Clinical articles

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.

The 2010 UK National Institute of Health and Care Excellence (NICE) guidelines for assessing patients with ‘chest pain of recent onset’ recommend coronary artery calcium scoring (CACS) to assess patients with a low risk of coronary artery disease (CAD) according to defined criteria. This study aims to evaluate the implementation of these guidelines in an area with a prevalence of CAD higher than the national average. 

Consecutive patients with recent onset stable chest pain were assessed by cardiologists in outpatient clinics at University Hospital Aintree, Liverpool, between January and December 2011. A total of 186 patients with a low risk of CAD underwent CACS and follow-on computed tomography coronary angiography (CTCA) if CACS <400. 

A CACS of zero was found in 94 patients and three of these were excluded due to motion artefacts. Of the remaining 91 patients, 75 (82.4%) had no visible atheroma, 10 (11%) had minor plaque, five (5.5%) had moderate disease and one (1.1%) had apparent severe disease, which was shown to be a false-positive result on subsequent invasive coronary angiography.

This study shows a negative predictive value for severe disease of 99% for a CACS of 0 in stable patients with a low pre-test probability of CAD. This supports the NICE guidelines, with CACS being the investigation of choice in the UK to rule out significant CAD in selected patient populations. The fact that almost half of all the patients referred for CTCA had a CACS of zero makes this a good quick rule-out tool and, hence, avoids the need for follow-on CTCA.

A 56-year-old male with no previous significant medical history initially presented to his general practitioner for a routine health check prior to starting a new occupation. An electrocardiogram (ECG) was taken that was found to be unusual and, hence, a referral to cardiology outpatients was made. Initial recommendation was made for ablation therapy based on the finding of Wolff-Parkinson-White (WPW) syndrome. After a successful procedure, the patient developed significant palpitations with haemodynamic compromise that required emergency direct current (DC) cardioversion. Subsequent re-investigation found a previously unmasked uncommon form of accessory tachyarrhythmia. This case report highlights the finding of Mahaim pathway in a patient initially treated for WPW syndrome.

Atrial fibrillation (AF) is the most common sustained arrhythmia faced by clinicians in primary and secondary care. Patients with AF face a significant risk of stroke and thromboembolic complications with associated morbidity and mortality. The role of antiplatelet agents is diminishing, while the use of oral anticoagulants is being actively encouraged. Warfarin has provided the mainstay of oral anticoagulation for more than half a century. New oral direct inhibitors (ODIs) of thrombin and activated factor X – commonly referred to as the new oral anticoagulants (NOACs) – are being prescribed with increasing frequency. These ODIs have a number of advantages over warfarin, including predictable response, no need for monitoring or dose changes and fewer drug and food interactions. Although the risk of intracranial bleeding is reduced, there is still a risk of major haemorrhage as patients are fully anticoagulated. An understanding of the ODIs’ metabolism and excretion, as well as their effects on coagulation tests, is paramount to the management of patients, particularly in emergency situations.

The possible overuse of coronary angiography in the investigation of suspected coronary artery disease has been raised as a concern in the literature. We examined our own coronary angiography database to assess the diagnostic yield from angiography in the investigation of patients with suspected coronary artery disease and also the subsequent rate of referral for revascularisation. Some coronary artery disease was found in 66% of patients. However, in spite of an overall diagnostic yield in keeping with National Institute for Health and Care Excellence (NICE) guidelines, only 28% of patients were referred for any form of revascularisation. The optimal use of coronary angiography has important resource implications and the rate of revascularisation may be a useful quality metric.

Heart failure (HF) accounts for 5% of all emergency hospital admissions in the UK. To ensure cost-effectiveness, the potential for any intervention to reduce admissions must be balanced against its required investment. This economic analysis compared cost-effectiveness of home- versus hospital-based exercise training as delivered within a randomised-controlled trial (RCT) for HF.

In conclusion, both training programmes incurred similar costs, which were offset by a reduction in emergency admission costs, compared with controls. Although hospital-training offered greater potential for reducing admission costs, with larger patient numbers, the cost of home-training per patient would decrease, increasing its likelihood of being the more cost-effective option.