Clinical articles

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and another structure. This rare condition has an incidence in the general population of 0.002%. A 57-year-old woman presented with angina, a normal electrocardiogram (ECG) and a peak troponin I of 0.22 µg/L (normal <0.04 µg/L). She was treated with a standard medical regimen for non-ST-elevation myocardial infarction. Coronary angiography revealed non-obstructed coronary arteries, with fistulae arising from the left anterior descending, left circumflex and right coronary arteries, all terminating in the pulmonary artery. Cardiac magnetic resonance (CMR) imaging was performed to investigate coronary steal syndrome. This confirmed there was no significant shunt or evidence of infarction. There was a small concentric pericardial effusion with a focal region of inferolateral epicardial fibrosis, suggesting a diagnosis of myopericarditis. The patient was treated with colchicine for three months.

CAF can cause patients to present with a variety of symptoms or potentially life-threatening complications, including fistula rupture and myocardial infarction. Early recognition, characterisation and shunt analysis are imperative to facilitate management. Although left/right heart catheterisation is considered the gold standard, CMR proved to be a useful diagnostic tool in our case, ruling out significant shunting and helping to identify a differential diagnosis.

This case report highlights the clinical course of a young patient with a history of ischaemic cardiomyopathy and severely impaired left ventricular (LV) systolic function following a delayed anterior myocardial infarction, which was further complicated by the presence of large LV thrombus. The patient subsequently presented with persistent ventricular tachycardia (VT) refractory to multiple anti-arrhythmic medications and antitachycardia pacing (ATP). VT ablation was contraindicated due to the LV thrombus, and the failure of conventional medical therapy. Heart transplantation was considered as the final viable management strategy. This case highlights the complexity of managing patients with advanced heart failure and ventricular arrhythmias, emphasising the importance of timely consideration of advanced therapeutic options in refractory scenarios.

Sudden cardiac death (SCD) in young athletes is a rare but devastating event, most often caused by structural or electrical abnormalities of the heart. Although athletes are generally among the healthiest individuals, the occurrence of SCD in this group attracts significant public attention, particularly as exercise may trigger fatal events in those with underlying disease. This has driven debate around the role of pre-participation screening (PPS) as a strategy to identify at-risk individuals before they compete. Several international sporting and scientific organisations have issued recommendations, but screening protocols vary, and the balance between benefit, feasibility, cost, and potential harm remains controversial. While evidence suggests that screening may detect otherwise silent cardiovascular disease, limitations include false-positives, false-negatives, interpretation challenges, and the ethical implications of disqualification. This review explores the benefits and potential challenges of cardiac screening in athletes, and the implications for protecting athlete health and ensuring safe participation in sport.

This article explores using artificial intelligence (AI) to detect atrial fibrillation (AF) early, highlighting its potential to revolutionise cardiology. It reviews numerous studies demonstrating AI’s superior accuracy to traditional methods, particularly in leveraging electrocardiography data from various sources like smart devices and chest radiographs. A key concern addressed is the ‘black box’ nature of some AI algorithms, emphasising the critical need for transparency to build clinician confidence and ensure ethical patient care. It concludes by advocating for policy changes and further research to enhance AI algorithm transparency and integration into clinical practice.

Drug-eluting stents (DES) are a common treatment for acute coronary syndrome (ACS) but pose risks like bleeding, re-stenosis, stent thrombosis, and neo-atherosclerosis. Drug-coated balloons (DCB) may mitigate these risks. This study compares DCB therapy’s effectiveness with DES in ACS patients with de novo lesions.

A retrospective observational study was conducted on ACS patients undergoing percutaneous coronary intervention (PCI) with either DES or DCB from May 2019 to August 2022 at a single tertiary centre. Patients with left central trunk lesions were excluded. The primary end point was a composite of major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, and target lesion revascularisation, evaluated 12 months post-intervention. Statistical analysis was performed using R software with significance set at a two-tailed p value <0.05.

Of 168 patients, 101 received DES and 67 received DCB. The DCB group had a mean age of 61.9 years, while the DES group averaged 63 years. The DCB group had more prior PCIs and myocardial infarctions. Baseline characteristics, including target and number of lesions, were comparable. MACE occurred in eight (11.9%) DCB patients and 11 (10.9%) DES patients, showing no significant difference (p=0.64).

In conclusion, this study suggests that DCB therapy may be an effective alternative to DES for ACS. However, limitations, including a single-centre setting and short follow-up, warrant the need for more extensive, randomised trials to validate these findings.

