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Clinical articles

April 2023 Br J Cardiol 2023;30:62–8 doi :10.5837/bjc.2023.012

Diagnosis and acute management of type A aortic dissection

Metesh Acharya, Giovanni Mariscalco

Abstract

Acute type A aortic dissection is a devastating aortic disease associated with significant morbidity and mortality. Clinicians should maintain a high degree of suspicion in patients presenting with sudden-onset chest pain, although the diagnosis may be confounded by the broad spectrum of attendant symptoms and signs. Accurate and timely identification of the acute dissection is of paramount importance to ensure suitable patients are referred promptly for definitive surgical management. This review focuses on the diagnosis of acute type A aortic dissection and discusses the haematological tests, and electrocardiographic, echocardiographic and radiological investigations necessary to confirm the diagnosis and assess for associated complications. The acute medical management of patients with acute type A dissection is also reviewed.

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March 2023 Br J Cardiol 2023;30:16–20 doi :10.5837/bjc.2023.009

Acute aortic dissection (AAD) – a lethal disease: the epidemiology, pathophysiology and natural history

Karen Booth (on behalf of UK-AS, the UK Aortic Society)

Abstract

Aortic dissection is a life-threatening condition that is often under-recognised. In the first in a series of articles about the condition, the epidemiology, pathology, classification and clinical presentation of aortic dissection are discussed.

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February 2023 Br J Cardiol 2023;30:26–30 doi :10.5837/bjc.2023.006

Antibiotic prophylaxis for patients at risk of infective endocarditis: an increasing evidence base?

Mark J Dayer, Martin Thornhill, Larry M Baddour

Abstract

Around 100 years ago, the first link between infective endocarditis (IE) and dental procedures was hypothesised; shortly after, physicians began to use antibiotics in an effort to reduce the risk of developing IE. Whether invasive dental procedures are linked to the development of IE, and antibiotic prophylaxis (AP) is effective, have since remained topics of controversy. This controversy, in large part, has been due to the lack of prospective randomised clinical trial data. From this suboptimal position, guideline committees representing different societies and countries have struggled to reach an optimal position on whether AP use is needed for invasive dental procedures (or other procedures) and in whom. We present the findings from an investigation involving a large US patient database, published earlier this year, by Thornhill and colleagues. The work featured the use of both a cohort and case-crossover design and demonstrated there was a significant temporal association between invasive dental procedures and development of IE in high-IE-risk patients. Furthermore, the study showed that AP use was associated with a reduced risk of IE. Additional data, also published this year, from a separate study using nationwide hospital admissions data from England by Thornhill’s group, showed that certain dental and non-dental procedures were significantly associated with the subsequent development of IE. Two other investigations have reported similar concerns for non-dental invasive procedures and risk of IE. Collectively, the results of this work support a re-evaluation of the current position taken by the National Institute for Health and Care Excellence (NICE) and other organisations that are responsible for publishing practice guidelines.

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February 2023 Br J Cardiol 2023;30:35–8 doi :10.5837/bjc.2023.007

Cardiac sarcoidosis: the role of cardiac MRI and 18F-FDG-PET/CT in the diagnosis and treatment follow-up

Muntasir Abo Al Hayja, Sobhan Vinjamuri

Abstract

Sarcoidosis is a multi-factorial inflammatory disease characterised by the formation of non-caseating granulomas in the affected organs. Cardiac involvement can be the first, and occasionally the only, manifestation of sarcoidosis. The prevalence of cardiac sarcoidosis (CS) is higher than previously suspected. CS is associated with increased morbidity and mortality. Thus, early diagnosis is critical to introducing immunosuppressive therapy that could prevent an adverse outcome. Endomyocardial biopsy (EMB) has limited utility in the diagnostic pathway of patients with suspected CS. As a result, advanced imaging modalities, i.e. cardiac magnetic resonance imaging (MRI) and positron emission tomography with 18F-Fluorodeoxyglucose/computed tomography scan (18F-FDG-PET/CT), have emerged as alternative tools for diagnosing CS and might be considered the new ‘gold standard’. This focused review will discuss the epidemiology and pathology of CS, when to suspect and evaluate CS, highlight the complementary roles of cardiac MRI and 18F-FDG-PET/CT, and their diagnostic and prognostic values in CS, in the current content of guidelines for the diagnostic workflow of CS.

