Clinical articles

Previous research estimates that up to 40% of palpitation presentations to the emergency department (ED) have cardiac aetiology. This study was performed to determine the proportion of patients referred on for cardiology investigations that consequentially had new significant pathology diagnosed; and the effect of follow-up investigation on patient re-attendance to the ED with the complaint of palpitations.

Patients referred to a community cardiology centre in 2016 for investigation into palpitations following an ED presentation were included. The diagnosis that each patient received from these investigations was analysed to see whether: (a) new underlying cardiac abnormality was identified and (b) that abnormality was significant, requiring follow-up.

There were 93 patients meeting criteria for analysis: 28% had a cardiac cause for their palpitations elicited, including 11% with new significant pathology identified. Rate of re-attendance to the ED was reduced once cardiology investigations were completed (0.11 presentations/patient; 95% confidence interval [CI] 0.04 to 0.18) compared with the investigation period (0.75 presentations/patient; 95%CI 0.3 to 1.2).

In conclusion, although only one tenth of patients referred for investigations had new significant cardiac pathology identified, completing cardiology investigations reduced ED re-attendance.

Recent studies have associated subclinical hypothyroidism with heart failure (HF) and increased mortality. To investigate the relationship between subclinical hypothyroidism and HF in Indian patients we prospectively recruited 350 HF patients between March 2013 and February 2017 at the department of cardiology Yashoda Hospital, Hyderabad, India. All patients underwent fasting serum glucose, lipid profile, N-terminal-pro-brain natriuretic peptide (NT-proBNP), and thyroid hormone levels. Risk factors and clinical evaluation were undertaken. We divided thyroid-stimulating hormone (TSH) levels into severity grade 1 (≤9.9 mIU/L) and grade 2 (≥10 mIU/L).

Out of 350 HF patients, 191 (54.5%) were men, mean age was 60.4 ± 10.2 years (range 36–85 years). The incidence of subclinical hypothyroidism was 18.5%, 69.4% had normal thyroid function, and 12% had overt hypothyroidism. Mean NT-proBNP levels were 3561 ± 5553 pg/mL and 10.5% suffered in-hospital mortality. Dyslipidaemia (p=0.004), elevated NT-proBNP levels (p<0.0001) and mortality (p<0.0001) were significantly associated with subclinical hypothyroidism compared with euthyroidism. After multi-variate analysis, hypertension (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.32, 3.8), dyslipidaemia (OR 1.7; 95%CI 1.12, 2.8), subclinical hypothyroidism (OR 1.39; 95%CI 0.99, 1.82) and NT-proBNP >600 pg/mL (OR 1.98; 95%CI 1.23, 2.04) were significantly associated with HF. Grade 2 TSH (OR 4.16; 95%CI 2.04, 8.48), elevated NT-proBNP >1800 pg/mL (OR 2.18; 95%CI 1.53, 4.82), and severe left ventricular dysfunction (OR 2.51; 95%CI 1.24, 2.07) were significantly associated with poor outcome.

In conclusion, our study has established that subclinical hypothyroidism is associated with HF and grade 2 TSH has an independent association with in-hospital mortality in Indian patients.

Ivabradine is an I(f)-channel blocker currently used for the treatment of angina and heart failure. Although these channels are known to be found within the sino-atrial node, recent studies have also found localisation within the ventricular myocardium, and there have been reports of ventricular arrhythmia suppression in animal models. We describe an unusual case of significant ventricular ectopy suppression in a patient with non-ischaemic dilated cardiomyopathy. This was accompanied by a significant improvement in percentage pacing from her cardiac resynchronisation device, with corresponding improvement in her functional status. This report suggests, first, that the morbidity and mortality benefit of ivabradine in heart failure may not be solely due to its sino-atrial heart-rate lowering effect, and, second, highlights a potential role for ivabradine in the management of ventricular arrhythmias, which requires further studies to substantiate.

Postural orthostatic tachycardia syndrome (PoTS) can be defined as tachycardia with or without hypotension in the upright posture, and more comprehensively as a manifestation of a wider dysautonomia. The scope of this article is to characterise patients with PoTS and look at patient-rated responses to treatment.

This research comprised a postal survey, sent to patients with diagnosed PoTS at a tertiary hospital in Southwest England. We collected data on the demographics of patients, time to diagnosis, methods of diagnosis, treatments and response to treatment.

PoTS has an impact on quality of life, with patients communicating a drop in quality of life from 7.5 to 3.75 on a 10-point scale. From 40 respondents, 29 patients describe their symptoms improving since diagnosis, with self-rated day-to-day function improving from 3.21 to 6.14 (on a 10-point scale) after initiating treatment.

Many patients experience a delay in receiving a diagnosis with PoTS, and present multiple times to a variety of healthcare professionals. With a simple bedside diagnostic test (sitting and standing heart rate), there is scope to improve the time taken from developing initial symptoms to diagnosis, treatment and an improvement in quality of life.

