Clinical articles

Current transcatheter mitral valve techniques are at the beginning of an era of innovation before their full potential is realised. The broadening of available options for mitral regurgitation (MR) reduction is welcome and transcatheter mitral valve interventions provide complementary strategies in the drive for more safe and effective therapies for patients. In this article, the evidence and indications for MitraClip^® are reviewed.

Postural tachycardia syndrome (PoTS) is a recently recognised condition that usually affects younger women, who develop symptoms of orthostatic intolerance and a persistent tachycardia on standing upright. Healthcare professionals, patients and the national patient support group (PoTS UK) together created a survey, and the responses of 779 UK PoTS patients were analysed. The most common symptoms of PoTS at presentation were the triad of fatigue, lightheadedness and palpitations. Mobility, ability to work or attend education, and quality of life were significantly restricted. Cardiologists, followed by patients, were most likely to be the first to suggest the diagnosis of PoTS. Patients waited a mean of almost four years from presentation to obtain their diagnosis and, meantime, psychiatric mislabeling was common. Advice given to patients regarding lifestyle changes was variable, and those referred to specialist practitioners for help, found practitioners had limited knowledge about management of PoTS. Increased education of healthcare professionals and improved services for patients are recommended. 

In 2010, the National Institute for Health and Care Excellence (NICE) introduced new guidelines for the assessment of people with recent-onset chest pain, recommending investigations based upon one’s pre-test likelihood of having coronary artery disease. We aim to determine the impact these guidelines have made on the numbers of patients being discharged and referred for further investigations. We retrospectively analysed a database of 337 consecutive patients seen in the rapid access chest pain clinic: 162 patients were seen in the three months preceding, and 175 were seen in the three months following implementation of the new guidelines. We found that after implementation of the new guidelines, fewer patients (25% vs. 37%, p=0.018) were discharged at the first visit, and a greater number of patients were referred for an angiogram (20% vs. 6%, p=0.0001). The number of referrals for stress imaging significantly reduced from 57% to 37%. According to the new guidelines, 18% of patients were referred for coronary calcium scoring. This reflects a definite change in clinical practice with reduced direct discharges from the chest pain clinic, reduced reliance on functional imaging and increased direct referrals for invasive coronary angiography, resulting in higher investigational costs of the chest pain service.

A 90-year-old man with a history of prostate cancer was admitted with haematuria and mild normocytic anaemia on routine blood tests. Baseline observations were normal and chest X-ray was unremarkable. Electrocardiogram (ECG) showed tri-fascicular block. He underwent successful bladder irrigation. Prior to discharge, he suffered a syncopal episode: ECG confirmed tri-fascicular block, for which he was discussed with the cardiology team for consideration of permanent pacemaker implantation. Pre-procedural transthoracic echocardiogram (TTE) revealed a large mobile thrombus attached to the tricuspid valve (TV) and extending to the right ventricle (RV), significant RV impairment and severe TV regurgitation (figure 1A–B). Following discussion between urology and cardiology teams and, in view of the significant risk of massive pulmonary embolism (PE), the patient underwent urgent thrombolysis. This was not complicated by significant haematuria. Post-intervention TTE demonstrated complete dissolution of the right-sided thrombus and mild TV regurgitation only (figure 1C–D). Warfarin was started and no further haematuria or syncope was reported on subsequent follow-up.

A 47-year-old woman had been referred to the cardiology department with a six-month history of intermittent chest discomfort not specifically related to exertion. Her risk factors: current smoker 10–15 per day and family history of ischaemic heart disease. She had no history of diabetes or hypertension. Lipid levels had not been tested. 

Structural heart disease may be missed using clinical examination alone and limited echocardiograms or ‘quick-scans’ may be a way to improve rates of detection. To evaluate the finding of clinically unexpected abnormalities using ‘quick-scans’, scans were performed in a general practice by a level 7 sonographer using a GE V scan system. Indications were: murmur; potentially cardiac symptom (e.g. chest pain or breathlessness); cardiac history in the GP notes (e.g. myocardial infarction); atrial fibrillation; chronic obstructive pulmonary disease with disproportionate dyspnoea; age ≥75 years. Standard transthoracic echocardiograms were performed if clinically indicated or if the ‘quick-scan’ detected a significant abnormality.

There were 163 ‘quick scans’ indicated, which were normal in 80 (49%), mildly abnormal in 67 (41%) and significantly abnormal in 16 (10%). Abnormalities were moderate left ventricular (LV) systolic dysfunction, moderate mitral regurgitation, moderate-to-severe aortic stenosis and mild aortic dilatation. Within the 90 patients without agreed indications the ‘quick-scans’ were normal in 64 (71%) and mildly abnormal in 26 (29%) while none were significantly abnormal.

