Clinical articles

In 2012, the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) published guidance on the standards and core components of cardiac rehabilitation (CR). However, annual reports from the UK National Audit of Cardiac Rehabilitation (NACR) have shown that, while there are examples of excellent practice in the UK, many CR programmes do not meet the BACPR standards. It is difficult for service managers, patients and commissioners to assess how a particular CR programme meets minimum standards of service delivery. These findings led the BACPR and NACR to work together to develop a UK National Certification Programme for CR that would be mainly based on assessment of quality-assured patient-level NACR data. The development of the certification process was built on surveys and interviews with CR service providers, patients and commissioners. Minimum standards for certification were developed by an expert group. The resulting process for certification of meeting minimum standards of CR service was then successfully pilot-tested with 16 CR programmes, of which 13 programmes have since met minimum certification standards. CR programmes that submit data to the NACR can now apply for assessment under the BACPR/NACR National Certification Programme.  

You can earn CPD credits while reviewing this subject in-depth, with our updated and revised angina learning programme (available here)

Refractory angina represents an important clinical problem. Spinal cord stimulation (SCS) for refractory angina has been used for over two decades to improve pain and, thus, quality of life. This case series reports the clinical efficacy and safety profile of SCS.

We included patients who had a SCS device implanted between 2001 and 2015 following a rigorous selection process. Patients were prospectively followed. We performed a descriptive analysis and used paired t-test to evaluate the difference in Canadian Cardiovascular Society angina (CCS) class before and after SCS implant.

Of the 100 patients included, 89% were male, the mean age was 65.1 years and mean follow-up time was 53.6 months. The CCS class after SCS implant was statistically improved from before (p<0.05) and 88% of patients who gave feedback were very satisfied. Thirty-two patients died, 58% of those who had a documented cause of death, died from a non-cardiac cause.

This study shows the outcome of 14 years’ experience of SCS implantation. The anginal symptoms had a statistically significant improvement and the satisfaction rate was higher than 90%. The complication rate is within the range reported in the literature. SCS seems to be an effective and safe treatment option for refractory angina.

You can earn CPD credits while reviewing this subject in-depth, with our updated and revised angina learning programme (available here)

Refractory angina (RA) describes those patients with persistence of symptoms despite optimal conventional strategies. It is often associated with a maladaptive psychological response, resulting in significant burden on hospital services. This observational study sought to assess the short- and long-term impact of psychotherapy on quality of life, mood and symptoms. 

Between 2011 and 2012, consecutive attendees to a specialised RA service were recruited. Intervention consisted of a course of cognitive-behavioural therapy allied with an education programme. Outcome measures were collated pre-intervention, one month and two years post-intervention. Validated questionnaires were utilised for scoring assessments: SF-36 (Short-Form 36) for quality of life, HADS (Hospital Anxiety and Depression Scale) for anxiety/depression, and SAQ (Seattle Angina Questionnaire) for functional assessment. 

There were 33 patients included. Median SF-36 scores increased and this effect remained in the long term. Levels of depression reduced, and improved further at subsequent review. Frequency of angina was comparable, both short and long term. Usage of glyceryl trinitrate (GTN) spray was similar at one-month follow-up and at two years. 

In conclusion, a short course of psychotherapy appears to improve quality of life and mood in patients with RA, and is achieved independent of symptom control. Further research is warranted so that the debilitating morbidity associated with this disorder can be abrogated.

You can earn CPD credits while reviewing this subject in-depth, with our updated and revised angina learning programme (available here)

Chronic refractory angina results in significant NHS costs due to chronic high use of resources. This audit evaluated the clinical effectiveness of a cognitive-behavioural (CBT) programme in reducing angina symptoms after maximal medical and surgical intervention. The primary outcome was self-reported angina. Additional questionnaire data comprised perceived quality of life/disability, angina misconceptions, self-efficacy and mood. Data from the electronic patient administration system was used to compare use of cardiology hospital resources in the two years before and two years after attendance. Patients completing questionnaires reported significant improvements in all areas post-group and at two months. Resource use was lower in the two years post-programme than the two years prior. A CBT-based approach to symptom management could offer additional clinical benefits in the cardiac rehabilitation menu.

Reflex syncope is the most common cause of transient loss of consciousness. Practical manoeuvres may help, but additional measures are often required. In our experience, midodrine gives consistently good results in patients with reflex syncope. This study also provides reassurance that the effect on blood pressure is measureable, but small, and side effects are infrequent. UK prescribing may have been limited when midodrine was unlicensed, but midodrine is now licensed.

We treated 195 patients, age 40 ± 18 years, 72 (37%) aged under 30 years, 151 female (78%), who attended a Rapid Access Blackouts Triage Clinic and gave a clear history of reflex syncope. The median duration of symptoms was 28 months. A misdiagnosis of epilepsy had occurred in 39 patients and 42 had significantly low blood pressure.

