Clinical articles

Transthoracic echocardiography (TTE) is used to assess for evidence of infective endocarditis (IE). Inappropriate patient selection leads to significant burden on healthcare services. We aimed to assess effectiveness of cardiology consultant vetting of TTE requests for suspected IE in reduction of unnecessary scans. All inpatient TTE requests querying IE over a six-month period were vetted. Clinical information and pathology results were reviewed, and requests were either accepted, deferred, or rejected. A total of 103 patients had TTE requested: 39 (38%) were accepted for scan; four cases of IE were confirmed on TTE. There were 62% of patient requests rejected and not scanned, and no cases of IE subsequently diagnosed. Thus, consultant vetting of TTE requests for suspected IE is an effective way to safely reduce unnecessary scans and enables cost-effective streamlining of echocardiography services.

This paper summarises ‘Share The Pressure’, a project that developed and piloted a scalable model for engaging patients on the benefits of risk factor control for healthy ageing; training healthcare professionals (HCPs) in cardiovascular disease (CVD) risk communication; and improving the shared decision-making process between nurses, pharmacists and patients. The study features the use of a CVD risk tool called Heart Age, which has been shown to effectively motivate risk factor reduction in individuals.

The study team engaged virtually with patients and HCPs through established relationships within the community, third sector, charities, and social media. In addition, patients living with high blood pressure (hypertension) participated via online focus groups and surveys, which provided insight into patients’ preferences for conveying CVD risk, quantification of intervention benefits, side effects and processes to facilitate shared decision-making.

This insight gained from the focus group and survey data informed adaptations made to the Heart Age tool to provide ‘years off’ – or lowering of heart age – benefits for different aspects of blood pressure lowering, focusing on the independent and joint benefits of medication management and lifestyle.

The study piloted a training programme for nurses and pharmacists to support them in communicating and framing risk and intervention benefits.

The study trained 1,148 HCPs from 37 countries over 17 sessions. Post-training survey results of HCPs indicated an increase in self-rated knowledge and a strong likelihood of applying information learned to their clinical practice. In addition, the Heart Age users found the personalised report and Heart Age test results very motivating for patients with high blood pressure.

Transcatheter edge-to-edge repair (TEER) was first performed in 2003, and is now established across the developed world as an effective, minimally invasive treatment option for patients with mitral regurgitation (MR). Multiple large registries have established the efficacy of mitral TEER in patients with primary or degenerative MR in whom surgery is considered prohibitive or high risk, while ongoing randomised-controlled trials will determine its role in younger and lower-risk patients. In patients with secondary or functional MR, in whom mitral valve surgery is not routinely recommended, the pivotal COAPT trial showed a profound reduction in both mortality and heart failure hospitalisation in carefully selected patients.

NHS England approved the routine commissioning of mitral TEER in 2019, and following a substantial delay, due in large part to the COVID pandemic, the procedure is now widely available across the UK. This review article describes the TEER procedure, currently available devices, the underlying evidence base, and the key facts needed for clinicians to understand who, how, and where to refer patients for consideration of mitral TEER. The emerging role of TEER in patients with severe symptomatic tricuspid regurgitation is also considered.

Thoracic aortic aneurysms are often asymptomatic until patients present with a life-threatening acute aortic syndrome. The vulnerability of an aorta to an acute aortic syndrome is determined by cross-sectional diameter and underlying aetiological factors, such as genotype or acquired disease. Screening the general population for thoracic aneurysms presents multiple resource issues including the availability of imaging modalities. Targeted screening of high-risk groups provides the only currently pragmatic solution. Opportunistic imaging through lung cancer screening programmes could pick up a proportion. Until we have a comprehensive screening programme it is incumbent on all healthcare professionals to have a low threshold for considering acute aortic pathologies when reviewing patients presenting with chest pain.

Surgical aortic valve replacement (SAVR) prolongs life and improves its quality in patients with severe aortic stenosis (AS). Unplanned SAVR is a failure of AS screening and follow-up programmes. We identified all elective, first, isolated SAVRs performed between 1 January and 31 December 2019 in a Welsh tertiary cardiac centre, and documented the clinical and echocardiographic variables, and reasons for unplanned SAVR.

Of 140 isolated SAVR, 37 (26%) were unplanned (16 female, mean age 72.3 ± 8.4 years). Twenty had been on the SAVR waiting list and had expedited operations because of concerns about the severity of the AS (12 patients), or because of acute (four patients) or chronic (four patients) left ventricular failure (LVF). Of the 17 not on the waiting list, AS was known in seven: three had acute pulmonary oedema while under follow-up with ‘moderate AS’, one had been referred but developed pulmonary oedema while waiting for a surgical outpatient appointment, one refused SAVR but was subsequently admitted with acute pulmonary oedema and accepted SAVR, one was admitted directly from home because concerns about worsening AS, and one had infective endocarditis with severe aortic regurgitation. Of 10 patients with a new diagnosis of AS, five presented with LVF, four with angina and in three there was a history of syncope (p=0.003 vs. known AS; multiple symptoms). Survival, age, Canadian Cardiovascular Society (CCS) and New York Heart Association (NYHA) class, number of risk factors, peak and mean aortic valve (AV) gradients, AV area, and stroke volume index were not different between patients who had planned versus unplanned SAVR, or with known or new AS. Patients with a new diagnosis of AS had longer pre-operative wait (22.3 ± 9.3 vs. 6.0 ± 10.3 days, p<0.001).

