Clinical articles

Multi-detector computed tomography coronary angiography (CTCA) is now an established highly effective non-invasive test in patients with chest pain and a low-to-intermediate pre-test likelihood of having coronary artery disease (CAD), as it has excellent sensitivity and negative predictive value (NPV).¹ The limiting factors for CTCA are fast or irregular heart rate, a very high body mass index (BMI), the presence of extensive calcium in the coronary arteries and radiation. Recent introduction of prospectively gated acquisition in CTCA, where the acquisition is limited to 10% of the cardiac cycle at end-diastole, has dramatically reduced the radiation dose to 2–3 mSv for CTCA of the native coronary arteries, but this is only possible in patients with a regular rhythm below 60 bpm. Otherwise, retrospectively gated CTCA with electrocardiographically controlled tube current modulation (ECTCM) during the cardiac cycle keeps the dose below 10 mSv. The CTCA scan range in patients with coronary artery bypass grafts (CABG) is from the level of the subclavian arteries to below the diaphragm, which is twice the length of a CTCA for the native coronary arteries, and, hence, doubles the radiation dose. However, while the low-dose prospectively gated CTCA technique may not be possible in all patients having CTCA of the native coronary arteries, the minimal motion of the grafts means that CABG patients can be adequately imaged even with higher or irregular heart rates or higher BMI with the low-dose technique. The American College of Cardiology (ACC) has recently published appropriateness criteria for the use of CTCA, which included the use in patients with recurrent symptoms after CABG.²

The very public resuscitation of a premier league footballer drew nationwide attention to fatal dysrrhythmias in the young. Survival was achieved by effective bystander cardiopulmonary resuscitation (CPR), rapid transportation and targeted resuscitation in a cardiac centre. In Emergency Departments in the UK, resuscitation from shockable dysrrhythmias follows the Advanced Life Support (ALS) protocol, using biphasic defibrillation (150–200 J) with subsequent adrenaline boluses and amiodarone. In patients with hypertrophic cardiomyopathy or primary ventricular arrhythmias without structural heart disease, high energy defibrillation (up to 360 J) is sometimes required and catecholamines predispose to recurrent dysrrhythmia.¹ On occasion, more can be learnt from failure than success. For this reason we present the following case. 

Patient knowledge and understanding of their condition is important in every field of medicine. It is particularly relevant in cardiology where choices between treatment options must be made and where patient participation in prevention of disease progression is a key part of therapy. In this study, knowledge and understanding of angina patients on options for revascularisation was explored. The aim was to reveal trends that may identify opportunities to improve care. This was a qualitative study utilising depth semi-structured interviews of angina patients who have had revascularisation (excluding primary percutaneous coronary intervention [PCI] for ST elevation myocardial infarction). The main outcome measure was patient perception on revascularisation options. It was conducted in an out-patient setting at the cardiac prevention and rehabilitation centre at Charing Cross Hospital, West London. Angina patients are referred to the centre before and after their revascularisation for rehabilitation and education sessions.

In conclusion, patients have limited understanding of angina and options for treatment but are generally satisfied with their care. However, it is likely that impaired patient understanding will impact on their ability to maintain secondary prevention, especially lifestyle changes and medication concordance.

We previously reported retrospective data on the place of death for people with heart failure (HF) known to heart failure nurse specialists (HFNS) working in two integrated cardiology palliative care teams. Here, we present prospective data on place of death, the supportive services accessed, and the role of HFNS.

In conclusion, recognition and planning for the end of life is possible for many with HF. HFNS were central in discussing patients’ concerns, providing and coordinating end-of-life care.

To see whether a nurse-led clinic might be useful we audited how often patients discharged from follow-up were elsewhere seen in the community and how often events were picked up in patients being seen in a nurse-led valve clinic. We audited patients implanted with an OnX bileaflet mechanical heart valve between 1999 and 2010 by postal audit asking for details of follow-up and adverse events. We also analysed the outcome and adverse events from our nurse-led clinic over 30 months between 2009 and 2011 using our valve clinic audit database.

In conclusion, a nurse-led clinic provides effective long-term monitoring of valve patients. Large proportions of patients are discharged from cardiology/surgical units and are at risk of adverse valve-related events

With conflicting findings from studies of omega-3 fatty acids in cardiovascular disease, many healthcare professionals are uncertain of whether they show any benefit. BJC seminars are held to promote evidencebased practice and we recently convened a meeting of UK professionals working in cardiovascular disease to review the evidence for omega-3 fatty acids supplementation, as well as review some of the data relating to dietary fish oils. The panel considered how supplementation with omega-3 fatty acids might be used in the future. The meeting was sponsored with an unrestricted educational grant from Abbott Laboratories.

Up to one-third of patients with heart disease have diabetes. Cardiological status should be considered when deciding on treatment for diabetes. Patients with stable coronary disease can be treated with metformin, sulphonylureas or pioglitazone. Following an acute coronary syndrome, intensive insulin therapy with multi-dose insulin has been shown to reduce mortality, and longerterm treatment with pioglitazone may reduce recurrent events. There is little trial information for glycaemia control in patients with chronic heart failure, and metformin and insulin are both frequently used. Dipeptidylpeptidase-4 (DPP-4) inhibitors are new oral antidiabetic drugs, which are weight neutral, and the injected glucagon-like peptide-1 (GLP-1) receptor agonists reduce weight. Long-term outcome studies are awaited to see if they have cardiovascular advantages in any particular group of patients.

Pacemakers are being implanted with increasing frequency. As with every procedure, there is the potential for complications. There are little recent data on implant complications and consequently we may be misinforming patients when we consent them. 

These are unselected data from a high volume district general hospital (DGH). Infection rates are low. Lead displacement rates are higher than other similar studies. Pneumothorax rates are also high, reflecting the fact that almost all access is via the subclavian vein.

We present a case of a 55-year-old female with a successfully reperfused myocardial infarction in whom Dressler’s syndrome was subsequently diagnosed. There have been no reported cases in the literature of Dressler’s syndrome following documented early coronary reperfusion, and its continued existence in the era of reperfusion has been questioned. In conclusion, this case demonstrates that this syndrome is still a possibility in the current realm of thrombolysis and cardiac catheterisation.

The importance of heart rate reduction in chronic stable heart failure (HF) has been highlighted in the recently published Systolic Heart Failure Treatment with I_f Inhibitor Ivabradine Trial (SHIFT). Patients with an elevated resting heart rate (HR) benefited from additional HR control despite optimal doses of beta blockers. The aim of this study was to define the prescribing patterns of beta blockers and the scope for additional HR control in a ‘real life’ HF population.

We conducted a retrospective analysis of two HF clinics, where patients were referred for protocol-guided, up-titration of HF medications. At each assessment we documented: HR, blood pressure, and HF medications including potential side effects. The primary objective was to identify the proportion of patients who had suboptimal HR control (HR ≥70 bpm) despite optimal conventional HF therapy.

From 172 patient records, 145 (84.3%)could tolerate long-term beta blockade with 57 (33.1%) prescribed the maximum recommended dose. Overall, 101 patients were in sinus rhythm with 31/101 (30.7% having an ejection fraction ≤35% and a resting HR ≥70 bpm.

In conclusion, suboptimal HR control is evident in approximately one in three HF patients in sinus rhythm despite aggressive optimisation of beta blocker therapy. This cohort may benefit from additional HR control.