Clinical articles

An observational study was conducted on patients with pre-existing coronary heart disease who were re-admitted to an acute district general hospital with a further acute coronary event. Their demographics, admission drug therapies and cardiovascular risk factor parameters were recorded and analysed. Of the 100 patients admitted over a nine-month period, more than a quarter of them were taking suboptimal secondary prevention drug therapies. Furthermore, a proportion of patients were not achieving adequate cholesterol, blood pressure and heart rate targets, which, in turn, may be a major contributory factor for their re-presentation to hospital. 

We conducted an observational study within a cardiology tertiary centre with the aim of increasing the primary prevention implantable cardioverter defibrillator (ICD) implantation rate in line with Heart Rhythm UK (HRUK) national target.

A total of 326 patients experienced ST-elevation myocardial infarction (STEMI) over a 14-month time period and were offered incidence screening for implantation of a primary prevention ICD at six weeks according to National Institute for Health and Clinical Excellence (NICE) guidelines (TA095). There were 273 (84%) patients who completed the screening process; 26 (8%) had an ejection fraction (EF) of <35%. Two patients had an EF of <30% with a QRS duration >120 msec. Two of 22 subjects had evidence of non-sustained ventricular tachycardia on 24-hour Holter monitoring; one had a positive ventricular tachycardia stimulation test. Overall, three patients received an ICD (0.9%).

In conclusion, this process was labour intensive and had a lower than expected yield.

The objective of our study was to evaluate the impact of atrial fibrillation (AF) on secondary care costs in Scotland. Patient hospitalisation data from the Information and Statistics Division (ISD) of the Scottish National Health Service (NHS) from 2004 to 2008 were analysed to estimate trends in hospital episodes in the 5.2 million population of Scotland. The associated costs were estimated using the tariff prices in Scotland for the respective years. 

Over the five-year period, AF-related hospital discharges increased by 33% compared with 20% for all cardiovascular discharges (29 and 37 per 1,000 population respectively). There were increases of: 21% in number of patients hospitalised; 27% in AF-related hospital admissions; and 15% in total patient bed days. Despite decreasing trends, mean length of inpatient stay for AF remained higher than for total cardiovascular conditions (10.9 vs. 8.7 days), as did inpatient cost per patient (£6,009 vs. £5,586). AF-related hospital costs increased from £138.9 million in 2004 to £162.5 million in 2008, accounting for 24% of all cardiovascular hospital costs. Overall, the burden of AF was higher among women and increased progressively with age. 

In conclusion, AF presents a significant and increasing burden on hospital care in Scotland. At 25% of the total cardiovascular burden, AF costs are increasing relatively faster. 

Improving patient access and implementation of the European Working Time Directive has proved a challenge for the National Health Service (NHS), particularly adding to workforce pressures and reducing continuity of care for patients. Innovative service and workforce redesign led to the introduction of new and extended roles based on service need. This paper outlines the introduction of one such new role, physician assistant (PA), introduced in the NHS in 2006, based on the established US PA model. UK-trained PA graduates are taking up newly created posts in primary and acute healthcare trusts and the aim of this paper is to share the first-year experience of introducing a newly qualified UK-trained PA within a busy district general hospital cardiology department, describing the internship year, achievements, limitations and how the role has evolved in line with service need. We believe the role has ideal potential in a cardiology department and, in particular, in the management of long-term chronic conditions, such as heart failure, where the number of specialist contacts with the patient can directly impact admissions, re-admissions, length of stay, adherence to medications and protocols of care positively.

A new heart failure service was established in Sheffield in 2008. The service provides specialist advice on the management of inpatients with heart failure, and optimises their medical therapy in a heart failure clinic led by heart failure nurse specialists. We undertook a survey of patients’ perception of the service provided by these clinics.

A postal survey was sent to the patients who attended the nurse-led heart failure clinics more than once in the first two years of the service. There were two types of questions: multiple-choice questions and those allowing free text answers. We approached 228 patients. We received responses from 192 (84%). Of these patients, the majority (80–90%) responded positively to most of the questions. The vast majority of patients regarded the service as providing excellent care, that the staff were courteous and professional, and they were able to establish a good relationship. The negative remarks were related to facilities such as parking spaces in the hospital, and to the label of heart failure. The team endeavours to make improvements to the service. 

In conclusion, the nurse-led heart failure clinic was positively received by heart failure patients.

A 26-year-old man presented with T4 adenocarcinoma of sigmoid colon, which was initially treated with a covering ileostomy and neoadjuvant chemotherapy with oxaliplatin and infusional 5-fluorouracil delivered through a right subclavian Hickman line. While receiving chemotherapy, he developed a massive right atrial thrombus, adherent to the inferior venacaval opening and the adjoining right atrial wall, mimicking a metastatic deposit, which was removed surgically on cardiopulmonary bypass. The patient subsequently underwent successful high anterior resection of the sigmoid cancer followed by adjuvant chemotherapy with oxaliplatin and capecitabine. The unusual features of this patient’s presentation include the extremely rapid growth of thrombus despite aggressive anticoagulation, the unusual site of thrombus on the inferior vena caval opening rather than around the Hickman line, and possible facilitation of thrombus formation by chemotherapeutic agents. We also discuss the diagnostic and therapeutic dilemmas in a patient with a concurrent malignancy and a right atrial mass.

