Clinical articles

Chronic kidney disease (CKD) adversely affects cardiovascular outcomes and mortality in the general population. We sought to determine the impact of renal function on angiographic and clinical results in ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (pPCI). 

Analyses were based on the prospective ‘all-comer’ registry of 1,064 consecutive STEMI patients treated with pPCI in our tertiary centre between February 2001 and October 2002. Admission serum creatinine concentration was known in 894 patients (84%). Mean serum creatinine was 105 ± 27 µmol/L and estimated glomerular filtration rate (eGFR) was 67 ± 18 ml/min/1.73 m². Thrombolysis in Myocardial Infarction grade 3 (TIMI3) flow was achieved in 751 patients (84%). During hospitalisation, 29 (3%) major bleedings, five (1%) strokes and 12 (1%) re-infarctions occurred. By day 30, two patients were lost to follow-up and 41 (5%) were dead. Renal function was independently associated with 30-day mortality (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.2–2.1, p=0.003). In CKD patients (eGFR <60 ml/min/1.73 m²), TIMI3 flow was restored less frequently (79% vs. 87%), in-hospital major adverse cardiac and cerebrovascular events (MACCE) were more frequent (15% vs. 4%) and 30-day mortality was higher than in non-CKD patients (9% vs. 2%). Lower eGFR was associated with increased risk of major bleeding (HR 1.6, 95% CI 1.3–2.1, p<0.0005). In the subgroup of conscious patients with normal serum creatinine, eGFR remained significantly associated with 30-day mortality. 

In conclusion, renal function expressed by eGFR is an independent predictor of procedural success and short-term outcomes in STEMI patients treated with pPCI, even in patients with normal serum creatinine. Thus, eGFR should be estimated in all STEMI patients to help identify a high-risk subgroup.

This study was designed to evaluate the impact of a novel iterative reconstruction (IR) algorithm on an established UK cardiac computerised tomography (CT) service. Areas assessed included image quality and effective radiation dose (ED). 

IR in cardiac CT offers substantial ED reduction without compromise in image quality.

A 73-year-old woman, with a history of deep vein thrombosis (DVT) in her legs, presented two years following coronary artery bypass graft (CABG) with left internal mammary artery (LIMA), left radial artery and left cephalic vein, with a massive right atrial mass. Pre-operative work up also showed a left adrenal mass on computed tomography (CT) scan. We discuss the diagnostic possibilities within such a scenario and review the literature for right atrial masses of diverse aetiology, including right atrial myxomas, benign and malignant tumours of right atrium and right atrial thrombosis. The case is unusual on account of the concomitant history of DVT and the presence of left adrenal mass, rapid growth of the mass within two years following CABG, the atypical origin of the myxoma near inferior vena caval opening and the near total obliteration of the right atrial myxoma by rapid growth of myxoma to a massive size.

Acute heart failure (AHF) is a common cause of hospitalisation, presenting substantial economic and humanistic burden for healthcare systems and patients. This study was designed to capture proxy UK health-related quality of life (HRQoL) data for hospitalised patients with AHF. 

Proxy assessments of HRQoL for patients were obtained from 50 experienced UK cardiac nurses (formal caregivers) and from 50 UK individuals who acted as caregivers for patients who had experienced an AHF event leading to hospitalisation (informal caregivers). Data were collected retrospectively for four time points (days 1, 3, 5 and 7 post-hospital admission for AHF event) using the EQ-5D. Results show a disparity in reported HRQoL at day 1 values between caregiver types (mean single utility index 0.20 vs. 0.68, respectively, p<0.001). By day 7, formal caregivers rated typical patients’ HRQoL as being comparable to informal caregivers’ assessments (0.82 vs. 0.73, respectively, p=0.145). 

In conclusion, collection of utility data in severe acute conditions is challenging. This study captures values through the use of proxy assessment. Data suggest that AHF hospitalisation is associated with a significant HRQoL burden and that there exists a need for development of new treatments aimed at improving hospitalisation outcomes.

We conducted a pilot study to evaluate the safety of the shuttle walking test (SWT) and exercise training for cardiac patients in community-based cardiac rehabilitation settings. Overall, 33 cardiac patients were tested (19 males and 14 females, 67 ± 8 years). Eleven cardiac patients (testing group) and 22 cardiac patients (training group) underwent ambulatory electrocardiogram (ECG) monitoring during the SWT and exercise training during a long-term cardiac rehabilitation programme. Frequency of ECG events was reported for the two groups. Chi-square test was performed to determine associations between the incidence of cardiovascular events and poor functional capacity (SWT <450 m). 

