Clinical articles

Glucagon-like peptide-1 (GLP-1) receptor agonists are an injectable glucose-lowering therapy used in the treatment of type 2 diabetes mellitus (T2DM). Alongside dipeptidyl peptidase-4 (DPP-4) inhibitors, they exert their effect by augmenting the incretin pathway. GLP-1 receptor agonists offer reductions in glycosylated haemoglobin (HbA_1c) and weight alongside a low risk of hypoglycaemia. The cardiovascular safety of GLP-1 receptor agonists in patients at elevated cardiovascular risk has been examined in large double-blind, placebo-controlled cardiovascular safety trials. Liraglutide demonstrated superiority over placebo with reduced major adverse cardiovascular events (MACE) in the treatment group. Exenatide, lixisenatide and semaglutide have shown non-inferiority versus placebo for MACE. These trials demonstrated no association between GLP-1 agonist therapy and hospitalisation for heart failure.

To examine the current practice of British Society of Cardiovascular Imaging (BSCI) members in the administration of beta blockers in computed tomography (CT) coronary angiography (CTCA) a 10-point online questionnaire was emailed to all registered members of the British Society of Cardiovascular Imaging. There were 61 respondents: 75% give intravenous (IV) metoprolol in the CT department, the rest a combination of oral and/or IV dosing. Over 50% were happy to administer 50 mg or more. No serious complications related to drug administration had been seen by 82%. Of the remaining 18%, half (six reports) documented severe hypotension and two reported a death. No physical observations were taken by 25%, at any point. Another 27% checked blood pressure before the scan only, 17% measured blood pressure before the scan and immediately after and 28% measured before the scan and after with a delay.

In conclusion, among BSCI members, there is no uniform strategy regarding the route or dose of beta blocker administration, or if, when and what physical observations should be performed. Several severe adverse events have been documented, including two deaths. This, however, is in the context of the large volume of CTCAs performed nationally, and so, despite some doses of beta blocker exceeding British National Formulary recommendations, this appears safe.

Wearable and smartphone-based activity and heart rate (HR) monitors are becoming increasingly common, with around 80 million devices in use in 2017. Wearable and smartphone-based devices may be dedicated HR monitors or part of an activity tracker system. One of the main aims of these devices is to encourage exercise and increase fitness, which is clearly desirable in a society with high levels of inactivity and obesity. These devices provide individuals with large amounts of data including HR information. This may, therefore, give an opportunity to document or diagnose arrhythmias. Undiagnosed atrial fibrillation is a common problem and is associated with a huge burden of potentially preventable stroke. Wearable HR monitors may provide the opportunity to identify these individuals and allow them to receive stroke prevention treatment. However, the consumer fitness market is unregulated and the manufacturers emphasise that their devices are not intended to be used for detecting heart rhythm problems. The reliability, sampling frequency and algorithms for the HR data these devices provide are hugely variable. Detected ‘abnormalities’ may inform clinical decision making but it may also trigger unnecessary anxiety and costly investigations in healthy people.

Atrial fibrillation (AF) is one of the most common arrhythmias, affecting approximately 2% of the general population. Identifying AF after an ischaemic stroke is particularly important as it changes the recommended antithrombotic therapy from antiplatelets to anticoagulation. Currently, there is no clear consensus with regards to the duration of rhythm monitoring post-stroke. In our study, we aim to review some of the pivotal studies regarding rhythm monitoring after an ischaemic stroke and identify the percentage of patients who get referred for prolonged rhythm monitoring after a stroke by providing real-world data from the Ipswich hospital. To our surprise, we did not identify any patients who got referred for prolonged rhythm monitoring (ILR) and the proportion of patients who did not have a 24-hour tape was unexpectedly high. In addition, there was a clear tendency for patients with lacunar strokes not to get investigated with 24-hour tape.

Despite documented evidence of benefits of lifestyle cardioprotective interventions in reducing recurrent coronary heart disease (CHD) events, many patients still fail to adhere to proposed lifestyle interventions. To determine the percentage adherence rate and to identify the perceived barriers influencing adherence rate to cardioprotective lifestyle interventions among patients treated with primary percutaneous coronary intervention (PPCI) a cross-sectional survey was designed.

