Clinical articles

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.

Our objective was to determine whether the development of a computed tomography coronary angiogram (CTCA) service has improved the yield of significant coronary artery disease (CAD) and subsequent referral for revascularisation following conventional invasive coronary angiography (ICA).

A retrospective audit comparing angiographic findings in a cohort of 2,094 patients investigated between 2007 and 2012 with findings from a cohort of 554 patients investigated in 2014 and 2015 during which time a CTCA service had been established. Cases included were those patients undergoing elective angiography for the assessment of possible coronary disease without any history of previous revascularisation.  

In the pre-CTCA and CTCA cohorts the rates of one-vessel, two-vessel, three-vessel and left main stem disease were 20% vs. 18%, 14% vs. 14%, 10% vs. 11%, 2% vs. 3%, respectively, with overall yield of obstructive CAD of 46% in both cohorts (p>0.05 for all groups).

In conclusion, the availability of a CTCA service has not had any significant effect on the diagnostic yield of ICA. We propose that, adherence to current guidelines, results in a potential underuse of CTCA in the investigation of suspected stable CAD because a sizeable proportion of patients undergoing ICA have non-significant disease.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a novel insulin-independent therapy for type 2 diabetes mellitus (T2DM). By inhibiting renal glucose re-absorption, they improve glycaemic control and have beneficial effects on weight and blood pressure. Current guidance states that any new diabetes medication must be shown not to unacceptably increase cardiovascular risk. The landmark EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) trial demonstrated that treatment with the SGLT2 inhibitor empagliflozin compared with placebo showed a significant reduction in the risk of major cardiovascular end points and hospitalisation for heart failure for patients with T2DM and existing cardiovascular disease. A positive impact on several renal outcomes was also demonstrated in secondary analysis. These milestone results are set to have significant implications on prescribing practice in T2DM, with potential benefits for many patients with existing cardiovascular disease.  

Characteristic electrocardiogram (ECG) features of posterior myocardial infarction (PMI) do not include typical ST-segment elevation and, therefore, carries the risk of delayed diagnosis and management. The aim of this study was to investigate how well PMIs are recognised and whether a lack of recognition translates to a larger infarction.

In conclusion, using door-to-balloon times as a marker for recognition, this study illustrated that patients suffering PMI experience delayed recognition and management compared with non-PMI STEMIs. This did not, however, result in a significantly larger size of infarction as shown by peak troponin levels.

Bifurcation lesions are complex, technically difficult, have a higher rate of adverse events and lower success rates. This has led to the introduction of dedicated bifurcation stents, generally deployed along with main-vessel stent. Cappella Sideguard^® is a dedicated bifurcation stent for treatment of bifurcation lesions, which otherwise could be technically challenging and may have low success rates. We report a very interesting case that resulted in a unique complication following the use of a dedicated bifurcation stent.

Improvements in cardiorespiratory fitness (CRF) are associated with better health outcomes. The Chester step test (CST) is used to assess the changes in CRF following a protocol-driven cardiovascular prevention and rehabilitation programme (CPRP) entitled MyAction. CRF expressed as predicted VO₂max, can be influenced by physiological adaptations and/or retest familiarity-efficiency. Therefore, we employed an index ratio between oxygen uptake and heart rate (O₂ pulse) to determine if the improvement in CRF is related to a true physiological adaptation.

In total, 169 patients, mean age 66.8 ± 7.3 years attended a 12-week MyAction CPRP. All were assessed using the CST on the initial and end-of-programme assessment. O₂ pulse was estimated from the CST and was calculated by dividing VO₂ into the exercise heart rate multiplied by 100. 

Following the CPRP, VO₂max increased by 2.8 ml/kg/min. These changes were associated with an overall increase in O₂ pulse by 0.6 ml/beat (p≤0.001) and a 4.1 beats/min (p≤0.001) reduction in the exercise heart rate response on the CST.

In conclusion, O₂ pulse provides transparency on the physiological adaptations following a CPRP and can be used to help patients recognise the benefits of exercise training. For example, the average patient increased his/her O₂ pulse by 0.6 ml/beats and saved 4–7 heart-beats on the CST.