In conclusion, ‘quick scans’ can detect clinically unexpected pathology. These results are consistent with a global move to use the hand-held ultrasound machine as an extension of the clinical examination.

Focused cardiac ultrasound using a pocket-sized imaging device (V scan) is increasingly being used to screen patients in the emergency setting for structural heart disease. We describe a patient who presented with light-headedness and pallor with elevated high-sensitivity troponin T (hs-TnT) and was initially thought to have acute coronary syndrome. A screening focused cardiac ultrasound revealed a dilated right ventricle with normal left ventricular function, and a computerised tomography pulmonary angiogram (CTPA) demonstrated a large saddle pulmonary embolus. The case highlights the application and utility of focused cardiac ultrasound and provides an overview of its current role in the acute setting reinforced by current guidelines from the European Society of Cardiology.

People with chronic heart failure (CHF) often experience exacerbations of their symptoms that require hospitalisation. The feasibility, safety and efficacy of early post-exacerbation rehabilitation are largely unknown in this population. 

This was a single-centre, feasibility trial of early rehabilitation versus usual care. Those assigned to the intervention started rehabilitation within 10 days of discharge and attended supervised sessions twice per week for eight weeks. The primary outcomes were feasibility of uptake and safety. Assessments were performed at baseline and three months: exercise tolerance (shuttle walking tests) and health status (questionnaire).

There were 1,298 patients screened, 16 patients recruited (<1% of those screened) and 11 randomised (five rehabilitation, six control). The primary reasons for exclusion were contraindication to exercise and normal ejection fraction. There were improvements in exercise tolerance and health status in both groups at three months; however, the study was not powered to report any within- or between-group significance. The early rehabilitation intervention was safe with no adverse events reported.

In conclusion, early rehabilitation, for patients with CHF, was unfeasible. The 10-day recruitment target was too restrictive in this population. This is important because there has been a drive towards early rehabilitation in CHF guidelines.

The proportion of patients with heart failure with preserved ejection fraction (HFPEF), compared with those with reduced ejection fraction (HFREF), is significant and rising. Studies have used an ejection fraction (EF) >50% as the sole criteria for identifying patients with HFPEF. However, European Society of Cardiology (ESC) guidelines include the diagnostic criteria of EF >50% and evidence of diastolic dysfunction.

In this retrospective cohort study based on admissions in 2012; we compared characteristics, treatment and outcomes between HFPEF and HFREF patients. One year readmission and survival rate was also assessed.

Overall, 41 (17%) patients had HFPEF (EF >50% and either medial or lateral E/E’ >15) compared with 200 (83%) with HFREF. Age was similar between the two groups (HFPEF: 84 ± 9 vs. HFREF: 82 ± 14, p=0.106). HFPEF patients were significantly more likely to be female (71% vs. 41.5%, p=0.001) and significantly less likely to have ischaemic heart disease (34% vs. 52%, p=0.043). Patients with HFPEF were significantly less likely to be taking loop diuretics, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors and aspirin on discharge. Ischaemic heart disease was a significant predictor of mortality in HFPEF patients (hazard ratio [HR] 7.14; 95% confidence interval [CI] 1.51–33.85, p=0.01). There was no difference in readmission and one-year survival rate (p=0.68 and p=0.551, respectively).

In conclusion, HFPEF patients are more likely to be female but less likely to have an ischaemic aetiology. There were significant differences in treatment of both phenotypes. Both groups have a similar poor prognosis.

Delays in achieving target international normalised ratio (INR) with warfarin after cardiac surgery can lead to suboptimal outcomes. The aims of the study are to determine the difference in warfarin dosage requirements, before and after cardiac surgery, needed to achieve therapeutic anticoagulation.

A single-centre, retrospective review was conducted from 2012 to 2014 in cardiac surgery patients who were on warfarin pre-operatively and who had warfarin therapy resumed postoperatively in hospital. The primary outcome was the difference in warfarin dosage needed to achieve target INR before and after cardiac surgery. 

Ninety-five patients were included in the study. The mean daily postoperative warfarin dose needed for achieving a therapeutic INR was 0.18 mg lower than the mean pre-operative dose (5.03 ± 2.10 vs. 4.85 ± 2.25 mg; p=0.358). 

In conclusion, there was no statistically significant difference in the warfarin dosage before and after cardiac surgery needed to achieve target INRs.