There is a lack of clarity around the current use of anti-arrhythmic drugs (AADs), highlighted by the recent changes to the European Medicines Agency (EMA) and US Food and Drug Administration (FDA) recommendations for dronedarone use, which were in response to the early termination of the Permanent Atrial Fibrillation Outcome Study Using Dronedarone On Top Of Standard Therapy (PALLAS) trial due to increased mortality in the dronedarone arm. A UK- and Ireland-based multi-disciplinary expert group was convened by Sanofi*, the manufacturers of dronedarone, to address the need for guidance in the practical implementation of guidelines for AADs. This position statement provides the group’s evidence-based recommendations for the practical use of AADs and dronedarone in particular. Since AADs are not always used in line with recommendations, the guidelines for the use of AADs, and the evidence base supporting them, are reviewed. The current recommendations for dronedarone use are set within this context. On consideration of the evidence, the recommendation for dronedarone use is for the maintenance of sinus rhythm in non-permanent atrial fibrillation (AF) patients, without severe heart failure, or amiodarone-related liver or lung toxicities, and with appropriate anticoagulation. Given that there have been no new AADs available in 25 years to address the need for an effective anti-arrhythmic with reduced side effects, dronedarone has a place in the treatment of non-permanent AF to provide options for clinicians and patients.

* Further detail of Sanofi’s support is declared in the conflict of interest statement at the end of this article.

We present a 37-year-old man who underwent coronary artery bypass grafting for severe left main stem stenosis and right coronary artery disease and was found to have left pleuropericardial agenesis with luxation of heart to the left in the left common pleuropericardial cavity. Although complete absence of pericardium is found in one out of 14,000 patients, agenesis of left pericardium as well as left pleura is extremely rare. Despite a number of related and unrelated pathologies having been described with this condition, there are only two or three reports of co-existence of coronary artery disease. We describe the technicalities of coronary artery surgery in this condition and also review the literature for clinical diagnosis, associated conditions and complications.

Despite statin use to lower low-density lipoprotein cholesterol, a residual cardiovascular risk remains in dyslipidaemic patients, particularly when high-density lipoprotein (HDL) levels are low. Increased cholesteryl ester transfer protein (CETP) activity is a major determinant of low HDL-cholesterol. CETP inhibition with anacetrapib, evacetrapib and dalcetrapib produces plasma HDL increases of approximately 140%, 80% and 30%, respectively, in patients already receiving statin therapy. However, recent research challenges whether raising HDL-cholesterol is in itself beneficial unless anti-atherogenic properties of HDL, such as cholesterol removal from arterial walls, stimulation of endothelial nitric oxide production or protection against oxidation and inflammation, are enhanced. Potentially important differences are emerging in the mechanisms by which CETP inhibitors operate, which may lead to variation in their anti-atherogenicity unrelated to the changes in HDL-cholesterol they induce. The outcome of clinical trials with CETP inhibitors may thus depend on the mechanisms by which they inhibit CETP. This review discusses clinical implications of CETP inhibition.

We report the early and late results of coronary artery bypass graft (CABG) for protected and unprotected left main coronary artery (LMS) stenosis in an era of growing interest in LMS stenting.

We identified 1,707 patients who had CABG for LMS stenosis between February 1996 and December 2009, and compared their clinical characteristics and outcomes with a contemporaneous group of 6,260 people with non-LMS disease. A subgroup analysis of protected versus unprotected LMS cohorts was also performed. Follow-up data were 99.9% complete.

The LMS group, often male (82% vs. 79%, p=0.01) and older (mean 65.3 ± 9 vs. 63.6 ± 9 years, p<0.0001), frequently had ejection fraction <0.50 (25.2% vs. 23.9%, p=0.002) and urgent/emergency surgery (40% vs. 24%, p<0.0001). Overall, operative mortality was higher for the LMS group (2.7% vs. 1.1%, p<0.0001), and there was improvement over time (2.3% vs. 0.8% in the later period). There was no difference between protected and unprotected LMS cohorts (operative mortality 2.2 vs. 2.8, p=0.54).

The respective 10-year survival rates for LMS and non-LMS patients were 75% and 79% (p=0.001). By multi-variate analysis, LMS stenosis was a predictor of operative mortality (odds ratio 2.05, 95% confidence interval 1.29–3.25, p=0.002) but not a determinant for late death. 

In conclusion, CABG yields good early and late survival benefit for LMS stenosis (protected and unprotected), although operative result is adversely affected by LMS disease.