Clinical articles

The authors describe a case of Takotsubo-like syndrome in a 59-year-old Caucasian woman.

A 37-year-old man presented with palpitations and recurrent episodes of pre-syncope. He had a past medical history of atrial septal defect (ASD) repair aged seven.

The management of acute coronary syndromes (ACS) has changed greatly over recent years. Trial evidence encouraged clinicians to consider early invasive management in high-risk patients and this has created a large clinical burden. We instituted a comprehensive system of nurse-led diagnosis and management of ACS. In-patients are seen by a cardiac outreach nursing team and depending on their risk profile may be managed in a designated acute cardiac unit (ACU) by cardiologists. We also piloted an ‘ACS clinic’ where patients with higher risk are seen within two weeks of discharge. We conducted audits to assess the impact of these new services.

A total of 158 consecutive patients from ACU with unstable angina or non-ST elevation myocardial infarction (NSTEMI) were identified. The in-patient coronary angiography rate was 48%, percutaneous coronary intervention (PCI) rate 15% and coronary artery bypass graft (CABG) rate 4%. The six-month re-admission rate was 28.5%, of whom 44.4% were within one month of discharge. In-patient coronary angiography almost halved the rate of re-admission (20.0% vs. 36.6%; p=0.026). We also audited the first 12 months of the ACS clinic. The six-month re-admission rate was 14.2%, a significant reduction compared with the first audit (p=0.0002). In conclusion, the strategy of nurse-led identification and follow-up of ACS patients promotes effective use of resources and reduces re-admissions.

The transradial approach is increasingly used in a wide range of percutaneous coronary interventions (PCIs) with few reported complications. It is established as a safe procedure with improved patient comfort and early mobilisation.1-3 This has translated into early discharge with reduced procedural cost leading to out-patient day-case PCI.4,5 However, with this increasing use, unusual and new complications will be recognised.

Research has shown that, following angiogram with femoral puncture, prolonged bed rest increases patient discomfort during recovery. This audit aimed to measure the effects of reducing the period of immobilisation from the local standard of four hours to only two hours. Almost 500 consecutive patients were selected for early ambulation at two hours post-angiogram. Overall, 86.8% of patients suffered no vascular complications. In addition to the beneficial effects on patient comfort, earlier ambulation will enable cardiology units to treat more patients, thereby maximising efficiency and income generation.

Vascular surgery is associated with a substantial risk of cardiovascular events and death. Cardiac troponin I (cTnI) is a contractile protein that is a highly sensitive and specific marker of myocardial necrosis. This case series examines the clinical course of 10 patients who had an asymptomatic pre-operative elevation in cTnI and underwent a vascular surgical procedure.

A prospective, two-year, observational, single-centre cohort study of all patients undergoing a vascular procedure with an expected cardiac event rate of >5% was performed. Pre-operative cTnI was carried out (cTnI >0.02 ng/ml positive). Post-operative screening for cardiac events at post-operative days two and five was performed.

Two-hundred and thirteen patients were recruited, of whom 11 (5.2%) had an asymptomatic elevated pre-operative cTnI. Ten patients in whom the pre-operative cTnI was not known prior to surgery, or in whom a procedure could not be delayed proceeded with the operation. One patient had surgery deferred. Four patients suffered a post-operative cardiac event and five died.

The outcome in this case series was poor with death in 50% of those taken to theatre and cardiac events in 40%. An elevated pre-operative cTnI in an otherwise asymptomatic patient identifies a very high-risk group of patients.

Clinical guidelines are vital to improving patient outcomes by helping reduce practice variation, raising care standards, improving efficiency and maximising resource utilisation. To investigate the implementation/local adaptation of national guidance and approaches to post-myocardial infarction (MI) care across the UK, an assessment of the availability and implementation of local post-MI guidelines in England among primary care trusts (PCTs) and cardiac networks (CNs) was conducted. Secondly, a survey of UK GPs and nurses (n=1,003) was performed to establish awareness of guidelines and to investigate whether there are regional variations in the management of post-MI patients.

Fifteen post-MI clinical guidelines were obtained (PCTs – 8; CNs – 7) and analysed according to the following topics: lifestyle modifications, cardiac rehabilitation, therapeutic intervention, therapeutic targets and communication between primary and secondary care. Considerable regional variation in the recommendations were found – particularly with regard to therapeutic interventions and targets – with differing targets for blood pressure and cholesterol management. This was mirrored in the survey results, which also showed significant inconsistencies in clinical practice as reported by UK healthcare practitioners.

In conclusion, little consistency in the availability and content of local post-MI clinical guidelines, coupled with disparities in national guidelines, suggest the need for national post-MI guidance, built on existing evidence, endorsed by clinicians and patients, which will promote optimal care and reduce practice variation.

A patient with inappropriate tachycardia is described who failed to respond to beta blockers or calcium channel blockade but had clinical improvement with ivabradine. The heart rate slowing with this drug was illustrated by the change in the R–R interval histogram.

It is well recognised that phase 3 cardiac rehabilitation is beneficial, reducing both mortality and morbidity following acute myocardial infarction. The role of ongoing phase 4 cardiac rehabilitation is less clear. This study was designed to assess the effectiveness of phase 4 cardiac rehabilitation in acute myocardial infarction.

Following acute myocardial infarction, 143 patients who had completed phase 3 cardiac rehabilitation were followed up. Analysis was divided into three groups: those who took up phase 4 rehabilitation, those offered who declined and those not offered phase 4 rehabilitation because it was not available locally. Risk factor profile, self-reported exercise and quality-of-life scores using the short form (SF)-36 were assessed in all patients.

Body mass index (BMI) shows no overall change in the ‘accepted’ group, but shows a significant increase between pre and five-year levels in the ‘declined’ group (p=0.024) and in the ‘not offered’ group (p=0.014). All groups showed an increase of SF-36 scores following phase 3, which showed a trend towards significance. Both the ‘accepted’ and ‘not offered’ groups maintained this improvement, while the ‘declined’ group returned to baseline (p=0.05 vs. ‘accepted’ and p=0.03 vs. ‘not offered’). All groups had similar exercise levels initially and all showed significant improvements after phase 3 with some deterioration out to five years. This decline in exercise was significant in the ‘declined’ group (p=0.029) and shows a trend in the ‘not offered’ group (p=0.057).

This small single-centre study suggests that there are observable benefits in participating in long-term phase 4 cardiac rehabilitation. Those who decline phase 4 cardiac rehabilitation clearly do less well. Whether the benefits seen can be attributed directly to phase 4 cardiac rehabilitation would require a different study design to address this issue.

Chest pain is a common presentation in general practice. Each year about 1% of the UK population visit their GP with chest pain.1 The average GP will see, on average, four new cases of angina each year.2 The Euro heart survey of newly diagnosed stable angina patients showed that the incidence of death and myocardial infarction (MI) was 2.3/100 patient-years. This is increased in patients with a previous MI, short history, more severe symptoms and with heart failure or other co-morbidities, such as diabetes.3 The recognition of these patients as at high risk for cardiovascular events has led to the improvement of diagnosis and management of angina. Rapid access chest pain clinics have been developed to allow quick assessment of patients with new onset angina as part of a National Service Framework for coronary artery disease.