Clinical articles

National guidelines on lipid modification for cardiovascular disease advise checking a lipid profile in all patients admitted with acute coronary syndrome (ACS). It has been demonstrated that ACS can impact lipid profiles in an unpredictable fashion, so cholesterol measurements should be taken within 24 hours of an infarct. National guidelines also recommend initiating early high-intensity lipid-lowering therapy (i.e. statins) in ACS for secondary prevention of cardiovascular disease. We first assess compliance with these guidelines in a large city-centre teaching hospital and identify the need for any improvement. Following varied interventions aimed at highlighting the need for adherence to these guidelines we demonstrate a large increase in the number of ACS patients having lipids checked within 24 hours of their admission. In some instances, baseline cholesterol was not measured (either at all or prior to statin therapy), potentially leaving familial and non-familial hypercholesterolaemia undiagnosed. Encouragingly, statins are already prescribed in accordance with guidelines for the majority of ACS patients regardless of our campaign. We ultimately demonstrate there is still much work to be done locally to improve cholesterol management in ACS and hope that our findings will encourage others to ensure compliance and ultimately improve patient outcomes.

Emergency transvenous temporary pacing is a potentially lifesaving procedure that can be associated with significant complications. Historically, this procedure was performed by relatively inexperienced doctors. In recent years, there have been moves to improve the delivery of emergency pacing in UK hospitals.

We aimed to identify trends in temporary pacing experience among medical registrars in the southwest of England between 2008 and 2016. Registrars currently or previously accrediting with General Internal Medicine (GIM) were surveyed about experience in emergency transvenous pacing.

There have been significant changes in the delivery of temporary pacing over the two time points. Significantly fewer temporary pacing wires had been inserted by medical registrars in 2016 compared with 2008: mean 4.51 versus 9.82 (p<0.0001). Significantly more medical registrars had never inserted a temporary pacing wire in 2016 compared with 2008: 57/84 (67.9%) versus 18/94 (19.1%), p<0.0001. Registrars increasingly did not rate themselves to be fully competent to perform the procedure in 2016, 76/84 (90%), compared with 54/92 (59%) in 2008, p=0.0097. Perceptions regarding who should provide this service have changed. In 2008, 65/92 (79.6%) thought cardiologists should be the sole operators compared with 81/84 (96.4%) in 2016.

In conclusion, there has been a significant change in the provision of emergency temporary pacing services from 2008 to 2016. UK medical registrars no longer have the experience to perform this procedure. It is hoped that a rapidly delivered, cardiology-led pacing service will continue to improve safety and patient care.

New York Heart Association (NYHA) class IV heart failure is one of the factors used in predicting in-hospital mortality in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of systolic heart failure (SHF), aside from NYHA classification, on peri-procedural outcomes is unclear.

The study population was identified from the 2016 Nationwide Readmissions Data database using International Classification of Diseases-Tenth Revision codes for TAVR and SHF. Study end points included in-hospital all-cause mortality, the length of hospital stay, cardiogenic shock, acute myocardial infarction (AMI), acute kidney injury (AKI), mechanical complications of prosthetic valve, bleeding, and 30-day readmission rate. Propensity matching was used to create a control group of TAVR patients without a SHF diagnosis (TAVR-C).

A total of 5,674 patients were included in each group (mean age 79.9 years; 35.6% female). The groups were comparable in terms of baseline characteristics and comorbidities. TAVR-SHF was associated with significantly higher in-hospital all-cause mortality (2.7% vs. 1.9%, p<0.01), longer hospital stay (7.5 vs. 5.5 days, p<0.01), higher cardiogenic shock (5.1% vs. 1.6%, p<0.01), AMI (4.0% vs. 1.9%, p<0.01), AKI (18.7% vs. 12.4%, p<0.01) and mechanical complications of prosthetic valve (1.2% vs. 0.6%, p<0.01). There was no significant difference between TAVR-SHF and TAVR-C in terms of bleeding (19.5% vs. 18.2%, p=0.08) and 30-day readmission rate (10.8% vs. 10.2%, p=0.29).

Compared with TAVR-C, TAVR-SHF was associated with higher in-hospital peri-procedural complications and all-cause mortality.

