Clinical articles

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.

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.

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.

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 38^th 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.

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.

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

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.

Takotsubo cardiomyopathy (TTC) is characterised by transient left ventricular dysfunction accompanied by apical ballooning of the ventricle. Takotsubo pathophysiology is poorly understood and is often triggered by an emotional or physical stressor. This is a case of a 71-year-old woman who presented with sudden-onset exertional chest pain leading to inferior ST-elevation on electrocardiography (ECG) with a significant troponin rise. Immediate coronary angiography revealed a severe mid-posterior left ventricular (PLV) branch of the right coronary artery stenosis. The left coronary system was normal. Left ventriculogram revealed mid-to-apical ballooning typical of TTC. Considering the disconnect between the coronary and ventriculogram findings, a decision was made to delay percutaneous coronary intervention (PCI). The patient was treated with heart failure medications and symptoms improved. Repeat angiogram of the mid-PLV after a short period of medical therapy revealed no coronary lesion and the left ventricular function had normalised. These findings suggest that coronary artery vasospasm may have contributed to the aetiology in this case of TTC. This case adds weight to previous theories of an interplay between TTC and coronary vasospasm.

Movement restrictions are given to patients after cardiac rhythm device implantation, despite little consensus, or evidence that they reduce complications. We conducted a UK survey assessing the nature of the advice and if it varies between individuals and institutions. A survey was distributed to cardiac rhythm teams at UK implanting centres. Questions concerned the advice that is given, its source, and who is responsible for providing it.

There were 100 responses from 42 centres. Advice is given by physiologists, nurses, and cardiologists. Advice comes from local protocols, information leaflets, current hospital opinion, manufacturers, national leaflets, published research and audit data. Within and between centres there was little agreement on what the advice should be. Depending on who gives the advice, a number of leisure pursuits were either completely unrestricted or restricted indefinitely. Cardiologists were less restrictive than others.

In conclusion, this is the first UK survey to assess the movement and mobilisation advice given to patients after device implantation. There is variation in the source and nature of advice. Over-restriction could impact on patients’ quality of life. Contradictory advice could cause uncertainty. Further work should determine the impact of this variation and how the effects could be safely mitigated.

Implantable cardiac monitors (ICMs), also known as implantable loop recorders (ILRs), are used for long-term heart rhythm monitoring of unexplained syncope or in the detection of arrhythmias. These devices are implanted by cardiologists within a cardiac catheter suite environment. The newer generation devices are miniaturised and inserted using a specific tool kit via a minimally invasive procedure. This paper describes the changes we have made to allow these devices to be implanted in a non-theatre environment by a cardiac physiologist and the benefits and cost reduction of this service redesign.

A cardiac physiologist (LC, Band 6) undertook specific training beginning in September 2015. A standard operating procedure (SOP) was developed and patient information videos were commissioned. The new service was introduced in September 2016 in the screening room of our critical care unit (CCU). Data were collected prospectively on the clinical outcome, patient satisfaction and costs.

Over a 13-month period LC independently performed 116 procedures (113 Medtronic Reveal LINQ™ ICMs and 3 St. Judes SJM CONFIRM™) with only one minor complication. Patients were highly satisfied with the redesigned service, which showed a reduction in cost of £241.27 per case.

ICMs/ILRs can be implanted safely and cost-effectively outside a cardiac catheter suite environment by a cardiac physiologist. This requires some specific training, a clinical SOP and is supported by use of dedicated patient information videos.