Clinical articles

Stroke is a major cause of mortality, morbidity and economic burden. Strokes can be thrombotic, embolic or haemorrhagic. The key risk factor for cardioembolic stroke is atrial fibrillation or flutter, and oral anticoagulation (OAC) is recommended in all but the lowest-risk patients with evidence of these arrhythmias. Risk factors for thrombotic stroke overlap strongly with those for other atherosclerotic cardiovascular diseases (ASCVDs). Antiplatelet therapy (APT) should be considered in patients with established ASCVD to reduce risk of cardiovascular events, including stroke. Intensification from single to dual APT or a combination of APT with low-dose OAC can reduce ischaemic stroke risk further, but increases bleeding risk. Blood pressure and lipid profile should be controlled appropriately to guideline targets. In patients with diabetes, good glycaemic control can reduce stroke risk. Inflammation is another emerging target for stroke prevention. Overall, comprehensive assessment and pharmacological modification of risk factors are central to stroke prevention.

To review the utility of cardiovascular magnetic resonance (CMR) in the management of hospital inpatients, we performed a retrospective review of all inpatient CMR scans performed over a six-month period at a tertiary referral cardiology centre. Patient demographics, indication for CMR imaging, results of the CMR scans and whether the results changed patient management were recorded. Change in management included medication changes, subsequent invasive procedures, or avoidance of such, and hospital discharge.

Overall, 169 patients were included in the study cohort, 66% were male, mean age was 57.1 years. The most common indication for inpatient CMR was to investigate for cardiomyopathy (53% of patients). The most prevalent diagnosis post-CMR in our cohort was ischaemic heart disease, including ischaemic cardiomyopathy and coronary artery disease. There was a complete change in diagnosis or additional diagnosis found in 29% of patients following CMR. Overall, inpatient CMR led to a change in management in 77% of patients; the most common being changes to medication regimen. CMR was well tolerated in 99% of patients and image quality was diagnostic in 93% of cine scans performed.

In conclusion, CMR is vital for the management of cardiology inpatients, having an impact that is at least as significant as in the management of outpatients.

Guidelines recommend decision-making using the heart team (HT) in complex patients considered for myocardial revascularisation, but there are little data on how this approach works in practice. We data-mined our electronic HT database and selected patients in whom the clinical question referred to revascularisation, and documented HT recommendations and their implementation.

We identified 154 patients (117 male), mean age 68.9 ± 11.4 years, discussed between February 2019 and December 2020. The clinical questions were coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) (141 cases, 91%), and medical treatment versus revascularisation by PCI (eight cases, 6%) or by CABG (five cases, 3%).

HT recommended CABG in 55 cases (35%), PCI in 43 (28%), medical treatment in 15 (10%), and equipoise in seven (5%) and further investigations in 34 (22%): non-invasive imaging for ischaemia in 11 (32%), invasive coronary physiology studies in eight (24%), further clinical assessment in seven (20%), structural imaging for five (15%), invasive coronary angiography in two (6%), and an electrophysiology opinion in one case (3%).

Decisions were implemented in 135 cases (89%). The average time between the HT and the implementation of its decision was 80.5 ± 129.3 days. There were 17 deaths: 10 cardiac, six non-cardiac and one of unknown cause. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p = 0.03).

In conclusion, almost 90% of the decisions of the HT on myocardial revascularisation are implemented, while ischaemia testing is the main investigation required for decision-making. Recent data on the futility of such an approach have not yet permeated clinical practice.

In this study, we evaluated the change in left ventricular end-diastolic pressure (LVEDP) after primary percutaneous coronary intervention (PCI) and its impact on in-hospital outcomes and 30-day and three-month quality of life (SAQ-7), ejection fraction (EF), and major adverse cardiovascular events (MACE). LVEDP ≥19 mmHg was taken as elevated LVEDP. In a sample of 318 patients, 18.9% (n=60) were females and mean age was 55.7 ± 10.52 years. Post-procedure elevated LVEDP was observed in 20.8% (n=66) with a mean reduction of 1.65 ± 4.35 mmHg. LVEDP declined in 39% (n=124) and increased in 10.7% (n=34). In-hospital mortality rate (9.1% vs. 2.4%, p=0.011), 30-day MACE (9.1% vs. 4.0%), and three-month MACE (21.2% vs. 5.6%) were found to be significantly higher among patients with elevated LVEDP, respectively. Elevated LVEDP was found to be associated with a reduced SAQ-7 score (89.84 ± 8.09 vs. 92.29 ± 3.03, p<0.001) and reduced (25–40%) EF (55.6% vs. 22.6%) at three-month follow-up. LVEDP declined acutely in a significant number of patients after primary PCI. Post-procedure elevated LVEDP was found to be associated with poor quality of life and an increased risk of immediate and short-term MACE.

Despite widespread use of statins and other lipid-lowering therapies for hypercholesterolaemia, cardiovascular (CV) mortality and morbidity remains high. The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, have been approved for use in patients with familial hypercholesterolaemia and high CV risk in the UK. We reviewed the records of patients at a large health board in Scotland, who were prescribed these agents, to determine their real-world efficacy and tolerability in routine clinical care.

