild-type transthyretin (wtATTR) causes progressive and severe organ dysfunction. The two key clinical phenotypes are transthyretin amyloid cardiomyopathy (ATTR-CM) or transthyretin amyloid polyneuropathy (ATTR-PN), which both carry significant morbidity and mortality. Hereditary ATTR amyloidosis frequently presents with a mixed phenotype (ATTR-mixed).

ATTR-CM is an infiltrative, restrictive cardiomyopathy characterised by congestive cardiac failure, often with preserved left ventricular ejection fraction, and significant risk of conduction disease.

Treatment focuses on supportive care, reduction and ideally elimination of transthyretin (TTR) from the plasma, stabilisation of the tetramic structure of TTR and dissolution of the existing ATTR amyloid matrix.

Liver transplantation, to remove variant TTR production remains a treatment option for a select cohort of patients with hereditary ATTR-PN, although it is likely to be replaced by novel RNA-targeting therapies aimed at reducing TTR production. TTR stabilisers, such as tafamidis and acoramidis, may offer disease-modifying therapy to the majority of elderly patients with wild-type ATTR-CM. The rapidly evolving landscape of treatment options for ATTR amyloidosis, particularly among older patients with wtATTR, validates improved efforts to diagnose ATTR-CM.

Introduction

Hyperkalaemia (HK) in heart failure and chronic kidney disease patients limits the use of renin–angiotension–aldosterone system (RAAS) inhibitors, and successful intervention may allow patients to remain on optimal RAAS therapy. The management of HK is an established practice, but the increasing popularity of novel potassium binders may represent an effective and better-tolerated alternative compared with conventional therapy, such as sodium polystyrene sulfonate.¹

This article reviews the efficacy, and safety profile of patiromer and sodium zirconium cyclosilicate (SZC), and summarises the National Institute for Health and Care Excellence (NICE) guidance for both agents.^2,3

A wide range of medications including antimalarial preparations (chloroquine, hydroxychloroquine), macrolide antibiotics (azithromycin) and the interleukin-6 inhibitor (tocilizumab) may be effective in treating patients with coronavirus disease 2019 (COVID-19). Such agents may be associated with cardiotoxicity, and the purpose of this brief review is to draw attention to potential areas of pharmacovigilance. These include prolongation of the QT-interval and the development of occult cardiomyopathy. Alternatively, some of the agents seem to have minimal impact on the cardiovascular system. The review highlights the need for an ongoing evaluation of such agents within carefully constructed clinical trials with embedded attention to cardiovascular safety.

The reason to be cautious when evaluating curative or symptomatic treatments is the fact that SARS-CoV-2 has affected large segments of the population, with disproportionate mortality rates within certain subgroups. Some of the enhanced mortality may reflect inherent cardiovascular disease risk factors related to acute COVID-19 infection.

It is hoped that the review will stimulate a greater awareness of potential cardiovascular side effects and encourage reporting of those in future trials.

Around 7.4 million people in the UK have heart and cardiovascular disease, coronary artery disease (CAD) being the most common type. The Driving and Vehicle Licensing Agency (DVLA) has guidance for medical professionals to aid assessment of cardiac patients with respect to driving. The guidance is different for personal, Public Carriage Office (PCO) and goods vehicles. It remains the doctors’ responsibility to advise patients of any driving restrictions, as certain cardiac conditions can limit patients’ ability to drive. This gains importance especially after certain procedures. A retrospective review of discharge summaries from electronic medical records was undertaken for a period of three months to review the number of patients getting appropriate advice. It was noted that frequently no written driving advice was recorded on discharge, neglecting an important element of patient safety. Steps were taken to counteract the lack of proper driving advice and documentation, which were effective on second review. Therefore, measures similar to ones outlined here should be put in place to ensure safe discharge and knowledge of the clinicians in accordance with the DVLA guidance.