Clinical articles

The U-wave on electrocardiogram (ECG) is a small deflection following the T-wave, the sixth wave. It is 25% or less of the preceding T-wave in amplitude.^1,2 While the genesis of the U-wave is uncertain, it is said to represent repolarisation of the Purkinje fibres.^1,2 Disproportionally large U-waves may indicate underlying cardiac or non-cardiac pathology. A relatively frequent cause for a large U-wave is hypokalaemia. It is observed in patients with bradycardia, ventricular hypertrophy, hypothyroidism, hypocalcaemia, hypomagnesaemia, mitral valve prolapse, hypothermia, increased intracranial pressure, or patients on anti-arrhythmic medicine.² A negative U-wave, on the other hand, may represent early myocardial ischaemia, specifically in the context of a lesion in the left main or proximal left anterior descending coronary artery.^2,3

Digital healthcare is being introduced to the management of heart failure as a consequence of innovations in information technology. Advancement in technology enables remote symptom and device monitoring, and facilitates early detection and treatment of heart failure exacerbation, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems. Although promising, there is, as yet, insufficient evidence to support the widespread implementation of digital healthcare. Patient-related barriers include user characteristics and health status; privacy and security concerns; financial costs and lack of accessibility of digital resources. Physician-related barriers include the lack of infrastructure, incentive, knowledge and training. There are also a multitude of technical challenges in maintaining system efficiency and data quality. Furthermore, the lack of regulation and legislation regarding digital healthcare also prevents its large-scale deployment. Further education and support and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure.

The ASPirin in Reducing Events in the Elderly trial (ASPREE) contributed important knowledge about primary cardiovascular disease (CVD) prevention among healthy older adults. The finding that daily low-dose aspirin (LDA) does not statistically prevent disability or CVD among adults aged over 70 years when compared with placebo, but does significantly increase risk of haemorrhage, immediately influenced clinical practice guidelines. In this article, we discuss nuances of the trial that may impact the extrapolation of the ASPREE trial results to the everyday individual clinical care of older adults.

A 78-year-old man presented to the emergency department with recurrent episodes of syncope precipitated by a variety of strong aromas. He denied chest pain, breathlessness or palpitations. There were no headaches, no blurred vision or limb weakness or seizure-like activity. On recovery, he had no post-ictal symptoms. He was initially discharged after initial investigations, including electrocardiogram (ECG), were normal. On the way to the main entrance, while passing cleaning equipment (which included strongly smelling bleach), he experienced a further syncopal episode. He was taken into the resuscitation bay, attached to cardiac monitoring and referred to the medical on-call team. When approached by the medical registrar on call (who was wearing ‘powerful’ aftershave), the patient commented the scent was precipitating a further attack. The registrar reviewed the cardiac monitor captured in figure 1 and witnessed a prolonged pause followed by asystole. Cardiopulmonary resuscitation (CPR) was commenced for approximately one minute, at which point there was a spontaneous recovery of cardiac output and a quick recovery to baseline.

Aldosterone/renin ratio (ARR) is commonly used to screen for primary hyperaldosteronism (Conn’s disease). A number of drugs can alter ARR measurements, thus requiring omission before testing. However, hormonal agents such as the combined oral contraceptive (COCP) or progestogen-only pill (POP) are not listed for omission. A 20-year-old woman was referred to the endocrinology team, following investigations for syncope by her cardiologist, when ARR was found to be elevated. She was taking POP (Cerelle^®) while having ARR measured. After omitting POP for four weeks, plasma aldosterone concentration was reduced by 52% (from 560 pmol/L to 271 pmol/L, reference range: 100–450 pmol/L), plasma renin concentration increased by 253% (from 3.6 mU/L to 12.7 mU/L, reference range: 5.4–30 mU/L) and ARR reduced from 156 to 21 (–86.5%) (reference range: <80 suggests Conn’s unlikely). To the best of our knowledge, this is the first reported case of POP-related false-positive ARR screening for primary hyperaldosteronism. Omission of POP should, therefore, be considered in women undergoing ARR measurement.