Primary percutaneous coronary intervention (PPCI) remains the gold-standard treatment for ST-elevation myocardial infarction (STEMI). Femoral arterial access for the procedure may be an ideal option in patients who are haemodynamically unwell. However, it is associated with rare, but life-threatening, complications such as perforation, leading to retroperitoneal haemorrhage. We present the case of a man in his 50s, admitted with cardiac arrest secondary to inferolateral STEMI. Successful PPCI was performed via right femoral artery, with access gained under ultrasound guidance. However, the patient deteriorated and was diagnosed to have a retroperitoneal haematoma secondary to femoral artery perforation. Additional arterial access via left brachial artery was obtained, and a covered stent was deployed successfully in the right femoral artery with satisfactory haemostasis. The patient recovered successfully and was discharged two weeks later. Early recognition of such complications is imperative to adequate management and percutaneous treatment is a viable option for such situations, in comparison with open surgical repair.

Persistent cardiac arrhythmias are readily amenable to detection by performing a standard electrocardiogram (ECG), but detection of transient (paroxysmal) arrhythmias has long been a significant cause of frustration to both doctors and patients. Often a significantly symptomatic arrhythmia is experienced by the patient but terminates before an ECG can be recorded to allow diagnosis. Prognostically important treatment is often delayed, and recurrent symptomatic attacks represent a high morbidity in patients’ lives and result in a burden on emergency services, who often arrive after the arrhythmia has terminated with no resultant progress in making a diagnosis.

Another area of concern has been the presence of asymptomatic, but clinically important, arrhythmias that can go unnoticed by people experiencing them and may result in permanent harm; asymptomatic paroxysmal atrial fibrillation in patients with high CHA₂DS₂-VASc scores being the most common example.

Both these issues are now being importantly addressed by the widespread availability of portable ECG recording devices, which patients can either manually activate themselves or program to automatically detect abnormal arrhythmias. Information on the range of devices available and their strengths and weaknesses is limited. This article aims to provide a helpful overview for patients and doctors advising them.

Andreas Grüntzig, an ardent angiologist crafted an indeflatable sausage-shaped dual-lumen balloon-catheter, designed its delivery to the heart, launched minimally invasive coronary intervention and taught by beaming live demonstration. Subsequent advances are just incremental tweaks and tinkers around this fully formed framework from 1978. The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug-eluting stent, drug-coated balloon, or both in different combinations and permutations. Now with Grüntzig’s balloon armed with an antiproliferative drug, it could dominate the field once more, as he originally envisaged.

Thrombus is the main finding in most patients with acute coronary syndrome (ACS), the type of which potentially impacts the end result of the interventional procedure in terms of no reflow and edge dissection. Optical coherence tomography (OCT) is considered a precise intra-vascular tool to image thrombi and characterise its properties. We aimed to study the impact of thrombus type, as defined by OCT, on procedural outcome in ACS patients. In this retrospective study we enrolled 100 patients who were treated by percutaneous coronary intervention (PCI) with the guidance of OCT. We recorded demographic and clinical data of the whole studied cohort. Angiographic details and procedural data were noted. Baseline OCT study was performed before intervention and repeated post-intervention. Plaque characterisation was identified, and thrombi were defined as red or white thrombi. Acute angiographic outcome was defined with special emphasis on no reflow.

Male patients and ST-elevation myocardial infarction (STEMI) patients more often had white thrombi (58.1% and 71.2%, respectively). Cases with red thrombi had longer pain duration, which was statistically significant. Edge dissection was more frequent with red thrombus, 44.7% versus 32.1% with white thrombus, but the difference is not statistically significant, while 17% of patients with white thrombi were complicated by no-reflow phenomenon versus only 4.3% in patients with red thrombi, and this difference was statistically significant.

In conculsion, OCT-guided PCI is feasible and safe in ACS settings. OCT-guided intra-procedural differentiation of thrombus type is potentially beneficial in predicting acute procedural outcome.

Remote delivery of cardiovascular rehabilitation (CR) has been vital during the COVID pandemic when restrictions have been placed on face-to-face services. In the future, CR services are likely to offer alternatives to centre-based CR, including digital options. However, little is known about the digital access and confidence of CR service users, or their CR delivery preferences.

A telephone survey was conducted of those referred for CR in the London boroughs of Lambeth and Southwark (n=60) in which questions were asked about digital access and confidence, as well as current and future delivery preferences for their CR.

Between March and July 2021, 60 service-users met the inclusion criteria and were recruited for a telephone survey (mean age 60 ± 11.2 years). Of those, 82% had regular access to a smartphone, 60% to a computer or laptop and 43% to a tablet device. A high proportion of service users perceived themselves to be ‘extremely’ or ‘somewhat’ confident to use their devices. Thirty-nine (65%) service users would currently prefer a face-to-face assessment, rising to 82% once the perceived COVID-19 threat and restrictions are less. Preferences for accessing exercise were equally split between face-to-face and remotely supported independent exercise, with low interest in digital options. Delivery preferences for education, relaxation and peer support were more heterogeneous with interest in all delivery options.

In conclusion, digital access and confidence in CR service users was good. Redesigning CR services to offer more rehabilitation delivery options, aligned with patient choice may increase uptake and further trials are needed to assess the impact.