Clinical articles

A 74-year-old man with a heterotopic heart transplant experienced alternating episodes of sustained native heart ventricular tachycardia and prolonged asystole. These were managed with cardioversion, drug therapy and pacemaker insertion. The unique physiology in such patients lends itself to numerous clinical considerations that would otherwise be routine management for most.

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) have demonstrated efficacy in reducing cardiovascular deaths and hospitalisations associated with heart failure patients. Despite well-established benefits observed in clinical trials, their real-world application remains underexplored. The purpose of this quality improvement project was to investigate and address the gap between evidence-based guidelines and the practical application of SGLT2i therapy in patients with heart failure with reduced ejection fraction (HFrEF).

The medical records were assessed in retrospect for HFrEF-related admissions at our cardiac centre. The main target of assessment was the dapagliflozin prescriptions in eligible patients. After the first cycle of data collection and analysis, several interventions, in the form of targeted teaching, empowering pharmacists, and utilising digital tools, were employed to improve compliance with prescriptions. After the implementation of our measures, a further cycle of data collection and analysis was carried out.

In the first cycle, 31% of 225 HFrEF patients, aged 74 ± 15 years, received dapagliflozin or had plans for its initiation. Prescription rates were influenced by age (mean 69 vs. 76 years, p<0.001) and admission under cardiology (70% vs. other specialties, p<0.001), while gender and diabetes had no impact. In the second cycle, 52% of 172 HFrEF, aged 74 ± 14 years, received dapagliflozin or had plans for its initiation. Prescription rates correlated with age (71 vs. 79 years, p<0.001) and admission under cardiology (59% vs. other specialties, p=0.002), with male patients more likely to be initiated on dapagliflozin (p=0.005).

Our quality improvement project sheds light on the challenges and opportunities in implementing dapagliflozin therapy for patients with HFrEF in a real-world clinical setting. The interventions introduced led to a substantial improvement in prescription rates, indicating the potential for positive change. There is a need for ongoing efforts to bridge the gap between evidence-based guidelines and clinical practice.

Traditionally, radial artery access (RAA) has been an exclusively ‘physician-delivered’ service, but with adequate training, nurse-led arterial cannulation can become widely adopted. In this clinical audit, senior nursing practitioners with at least two years of catheter lab experience, were offered RAA training. In phase 1 of training, two nurses were initially familiarised with a well-structured training protocol. Each of the two nurses carried out the first 50 RAA procedures under supervision on elective patients. In phase 2, candidates independently performed 100 procedures. The success and complication rates of these procedures were evaluated prior to their sign-off as competent. The procedural efficacy of nurses was compared with medical registrars of the department to assess the measures of patient satisfaction and time elapsed prior to the insertion of sheath.

During the first 100 directly observed RAA procedures, nurse 1 and nurse 2 achieved success rates of 84% (42/50 procedures) and 86% (43/50 procedures), respectively. During the second phase, nurse 1 achieved a success rate of 82% (82/100 procedures), whereas nurse 2 achieved a success rate of 97% (97/100 procedures). Overall, a success rate of 88% was achieved in the first 300 patients. No significant complications were noted. In contrast to medical registrars, nurse-led cannulation was associated with a greater extent of patient satisfaction, reduced pain intensity (p<0.001), and decreased patient-on-table to sheath insertion intervals (p<0.001). During embedding of the programme, the two nursing practitioners trained additional nurses. Of the five nurses that subsequently entered into training, two have successfully completed both training phases while a further three have completed phase 1. To date, an overall success rate of 91.1% (1,307/1,435 procedures) has been documented.

In conclusion, a nurse-led RAA program is feasible, with satisfactory success rates, no significant complications, and improved rates of patient satisfaction.

A young man with multifocal cavitating pneumonia presented with early abscess formation secondary to Staphylococcus aureus bacteraemia treated with intravenous (IV) flucloxacillin. Further workup with transthoracic echocardiography revealed a large vegetation on the tricuspid valve with at least moderate tricuspid regurgitation; however, there were no peripheral stigmata of infective endocarditis. There was no history of intravenous drug use, but he had a history of administering frequent intramuscular recreational steroid injections. He also had a recent history of a loose tooth. In addition, there were multiple skin excoriations from scratching related to anxiety. Transoesophageal echocardiography confirmed two vegetations on the tricuspid valve, the largest measuring 21 mm with evidence of severe tricuspid regurgitation. The findings were discussed in the cardiac surgery multidisciplinary meeting and the consensus was for initial sterilisation with IV antibiotics followed by surgery.