Follow-up was 50 ± 42 months in 184 patients (93%), with 11 patients lost to follow-up. Twenty-eight patients had minor electrocardiogram (ECG) changes but had a normal echocardiogram. Overall, 143 (73%) patients improved on a mean dose of 10 mg a day of midodrine. Syncopal events fell from 16 ± 16 to 2.6 ± 5 per six months (p<0.05), and in 69 (35%) patients, syncope was eradicated. Nineteen (10%) patients were able to stop midodrine after 52 ± 42 months due to symptom resolution. Fifteen patients (7%) stopped midodrine because of side effects, while 17 (8%) patients failed to respond. Mean supine systolic blood pressure rose from 114 mmHg to 121 mmHg at final midodrine dose (p<0.05).

In conclusion, in patients with reflex syncope, midodrine shows clinical benefit in greater than 70%, with 24% having complete symptom resolution. Side effects are rare, and there is little evidence of a hypertensive effect.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital condition that proves to be fatal in most individuals during childhood due to significant left ventricular ischaemia. However, there are case reports of individuals surviving into adulthood that have varying presenting symptoms. We report a case of a young male, who presented to our cardiology clinic with typical ischaemic cardiac pain, with no established risk factors, and was found to have anomalous origin of the left coronary artery from the pulmonary artery that was subsequently surgically corrected.  

Despite the significant improvements in both diagnostic and therapeutic procedures in recent years, infective endocarditis (IE) remains a medical challenge due to poor prognosis and high mortality. Echocardiographically, the majority of the patients demonstrate vegetations on a single valve, while demonstration of involvement of two valves occurs much less frequently; triple-valve involvement is extremely rare. Reported operative mortality after triple-valve surgery is high and ranges between 20% and 25%. 

Surgical treatment is used in approximately half of patients with IE because of severe complications. Reasons to consider early surgery in the active phase, i.e. while the patient is still receiving antibiotic treatment, are to avoid progressive heart failure and irreversible structural damage caused by severe infection, and to prevent systemic embolism. Prognosis in IE is influenced by four main factors: characteristics of the patient, the presence or absence of cardiac and non-cardiac complications, the infecting organism, and echocardiographic findings. Prognosis of right-sided native valve endocarditis is relatively good, with an in-hospital mortality rate of about 10%.

We present a case of a young man with triple-valve endocarditis followed by a brief review of the literature.

This was a pilot study, in which 55 breast cancer patients were enrolled, to evaluate the alterations of strain and strain-rate parameters in breast cancer patients receiving doxorubicin and compare them with serial conventional echocardiography changes. A week prior to, and a week after, chemotherapy with doxorubicin, left ventricular ejection fraction (LVEF) and strain and strain-rate parameters were measured by conventional 2D echocardiography and tissue Doppler-based imaging, respectively.

Comparison of the results of pre- and post-chemotherapy evaluation demonstrated that strain and strain-rate parameters were significantly reduced. Mean difference (standard deviation) for the strain measurement of basal-septal, basal-lateral, basal-inferior, and basal-anterior values were 2.58% (2.15), 3.20% (1.94), 4.13% (3.48), and 2.86% (2.65), respectively; and for the strain-rate values were 0.18 s^–1 (0.17), 0.17 s^–1 (0.17), 0.24 s^–1 (0.19), and 0.19 s^–1 (0.14), respectively; all p values <0.001. There was no significant change in patients’ LVEF after chemotherapy (pre-intervention 61.10 (4.86), post-intervention 61.06 (4.82), p=0.857). 

In conclusion, strain/strain-rate significant reduction, in the setting of normal range LVEF, suggests subclinical heart failure. Whether the strain and strain-rate imaging should replace the conventional echocardiography for early monitoring of cardiotoxicity of doxorubicin requires further investigations.

A 79-year-old lady was taken to the emergency department by her carer, who had noticed an acute deterioration of her general condition. Unfortunately, it was difficult to obtain an accurate history from the patient due to cognitive impairment, and her carer was not aware of her past medical history. However, she had been observed clenching her hands to her chest. She was not previously known to the admitting hospital.

Current guidelines recommend against vigorous sports for all patients with an implantable cardioverter defibrillator (ICD). In this study, we established the risk of life-threatening arrhythmias and shocks in patients with an ICD participating in sports. 

In this single-centre, cohort survey with 71 patients (59% male) ≤40 years old at ICD implantation and with a left ventricular ejection fraction (LVEF) ≥35%, 16 patients were defined as athlete (exercise ≥5 hours per week). Sports-related and clinical data were obtained using questionnaires and medical records. Median age was 38 years (19–53 years). Median follow-up period was 67 months (11–249 months). Idiopathic ventricular fibrillation (VF) was the most frequent indication (20%) for implantation. There were 22 patients (31%) who experienced 127 shock episodes, of which 112 were appropriate: 15% of shocks occurred during physical exercise. Shocks did not occur more frequently in athletes (25%) compared with non-athletes (33%, p=0.760). Intensity of exercise and appropriateness of shocks were not associated. 

In conclusion, we found no evidence that participation in sports contributed to the risk of life-threatening arrhythmias and (in)appropriate ICD shocks in patients with an ICD. In individual cases, the advice to participate in sports could be more lenient compared with current guidelines.