May 2020 Br J Cardiol 2020;27:64–6 doi :10.5837/bjc.2020.011
Yuen W Liao, James Redfern, John D Somauroo, Robert M Cooper
The health benefits of physical activity are well documented. Patients with hypertrophic cardiomyopathy (HCM) are often discouraged from participating in physical activity due to a perceived increase in the risk of sudden cardiac death (SCD). As a result, only 45% of patients with HCM meet the minimum guidelines for physical activity, and many report an intentional reduction in exercise following diagnosis. Despite most SCD being unrelated to HCM, guidelines traditionally focused on the avoidance of potential risk through restriction of exercise, without clear recommendations on how to negate the negative health impact of inactivity. Retrospective reviews have demonstrated that the majority of cardiac arrests in patients with HCM occurred at rest or on mild exertion and that the overall incidence of HCM-related SCD is significantly lower than previously reported. We will discuss current international guidelines and recommendations and consider the outcomes of various studies that have investigated the effects of exercise of different intensities on patients with HCM. In light of the growing evidence suggesting that carefully guided exercise can be both beneficial and safe in patients with HCM, we ask whether it is time to let the shackles off exercise restriction in HCM.
May 2020 Br J Cardiol 2020;27:60–3 doi :10.5837/bjc.2020.012
Kevin Cheng, Ranil de Silva
Refractory angina (RA) is a growing clinical problem. Long-term mortality is better than expected and focus has shifted to improving symptoms, quality of life and psychological morbidity. We established a dedicated multi-disciplinary care pathway for patients with RA and assessed its effect on psychological outcomes, quality of life and polypharmacy. We reviewed electronic health records to capture demographics, changes in medication use, and patient-related outcome measures (Seattle Angina Questionnaire [SAQ] and Hospital Anxiety and Depression Scale) before and after enrolment.
One hundred and ninety patients were referred to our service. Pre- and post-questionnaire data were available in 83 patients. Anxiety and depression scores significantly improved (p<0.05) as well as quality of life and all subcategories of the SAQ (p<0.0001). Patients were most commonly on three or four anti-anginal drugs. In patients with no demonstrable reversible ischaemia, there was a significant reduction in anti-anginal usage (mean reduction of two drugs) after completion of our pathway (p<0.025).
In conclusion, a dedicated multi-disciplinary pathway for RA is associated with improvements in quality of life, mental health and polypharmacy. An ischaemia-driven method to rationalise medication may reduce polypharmacy in patients with RA, particularly in patients with no demonstrable ischaemia.
May 2020 Br J Cardiol 2020;27:71 doi :10.5837/bjc.2020.013
JJ Coughlan, Max Waters, David Moore, David Mulcahy
“I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh” – Ezekiel 36:26
May 2020 Br J Cardiol 2020;27:72–3 doi :10.5837/bjc.2020.014
Sinead Curran, Waleed Arshad, Arvinder Kurbaan, Han B Xiao
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
March 2020 Br J Cardiol 2020;27:27–30 doi :10.5837/bjc.2020.006
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.
March 2020 Br J Cardiol 2020;27:31–3 doi :10.5837/bjc.2020.007
J William McEvoy, Michael Keane, Justin Ng
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.
March 2020 Br J Cardiol 2020;27:40 doi :10.5837/bjc.2020.008
Grace Lydia Goss, Tarik Salem Ahmed Salim, John Huish, Gethin Ellis
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.
March 2020 Br J Cardiol 2020;27:37–40 doi :10.5837/bjc.2020.009
Alexander Birkinshaw, Pankaj Sharma, Thang S Han
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.
January 2020 Br J Cardiol 2020;27:19–23 doi :10.5837/bjc.2020.002
Simon G Findlay, Ruth Plummer, Chris Plummer
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.
January 2020 Br J Cardiol 2020;27:24–5 doi :10.5837/bjc.2020.003
Amaliya A Arakelyanz, Tatiana E Morozova, Anna V Vlasova, Roman Lischke
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.