The findings showed only minor events provoked during the SWT or exercise training, and no event-related hospitalisation, syncope episodes or fatality. The most important cardiac event was silent myocardial ischaemia (testing group: 27.3%; training group: 18%). Poor functional capacity was not associated with the risk of a cardiac event during exercise (testing group: χ²=0, p=0.99, phi=0.24; training group: χ²=2.1, p=0.15, phi=–0.42). 

In conclusion, supervised exercise testing and training are accompanied only by minor cardiovascular events and they can be carried out safely in community-based cardiac rehabilitation settings.

This single-centre, retrospective, cohort study aims to provide insight into the long-term survival of patients ≥85 years old undergoing percutaneous coronary intervention (PCI) over a four-year observational period in a high-volume PCI centre. Between 2006 and 2010, 294 patients (mean age 88 ± 2 years, 56% male) underwent PCI at our institute. A total of 180 patients (61.2%) had an acute coronary syndrome (ACS) defined as unstable angina, non-ST elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI). One hundred and fourteen patients underwent PCI electively (38.8%). 

We conclude that PCI appears to be a safe treatment option in very elderly patients with good one-year survival rates. Future randomised-controlled trials should specifically include this age group to guide interventional cardiologists in making decisions when faced with this very challenging cohort.

Primary percutaneous coronary intervention (PCI) has become treatment of choice for ST-elevation myocardial infarction (STEMI) in England. The assumption in most trials, and in their translation into clinical practice, is that centralisation of primary PCI for STEMI into large facilities is inevitable and essential. We feel that a successful and preferable primary PCI service can be delivered in a medium-sized district general hospital (DGH).

We performed a retrospective analysis of the first 18 months of primary PCI for STEMI in our unit. We compared our results with standards set out in the National Infarct Angioplasty Project report. Our median call-to-balloon time was 95 minutes and median door-to-balloon time was 50 minutes. Door-to-balloon times were shorter during working hours than out of hours, and were shorter for patients taken directly to the catheterisation laboratory than those admitted via A&E. During the period of assessment, 14% of patients experienced a major adverse cardiovascular and cerebrovascular event (MACCE). The overall mortality rate was 6.7%. No patients were transferred to our surgical centre for emergency treatment. 

We believe our data demonstrate that a system utilising regional Heart Attack Centres is not essential for satisfactory clinical outcomes, and may not be the preferred choice for patients and their ongoing post-myocardial infarction care. Expansion of PCI services in well-organised DGHs may be an equally good solution.

Diagnostic coronary angiography (CA) remains the gold-standard assessment of coronary artery disease (CAD). Transfemoral access remains a commonly used approach. Arterial tortuosity can lead to difficulties in coronary engagement, particularly when intubating the right coronary artery (RCA). Excessive catheter manipulation may result in knotting. 

Eliminate non-cardiac chest pain. Or rather, eliminate the expression. Cumulative irritation over several years leads me to comment on the readiness of doctors to use this, and ‘atypical chest pain’, as a diagnosis, and even carry out trials to assess treatment. To study a condition defined by what it is not seems weird; perhaps some people also describe non-brain head pain or atypical abdominal pain? 

Current European Society of Cardiology guidelines state that in troponin-negative acute coronary syndrome with no ST-segment change on electrocardiogram (ECG), a stress test is recommended. In the UK, exercise tolerance testing (ETT) is currently the most common first-line test. The high proportion of false-positive and inconclusive results often mandates second-line tests. We compared the diagnostic accuracy and cost implication
of computed tomography coronary angiography (CTCA) as first-line investigation compared with ETT. We hypothesised that CTCA would outperform ETT because of its excellent negative-predictive value. 

Our results suggest that it is feasible to use CTCA to investigate patients with acute low-to-intermediate likelihood chest pain in place of ETT at no extra cost. Moreover, this cost analysis only took into consideration the actual cost of investigation. Three US clinical trials have shown that CTCA in the emergency room can substantially reduce patient length of stay, reducing overall cost further. CTCA also recognises non-obstructive coronary atheroma, which, combined with clinical risk factors, may prompt the physician to initiate secondary prevention medication earlier.