This case report explores the effects of myocarditis induced by coronavirus disease 2019 (COVID-19) on a cardiac implanted electronic device (CIED) and its ability to differentiate depolarisation and repolarisation. Through the modification of the device settings, inappropriate CIED discharges were prevented for the duration of the illness in this 76-year-old male patient. This provides supporting evidence to consider episodes of acute COVID-19 as a cause for T-wave oversensing (TWOS).

Sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are established glucose-lowering and weight-lowering agents used in the management of type 2 diabetes mellitus and obesity. Several recent clinical trials have provided evidence that these agents can decrease the risk of, and slow progression of, cardiovascular and renal diseases independently of their glucose-lowering and weight-lowering effects. In clinical trials and ‘real-world’ observational studies in people with and without diabetes, SGLT2 inhibitors have offered protection against heart failure and chronic kidney disease, while GLP-1 receptor agonists have been associated with reductions in atherosclerotic cardiovascular events and albuminuria. Based on this evidence, SGLT2 inhibitors and GLP-1 receptor agonists can now be considered for use beyond diabetes and obesity as new treatment options in the management of cardiorenal disease.

Clinical trials and observational studies have demonstrated that long-term systolic blood pressure variability derived from repeated measurements of visit-to-visit clinic blood pressure is an important predictor of cardiovascular outcomes, independent of average levels of systolic pressure. Even in patients with well-controlled blood pressure (<140/90 mmHg), high systolic blood pressure variability confers an increased risk of cardiovascular events. Systolic blood pressure variability is currently derived from several measurements of visit-to-visit clinic blood pressure and expressed as the standard deviation of systolic pressure. Values in excess of 12 are indicative of high systolic blood pressure variability. Ongoing studies aim to determine whether home blood pressure monitoring may be an alternative way of measuring blood pressure variability. Evidence from several clinical trials shows that long-acting calcium-channel blockers, such as amlodipine, and thiazide-like diuretics are the only antihypertensive drugs that reduce long-term systolic blood pressure variability, and should be used preferentially in patients with high variability.

Subclavian venoplasty is commonly performed for subclavian vein stenosis in patients with long-term dialysis lines or fistulae. Such stenosis may also occur in patients with previously implanted intra-cardiac devices. It poses a problem if a further device upgrade or implantation is planned as the stenosis restricts the advancement of leads. Venoplasty before device implantation may provide a feasible alternative to lead tunnelling or extraction, which have their limitations. Four cases of varying complexities and devices that were implanted in patients with subclavian stenosis are presented herein. These were done in a district general hospital within the cardiology team. Venoplasty was performed using peripheral angioplasty balloons after which the device was implanted. All cases were performed successfully without any immediate complications with the patients discharged home the same day. These cases show the utility of subclavian venoplasty in facilitating device implantation without the need to utilise contralateral venous access, hence preserving venous access for the future. Additionally, they illustrate that this may be performed locally in a district general hospital setting, where appropriate expertise is available, with a high success rate and without the need to refer patients to an alternate tertiary care institute which may be associated with additional difficulties for the patient. To the best of our knowledge, this is the first instance where several cases of this procedure were performed successfully in a secondary care setting.

Pathogenic genetic variants in the HCN4 (hyperpolarisation-activated and cyclic nucleotide-gated channel) gene can cause sinus node dysfunction, disrupting the function of the pacemaker region of the heart. Patients with such variants can present with a wide spectrum of arrhythmias but sudden death is generally considered rare. We report two cases from the same family with different outcomes to highlight a potential high-risk phenotype in HCN4-related disease.

Heart failure (HF) is a prevalent and complex condition that demands precise and efficient management. This paper delves into a critical, yet often under-recognised, challenge in HF care – the accurate coding of patients on HF registers. We explore how discrepancies in coding, including missing patients and incorrect HF type classifications, can significantly impact patient management. The experiences of our healthcare system’s staff are examined to shed light on the real-world implications of these issues.

Clinicians and administrative staff in primary care can play a pivotal role in identifying, monitoring, and ensuring the accuracy of patient coding. By sharing their insights, we uncover the intricacies of addressing coding discrepancies and strategies suggested to optimise patient management. Furthermore, we investigate the technology and systems in place to aid staff in this endeavour.

This paper aims to contribute to the broader healthcare community’s understanding of the challenges related to coding accuracy in HF registers and to offer insights into potential solutions. By rectifying these coding discrepancies, we can enhance patient care, minimise potential oversights, and ultimately improve outcomes for individuals living with HF. Our findings underscore the significance of ensuring that no HF patient is missed or misclassified, emphasising the need for continued improvement in this vital aspect of HF care.