The frontal QRS-T angle (QTA) is widely available on routine 12-lead electrocardiograms (ECGs), but its practical significance is little recognised. An abnormally wide QTA is known to be a prognostic predictor of cardiovascular events. It has even been considered as a stronger prognostic predictor than the commonly used ECG parameters including ST-T abnormality and QT prolongation. The aim of this study was to investigate the influence of ageing on the QTA in a low-risk population where there were no obvious ECG abnormalities. Having analysed 437 consecutive patients, we found a positive correlation between age and QTA, but no age difference in heart rate, QRS duration, QT interval and P-wave axis. As hypertension was more prevalent in older patients, we compared patients with hypertension to those without and found no significant difference in QTA. Therefore, ageing alone is a significant contributory factor to the widening of QRS-T angle. Further study to confirm QTA as a prognostic predictor for all-cause mortality, independent of age itself and in the absence of ECG abnormalities, in an older population would be significant.

Cardiac magnetic resonance (CMR) imaging has developed into a crucial diagnostic tool in all patients with known or suspected heart disease. The aim of this study was to review real-world data regarding the case mix and performance of stress CMR for the large Essex region, a population of 1.4 million.

All studies from April 2017 to April 2018 were reviewed. All scans were performed on a 1.5-T scanner (Siemens MAGNETOM Aera). We have not included research scans or repeat studies. A total of 1,706 clinical studies were performed, including 592 adenosine stress perfusion scans (35%). Mean age of patients was 59 years ± 16 (range 16–97) and the majority were male (66%). Ischaemic heart disease (IHD) was diagnosed in 28% of patients. Objective ischaemia was evident in 226 cases (38% of all stress scans). The positive predictive value of stress imaging was 91%. Non-ischaemic cardiomyopathies were diagnosed in 598 patients (35%), including dilated cardiomyopathy (DCM, 23%) and hypertrophic cardiomyopathy (HCM, 8%) as the most common phenotypes. The mean left ventricular ejection fraction (LVEF) was 51% across all groups (range 3–78%) with a significant difference between ischaemic and non-ischaemic cardiomyopathy (48% vs. 41%, p<0.0001); despite this, there was no significant difference in survival (p=0.177).

In conclusion, stress perfusion imaging accurately identifies true-positive ischaemia, as well as offering additional information regarding cardiac structure. The burden of non-ischaemic cardiomyopathy in Essex is significant, with 50 new diagnoses per month, across five hospitals. Coordination of services is needed to standardise practice and management of cardiomyopathy patients.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have opened a new avenue in the management of dyslipidaemia in patients with familial hypercholesterolaemia (FH), but real-world experience with PCSK9 inhibitors is limited.

We aimed to explore the efficacy and safety of PCSK9 inhibitors in a single-centre study, and to conduct a meta-analysis of the available observational studies to report pooled data on these efficacy and safety parameters.

The Hull PCSK9 inhibitor study consisted of patients from the Lipid Clinic at the Hull Royal Infirmary–Hull University Teaching Hospitals NHS Trust during the period 2016–2018. Patients with FH and atherosclerotic cardiovascular disease (ASCVD) were screened for eligibility and were prescribed PCSK9 inhibitors. Lipid profile, liver function, renal function, and creatine kinase levels were measured at baseline and after a 12-week follow-up. For the meta-analysis, review of the literature identified six additional observational studies for FH, which were used to calculate pooled percentage low-density lipoprotein (LDL)-cholesterol (LDL-C) reduction.

The Hull PCSK9 inhibitor study consisted of 16 patients with definite FH (LDL-receptor mutation-positive), 20 patients with clinical FH and 15 patients with ASCVD with a mean age of 60.6 ± 13.9 years, 60% female. Baseline median (interquartile range) LDL-C levels (mmol/L) in the definite FH, clinical FH and ASCVD were 4.9 (4.6–5.9), 6.7 (5.3–7.1) and 4.4 (4.1–4.7). After 12 weeks, the LDL-C levels (mmol/L) dropped significantly (p<0.0001) in all three groups to 2.0 (1.6–3.4), 2.3 (1.9–2.6) and 2.2 (1.7–2.8) in the definite FH, clinical FH and ASCVD groups, respectively. The meta-analysis of the seven observational studies in 446 patients with FH showed pooled mean reduction of 55.5 ± 18.1% in the LDL-C levels, with 58% of patients reaching treatment targets. Treatment-associated side effects occurred in 6% to 45% of patients, and 0–15% of patients discontinued treatment due to intolerable side effects.

