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Clinical articles

May 2019 Br J Cardiol 2019;26:67–8 doi :10.5837/bjc.2019.020

Incidence and epidemiology of infective endocarditis from 2010 to 2017 in a rural UK hospital

Laura A Hughes, Andrew Epstein, Neeraj Prasad

Abstract

Infective endocarditis (IE) is an increasingly common disease associated with significant morbidity and mortality. It is known that the incidence of IE has been rising globally, but the reasons for this rise are not fully understood. This study sought to investigate the epidemiology of IE in a UK population, with a review of mortality outcomes based on current clinical practice.

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May 2019 Br J Cardiol 2019;26:69–71 doi :10.5837/bjc.2019.021

What are we?* The BMI should accept terms for a graceful retirement
*with apologies to The Bunyip of Berkeley’s Creek

Michael E J Lean, Thang S Han

Abstract

Body mass index (BMI) was first proposed in 1835 as a way to standardise body composition assessment for people of different heights, at a time when malnutrition was the main public health concern. BMI has been considered appropriately as a part of nutritional assessment in populations. It is not, however, a useful tool for assessment of individuals because there is so much individual variability in body composition and in its impact on health outcomes. Similarly, high BMI does not distinguish between excess body fat (bad for health) and large muscle mass (good). In contrast, we propose that individuals need to be assessed using clinical criteria, monitored over time to trigger different interventions. A diagnosis of obesity should be based on estimates of body fat (BMI, now being replaced by percentage body fat) at a particular age, and a clinical staging system.

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May 2019 Br J Cardiol 2019;26:72–5 doi :10.5837/bjc.2019.022

Practical basics of coronary physiology

Max B Sayers, Cristopher M Cook, Takayuki Warisawa, Justin E Davies

Abstract

Coronary physiology is the collective term for a group of indexes aimed at directly measuring the intracoronary haemodynamic changes that occur across a stenosis in order to guide revascularisation decision-making. Fractional flow reserve (FFR) uses pharmacological dilatation and miniaturised pressure-wires to measure coronary pressure proximal and distal to a stenosis, thereby estimating flow reduction across a stenosis. Several clinical trials have shown that FFR-guided revascularisation improves clinical outcomes, and that deferring revascularisation in patients shown by FFR to have non-haemodynamically significant lesions is safe. Instantaneous wave-free ratio (iFR) is a novel technique that measures the ratio of distal coronary to aortic pressure during a specific period in diastole that obviates the need for pharmacological vasodilatation. Recent randomised-controlled trials have shown iFR to be non-inferior to FFR with respect to major adverse cardiac events, while reducing adverse procedural symptoms and procedure duration.

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April 2019 Br J Cardiol 2019;26:53–8 doi :10.5837/bjc.2019.012 Online First

Safety, effectiveness and quality of nurse diagnostic coronary angiography

Ghazala Yasin, Mark Davies, Piers Clifford, Soroosh Firoozan

Abstract

Advanced nursing roles supported by competency-based training have been pioneered over the last 25 years, with emphasis on the development of specific medical skills. This has largely been influenced by increasingly complex medical needs, costs of healthcare and the significant reduction in available doctors. With this reduction of doctors in training and departmental support for expanding nursing roles, we devised a local initiative to train an experienced nurse to perform diagnostic coronary angiography. Our aim was to provide a safe and enhanced service and improve procedural efficiency within the cardiac day unit.

A prospective audit of 250 coronary angiography procedures was performed in the training period between 24 September 2014 and 9 October 2015. Post-training, 143 procedures were performed between 12 October 2015 and 20 July 2016. The prospective audit was performed to explore the safety, effectiveness and quality of nurse-delivered diagnostic coronary angiography. An audit form was created to assess each component of the procedure. This included, gaining patient consent, success in gaining arterial access, success in intubating the left and right coronary arteries, observation of haemodynamics, observation of complications and reporting the findings. Financial impact, patient satisfaction and staff perception outcomes were also audited.

When directly compared with contemporaries, nurse-delivered diagnostic coronary angiography resulted in successful and appropriate arterial access, successful intubation of both coronary arteries, safe monitoring throughout the procedure and correct reporting of each study, with a similar level of patient satisfaction.

In conclusion, this study demonstrates that nurses can, under the right supervision and governance, perform diagnostic coronary angiography to a safe, highly effective standard, which is equivalent to contemporaries.

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April 2019 Br J Cardiol 2019;26:97–8 doi :10.5837/bjc.2019.015 Online First

Avoiding needless deaths in aortic stenosis

John B Chambers

Abstract

Echocardiography is key for the assessment of aortic stenosis (AS), but taking a good history is also crucial and requires specialist competency. Symptomatic AS requires surgery and, if physicians miss the onset of symptoms, the risk of death rises from 1% per annum in patients without symptoms to 14% on a six-month surgical waiting list. A case is described illustrating the difficulty of obtaining the history in a patient with AS, and suggests how to take a careful history and questions to ask. Patients with a murmur suggesting AS should be considered for a specialist valve clinic.

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April 2019 Br J Cardiol 2019;26:76–8 doi :10.5837/bjc.2019.016 Online First

Fatal anaphylaxis following teicoplanin administration during pacemaker implantation

Michael Chapman, Andrew Turley, Thanh Phan, Nicholas Linker

Abstract

Over 50,000 cardiac implantable electronic device procedures are undertaken annually in the UK. Despite prophylactic measures, device infection still occurs. Anaphylaxis following teicoplanin is extremely rare with evidence limited to case reports and one case series. We present two fatal cases of anaphylaxis following teicoplanin administration. Both cases meet the World Allergy Organisation definition of anaphylaxis. These cases highlight the importance of anaphylaxis to teicoplanin as a procedural complication. Despite prompt treatment, this reaction was fatal. Operators should be aware of this risk in an era of increasing procedures and rising incidence of anaphylaxis.

