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Clinical articles

Utility of MPS in AAA repair and prognostication of cardiovascular events and mortality

October 2018 Br J Cardiol 2018;25:150–1 doi :10.5837/bjc.2018.027 Online First

Utility of MPS in AAA repair and prognostication of cardiovascular events and mortality

Mark G MacGregor, Neil Donald, Ayesha Rahim, Zara Kwan, Simon Wong, Hannah Sharp, Hannah Burkey, Mark Fellows, David Fluck, Pankaj Sharma, Vineet Prakash, Thang S Han

Abstract

Myocardial perfusion scintigraphy (MPS) is a non-invasive method that can be used to assess reversible left ventricular myocardial perfusion defect (<20% indicates limited and ≥20% indicates extensive ischaemia), and left ventricular ejection fraction (LVEF) at rest and at stress. Data on the utility of MPS used to stratify cardiac risk prior to abdominal aortic aneurysm (AAA) repairs are limited. We evaluated MPS as a stratification tool for patients scheduled for endovascular aneurysm repair (EVAR) or open repair, between 2013 and 2016 at Ashford and St Peter’s NHS Foundation Trust, and 4.9 years (median 2.8 years, interquartile range [IQR] 2.1–3.8) cardiovascular events (n=15, 17.9%) all-cause mortality (n=17, 22.6%). Of the 84 patients recruited (median age 75.7 years, IQR 69.4–79.6), 57 (67.9%) had limited and 27 (32.1%) extensive ischaemia, 62 (73.8%) underwent EVAR and 22 (26.2%) open repair. Compared with open repair patients, EVAR patients were older (median age 70.6 years vs. 76.4 years, p=0.015), had higher rates of extensive ischaemia (13.6% vs. 38.7%, p=0.025), and abnormal LVEF reserve (LVEF at stress minus LVEF at rest ≤0: 40.0% vs. 76.6%, p=0.011), while having lower rates of 30-day postoperative major adverse cardiac events (13.6% vs. 3.3%, p=0.040) but no difference for cardiovascular events (p=0.179) or 4.9 year all-cause mortality (22.7% vs. 22.6%, adjusted hazard ratio 0.80, 95% confidence interval [CI] 0.22 to 3.20, p=0.799). Our findings indicate that MPS provides valuable information for AAA repair procedure.

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October 2018 Br J Cardiol 2018;25:143–6 doi :10.5837/bjc.2018.028 Online First

New-onset giant T-wave inversion with prolonged QT interval: shared by multiple pathologies

Debjit Chatterjee, Priya Philip, Kay Teck Ling

Abstract

This is a case series of 10 patients who presented with the same electrocardiogram (ECG) manifestation of new-onset giant T-wave inversion and QT prolongation over a period of 24 months in a district general hospital. This unique ECG manifestation has been described with several cardiac and non-cardiac conditions.

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October 2018 Br J Cardiol 2018;25:157–8 doi :10.5837/bjc.2018.029 Online First

A case report of transient acute left ventricular dysfunction

Allam Harfoush

Abstract

Stunned myocardium is a rare, but serious, medical condition, and requires emergency intervention. Short periods of hypoperfusion may lead to a prolonged cardiac hypokinesia (hours to days), even though the perfusion is retained eventually. In other words, although the coronary circulation is retained, the hypokinesia remains. It might be considered as a case of prolonged post-ischaemic dysfunction.

In this case, a 60-year-old woman, visiting her siblings, presented with severe dyspnoea and cyanosis to the emergency department. Pulmonary oedema was diagnosed, and transthoracic echocardiography (TTE) showed general hypokinesia and reduced ejection fraction (15%), nevertheless, sequential TTE monitoring after the required medical intervention revealed a continuous improvement, with a 45% ejection fraction three days later and a specific anterior wall hypokinesia, solely.

In conclusion, rapid diagnosis and treatment are essential for stunned myocardium, as these could change the progress of the clinical condition.

