Clinical articles

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.

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.