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January 2023 Br J Cardiol 2023;30:21–5 doi :10.5837/bjc.2023.002

Evaluating initiation and real-world tolerability of dapagliflozin for the management of HFrEF

Alyson Hui Ling Tee, Gayle Campbell, Andrew D’Silva

Abstract

Untreated heart failure with reduced ejection fraction (HFrEF) has a one-year mortality rate of 40%. The DAPA-HF trial found that dapagliflozin reduces mortality and heart failure (HF) hospitalisation by 17% and 30%, respectively. We describe the initiation and real-world tolerability of dapagliflozin for the management of HFrEF at a large university teaching hospital in central London.

We reviewed 118 HFrEF patients initiated on dapagliflozin from January to August 2021 in both inpatient and outpatient settings using the Trust’s electronic records. A total of 69 (58.4%) patients were on optimised HF pharmacological therapy upon initiation of dapagliflozin. Dapagliflozin was discontinued in 12 (13.0%) patients. Twenty-three (42.6%) patients either discontinued or had a dose reduction in loop diuretics post-initiation of dapagliflozin.

In clinical practice, early initiation of dapagliflozin is safe, well-tolerated and resulted in earlier discontinuation or dose reduction in loop diuretics, providing opportunities to further optimise other HF medicines. This retrospective observational study supports the safety of the updated European Society of Cardiology (ESC) guidelines to initiate all four key HF medicines to minimise delays in HF treatment optimisation, which could translate to reduced National Health Service healthcare costs through fewer HF hospitalisations.

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January 2023 Br J Cardiol 2023;30:39–40 doi :10.5837/bjc.2023.004

Pectus excavatum with right ventricular compression-induced ventricular arrhythmias

Lisa Ferraz, Diana Carvalho, Simão Carvalho, Adriana Pacheco, Ana Faustino, Ana Neves

Abstract

A 33-year-old woman, with palpitations since the age of 15, was referred to a cardiology consultation due to very frequent ventricular extrasystoles with morphology of left bundle branch block, inferior frontal axis, late precordial transition, rS in V1, R in V6 and rS in DI. She had pectus excavatum. The cardiac magnetic resonance showed severe pectus excavatum associated with exaggerated cardiac levoposition, compression and deformation of the right cardiac chambers. However, the patient became pregnant, and follow-up was delayed.

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January 2023 Br J Cardiol 2023;30:31–4 doi :10.5837/bjc.2023.005

The prognostic impact of HDL-C level in patients presenting with ST-elevation myocardial infarction

Ahmed Mahmoud El Amrawy, Abdallah Almaghraby, Mahmoud Hassan Abdelnabi

Abstract

Low high-density lipoprotein-cholesterol (HDL-C) concentration is among the strongest independent risk factors for cardiovascular disease, however, studies to assess the cardioprotective effect of normal or high HDL-C level are lacking.

To determine the prognostic impact of initial serum HDL-C level on in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) and the one-year all-cause mortality in patients presenting with ST-elevation myocardial infarction (STEMI) we performed a retrospective analysis of the data from 1,415 patients presenting with STEMI in a tertiary-care centre equipped with a 24-hour-ready catheterisation laboratory. The period from June 2014 to June 2017 was reviewed with a follow-up as regards one-year all-cause mortality. Patients were divided into two groups according to HDL-C level. HDL-C <40 mg/dL (2.22 mmol/L) was considered low, while HDL-C ≥40 mg/dL was considered normal.

There were 1,109 patients with low HDL-C, while 306 had normal HDL-C levels, which was statistically significant (p<0.001). Total MACCE and all-cause mortality were significantly lower in patients with normal HDL-C (p=0.03 and p=0.01, respectively).