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August 2018 Br J Cardiol 2018;25:86–7 doi :10.5837/bjc.2018.024

Artificial intelligence in cardiology: applications, benefits and challenges

Panos Constantinides, David A Fitzmaurice

Abstract

The introduction of such digital technologies as robotic implants, home monitoring devices, wearable sensors and mobile apps in healthcare have produced significant amounts of data, which need to be interpreted and operationalised by physicians and healthcare systems across disparate fields.1 Most often, such technologies are implemented at the patient level, with patients becoming their own producers and consumers of personal data, something which leads to them demanding more personalised care.2

This digital transformation has led to a move away from a ‘top-down’ data management strategy, “which entailed either manual entry of data with its inherent limitations of accuracy and completeness, followed by data analysis with relatively basic statistical tools… and often without definitive answers to the clinical questions posited”.3 We are now in an era of a ‘bottom-up’ data management strategy that involves real-time data extraction from various sources (including apps, wearables, hospital systems, etc.), transformation of that data into a uniform format, and loading of the data into an analytical system for final analysis.3

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August 2018 Br J Cardiol 2018;25:97–101 doi :10.5837/bjc.2018.025

Impact of hyperkalaemia in managing cardiorenal patients – a healthcare professional perspective

Navneet Kalsi, Sarah Birkhoelzer, Philip Kalra, Paul Kalra

Abstract

A recent survey of healthcare professionals confirms that hyperkalaemia is considered as a common and important clinical issue for patients receiving renin-angiotensin-aldosterone-system (RAAS) inhibitors in particular. Successful interventions to manage hyperkalaemia appear beneficial rather than avoidance or dose reduction of these RAAS inhibitors in patients with chronic heart failure, diabetic nephropathy or prior myocardial infarction.

Two newer potassium exchange resins, patiromer and sodium zirconium cyclosilicate (ZS-9), may offer improved predictability, tolerability, and efficacy for managing patients with hyperkalaemia.

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July 2018 Br J Cardiol 2018;25:115–7 doi :10.5837/bjc.2018.018 Online First

A pulmonary triad in a patient with a giant left atrial myxoma

Andrea Calo, Madeleine Openshaw, Timothy J Bowker, Han B Xiao

Abstract

A 55-year-old man with suspected community-acquired pneumonia and atrial fibrillation was found to have a very large left atrial myxoma complicated with a pulmonary triad – pulmonary hypertension, pulmonary infarction, and pulmonary lymphadenopathy. The myxoma was successfully removed and complete resolution of all three pulmonary complications followed. He re-presented two weeks post-surgery with atrial flutter, which was medically treated and considered for ablation. We have taken the opportunity to undergo a mini-literature review on myxoma and its pulmonary complications.

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Opinions on the expanding role of CTCA in patients with stable chest pain and beyond: a UK survey

July 2018 Br J Cardiol 2018;25:107–9 doi :10.5837/bjc.2018.019 Online First

Opinions on the expanding role of CTCA in patients with stable chest pain and beyond: a UK survey

Saad Fyyaz, Alexandros Papachristidis, Jonathan Byrne, Khaled Alfakih

Abstract

The National Institute for Health and Care Excellence (NICE) released an updated guideline on stable chest pain in 2016. They recommended that all patients with chest pain, typical or atypical, should be investigated with computed tomography coronary angiography (CTCA) in the first instance. Functional imaging tests were reserved for the assessment of patients with chest pain and known coronary artery disease (CAD) and for patients where the CTCA is equivocal or has shown CAD of uncertain significance. The European Society of Cardiology (ESC) guidelines on stable chest pain, however, recommend functional imaging tests for all stable chest pain patients, with CTCA as an alternative in patients with low-to-intermediate likelihood of CAD. The ESC guidelines also allow for the use of the exercise electrocardiogram (ECG) as an alternative to functional imaging tests in patients with low-to-intermediate likelihood of CAD, if functional imaging tests are not available.

Furthermore, traditionally, the aetiology of heart failure or left ventricular (LV) dysfunction was investigated with diagnostic invasive coronary angiography. More recently, cardiac magnetic resonance imaging (MRI) tissue characterisation was proposed as an effective alternative test. We conducted a survey of UK cardiologists’ opinions on the use of CTCA in patients with stable chest pain and in the investigation of the aetiology of heart failure.

