Clinical articles

Data for low-risk ST-elevation myocardial infarction (STEMI) patients in the Essex cardiothoracic centre (CTC) during a three-month period were evaluated and the average duration of admission was calculated to be 67.2 hours. The data were sifted by applying Second Primary Angioplasty in Myocardial Infarction (PAMI-II) criteria for low-risk STEMI patients who could be safely discharged after 48 hours. After application of a proforma as a quality improvement intervention tool, data were re-assessed and the average time of admission observed for a similar cohort of patients dropped down to an average of 55.2 hours. Overall, there was a 13% average increase in rate of early discharge for low-risk STEMI patients.

Exercise training is associated with positive health outcomes in people with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). However, fear of hypoglycaemia is a potential barrier to participants attending a cardiac exercise class. Therefore, we assessed the capillary blood glucose (CBG) responses to the Imperial NHS Trust cardiac exercise class.

Forty patients (median age 66 years, interquartile range [IQR] 57–74 years) with CVD and T2DM treated with insulin and/or sulfonylureas completed a cardiac exercise class. CBG was measured immediately before and after the exercise class. Subgroup analysis assessed CBG levels in patients who had consumed food <2 and ≥2 hours and had taken their insulin and/or sulfonylureas <4 and ≥4 hours before the exercise class.

Overall, post-exercise CBG had significantly decreased (–3.0 mmol/L, p≤0.0001). Subgroup analyses demonstrated significant reductions in CBG in both food consumption groups (<2 hours –2.9 mmol/L, p≤0.0001, and ≥2 hours –3.1 mmol/L, p≤0.0001) and medication groups (<4 hours –3.4 mmol/L, p≤0.0002, and ≥4 hours –2.7 mmol/L, p≤0.0001). However, there were no significant differences in CBG between the food consumption groups and the medication groups, respectively (p=0.7 and p=0.3).

Cardiac exercise classes resulted in significant reductions in CBG levels. However, the timing of food consumption or medication intake did not influence the magnitude of CBG decline after the cardiac exercise class.

The inflammatory component of ischaemic heart disease (IHD) is well recognised. An elderly male, following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI), had, otherwise unexplained, severely elevated C-reactive protein (CRP) prior to sudden cardiac death (SCD). Post-mortem showed only old infarct, no re-stenosis, and no evidence of inflammation elsewhere. The levels of CRP in this case are much higher than those documented previously in IHD. Current guidelines advocate for implantable cardioverter defibrillator (ICD) implantation after acute coronary syndrome (ACS) only in the context of left ventricular ejection fraction <35%, therefore, this patient would not qualify. Multiple risk-stratification tools have been developed to widen ICD prescription after ACS, but have not yet been integrated into the National Institute for Health and Care Excellence (NICE) guidelines. This case is a poignant reminder that we must widen ICD prescription, and CRP should be considered as a likely predictor.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly that can present as aortic insufficiency later in life. We report a case of aortic regurgitation associated with a QAV, treated by aortic valve replacement. The patient presented with breathlessness, lethargy and peripheral oedema. Echocardiography and cardiac magnetic resonance revealed abnormal aortic valve morphology and coronary angiography was normal. The presence of a quadricuspid aortic valve was confirmed intra-operatively. This was excised and replaced with a bioprosthetic valve and the patient recovered well postoperatively. Importantly, the literature indicates that specific QAV morphology and associated structural abnormalities can lead to complications. Hence, early detection and diagnosis of QAV allows effective treatment. Aortic valve surgery is the definitive treatment strategy in patients with aortic valve regurgitation secondary to QAV. However, the long-term effects and complications of treatment of this condition remain largely unknown.

In the UK, there is a difference between the medical specialties and cardiology in recruitment of women. Research, thus far, has concentrated on women already in cardiology. Although invaluable in understanding barriers to training, these studies fail to provide insight into why other trainees chose an alternative. Therefore, we designed a survey aimed at medical personnel, evaluating why higher trainees in other specialties overlooked cardiology.

An online survey was distributed via email to non-cardiology higher trainees in Wales. Questions covered previous clinical experiences of cardiology, interactions with cardiologists, and tried to identify deterrent factors.

