Clinical articles

Heart failure (HF) is a chronic, symptomatic and progressive disease associated with reduced health-related quality of life (HRQoL) in both patients and their caregivers. This study assessed the HRQoL of HF patients (n=191; mean age 70 [range 21–95] years; New York Heart Association [NYHA] class II–IV) and their caregivers (n=72; mean age 69 [range 43–88] years) in England. Patients had poor HRQoL assessed by the EQ-5D-5L weighted index (mean ± standard deviation [SD] 0.60 ± 0.25 [normal 0.78 ± 0.26 for people aged 65–74 years]). The impact of HF on patients’ HRQoL varied markedly; importantly, the extent of comorbidity most influenced the reduction in patients’ HRQoL, as well as disease-related symptoms. The impact on HRQoL on caregivers of patients with HF was on average limited, with the EQ-5D-5L index for caregivers (0.75 ± 0.18) in-line with the normal values for their age range. However, as with the patients, the impact on HRQoL varied markedly, with some caregivers having a bad caregiving experience as measured by the Carer Experience Scale weighted index. This study provides important information on the impact on HRQoL and burden of HF for patients and their caregivers.

Ischaemic conditioning is the phenomenon of protection against reperfusion injury via the application of brief, repeated episodes of non-lethal ischaemia. This review has three aims: 1) to briefly explain the various categories of ischaemic conditioning; 2) to explore past clinical trials and their failures; 3) to explore the future of clinical trials in the realm of ischaemic conditioning. 

Dipeptidyl peptidase-4 (DPP-4) inhibitors are one of two classes of antidiabetes drugs that mediate their glucose-lowering effect through the incretin pathway. They are administered orally and offer significant glucose-lowering with a neutral weight profile and a low risk of hypoglycaemia. Three large randomised-controlled trials have demonstrated cardiovascular safety, with no increase in major adverse cardiovascular events comparing DPP-4 inhibitors (saxagliptin, alogliptin and sitagliptin) with placebo. An increase in heart failure hospitalisation was noted with saxagliptin compared with placebo, and a similar increase was also noted in one subgroup receiving alogliptin compared with placebo. Further cardiovascular safety trials with DPP-4 inhibitors are ongoing, including a trial comparing the DPP-4 inhibitor linagliptin with the sulphonylurea glimepiride.

In this article, we explain the clinical requirement for cardio-oncology services and reflect on our experiences in setting these up at Barts Heart Centre and at University College London Hospital.

A 61-year-old East European woman was admitted with atypical chest pain. Risk factors: smoker of 5–10 cigarettes per day, hypertension, hypercholesterolaemia and family history of ischaemic heart disease. Highly sensitive troponin-T, electrocardiogram (ECG) and exercise stress test were normal.

The rationale behind secondary prevention post-ST-elevation myocardial infarction (STEMI) is well established. Guidelines recommend titration of several medications for secondary prevention up to a maximally tolerated dose in order to confer maximum benefit. Due to decreasing duration of inpatient stays post-myocardial infarction (MI), this up-titration must often take place in primary care. Guidelines also recommend clearly informing GPs regarding duration of dual antiplatelet therapy and monitoring cardiovascular risk factors. Clear communication between secondary/tertiary and primary healthcare practitioners is essential in order to ensure our patients are receiving optimum care. 

We examined all discharge summaries for patients discharged post-STEMI in our tertiary referral centre. This encompassed rates of prescribing of the National Institute for Health and Care Excellence (NICE) recommended medications post-MI, rates of therapeutic prescribing of these medications and communication with GPs regarding duration of dual antiplatelet therapy, up-titration of medications and repeat checking of fasting lipid profiles. In order to improve compliance with guidelines, incoming junior staff were educated on guidelines for communication post-STEMI at our journal club. We then re-audited our practice in order to see if compliance with the guidelines improved. 

Our results showed that, while the majority of our patients were discharged on the correct medications post-MI, most were receiving subtherapeutic doses of angiotensin-converting enzyme (ACE) inhibitors and beta blockers. In addition, we exhibited poor communication with primary healthcare practitioners. Compliance with the NICE guidelines on communication significantly improved after our intervention. 

In conclusion, education of junior staff can significantly improve communication with GPs. This, in turn, could help optimise secondary prevention strategies post-MI.