In conclusion, we showed that PCSK9 inhibitors are overall well-tolerated when used in real-world settings, and their efficacy is comparable with that reported in clinical trials. Longitudinal population-based registries are needed to monitor responses to treatment, treatment adherence and side effects of these lipid-lowering agents.

Cardiac tamponade and myocardial infarction (MI) are rare as the initial presentation of a malignancy. ST-elevation myocardial infarction (STEMI) and cardiac tamponade have been described to present together in the setting of a type-A aortic dissection causing coronary malperfusion. We describe a case with an atypical presentation of an MI due to a thrombus in the right coronary artery occurring simultaneously with a pericardial effusion causing tamponade physiology, related to malignancy. We present this unique case of MI and cardiac tamponade as it was not caused by a type-A aortic dissection. We suggest that malignancy be considered in the differential diagnosis when these findings present together.

The management of aortic stenosis has dramatically changed over the last 60 years. We briefly describe these remarkable advances from the personal perspective of Anthony P C Bacon (APCB) who was one of the first physicians to observe the importance of this pathological process and who watched, first-hand, some of the first surgical aortic valve procedures being performed in the UK. He most recently benefited from treatment with transcatheter aortic valve implantation (TAVI) himself, and provides a personal perspective of his experiences.

This article is available as a ‘Learning with reflection’ CPD activity

In November 2016, the National Institute for Health and Care Excellence (NICE) published an update of its guideline for the investigation of chest pain of recent onset (CG95), bringing computed tomography coronary angiography (CTCA) to the forefront as the first-line investigation. CTCA has a high negative-predictive value for the identification of obstructive coronary artery disease (CAD), but its positive-predictive value may be as low as 48%. Moreover, until recently it was unable to determine the functional significance of stenoses identified by CTCA. Using advanced computational fluid dynamics (CFD), HeartFlow® has pioneered a system that can predict the invasive fractional flow reserve (FFR) from a standard CTCA acquisition (FFR_CT). The PLATFORM study has demonstrated that the use of CTCA with FFR_CT was associated with equivalent clinical outcomes in terms of major adverse cardiovascular events (MACE) and quality of life at one year compared with usual testing. The global ADVANCE registry, and other long-term follow-up studies in over 9,000 patients, have demonstrated extremely good long-term outcomes when patients with CAD but negative FFR_CT are managed conservatively without invasive testing. In a technology appraisal (MTG32), NICE projected that the adoption of this technology within the NHS in England could save at least £9.1 million by 2022. While it is accepted that the HeartFlow® FFR_CT shows a lot of promise, there are a number of limitations that need to be considered.

Radial artery access coronary angiography is associated with high procedural success and lower rates of complications, compared with femoral access, in patients without prior coronary artery bypass surgery (CABG). Whether or not this applies to patients who have undergone CABG is not known.

We retrospectively examined hospital records of 5,993 consecutive patients undergoing coronary angiography to identify patients with previous CABG undergoing the procedure by the radial or femoral access routes. We compared clinical characteristics, procedural success and complications up to 30 days, adjusting for significant baseline differences.

Among the 5,993 patients undergoing angiography, 471 (8%) had previous CABG; 164 (35%) underwent angiography by the radial and 307 (65%) by the femoral artery. Procedural success was lower in the radial than femoral groups; 28/164 (17%) radial versus 1/307 (0.3%) femoral patients required access-site cross-over (p<0.001) and 254/347 (73%) versus 496/594 (84%) bypass grafts were selectively identified without the need for further imaging investigations (p=0.008), respectively. Access-site bleeding requiring compression affected 1/164 (0.6%) in the radial group and 12/307 (3.9%) in the femoral group (p=0.04 for difference) with no significant differences in other major complications.

About one in 12 patients undergoing coronary angiography have had previous CABG surgery. In such patients, the radial access route was associated with lower procedural success than the femoral route but also a lower rate of bleeding complications.