Cardiotoxicity, including left ventricular (LV) dysfunction, is a dreaded side-effect of selected drugs that are widely used in oncology. Guidelines recommend the assessment of LV systolic function, primarily by echocardiography, before and during exposure to cardiotoxic medications. However, apart from LV ejection fraction (LVEF), echocardiography reports include dozens of numerical data points and other detailed information familiar to cardiologists, but which may not be familiar to other specialties.

With a rising need for echo in oncology patients, and with no cardio-oncology service within our hospital, we assessed what is understood by oncologists regarding the information provided within an echocardiographic report, and what action they take subsequent to the report. Morriston Cardiac Centre provides tertiary care to a population of 1.2 million and conducts 12,000 transthoracic echocardiograms (TTE) annually.

We ran a survey of all consultant clinical oncologists in Wales, using a set of multiple-choice questions via Google Forms. We presented the responders to our questionnaire with a set of hypothetical echocardiographic findings, drawn from common clinical scenarios, and asked what they would do if they received a report containing such a finding. Our questionnaire was completed by 14 of 19 (74%) oncology consultants.

Only a little better than half reported low-to-moderate confidence in interpreting the findings that echo reported. Oncologists varied in their level of confidence and understanding of what TTE findings meant, and the responses to commonly reported echocardiographic findings (e.g. actions they would take if echo report stated low-normal ejection fraction) had inhomogeneity.

Our work supports the utility of a dedicated cardio-oncology clinical pathway or service, which would assist with these queries, and may even obviate them, by providing the echo report directly to a cardio-oncologist.

Adults with Fontan palliation face variable risks of thrombosis and bleeding. The optimal thromboprophylaxis strategy remains unclear. There is a balance between the risk of thromboembolism and bleeding with thromboprophylaxis. Recent studies suggest direct oral anticoagulants (DOACs) may provide effective thromboembolism prevention, but concerns regarding bleeding risk, hepatic impairment, and lack of robust data persist. This study investigates thromboprophylaxis practices among UK adult congenital heart disease (ACHD) specialists, focusing on the use of DOACs in Fontan patients.

An electronic survey was distributed to UK National ACHD Consultant Group members from February to March 2023. Based on hypothetical clinical scenarios, the survey collected demographic data, familiarity with DOACs, and preferred thromboprophylaxis strategies. Responses were analysed using descriptive statistics to identify patterns in practice.

There was a maximum response rate of 42%, with 32 respondents participating, primarily consultants from level 1 ACHD centres. Thromboprophylaxis strategies varied significantly: DOACs, warfarin, and aspirin were used with varying frequency, depending on clinical factors, such as arrhythmias, thrombosis history, and patient-specific challenges. While 35% of respondents were comfortable prescribing DOACs, 42% expressed reservations, citing limited evidence and concerns about risks.

This study highlights wide variability in thromboprophylaxis strategies for Fontan patients in the NHS, underscoring significant gaps in evidence. Hepatic considerations, patient-specific challenges, and the lack of DOAC licensing for certain scenarios contribute to the complexity of clinical decision-making. Prospective studies are essential to guide practice, and patient involvement in shared decision-making is critical in the interim.

Temporary epicardial pacing is a cornerstone of postoperative cardiac care, but improper management, particularly of atrial pacing, may contribute to the onset of postoperative atrial fibrillation (POAF). In this article we review the challenges involved in identifying atrial lead malfunction and the associated arrhythmogenic risk. As well as implementing strategies to reduce risk, the development of advanced technology capable of detecting and correcting atrial pacing dysfunction in real time should be a priority.

Reduction in low-density lipoprotein-cholesterol (LDL-C) in patients with hypercholesterolaemia is associated with a lower risk of cardiovascular (CV) events. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibiting therapy is approved by the National Institute for Health and Care Excellence (NICE) and the Scottish Medicines Consortium (SMC) for use in high-risk patients who are unable to achieve the LDL-C target levels, despite other maximum tolerated lipid-lowering therapies. Our prior publication analysed the records of patients in a large Scottish health board with familial hypercholesterolaemia and high CV risk and confirmed the real-world efficacy of PCSK9 inhibiting monoclonal antibodies (mAbs) in routine clinical care.

In this follow-up study, we examined the comparative efficacy of inclisiran, a small-interfering ribonucleic acid (siRNA) therapeutic, in a similar patient cohort to provide real-world data that can guide clinicians in optimising lipid-lowering strategies.

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management.