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July 2018 Br J Cardiol 2018;25:110 doi :10.5837/bjc.2018.020 Online First

Comprehensive study of routine clinical use of cardiac MRI in a district general hospital setting

George Abraham, Aamir Shamsi, Yousef Daryani

Abstract

The study sought to evaluate the indications, image quality, safety and impact on patient management of cardiac magnetic resonance imaging (CMR) in a district general hospital setting.  The database was developed using retrospective analysis of patient records from the start of the local CMR service in January 2014 until January 2017. All 791 consecutive patients were included in the dataset.

The most important indications were the investigation of myocarditis/cardiomyopathies (54.5%), work-up of suspected coronary artery disease (CAD)/ischaemia (27.1%), and assessment of viability (9.1%). Image quality was diagnostic in 99.9% of cases. Mild adverse effects were reported for 3.8% of patients for stress CMR and in 1.1% of non-stress CMR. No serious adverse events were reported in this study population. In 26.5% of cases, CMR findings resulted in therapeutic modifications. In 18.1%, the final diagnosis based on CMR was different to that suspected before the CMR.

In conclusion, the findings of this study emphasise that CMR is a safe procedure with high image quality. In many cases, CMR can be shown to change a patient’s management plan.

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July 2018 Br J Cardiol 2018;25:111–4 doi :10.5837/bjc.2018.021 Online First

Hypertension in pregnancy as the most influential risk factor for PPCM

Hawani Sasmaya Prameswari, Triwedya Indra Dewi, Melawati Hasan, Erwan Martanto, Toni M Aprami

Abstract

Peri-partum cardiomyopathy (PPCM) is one of the leading causes of maternal mortality worldwide, but the exact cause of PPCM is still unknown. PPCM is often associated with many risk factors, especially hypertension in pregnancy. This study aimed to evaluate the most influential risk factors of PPCM in Javanese ethnic patients.

The study was a case-control study involving 96 PPCM patients and 96 healthy non-PPCM parturients (control group) in the Hasan Sadikin Central General Hospital, West Java, Indonesia in the period from 2011 to 2014. A multiple logistic regression analysis was performed to evaluate the most influential risk factors for PPCM.

There were four significant and independent risk factors in this study, which were low socioeconomic status (adjusted odds ratio [OR] 3.312; confidence interval [CI] 1.383, 7.932), history of hypertension in previous pregnancy (adjusted OR 4.862; CI 1.245, 8.988), hypertension in current pregnancy (adjusted OR 2.311; CI 1.164, 4.590), and multi-foetal pregnancy (adjusted OR 7.057; CI 0.777, 64.097). Multiple logistic regression analysis showed the history of hypertension in previous pregnancy or hypertension in current pregnancy were the most influential independent risk factors of PPCM based on the narrowest confidence interval range, and after adjustment for other significant risk factors.

In this study, history of hypertension in previous pregnancy and hypertension in current pregnancy were the most influential and independent risk factors for PPCM. This study may increase awareness of treatment required for patients with hypertension in pregnancy, and also supports the pathogenesis of hypertension in pregnancy associated with PPCM, especially pre-eclampsia.

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July 2018 Br J Cardiol 2018;25:118–20 doi :10.5837/bjc.2018.022 Online First

A transitory right bundle branch block

Cristina Aguilera Agudo, Silvia Vilches Soria, Jorge Enrique Toquero Ramos

Abstract

The clinical presentation of patients with cardiac tamponade largely depends upon the length of time over which pericardial fluid accumulates and the clinical situation. It can result in a clinical picture ranging from cardiogenic shock to general malaise, including dyspnoea, chest discomfort or fullness, peripheral oedema and fatiguability.

Although cardiac tamponade is a clinical diagnosis, two-dimensional and Doppler echocardiography play major roles in the identification of pericardial effusion and in assessing its haemodynamic significance. Despite this, some other imaging techniques or diagnostic tools could also be used for diagnosis. With this case we want to highlight not only the role of the electrocardiogram (ECG), but also its utility in assessing the haemodynamic changes in this clinical entity.

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