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April 2019 Br J Cardiol 2019;26:79–80 doi :10.5837/bjc.2019.017 Online First

An unusual cause of pericardial tamponade in pregnancy

Bishav Mohan, Hasrat Sidhu, Rohit Tandon, Rajesh Arya

Abstract

Pericardial involvement is sporadic during pregnancy. We present the case of a young woman who presented to the emergency department with a short history of rapidly progressive dyspnoea in her 38th week of pregnancy. Coronary arteriovenous fistula (CAVF) has been uncommonly described as a cause of pericardial effusion. We believe this is a rare case of a CAVF presenting as cardiac tamponade in pregnancy.

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Non-prescription of anticoagulants in patients discharged with stroke and atrial fibrillation

February 2019 Br J Cardiol 2019;26:23–6 doi :10.5837/bjc.2019.007

Non-prescription of anticoagulants in patients discharged with stroke and atrial fibrillation

Calum Creaney, Karissa Barkat, Christopher Durey, Susan Gallagher, Linda Campbell, Ashish MacAden, Paul Findlay, Gordon F Rushworth, Stephen J Leslie

Abstract

Atrial fibrillation (AF) increases stroke risk fivefold. Oral anticoagulation (OAC) with warfarin reduces the risk of stroke by 64%. Direct oral anticoagulants are non-inferior to warfarin in preventing stroke in non-valvular AF, but have a lower risk of fatal intracranial haemorrhage. We determined how many patients discharged with a diagnosis of ischaemic stroke and AF were prescribed OAC, and established reasons for, and associations with, non-prescription of OAC.

All patients discharged with a diagnosis of ischaemic stroke and AF during the four-year period between 2013 and 2016 within NHS Highland were included in the study. Patients who started OAC after a period of treatment with antiplatelets were considered as being treated with OAC. Electronic patient records provided demographics, CHA2DS2-VASc and HAS-BLED scores and information on why patients were not started on OAC.

A total of 181 patients were discharged with a diagnosis of ischaemic stroke and AF over the study period: 52.5% (n=95) were female (p=0.45); 35.4% (n=64) were discharged without OAC. The median CHA2DS2-VASc score for patients not treated with OAC was 5 (interquartile range [IQR] 4–6). The median HAS-BLED score was 3 (IQR 2.5–4). There was no difference in rate of OAC prescription between men and women (67% vs. 62%, p=0.45). Patients 80 years of age or older were significantly less likely to be prescribed OAC on discharge than those under 80 years (54% vs. 76%, p=0.002). The two most common reasons for withholding OAC were concern over bleeding risk and falls. Patients treated at a hospital with a stroke unit were no more likely to be discharged on OAC compared with those treated at hospitals without a stroke unit (66% vs. 62%, p=0.64). Of patients not treated with OAC, 64% (n=41) were discharged on long-term antiplatelet drugs.

In conclusion, raising awareness of the relatively low risk of major bleeding, even in elderly patients and in those at risk of falls, might help increase OAC usage and reduce recurrent strokes.

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February 2019 Br J Cardiol 2019;26:34 doi :10.5837/bjc.2019.008

Is six weeks too long for the first outpatient review after cardiac surgery? FORCAST6

Dumbor L Ngaage, Michael R Gooseman, Kerry L Bulliment, Martin A Jarvis, Mubarak A Chaudhry, Alexander R Cale, Michael E Cowen

Abstract

The traditional practice of conducting the first outpatient review six weeks after cardiac surgery is not evidence-based. This study was designed to determine mortality and morbidity in the interval between hospital discharge and the first outpatient follow-up.

We enrolled patients undergoing non-emergency cardiac surgery from June 2016 to May 2017 into this prospective observational study. Prior to hospital discharge, patients were consented and given a questionnaire to document attendance at any healthcare facility. Ethical approval was obtained from the Health Research Authority.

The mean age of the 72 study patients was 68 ± 4 years. The majority underwent coronary artery bypass grafting (56.9%). The six-week postoperative morbidity rate was 38.9% and hospital readmission  15.3%. Morbidity, highest in the first week after discharge, declined to its lowest level by four weeks. Surgical site (13.9%) and respiratory complications (13.9%) were predominant causes of late morbidity. There was no mortality. Most patients (50%) expressed satisfaction with current practice, but a significant number (44.4%) would prefer earlier review.

In conclusion, morbidity during the six-week wait for the first outpatient review after cardiac surgery is not insignificant, but declines over time. Current practice does not seem to enable a positive specialist influence of the post-surgery recovery pathway.

Clinical Trials.gov registration number: NCT02832427

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The future of atrial fibrillation: does the answer lie in ablation or anti-arrhythmics?

February 2019 Br J Cardiol 2019;26:31–3 doi :10.5837/bjc.2019.009

The future of atrial fibrillation: does the answer lie in ablation or anti-arrhythmics?

Mark T Mills

Abstract

Anti-arrhythmic drugs and pulmonary vein isolation (with radiofrequency ablation) are established treatment options in the management of atrial fibrillation. Both methods have their advantages and drawbacks. Atrial fibrillation is the consequence of complex systemic and atrial factors, resulting in atrial remodelling. Emerging treatment strategies that target and reverse atrial remodelling may offer a promising alternative to anti-arrhythmics and ablation.

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