Postural tachycardia syndrome (PoTS) is a form of dysautonomia, a term used to describe dysfunction of the autonomic nervous system. The condition can cause marked physical and cognitive impairment that can significantly impact upon activity. Although the exact UK prevalence is unknown, its frequency has stimulated an increase in studies. Occupational therapy services should place themselves in a position to respond to the potential need. 

This study aimed to determine how PoTS impacts upon activity, in order for occupational therapists to understand the implications of this condition and develop appropriate interventions. 

We recruited 201 adults (aged 18–70 years) via two patient support charities to participate in an online quantitative survey. Participants rated their experiences pre-symptoms versus present day in relation to their occupations, producing ordinal data under self-care, leisure and productivity domains, including their physical ability, motivation and fatigue levels.

The pre-symptom versus present day probability scores of <0.001 can be viewed as ‘very significant’ and confirm that PoTS has a significant negative impact across all three occupational domains.

In conclusion, PoTS has a significant negative impact upon occupation and is associated with considerable morbidity. With their understanding of the central role of occupation in wellbeing, occupational therapists may need to support people with PoTS in achieving a satisfying balance of occupations that will support their health.

National Institute for Health and Care Excellence (NICE) clinical guideline 95 (CG95) was introduced to rapid-access chest pain clinics (RACPC) to aid investigation of possible stable angina based on pretest probability of coronary artery disease (CAD). Following a six-month audit of its implementation we introduced a modified version: patients with low/moderate risk of CAD were referred for computed tomography coronary angiography (CTCA), while those at high/very high risk were referred for invasive angiography.

Patient records of 546 patients referred to our RACPC over a six-month period were retrospectively analysed. Pretest probability of CAD, referral for initial investigation, and outcomes at a minimum follow-up time of six months were documented.

Incidence of CAD correlated well with pretest probability. Moderate-risk patients had a low incidence of CAD and revascularisation. High/very high-risk patients had a high incidence of revascularisation, and this was predominantly for prognostically significant disease.

In conclusion, low rates of CAD in low- and moderate-risk groups justifies the use of CTCA as a first-line investigation in these patients. Routine investigation of very high-risk patients allows a high proportion to undergo revascularisation for prognostically significant disease. Strict adherence to NICE CG95 could lead to these patients being missed. 

Bleeding is one of the complications associated with percutaneous coronary intervention from the femoral route due to the use of potent antiplatelet therapies including adenosine diphosphate receptor blockers and glycoprotein IIb/IIIa inhibitors. Complications include haematoma, retroperitoneal haemorrhage, pseudoaneurysm, arteriovenous fistula, arterial occlusion, femoral neuropathy and infection. Complications for diagnostic procedures are lower due to the lack of antiplatelet therapies on board. Often, incorrect location of the femoral artery puncture site results in complications. Puncturing below the femoral bifurcation can result in psedoaneurysm, haematoma and arteriovenous fistulas, whereas retroperitoneal haemorrhage is caused by high femoral punctures. Identification of bleeding and vascular complications is paramount as bleeding is associated with adverse events. Techniques to reduce the risk of femoral arterial complications include the use of ultrasound scan or fluoroscopy guided femoral punctures. Furthermore, the micropuncture technique has been shown to reduce complications but is not widely adopted. Ultimately, the radial route is preferable to the femoral route as vascular complications are significantly lower.

National Institute for Health and Care Excellence (NICE) guidance supports the introduction of sacubitril/valsartan under the supervision of a heart failure specialist with access to a multi-disciplinary heart failure team. Clinical information was obtained retrospectively on all patients with a primary coded diagnosis of heart failure discharged from the Conquest Hospital, Hastings, UK during the calendar year 2015. We recorded the proportion of patients meeting the NICE recommendation and those patients meeting the additional PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) study inclusion criteria. 

In a total of 205 assessable patients discharged with a primary diagnosis of heart failure during the calendar year 2015, inpatient mortality was 11%, with a crude readmission rate during the year of 17%. The number of patients meeting the NICE criteria was 26 (13%). In hierarchical analysis taking the major PARADIGM-HF inclusion criteria, 20 patients (10%) patients met the inclusion criteria. 

In conclusion, the findings from this audit suggest that the number of patients potentially suitable for sacubitril/valsartan therapy is low. Given the PARADIGM-HF study run-in design, the optimal dose and stability of angiotensin-converting enzyme (ACE) inhibitor and angiotensin-receptor blocker medication may need to be clarified if sacubitril/valsartan is to be commenced during or shortly after hospitalisation.