Clinical articles

Sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are established glucose-lowering and weight-lowering agents used in the management of type 2 diabetes mellitus and obesity. Several recent clinical trials have provided evidence that these agents can decrease the risk of, and slow progression of, cardiovascular and renal diseases independently of their glucose-lowering and weight-lowering effects. In clinical trials and ‘real-world’ observational studies in people with and without diabetes, SGLT2 inhibitors have offered protection against heart failure and chronic kidney disease, while GLP-1 receptor agonists have been associated with reductions in atherosclerotic cardiovascular events and albuminuria. Based on this evidence, SGLT2 inhibitors and GLP-1 receptor agonists can now be considered for use beyond diabetes and obesity as new treatment options in the management of cardiorenal disease.

Clinical trials and observational studies have demonstrated that long-term systolic blood pressure variability derived from repeated measurements of visit-to-visit clinic blood pressure is an important predictor of cardiovascular outcomes, independent of average levels of systolic pressure. Even in patients with well-controlled blood pressure (<140/90 mmHg), high systolic blood pressure variability confers an increased risk of cardiovascular events. Systolic blood pressure variability is currently derived from several measurements of visit-to-visit clinic blood pressure and expressed as the standard deviation of systolic pressure. Values in excess of 12 are indicative of high systolic blood pressure variability. Ongoing studies aim to determine whether home blood pressure monitoring may be an alternative way of measuring blood pressure variability. Evidence from several clinical trials shows that long-acting calcium-channel blockers, such as amlodipine, and thiazide-like diuretics are the only antihypertensive drugs that reduce long-term systolic blood pressure variability, and should be used preferentially in patients with high variability.

Subclavian venoplasty is commonly performed for subclavian vein stenosis in patients with long-term dialysis lines or fistulae. Such stenosis may also occur in patients with previously implanted intra-cardiac devices. It poses a problem if a further device upgrade or implantation is planned as the stenosis restricts the advancement of leads. Venoplasty before device implantation may provide a feasible alternative to lead tunnelling or extraction, which have their limitations. Four cases of varying complexities and devices that were implanted in patients with subclavian stenosis are presented herein. These were done in a district general hospital within the cardiology team. Venoplasty was performed using peripheral angioplasty balloons after which the device was implanted. All cases were performed successfully without any immediate complications with the patients discharged home the same day. These cases show the utility of subclavian venoplasty in facilitating device implantation without the need to utilise contralateral venous access, hence preserving venous access for the future. Additionally, they illustrate that this may be performed locally in a district general hospital setting, where appropriate expertise is available, with a high success rate and without the need to refer patients to an alternate tertiary care institute which may be associated with additional difficulties for the patient. To the best of our knowledge, this is the first instance where several cases of this procedure were performed successfully in a secondary care setting.

Pathogenic genetic variants in the HCN4 (hyperpolarisation-activated and cyclic nucleotide-gated channel) gene can cause sinus node dysfunction, disrupting the function of the pacemaker region of the heart. Patients with such variants can present with a wide spectrum of arrhythmias but sudden death is generally considered rare. We report two cases from the same family with different outcomes to highlight a potential high-risk phenotype in HCN4-related disease.

Heart failure (HF) is a prevalent and complex condition that demands precise and efficient management. This paper delves into a critical, yet often under-recognised, challenge in HF care – the accurate coding of patients on HF registers. We explore how discrepancies in coding, including missing patients and incorrect HF type classifications, can significantly impact patient management. The experiences of our healthcare system’s staff are examined to shed light on the real-world implications of these issues.

Clinicians and administrative staff in primary care can play a pivotal role in identifying, monitoring, and ensuring the accuracy of patient coding. By sharing their insights, we uncover the intricacies of addressing coding discrepancies and strategies suggested to optimise patient management. Furthermore, we investigate the technology and systems in place to aid staff in this endeavour.

This paper aims to contribute to the broader healthcare community’s understanding of the challenges related to coding accuracy in HF registers and to offer insights into potential solutions. By rectifying these coding discrepancies, we can enhance patient care, minimise potential oversights, and ultimately improve outcomes for individuals living with HF. Our findings underscore the significance of ensuring that no HF patient is missed or misclassified, emphasising the need for continued improvement in this vital aspect of HF care.

