March 2018 doi :10.5837/bjc.2018.006
Anthony D Dimarco, Eunice N Onwordi, Conrad F Murphy, Emma J Walters, Lorraine Willis, Nicola J Mullan, Nicholas S Peters, Mark A Tanner
Palpitations are a common symptom leading to primary care consultation. Establishing a symptom-rhythm correlation is important for providing a diagnosis. The Kardia Mobile personalised smartphone electrocardiogram (ECG) can provide patient-driven real-time ECG recording over extended periods. We investigated if this device might provide an effective alternative to conventional ECG recorders as the first-line investigation of low-risk palpitations.
Patients referred to our institution for investigation of intermittent palpitations but without syncope were supplied with a Kardia Mobile device if they had access to a compatible smartphone. Patients were asked to record an ECG when symptomatic.
Between March 2015 and June 2016, 148 patients were issued with a Kardia Mobile: 113 (76.4%) patients made symptomatic recordings during this period. A symptom-rhythm correlation was possible for all patients who submitted downloads. Median time to diagnosis was nine days (1–287 days). Diagnoses were: sinus rhythm n=47 (41.6%), sinus tachycardia n=21 (18.6%), supraventricular/ventricular ectopics n=31 (27.4%), atrial fibrillation n=8 (7.1%), and supraventricular tachycardia n=6 (5.3%).
In conclusion, the Kardia Mobile diagnosed the cause of intermittent palpitations in the majority of patients referred for specialist evaluation. Use of the Kardia Mobile may permit patients with palpitations to be evaluated in primary care.
March 2018 doi :10.5837/bjc.2018.007
Emma Johns, Gerry McKay, Miles Fisher
In this article we review the latest cardiovascular outcomes trials performed using older diabetes drugs.
March 2018 doi :10.5837/bjc.2018.008
Wala Mattar, Christopher Walker, Shelley Rahman Haley, Andre Simon, Charles Ilsley
We present a patient with progressive aortic regurgitation that developed following successful implantation of a left ventricular assist device (LVAD). We were able to correct this known complication of LVAD by occluding the aortic valve percutaneously with an AmplatzerTM multi-fenestrated septal occluder – Cribriform. This is the first such case to be reported in the UK.
January 2018 doi :10.5837/bjc.2018.001 Online First
Jonathan Bennett, Alexander R Lyon, Chris Plummer, Stuart D Rosen, Kai-Keen Shiu
This review aims to summarise the cardiovascular complications from cancer treatments and the methods used to prevent, identify, and treat them.
While the field of cardio-oncology is relatively new, it is developing rapidly in the UK. There is a need to develop services to care for the patients with current cardiac problems, to undertake research and education to identify those patients at higher risk of complications, and to apply modern imaging methods and biomarkers to detect problems early and implement prevention strategies. An evidence-based approach is required to enhance delivery of care and prevent cardiovascular toxicity in this patient population.
January 2018 doi :10.5837/bjc.2018.002 Online First
Alison Carr, Fosca De Iorio, Martin R Cowie
Despite guidelines on the treatment of acute heart failure (AHF), treatment remains heterogeneous, particularly regarding intravenous (IV) nitrate use. This clinical decision-making study assessed the use of IV nitrates and diuretics by 40 UK hospital physicians, each ‘treating’ the same 10 virtual patients. Semi-structured interviews were performed to investigate participants’ decision-making rationale.
IV nitrates were prescribed in 37% of clinical decisions. Considerable variability was seen in the administration of IV nitrates among physicians. Interview data revealed polarised opinions regarding the efficacy of IV nitrates and the evidence base supporting their use. Physicians’ treatment decisions were more heavily influenced by their perceptions and beliefs regarding IV nitrates than by consideration of the evidence. In contrast, diuretics were prescribed more frequently (78%) and more consistently.
In conclusion, where there is a limited evidence base and no strong recommendation from clinical guidelines, prescribing behaviour for AHF therapies such as IV nitrates are likely to reflect variability in physicians’ beliefs, experiences, and decision-making styles.
January 2018 doi :10.5837/bjc.2018.004 Online First
Ruan Vlok, Joshua Wall, Hannah Kempton, Thomas Melhuish, Astin Lee, Leigh White
Identification of ST elevation on the electrocardiogram (ECG) is the cornerstone of diagnosis of ST-elevation myocardial infarction (STEMI). While lesion localisation can usually be achieved by regional ST-elevation patterns on ECG, clinicians often neglect changes in the ST segment of lead aVR, possibly contributing to delayed recognition and poorer outcomes for these patients.
