Clinical articles

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.

Endomyocardial biopsy (EMB) has been long established as a diagnostic tool in myocardial disease. EMB surveillance for rejection of cardiac allografts continues to be routinely performed. However, the use of EMB beyond transplant monitoring is controversial. In recent years, the procedure has fallen out of favour. This is most likely due to the growing capabilities of non-invasive imaging modalities and the questionable impact of EMB findings on treatment.

This article aims to examine current practice of EMB in England, discuss the utility of EMB in myocardial diseases and compare prominent society guidelines from recent years. Information gained from freedom of information requests shows just 18% of NHS trusts reported performing EMB, and only 46% referred to other centres for EMB in England in 2014–2015. Despite the limitations of EMB, it remains the only procedure capable of obtaining a histological diagnosis of cardiac disease.

Glitazones improve glycaemic control in type 2 diabetes mellitus (T2DM) by increasing whole-body insulin sensitivity. They can cause fluid retention and are, therefore, contraindicated in heart failure. A 2007 meta-analysis linked rosiglitazone with an increased risk of myocardial infarction, leading to its European marketing authorisation being suspended in 2010. Pioglitazone has demonstrated cardiovascular safety for atherosclerotic events in a large, randomised, placebo-controlled trial. A 2016 study in patients with insulin resistance and recent cerebrovascular event showed pioglitazone was associated with reduced risk of further stroke or transient ischaemic attack when compared with placebo, as well as reduced diabetes incidence.

A sixty-two-year-old asymptomatic man presented for a routine insurance medical. He had no previous cardiac history, nor any significant cardiac risk factors. His examination was normal. His electrocardiogram (ECG), however, was noted to be significantly abnormal, with deep anterior T-wave inversion in the precordial leads (figure 1). Given this abnormality and the potential differential diagnoses, a cardiovascular magnetic resonance (CMR) (Siemens Aera 1.5 T) with regadenosine stress perfusion was performed and images analysed using CMR 42 software (Circle CVI, Calgary).

Blackouts are common, affecting up to 50% of the population. However, little is known about the incidence and initial management of blackouts in primary care. A retrospective computerised search of the medical records of 16,911 patients in two UK practices found the incidence of first presentation with blackout to the GP to be 3.4/1,000 patients/year. Affected patients’ records were then individually reviewed to assess whether key aspects of National Institute of Health and Care Excellence (NICE) blackouts and European Society of Cardiology syncope guidelines had been followed during that initial consultation. GPs were generally better at enquiring about features that differentiate between vasovagal syncope and epilepsy. They were not as good at detecting syncope red flags, which help to identify the cardiac causes of syncope that are associated with higher mortality. Raising awareness of these red flags in primary care was recommended. 

A discharge summary is intended to communicate relevant clinical information to GPs after hospital admission. High-quality discharge summaries are especially important in complex clinical syndromes, such as chronic heart failure, where effective communication between multi-disciplinary teams is necessary to coordinate safe community care and reduce re-hospitalisation risk.

This study demonstrates that a primary heart failure diagnosis may be inaccurate in approximately a quarter of all discharge summaries. The provision of a 10-point checklist was associated with a statistically significant improvement in the quality of heart failure discharge summaries issued from our Trust. This intervention was simple to implement at minimal cost and helps junior doctors communicate more effectively with primary care.