In this four-part editorial series, we have looked at the significance of research within cardiology training in the UK. The first three instalments explored the impact of research on a career in cardiology, identified the diverse research avenues, and provided guidance on navigating the application process. In the final part of this series, our focus shifts to post-higher degree opportunities within the field, and discuss the skills developed in research that can be applied to clinical practice.

In recent years, artificial intelligence (AI) has been used to improve the precision of valvular heart disease diagnosis and treatment. It has the ability to identify and risk stratify patients with valvular heart disease and holds promise in improving the innovation of new treatments through shorter, safer and more effective clinical trials. AI can help to guide the treatment of patients with valvular heart disease, by aiding in optimal device selection for transcatheter valvular interventions and, potentially, predicting the risk of specific complications. This review article explores the various potential applications of AI in the diagnosis and treatment of valvular heart disease in more detail.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce cardiovascular rehospitalisation in heart failure with reduced ejection fraction (HFrEF) patients. However, it is unknown whether initiating SGLT2i during an inpatient stay for a HFrEF exacerbation results in better outcomes versus initiation post-discharge in a cohort of diabetic and non-diabetic patients. This study compares cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death between patients initiated on SGLT2i as an inpatient versus post-discharge.

A retrospective study of four hospitals in England involving 184 patients with HFrEF exacerbations between March 2021 and June 2022 was performed. Cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death were compared between the two groups using Cox regression. A Cox proportional-hazards model was fitted to determine predictors of cardiovascular rehospitalisation.

There were 148 (80.4%) individuals who received SGLT2i as an inpatient, while 36 (19.6%) individuals received SGLT2i post-discharge. Median follow-up was 6.5 months for inpatients and 7.5 months for post-discharge patients (p=0.522). SGLT2i inpatients had significantly reduced cardiovascular rehospitalisations (22.3%) versus post-discharge patients (44.4%) (p=0.005), and significantly reduced heart failure specific rehospitalisations (10.1%) versus post-discharge patients (27.8%) (p=0.018). There was no significant difference in all-cause death (p=0.743) and cardiovascular death (p=0.816) between the two groups. Initiating SGLT2i post-discharge was an independent predictor of cardiovascular rehospitalisation (hazard ratio 2.40, 95% confidence interval 1.31 to 4.41, p=0.005).

In conclusion, inpatient SGLT2i initiation for HFrEF exacerbations may reduce cardiovascular and heart failure specific rehospitalisation versus initiation post-discharge. In the absence of contraindications, clinicians should consider initiating SGLT2i once patients are clinically stable during inpatient HFrEF admissions.

Atrial fibrillation (AF) is responsible for significant patient morbidity, and obesity is a major contributor to AF incidence and symptom burden. Weight loss has been shown to positively modify AF symptoms, but weight loss in a real-world population is often only temporary. This randomised study set out to examine if smartphone-based app technology could increase weight loss in a patient population with obesity and AF.

Individuals were screened following outpatient referral to Leeds Teaching Hospitals NHS Trust for symptomatic AF. Block randomisation was performed to allocate the treatment groups to either clinical follow-up or app-based follow-up, with weight loss updates planned fortnightly. Patients randomised to clinical follow-up received nurse-led telephone calls every two weeks, while those in the app arm received automated reminder messages every two weeks. Final follow-up at six months included clinical and weight data and a quality-of-life questionnaire.

Sixty-four patients underwent randomisation. No significant difference in weight loss was seen between the groups. Patient engagement was far more consistent in the telephone follow-up group.

In conclusion, no significant difference in weight loss was seen between the two groups, despite patient education on the value of weight loss to improve their AF symptoms.

Obesity is a global pandemic and is a recognised risk factor for cardiovascular diseases. However, its impact on cardiac structure and function using echocardiography, as well as its association with anthropometric parameters in otherwise healthy individuals, requires further investigation. Therefore, we conducted an observational study with a cohort of 196 participants, comparing various echocardiographic parameters in normal weight individuals and those who were overweight or obese but had no other risk factors. Our findings revealed that obese participants had significant changes in echocardiographic measurements of the structure and functions of the left ventricle, left ventricular global longitudinal strain, left atrium, right ventricle and right ventricular global longitudinal strain compared with the control group. Body surface area and body mass index were important anthropometric features that correlated with the above echocardiographic changes, and should be routinely evaluated to assess cardiovascular risk in patients. Further larger studies are necessary to determine the clinical significance of the echocardiographic changes observed in obese individuals and their impact on health.