A total of 193 consecutive patients, with a clinical diagnosis of CHD who had a PPCI, were identified retrospectively between 2008 and 2013, and were subsequently telephone surveyed. Data were analysed using chi-square tests and Fisher’s exact tests. At survey, 21.8% of patients smoked cigarettes, 30.6% were adhering to physical activities as per guidelines, 36.3% were consuming five portions of fruits and vegetables per day, and 9.8% were consuming three portions of oily fish per week. Negative stress, low mood, advanced age, poor health, lack of enjoyment from physical activities, low expectations from physical activity benefits, obesity and diabetes, were associated with non-adherence to physical activities as per guidelines.

In conclusion, risk factor targets for secondary prevention were not reached by a large proportion of patients. Several barriers exist among these individuals. Thus, there is still considerable potential for cardiac rehabilitation clinicians to improve standards of preventive cardiology by clearly identifying barriers and ways to overcome them. 

Invasive coronary angiography (ICA) is an important diagnostic test in the diagnosis of coronary artery disease (CAD). However, it is associated with a small risk and is a relatively expensive procedure. National Institute for Health and Care Excellence (NICE) 2010 guidelines on stable chest pain recommended that patients with stable chest pain and high probability of CAD should be investigated with ICA.

We audited our own practice at a district general hospital (DGH), with a single catheter lab, to assess the yield of significant CAD at ICA in patients presenting with stable chest pain and acute coronary syndromes (ACS). There were 457 patients who were referrals for ICA with stable chest pain and 250 were inpatients undergoing ICA for ACS. The incidence of severe CAD in the whole cohort was 41%, with a further 20% found to have moderate CAD. The prevalence was higher in the ACS subgroup with 55% of patients having severe CAD compared with 33% in the stable chest pain sub-group. Of the patients having ICA for stable chest pain, 72% were direct referrals, with 30% found to have severe CAD. Our data show that overall detection rate of severe CAD in patients presenting with stable chest pain, at ICA, is relatively low.

Brugada syndrome is a distinct arrhythmogenic disorder widely recognised as a sudden cause of death in the young. It is identified by a classical ST-segment elevation on electrocardiogram (ECG) that may be provoked in the context of a fever or vagal stimulation. The pathophysiology and genetic basis have been elucidated as an abnormality in ion channels. Diagnosis takes into account, not only the ECG, but clinical features and modulating factors; the inducibility of a suspect ECG when febrile is one such observation. Anti-arrhythmic drugs like ajmaline can also induce Brugada syndrome and have a role in its work-up. Electrophysiology studies may be useful in assessment and risk stratification of select cases. The management is centred around device therapy with the implantable cardioverter defibrillator (ICD), though pharmacological treatments are being actively pursued.

This is a rare case with dramatic image of multiple clot formation in the left atrium in a patient with mitral stenosis when anticoagulation was stopped for a few days before cancer surgery.

This article won first prize in the recent British Junior Cardiologists’ Association (BJCA) essay competition.

Coronary angiography stubbornly bucks the hospital-wide trend to non-invasive diagnostic tests. New imaging technologies offer paths to better ways to investigate and manage ischaemic heart disease. 

Spasm after transradial approach for catheterisation decreases procedural success and offers discomfort to the patient. Nitroglycerin is one of the drugs applied prophylactically to prevent spasm. The aim of this study was to assess the effect of preventive nitroglycerin on the comfort of patients during cardiac catheterisation.

A total of 328 patients were randomly assigned to receive either 200 µg nitroglycerin (n=164) or placebo (n=164). The main outcome was the evaluation of spasm using a visual analogue scale to measure the pain of the patient, and procedural time and radiation used to measure the operator difficulty during the examination. 

The pain evaluation was equal in both groups (nitroglycerin 24.74 vs. placebo 24.75, p=0.72). Using the operator’s impression, there was a higher incidence of spasm in the placebo group (9.1% grade 3 or 4 vs. 2.4% in the nitroglycerin group, p=0.004), while procedural time (21.36 minutes vs. 22.24 minutes, p=0.23) and radiation exposure (655.61 mGy vs. 660.92 mGy, p=0.63) were comparable in both arms.

In conclusion, the prophylactic use of nitroglycerin offers no advantage in terms of comfort to the patient during cardiac catheterisation by a transradial approach. Although there was difference in operators’ perception of spasm, omission of vasodilator does not cause any objective difficulty to operators.