Clinical articles

Providing cardiopulmonary bypass and surgical back-up for transcatheter aortic valve implantation has significant implications for surgical services. It is unclear how practice varies around the UK and whether valve-type influences practice. We performed an email-based survey to gain a UK-wide snapshot of current practice. We found that bypass was available in the catheter lab in 94% of Edwards versus 30% of CoreValve centres (p=0.0003), and that a full surgical team and theatre were kept free in 89% of Edwards versus 20% of CoreValve centres (p=0.008). Further research is required to understand whether this difference in surgical provision, related to valve-type, confers outcome benefit.

To determine whether the ‘smoker’s paradox’ exists in the acute coronary syndrome (ACS) population, we performed the first meta-analysis of adjusted risk estimates separately for early and late mortality. Eligible studies were comparative studies of smokers versus non-smokers enrolling patients hospitalised for ACS and reporting adjusted risk estimates for all-cause mortality.

Twenty-six risk-adjusted studies of smokers versus non-smokers enrolling >700,000 patients with ACS were identified and included. Pooled analysis suggested that smoking was associated with a statistically significant reduction in early (in-hospital or 30-day) mortality for the comparison of current versus never smokers (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.75 to 0.96), any comparisons (current vs. never, former vs. never, current vs. former/never, and current/former vs. never smokers; OR 0.89; 95% CI 0.84 to 0.94), and patients with exclusive ST-segment elevation myocardial infarction (OR 0.80; 95% CI 0.73 to 0.87) and acute myocardial infarction (OR 0.87; 95% CI 0.82 to 0.92). Smoking was associated with a statistically non-significant increase in late mortality for any comparisons (hazard ratio 1.07; 95% CI 0.95 to 1.21).

In conclusion, the ‘smoker’s paradox’ for mortality may exist in the early phase following ACS but it may vanish in the late phase.

We present an investigation into the safety of providing training in coronary angiography within a district general hospital setting.

An unusual case of endomyocardial fibrosis presenting secondary to idiopathic hypereosinophilic syndrome, diagnosed with the aid of cardiovascular magnetic resonance (CMR) imaging. This case highlights how CMR imaging is a powerful addition to current non-invasive diagnostic tools, for early clinical diagnosis of eosinophilic endomyocardial disease, and may potentially obviate the need for cardiac biopsy in the future.

Lipoproteins play a pivotal role in the development of atherosclerosis, where apolipoprotein B-containing lipoproteins are considered pro-atherogenic and high-density lipoprotein anti-atherogenic. The retention and accumulation of modified low-density lipoprotein in foam cells within the intima of the arterial vessel wall is characteristic of the atherosclerotic process. Conversely, high-density lipoprotein plays an important role in the efflux of excess free cholesterol from the arterial wall through the process of reverse cholesterol transport. High-density lipoprotein also has antioxidant and anti-inflammatory properties that may also confer a protective effect on the vasculature. Statins are the first-line treatment for lowering low-density lipoprotein, but the residual risk of disease remains high. Novel therapies are under investigation that may offer a new therapeutic approach to treating atherosclerosis and additional protection against cardiovascular disease.

In 2010, the National Institute of Health and Care Excellence (NICE) published a new guideline for the investigation of patients with chest pain of recent onset. The guidelines were the first to recommend the use of a pre-test probability (PTP) and the first to recommend the use of cardiac computed tomography (CT) in patients with low PTP. 

We carried out an online survey of nurses who deliver rapid access chest pain (RACP) clinics and consultant cardiologists to establish current practice and response to the guidelines. Our results demonstrate that assessing PTP is now accepted as a key part of management. The first-choice investigations, at present, for low PTP patients are cardiac CT (used by 44%) and exercise tolerance tests (ETT 43%) with further use of cardiac CT limited only by availability. There is a broad range of investigations used in the medium PTP group including use of all modalities of functional imaging, ETT and cardiac CT. Cardiologists continue to use functional tests including ETT in the high PTP group, but the majority use invasive coronary angiography (ICA) as a first-line test. 

This survey shows that the NICE guidelines have been broadly accepted and there are ongoing efforts to implement them, subject to availability of tests and resources. There is some disagreement with the guidelines, with some cardiologists still preferring to use the ETT in all risk groups, and some preferring to use functional imaging tests in higher risk patients, in preference to ICA. 

In conclusion, there is very good uptake of the NICE guidelines on management of patients with chest pain. The reasons the guidelines are not fully implemented revolves around availability of resources, as well as a preference for functional tests for the additional prognostic information. This point is supported by the European Society of Cardiology (ESC) guidelines, which have built on and added to the NICE guidelines.

It is unknown whether topical tissue adhesive provides comparable wound healing to absorbable sutures following cardiac device implant. This study was designed to compare wound closure using cyanoacrylate topical tissue adhesive with standard wound closure using absorbable sutures in patients receiving an elective permanent pacemaker implant.