In conclusion, this retrospective study to assess the prognostic effect of HDL-C in patients presenting with STEMI, found normal HDL-C level was associated with lower in-hospital MACCE and all-cause mortality at one-year follow-up.

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November 2022 Br J Cardiol 2022;29:141–4 doi :10.5837/bjc.2022.037

Outpatient-based acute HF care calls for development of clinical psychology service for whole-person care provision

Abdullah Abdullah, Suzanne Y S Wong, Robbie Jones, Kenneth Y K Wong

Abstract

Acute heart failure (AHF) is associated with 9.3% mortality. Depression and hopelessness are prevalent. We conducted an online survey using Survey Monkey, via the UK Heart Failure (HF) Investigators Research Network of 309 cardiologists, in 2021, to determine: what proportion of UK centres offer outpatient-based management (OPM) for AHF including the use of parenteral diuretics; and what proportion of HF services have clinical psychology support.

There were 51 services that responded, and an estimated 25,135 patients with AHF receive inpatient care per year (median 600 per site). There are 2,631 patients (median 50 per site) treated per year with OPM (9.7% of the population of AHF patients). While 65% of centres provided access to OPM, only 20% have a clinical psychology service.

In conclusion, nearly 10% of patients with AHF receive outpatient-based intravenous diuretic therapy. Only 20% of hospitals have a clinical psychology service for patients who suffer from HF.

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November 2022 Br J Cardiol 2022;29:145–9 doi :10.5837/bjc.2022.038

Should we be screening people with diabetes for atrial fibrillation? Exploring patients’ views

Angela Hall, Andrew Robert John Mitchell, Lisa Ashmore, Carol Holland

Abstract

Atrial fibrillation (AF) and diabetes are increasingly prevalent worldwide, both increasing stroke risk. AF can be detected by patient-led electrocardiogram (ECG) screening applications. Understanding patients’ views around AF screening is important when considering recommendations, and this study explores these views where there is an existing diagnosis of diabetes.

Nine semi-structured qualitative interviews were conducted with participants from a previous screening study (using a mobile ECG device), who were identified with AF. Thematic analysis was completed using NVivo 12 Plus software and themes were identified within each research question for clarity.

Themes were identified in four groups:

  1. patients’ understanding of AF – the ‘concept of irregularity’ and ‘consideration of consequence’;
  2. views on screening – ‘screening as a resource-intensive initiative’, ‘fear of outcomes from screening’ and ‘expectations of screening reliability’;
  3. views on incorporating screening into routine care – ‘importance of screening convenience’; and
  4. views on the screening tool – ‘technology as a barrier’ and ‘feasibility of the mobile ECG recording device for screening’.

In conclusion, eliciting patients’ views has demonstrated the need for clear and concise information around the delivery of an AF diagnosis. Screening initiatives should factor in location, convenience, personnel, and cost, all of which were important for promoting screening inclusion.

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November 2022 Br J Cardiol 2022;29:150–3 doi :10.5837/bjc.2022.039

Patient satisfaction with telephone consultations in cardiology outpatients during the COVID-19 pandemic

Jack William Goodall, Ravish Katira

Abstract

The COVID-19 pandemic required a radical change in healthcare delivery methods, including the remote delivery of many outpatient services. We aimed to understand patient satisfaction with telephone consultations.

Patients who had undergone a cardiology telephone consultation between 24 February and 19 July 2021 were asked to complete a survey. The survey assessed their satisfaction with the consultation and their preference between remote and face-to-face consultation. The 56 responses demonstrated high levels of satisfaction with 56% agreeing they were “completely satisfied” with the consultation compared with 5% who disagreed. However, 63% would have preferred a face-to-face appointment compared with 22% preferring a telephone consultation.

No patterns were observed that might help to guide who should be offered the different modalities of consultation; to maximise patient satisfaction a flexible and individualised approach is likely to be required.

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