Recent advances in immune therapy for cancer have significantly improved the clinical outcomes of patients with advanced cancers, where prognosis has historically been very poor. With these new treatments have come new toxicities and, as the use of immunotherapy increases, we will see an increasing incidence of immune-related adverse events, with patients presenting as an emergency. It is important that all cardiologists, and other physicians who see these patients, are aware of life-threatening immune-related toxicities, in addition to their recommended investigation and treatment.

We describe a patient with acute cardiotoxicity secondary to immune therapy to illustrate the complexity of these adverse cardiovascular events, providing recommendations for screening, diagnosis and management.

This short review of cardiac tumours presents a case that clearly demonstrates the manifestation of embolic and cardiac symptoms of an intracardiac mass. Acute onset and rapid progression of a neoplastic process in the heart leading to arrhythmia, cardiac conduction disorders and heart failure combined with highly mobile fragments of tumour, which can cause emboli in cerebral vessels, are characteristic signs of an intracardiac mass. Early diagnosis and immediate treatment may improve the long-term prognosis, but overall the prognosis is poor. Cardiac tumours present to the cardiologist when the patient presents with cardiac symptoms, and the neurologist when there are cerebral symptoms. Most cardiac masses are not amenable to percutaneous biopsy; therefore, definitive diagnosis often awaits surgical excision.

A 52-year-old man, previously fit and well, presented with myocardial infarction complicated by ischaemic ventricular septal defect (VSD) and acute right ventricular failure, was successfully treated with early percutaneous coronary reperfusion, surgical VSD repair and temporary right ventricular assist device (VAD) support.

This case is an example of how a modern healthcare system can successfully manage complex emergency cases, combining high levels of clinical care and medical technology. Access to temporary mechanical support played a vital role in this case. We believe that wider access to VADs may contribute to improvement in the, widely recognised, poor outcome of ischaemic VSD.

Depressive symptoms in coronary artery disease (CAD) are known to associate with increased mortality. We evaluated management of depression screening in the outpatient setting for patients with known CAD at ambulatory visits. We assessed whether depression screening was performed with a patient health questionnaire, as well as what was done with positive results. Our study identified 355 patients who visited an ambulatory primary care clinic over a three-year period, 57% of whom were screened at least once. Positive scores for depression were found in 20% of patients screened, with 54% of screening-positive patients given plans for additional care. We found disparities between screening rates, with whites screened least for depression, as well as in management plans, with whites given highest probability of mentioned treatment in their assessment and plan if depression screening was positive. Given the association with increased mortality in known CAD, depression screening may represent an opportunity to decrease health outcomes disparities and to improve outcomes for patients with CAD in the outpatient setting.

A syncope pathway for secondary care was launched in the Queen Elizabeth University Hospital (QEUH), Glasgow, in 2016. The pathway aims to risk stratify patients into three categories: high risk (requiring admission), intermediate risk (suitable for discharge ± outpatient review) or low risk (no further investigation required). There are clear referral procedures to the rapid access syncope clinic (RASCL). Our aim was to assess the impact of the pathway on unscheduled care in terms of admission rates, length of stay and referrals to RASCL.

Data were collected on three occasions: before the introduction of the pathway, immediately after and again 14 months later. Those patients with a diagnostic ICD-10 code of ‘syncope and collapse’ or ‘orthostatic hypotension’ presenting to the QEUH (both emergency department and immediate assessment unit, via GP referral) were identified.

There were 779 patients identified, 538 were included for analysis once other diagnoses were excluded: 46% were male with an age range from 16 to 95 years with a median age of 65.5 years.

All high-risk patients were admitted. For intermediate-risk patients the admission rate fell from 62% to 52% immediately after pathway introduction and after one year to 42%, suggesting sustained improvement (p=0.08). Admission for low-risk patients after one year of pathway roll out fell from 27% to 12% (p=0.04). The median length of stay prior to introduction was three days, this fell to one day one-year post-pathway, saving 56 bed days per month.

In conclusion, a syncope pathway and RASCL has reduced admission of low-risk patients, provided appropriate follow-up for intermediate risk, and reduced length of stay for those requiring admission.