Clinical articles

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.

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.