Patients admitted for elective pacemaker implant were randomised to receive wound closure with either absorbable sutures or topical tissue adhesive (glue). Procedure duration, wound closure duration and wound size were recorded. Patients were evaluated at six and 12 weeks post-implant using validated wound evaluation scores by an experienced plastic surgeon who was blinded to the closure method.

Of 122 patients enrolled, 64 received topical tissue adhesive and 58 received absorbable sutures. Patients were well matched for baseline demographics. Use of topical adhesive was associated with shorter wound closure time (117 s, interquartile range [IQR] 92–136 vs. 277 s, IQR 231–311); no difference was seen in overall procedure duration. A total of 100 subjects completed review at 12 weeks. There was no significant difference in any of the wound evaluation scores measured. There was a trend to improvement in cosmetic appearance in patients who received topical adhesive, as judged subjectively by the blinded plastic surgeon. There was no difference in adverse event rates between the two groups.

In conclusion, use of topical tissue adhesive for wound closure following permanent pacemaker implant was not superior to traditional closure techniques with absorbable sutures with regard to cosmetic outcome.

Atrial fibrillation (AF) is a dangerous, prevalent condition whose first presentation may be ischaemic stroke. Anticoagulation dramatically reduces stroke risk if patients are first identified. While screening enhances AF detection, it is unclear whether opportunistic pulse palpation or systematic electrocardiogram (ECG) screening is superior.

Patients across 15 general practices in the Bradford and Airedale primary care trust aged over 65 years were invited for a limb-lead ECG. A total of 6,856 patients were subjected to an ECG. This study aimed to determine if screening improved AF detection and the prevalence of cardiac rhythms that may cause an irregular radial pulse.

There were 248 patients diagnosed with AF (3.6%): 153 out of 207 traceable patients were previously diagnosed, hence, screening increased AF detection by 26.1%. Further abnormalities capable of causing an irregular pulse (i.e. ectopy) were highly prevalent at 18.3%. Overall, 99.0% of recorded ECGs were interpretable.

In conclusion, limb-lead ECG screening improved detection rates in a simple and feasible screening strategy, avoiding the need for more costly and cumbersome 12-lead ECG screening. Furthermore, the high prevalence of ectopy suggests systematic ECG screening is more specific than opportunistic screening. This study demonstrates simple ECG models may have a promising potential role in improving AF detection, particularly if asymptomatic.

National Institute for Health and Care Excellence (NICE) CG95 guidelines recommend a diagnostic algorithm based on pre-test probability of significant coronary artery disease (SCAD). We hypothesised that these probabilities overestimate the risk of SCAD in our population leading to unnecessary invasive coronary angiography. 

Data were collected prospectively for
every adult patient attending the rapid access chest pain clinic (RACPC) at a South London acute general hospital from 1 April 2012 to 31 March 2013. SCAD was defined as a luminal narrowing of ≥70% in a major coronary artery or >50% in the
left main stem.

There were 551 people assessed with a mean age of 59.9 years; 52% were female. In total, 140 patients underwent coronary angiography. Of these, 79 patients fell within the 61–90% risk bracket, but only 32 (40.5%; 95% confidence interval [CI] 29.7–51.3%) had SCAD. Of patients undergoing angiography, 48 had a risk of >90% but only 26 (54.2%; 95% CI 40.1–68.3%) had SCAD. No individual component of the pre-test probability calculation (age, gender, typicality of symptoms, and cardiac risk factors) predicted an increased chance of SCAD. 

We conclude that NICE prediction tables overestimate the risk of SCAD in our patient population. We recommend that the risk tables be updated to represent contemporary patient cohorts in order to reduce the number of potentially unnecessary angiograms. 

Occupational radiation exposure in fluoroscopy-guided procedures is highest among medical staff, particularly cardiologists involved in interventional procedures. The danger of radiation-induced cataracts in operators, and the suggestion of a higher incidence of malignancy among interventional cardiologists, have led to a significant focus on radiation safety in the cardiac catheterisation laboratory. We examined our mean eye and tibia dosimeter reading trends between 1993 and 2011 (among different sub-specialised cardiologists), and the impact of shin tibia lead protectors. During the period 1993 to 2011 there was a steady decline in radiation doses. The dosimeter readings level fell from a peak of 34 to 6.0 mSv per year and 29 to 1.0 mSv per year at the eye and at the tibia, respectively. Interventional and electrophysiology/pacing cardiologists tend to have a trend of higher radiation doses at the tibia level as compared with non-interventional cardiologists. The introduction of shin leg protectors further reduced radiation exposure from a peak of 6.0 mSv per annum in 2008 to ≤1.0 mSv per annum. Radiation safety awareness and policies have led to a significant fall in operator radiation exposure. The shins, not protected by conventional lead aprons, receive a significant exposure. We have demonstrated that the routine wearing of shin protectors reduces radiation exposure to a minimal level.