This study compared the ‘door-to-balloon time’ and peak troponins – as a surrogate marker of infarct size – for patients presenting with STEMI with ST-segment elevation in aVR compared with those patients without elevation in aVR. A total of 179 patients, including 17 patients presenting with ST-elevation in aVR, were included in this study. Patients presenting with elevation in aVR had significantly longer door-to-balloon times than those patients presenting with ‘traditional’ patterns of ST-elevation. There was, however, no significant difference in peak troponin as a marker of infarct size. While patients presenting with ST-elevation in lead aVR may have a delayed time to intervention, the present study does not suggest the use of aVR elevation as an indication for urgent angiography.
November 2017 Br J Cardiol 2017;24:152–5 doi :10.5837/bjc.2017.030
Emma Johns, Gerry McKay, Miles Fisher
Glucagon-like peptide-1 (GLP-1) receptor agonists are an injectable glucose-lowering therapy used in the treatment of type 2 diabetes mellitus (T2DM). Alongside dipeptidyl peptidase-4 (DPP-4) inhibitors, they exert their effect by augmenting the incretin pathway. GLP-1 receptor agonists offer reductions in glycosylated haemoglobin (HbA1c) and weight alongside a low risk of hypoglycaemia. The cardiovascular safety of GLP-1 receptor agonists in patients at elevated cardiovascular risk has been examined in large double-blind, placebo-controlled cardiovascular safety trials. Liraglutide demonstrated superiority over placebo with reduced major adverse cardiovascular events (MACE) in the treatment group. Exenatide, lixisenatide and semaglutide have shown non-inferiority versus placebo for MACE. These trials demonstrated no association between GLP-1 agonist therapy and hospitalisation for heart failure.
November 2017 Br J Cardiol 2017;24:156–60 doi :10.5837/bjc.2017.031
Baltej S Pandher, Samuel D Cripps, Andrew Edwards, Nicholas Hollings, Robin van Lingen
To examine the current practice of British Society of Cardiovascular Imaging (BSCI) members in the administration of beta blockers in computed tomography (CT) coronary angiography (CTCA) a 10-point online questionnaire was emailed to all registered members of the British Society of Cardiovascular Imaging. There were 61 respondents: 75% give intravenous (IV) metoprolol in the CT department, the rest a combination of oral and/or IV dosing. Over 50% were happy to administer 50 mg or more. No serious complications related to drug administration had been seen by 82%. Of the remaining 18%, half (six reports) documented severe hypotension and two reported a death. No physical observations were taken by 25%, at any point. Another 27% checked blood pressure before the scan only, 17% measured blood pressure before the scan and immediately after and 28% measured before the scan and after with a delay.
In conclusion, among BSCI members, there is no uniform strategy regarding the route or dose of beta blocker administration, or if, when and what physical observations should be performed. Several severe adverse events have been documented, including two deaths. This, however, is in the context of the large volume of CTCAs performed nationally, and so, despite some doses of beta blocker exceeding British National Formulary recommendations, this appears safe.
October 2017 Br J Cardiol 2017;24:137–41 doi :10.5837/bjc.2017.025 Online First
Edward Doris, Iain Matthews, Honey Thomas
Wearable and smartphone-based activity and heart rate (HR) monitors are becoming increasingly common, with around 80 million devices in use in 2017. Wearable and smartphone-based devices may be dedicated HR monitors or part of an activity tracker system. One of the main aims of these devices is to encourage exercise and increase fitness, which is clearly desirable in a society with high levels of inactivity and obesity. These devices provide individuals with large amounts of data including HR information. This may, therefore, give an opportunity to document or diagnose arrhythmias. Undiagnosed atrial fibrillation is a common problem and is associated with a huge burden of potentially preventable stroke. Wearable HR monitors may provide the opportunity to identify these individuals and allow them to receive stroke prevention treatment. However, the consumer fitness market is unregulated and the manufacturers emphasise that their devices are not intended to be used for detecting heart rhythm problems. The reliability, sampling frequency and algorithms for the HR data these devices provide are hugely variable. Detected ‘abnormalities’ may inform clinical decision making but it may also trigger unnecessary anxiety and costly investigations in healthy people.
October 2017 Br J Cardiol 2017;24:(4) doi :10.5837/bjc.2017.026 Online First
Ioannis Merinopoulos, Sajid Alam, David Bloore
Atrial fibrillation (AF) is one of the most common arrhythmias, affecting approximately 2% of the general population. Identifying AF after an ischaemic stroke is particularly important as it changes the recommended antithrombotic therapy from antiplatelets to anticoagulation. Currently, there is no clear consensus with regards to the duration of rhythm monitoring post-stroke. In our study, we aim to review some of the pivotal studies regarding rhythm monitoring after an ischaemic stroke and identify the percentage of patients who get referred for prolonged rhythm monitoring after a stroke by providing real-world data from the Ipswich hospital. To our surprise, we did not identify any patients who got referred for prolonged rhythm monitoring (ILR) and the proportion of patients who did not have a 24-hour tape was unexpectedly high. In addition, there was a clear tendency for patients with lacunar strokes not to get investigated with 24-hour tape.