There were 227 responses received over six weeks: 61.7% (n=137) female respondents, 23.5% (n=52) less than full-time. Of these, 49% completed a cardiology placement previously. Bullying was witnessed and experienced equally among genders, females witnessed and experienced sexism, 24% (n=24) and 13% (n=13), respectively. In contrast, male trainees witnessed and experienced sexism 14% (n=7) and 0%. There were 62% (n=133) who felt cardiologists and registrars were unapproachable. Work-life balance ranked first (40%), as the most important factor influencing career choice. The negative attitudes of cardiologists and registrars was ranked top 3 for not pursuing cardiology.

In conclusion, many barriers exist to cardiology training including poor work-life balance, sexism and lack of less than full-time opportunities. However, this survey highlights that the behaviour of cardiologists and registrars has the potential to impact negatively on trainees. It is, therefore, our responsibility to be aware of this and encourage change.

We provide the details of three cases utilising intravascular lithotripsy, a novel approach to percutaneous coronary intervention (PCI).

The utility of computed tomography (CT) coronary angiography (CTCA) is underpinned by its excellent sensitivity and negative-predictive value for coronary artery disease (CAD), although it lacks specificity. Invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR), are gold-standard investigations for coronary artery disease, however, they are resource intensive and associated with a small risk of serious complications. FFR-CT has been shown to have comparable performance to FFR measurements and has the potential to reduce unnecessary ICAs. The aim of this study is to briefly review FFR-CT, as an investigational modality for stable angina, and to share ‘real-world’ UK data, in consecutive patients, following the initial adoption of FFR-CT in our district general hospital in 2016.

A retrospective analysis was performed of a previously published consecutive series of 157 patients referred for CTCA by our group in a single, non-interventional, district general hospital. Our multi-disciplinary team (MDT) recorded the likely definitive outcome following CTCA, namely intervention or optimised medical management. FFR-CT analysis was performed on 24 consecutive patients where the MDT recommendation was for ICA. The CTCA + MDT findings, FFR-CT and ICA ± FFR were correlated along with the definitive outcome.

In comparing CTCA + MDT, FFR-CT and definitive outcome, in terms of whether a percutaneous coronary intervention was performed, FFR-CT was significantly correlated with definitive outcome (r=0.471, p=0.036) as opposed to CTCA + MDT (r=0.378, p=0.07). In five cases (21%, 5/24), FFR-CT could have altered the management plan by reclassification of coronary stenosis. FFR-CT of 60 coronary artery vessels (83%, 60/72) (mean FFR-CT ratio 0.82 ± 0.10) compared well with FFR performed on 18 coronary vessels (mean 0.80 ± 0.11) (r=0.758, p=0.0013).

In conclusion, FFR-CT potentially adds value to MDT outcome of CTCA, increasing the specificity and predictive accuracy of CTCA. FFR-CT may be best utilised to investigate CTCAs where there is potentially prognostically significant moderate disease or severe disease to maximise cost-effectiveness. These data could be used by other NHS trusts to best incorporate FFR-CT into their diagnostic pathways for the investigation of stable chest pain.

Cardiorenal syndrome is a complex condition associated with significant morbidity in the form of symptoms secondary to fluid overload, leading to hospitalisations, and portends increased mortality. Both the diagnosis and management of the conditions are complicated by the fact that there is dysfunction of the heart as well as the kidney, usually with uncertainty with regards to the timing of the first insult. Management in primary care, or in the emergency setting, tends to be predominantly focused on short-term improvement in function of one organ, leading to deleterious effects on the other. A consensus multi-disciplinary approach involving both cardiologists and nephrologists has been advocated in order to devise a unified management plan. Our report presents findings of monthly cardio-nephrology multi-disciplinary team meetings and illustrates that this can be an efficacious approach both in terms of avoiding unnecessary outpatient clinic visits, as well as consensus decision-making.

Ventriculophasic arrhythmia (VPA) is an intriguing electrocardiogram (ECG) phenomenon, often seen in patients with complete heart block, and could sometimes pose a challenging diagnostic dilemma for physicians. By definition, in VPA, the P–P intervals that contain a QRS complex are shorter than the P–P intervals that do not have a QRS complex. VPA is often a tell-tale ECG finding of complete heart block. We describe a case in which paroxysmal VPA led us to diagnose complete heart block.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibro-inflammatory immune-mediated disease, which has been defined in the past few years. IgG4-RD affects various organs and leads to a variety of clinical manifestations. As it is a relatively newly defined entity, new manifestations are now being recognised and reported. We describe a case involving the cardiovascular system.