In conclusion, a quarter of SAVRs are unplanned and half are in patients without a prior diagnosis of AS. Unplanned SAVR is associated with prolonged length of hospital stay and with a history of syncope, but other conventional clinical and echocardiographic parameters do not differ between patients undergoing planned versus unplanned SAVR.

Undertaking a period of research in cardiology is considered a vital part of training. This has many advantages including enhancing skills that better equip the clinician for patient care. However, in modern cardiology training, the feasibility and necessity of undertaking a period of formal research during training should be considered on an individual basis. The first of this four-part editorial series will explore the benefits of and obstacles to pursuing research in cardiology, with the aim of equipping the reader with an understanding of the options around research during cardiology training in the UK.

At least 5% of GP and accident and emergency (A&E) attendances are undifferentiated chest pain. Rapid access chest pain clinics (RACPC) offer urgent guideline-directed management of suspected cardiac chest pain. The National Institute for Health and Care Excellence (NICE) recommends computed tomography coronary angiography (CTCA) as a first-line investigation. We evaluated the effectiveness and efficiency of a local RACPC.

Retrospective analysis of unselected referrals to a RACPC in the Northeast of England was conducted for 2021. Baseline demographics and major adverse cardiovascular events (MACE) were compared between typical, atypical and non-angina. Anatomical and functional imaging results were recorded. Backward stepwise binary logistic regression modelled obstructive coronary artery disease (CAD) incidence.

There were 373/401 (93.0%) patients with chest pain; 139 (37.3%) typical angina, 122 (32.8%) atypical angina and 112 (30.0%) non-angina. Typical angina patients were older (p<0.001) with more cardiovascular risk factors (p<0.001) and increased risk of obstructive CAD (adjusted odds ratio [OR] 6.27, 95% confidence interval [CI] 2.93 to 13.38) and MACE (9.4%, p=0.029). In total, 164 (44.0%) had invasive coronary angiography (ICA) within 7.4 ± 4.8 weeks; 19.5% had normal coronary arteries, 26.2% had obstructive CAD and 22.6% proceeded to invasive haemodynamic assessment ± PCI without major procedural complications. There were 39 (10.5%) who had CTCA within 34.6 ± 18.1 weeks; 25.6% needed ICA to clarify diagnosis.

In conclusion, typical angina patients were at heightened risk of cardiovascular events. In the absence of adequate CTCA capacity, greater reliance on ICA still facilitated accurate diagnosis with options for immediate revascularisation, timely and safely, in the right patients. Better risk stratification and expansion of non-invasive imaging can improve local RACPC service delivery in the wider Northeast cardiology network.

A 62-year-old man presented complaining of atrial fibrillation.  Plain chest radiography and contrast-enhanced computed tomography (CT) revealed a large fusiform aneurysmal dilatation of the upper segment of the superior vena cava (SVC) without evidence of rupture, thrombosis, or pulmonary embolism. It was decided to treat the patient conservatively with follow-up imaging recommended.

We sought to remedy the limited guidance that is available to support the resuscitation of patients with the Impella Cardiac Power (CP) and 5.0 devices during episodes of cardiac arrest or life-threatening events that can result in haemodynamic decompensation.

In a specialist tertiary referral centre we developed, by iteration, a novel resuscitation algorithm for Impella emergencies, which we validated through simulation and assessment by our multi-disciplinary team. A mechanical life support course was established to provide theoretical and practical education, combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to resolve a suction event) and a multiple-choice question (MCQ) examination.

Following this intervention, median confidence score increased from 2 (interquartile range [IQR] 2 to 3) to 4 (IQR 4 to 4) out of a maximum of 5 (n=53, p<0.0001). Theoretical knowledge of the Impella, as assessed by median MCQ score, increased from 12 (IQR 10 to 13) to 13 (12 to 14) out of a maximum of 17 (p<0.0001).

The use of a bespoke Impella resuscitation algorithm reduced the mean time taken to identify and resolve a suction event by 53 seconds (95% confidence interval 36 to 99, p=0.0003).

In conclusion, we present an evidence-based resuscitation algorithm that provides both technical and medical guidance to clinicians responding to life-threatening events in Impella recipients.

Several studies have shown that elevated serum ferritin level is associated with a higher risk of coronary artery disease. Recently, it has been shown that high serum ferritin levels in men are independently correlated with an increased risk of cardiovascular mortality. This study aimed to investigate the possible correlation between the initial serum ferritin level and in-hospital mortality in patients presenting with ST-elevation myocardial infarction (STEMI).

This retrospective cohort study included 890 patients who presented with acute STEMI and underwent successful primary percutaneous coronary intervention (PPCI) according to the standard techniques during the period from 1 May 2020 to 1 May 2021. At the time of admission, an initial serum ferritin level was measured in all patients. Comparison between initial ferritin levels was made between two groups: died and survived. Propensity matching was performed to exclude confounding factors effect.

Forty-one patients had in-hospital mortality. There was no significant difference between both groups regarding baseline clinical characteristics. Initial serum ferritin levels were higher in deceased patients, even after propensity matching.

In conclusion, even after propensity matching, initial ferritin levels were significantly higher in patients who died after being admitted for STEMI.