Thrombus aspiration during primary percutaneous coronary intervention (PCI) has been extensively studied. Conflicting results have consistently emerged, hence, no clear guidance has been produced. The authors have examined several key clinical trials and meta-analyses, and discovered, arguably, major flaws within the designs of most trials, thus, accounting for the persistently discordant results. The authors conclude that there is some evidence to support the selective use of thrombectomy in primary PCI but a large-scale trial with the appropriate patient selection criteria is needed in order to substantiate or refute the argument.

Presentation of an interrupted aortic arch in adulthood is rare, and, up until, recently the only treatment strategy was through surgical repair. Advances in percutaneous interventions for congenital heart disease have included the percutaneous repair of coarctation of the aorta – from straightforward luminal narrowing through to full aortic interruption.^1-3 We present a case of a 28-year-old man who was diagnosed with a complete aortic interruption and successfully percutaneously treated.

Open-heart surgery is a major surgical procedure that requires intensive patient monitoring. Clinicians require prompt laboratory test results to assist them in this monitoring. Timeliness of result delivery is of great importance in taking prompt clinical decisions. We set out to evaluate the performance of the support laboratory before and after domiciliation at the cardiac centre using turnaround time (TAT) of electrolytes and liver function tests as benchmarks.

This hospital-based descriptive study was carried out at the University of Nigeria Teaching Hospital (UNTH), Enugu. The authors conducted a desk review of laboratory records for electrolytes and liver function tests from March 2013 to July 2017. Relevant laboratory personnel were also interviewed to ascertain types of equipment used and possible causes of delay at different stages of transition during the period under review. The TAT was calculated as the time from sample reception to time of dispatch of results.

Between 2013 and 2014, TAT for electrolytes and liver function tests were ~2 and ~6 hours, respectively. In 2015, TAT reduced to ~1 hour for electrolytes and ~1½ hours for liver function tests. Between 2016 and July 2017, TAT further reduced to ~10 minutes for electrolytes and ~30 minutes for liver function tests.

In conclusion, we were able to demonstrate improvement in performance of the support laboratory as shown by a reduction in TAT following the transition from the main laboratory to being domiciled in the cardiac centre.

Myocardial perfusion scintigraphy (MPS) is a non-invasive method that can be used to assess reversible left ventricular myocardial perfusion defect (<20% indicates limited and ≥20% indicates extensive ischaemia), and left ventricular ejection fraction (LVEF) at rest and at stress. Data on the utility of MPS used to stratify cardiac risk prior to abdominal aortic aneurysm (AAA) repairs are limited. We evaluated MPS as a stratification tool for patients scheduled for endovascular aneurysm repair (EVAR) or open repair, between 2013 and 2016 at Ashford and St Peter’s NHS Foundation Trust, and 4.9 years (median 2.8 years, interquartile range [IQR] 2.1–3.8) cardiovascular events (n=15, 17.9%) all-cause mortality (n=17, 22.6%). Of the 84 patients recruited (median age 75.7 years, IQR 69.4–79.6), 57 (67.9%) had limited and 27 (32.1%) extensive ischaemia, 62 (73.8%) underwent EVAR and 22 (26.2%) open repair. Compared with open repair patients, EVAR patients were older (median age 70.6 years vs. 76.4 years, p=0.015), had higher rates of extensive ischaemia (13.6% vs. 38.7%, p=0.025), and abnormal LVEF reserve (LVEF at stress minus LVEF at rest ≤0: 40.0% vs. 76.6%, p=0.011), while having lower rates of 30-day postoperative major adverse cardiac events (13.6% vs. 3.3%, p=0.040) but no difference for cardiovascular events (p=0.179) or 4.9 year all-cause mortality (22.7% vs. 22.6%, adjusted hazard ratio 0.80, 95% confidence interval [CI] 0.22 to 3.20, p=0.799). Our findings indicate that MPS provides valuable information for AAA repair procedure.

This is a case series of 10 patients who presented with the same electrocardiogram (ECG) manifestation of new-onset giant T-wave inversion and QT prolongation over a period of 24 months in a district general hospital. This unique ECG manifestation has been described with several cardiac and non-cardiac conditions.

Stunned myocardium is a rare, but serious, medical condition, and requires emergency intervention. Short periods of hypoperfusion may lead to a prolonged cardiac hypokinesia (hours to days), even though the perfusion is retained eventually. In other words, although the coronary circulation is retained, the hypokinesia remains. It might be considered as a case of prolonged post-ischaemic dysfunction.

In this case, a 60-year-old woman, visiting her siblings, presented with severe dyspnoea and cyanosis to the emergency department. Pulmonary oedema was diagnosed, and transthoracic echocardiography (TTE) showed general hypokinesia and reduced ejection fraction (15%), nevertheless, sequential TTE monitoring after the required medical intervention revealed a continuous improvement, with a 45% ejection fraction three days later and a specific anterior wall hypokinesia, solely.

In conclusion, rapid diagnosis and treatment are essential for stunned myocardium, as these could change the progress of the clinical condition.