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Clinical articles

July 2020 Br J Cardiol 2020;27:93–6 doi :10.5837/bjc.2020.023

Shared decision-making for ICDs: a regional collaborative initiative

Honey Thomas, Mark Lambert, Chris Plummer, Craig Runnett, Richard Thomson, Anne Marie Troy-Smith, Andrew J Turley

Abstract

The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision-making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.

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July 2020 Br J Cardiol 2020;27:97–9 doi :10.5837/bjc.2020.024

Computed tomography artefact finding of pacing lead perforation

Holly Morgan, Christopher Williams, Robert A Bleasdale

Abstract

Computed tomography (CT) is a widely available imaging modality and artefactual findings are not uncommon, particularly in the presence of foreign bodies.

We conducted a retrospective analysis of all CT scans carried out in our trust in a 12-month period, identifying all reports containing the word “pacemaker”. There were 88 scans identified, six of which reported findings related to the pacemaker. In five cases right ventricular lead perforation was reported. All patients underwent further investigations, which did not show any evidence of true lead perforation.

In conclusion, it is important that both cardiologists and radiologists are aware of the possibility of artefactual lead perforation on CT.

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June 2020 Br J Cardiol 2020;27:51–54 doi :10.5837/bjc.2020.017

Impact of COVID-19 on primary percutaneous coronary intervention centres in the UK: a survey

Ahmed M Adlan, Ven G Lim, Gurpreet Dhillon, Hibba Kurdi, Gemina Doolub, Nadir Elamin, Amir Aziz, Sanjay Sastry, Gershan Davis

Abstract

During the coronavirus disease (COVID-19) pandemic, the British Cardiovascular Society/British Cardiovascular Intervention Society and the British Heart Rhythm Society recommended to postpone non-urgent elective work and that primary percutaneous coronary intervention (PCI) should remain the treatment of choice for patients with ST-segment elevation myocardial infarction (STEMI). We sought to determine the impact of COVID-19 on the primary PCI service within the United Kingdom (UK).

A survey of 43 UK primary PCI centres was performed and a significant reduction in the number of cath labs open was found (pre-COVID 3.6±1.8 vs. post-COVID 2.1±0.8; p<0.001) with only 64% of cath labs remained open during the COVID-19 pandemic. Primary PCI remained first-line treatment for STEMI in all centres surveyed.

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June 2020 Br J Cardiol 2020;27:55–9 doi :10.5837/bjc.2020.018

COVID-19: the heart and other issues

Cormac T O’Connor, David Mulcahy

Abstract

From the time that the first cases were reported from Wuhan, China on the 31st December 2019,1 our knowledge of the clinical and virological associations of the novel coronavirus (COVID-19) has been evolving at a rapid pace. On 18th May 2020, COVID-19 had caused over 4.82 million cases worldwide and resulted in 316,959 deaths.2 Whilst the primary focus of management for patients with COVID-19 remains close monitoring of respiratory function, there have been high levels of cardiac dysfunction in emerging cross-sectional and observational analyses, suggesting the need for heightened awareness in patients who may require cardiac input as part of a multidisciplinary approach. We review the current data on the association of COVID-19 and the heart.

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June 2020 Br J Cardiol 2020;27:67–70 doi :10.5837/bjc.2020.020

An exercise-based cardiac rehabilitation programme for AF patients in the NHS: a feasibility study

Mark Mills, Elizabeth Johnson, Hamza Zafar, Andrew Horwood, Nicola Lax, Sarah Charlesworth, Anna Gregory, Justin Lee, Jonathan Sahu, Graeme Kirkwood, Nicholas Kelland, Andreas Kyriacou

Abstract

There is increasing evidence for the role of exercise-based cardiac rehabilitation in the management of patients with atrial fibrillation (AF). However, this intervention has not yet been widely adopted within the National Health Service (NHS).

We performed a feasibility study on the utilisation of an established NHS cardiac rehabilitation programme in the management of AF, and examined the effects of this intervention on exercise capacity, weight, and psychological health. We then identified factors that might prevent patients from enrolling on our programme.

Patients with symptomatic AF were invited to participate in an established six-week exercise-based cardiac rehabilitation programme, composed of physical activity and education sessions. At the start of the programme, patients were weighed and measured, performed the six-minute walk test (6MWT), completed the Generalised Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9). Measurements were repeated on completion of the programme.

Over two years, 77 patients were invited to join the programme. Twenty-two patients (28.5%) declined participation prior to initial assessment and 22 (28.5%) accepted and attended the initial assessment, but subsequently withdrew from the programme. In total, 33 patients completed the entire programme (63.9 ± 1.7 years, 58% female). On completion, patients covered longer distances during the 6MWT, had lower GAD-7 scores, and lower PHQ-9 scores, compared with their baseline results. Compared with patients that completed the entire programme, those who withdrew from the study had, at baseline, a significantly higher body mass index (BMI), covered a shorter distance during the 6MWT, and had higher PHQ-9 and GAD-7 scores.

In conclusion, enrolling patients with AF into an NHS cardiac rehabilitation programme is feasible, with nearly half of those invited completing the programme. In this feasibility study, cardiac rehabilitation resulted in an improved 6MWT, and reduced anxiety and depression levels, in the short term. Severe obesity, higher anxiety and depression levels, and lower initial exercise capacity appear to be barriers to completing exercise-based cardiac rehabilitation. These results warrant further investigation in larger cohorts.

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May 2020 Br J Cardiol 2020;27:64–6 doi :10.5837/bjc.2020.011

Hypertrophic cardiomyopathy and exercise restrictions: time to let the shackles off?

Yuen W Liao, James Redfern, John D Somauroo, Robert M Cooper

Abstract

The health benefits of physical activity are well documented. Patients with hypertrophic cardiomyopathy (HCM) are often discouraged from participating in physical activity due to a perceived increase in the risk of sudden cardiac death (SCD). As a result, only 45% of patients with HCM meet the minimum guidelines for physical activity, and many report an intentional reduction in exercise following diagnosis. Despite most SCD being unrelated to HCM, guidelines traditionally focused on the avoidance of potential risk through restriction of exercise, without clear recommendations on how to negate the negative health impact of inactivity. Retrospective reviews have demonstrated that the majority of cardiac arrests in patients with HCM occurred at rest or on mild exertion and that the overall incidence of HCM-related SCD is significantly lower than previously reported. We will discuss current international guidelines and recommendations and consider the outcomes of various studies that have investigated the effects of exercise of different intensities on patients with HCM. In light of the growing evidence suggesting that carefully guided exercise can be both beneficial and safe in patients with HCM, we ask whether it is time to let the shackles off exercise restriction in HCM.

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May 2020 Br J Cardiol 2020;27:60–3 doi :10.5837/bjc.2020.012

A multi-disciplinary care pathway improves symptoms, QoL and medication use in refractory angina

Kevin Cheng, Ranil de Silva

Abstract

Refractory angina (RA) is a growing clinical problem. Long-term mortality is better than expected and focus has shifted to improving symptoms, quality of life and psychological morbidity. We established a dedicated multi-disciplinary care pathway for patients with RA and assessed its effect on psychological outcomes, quality of life and polypharmacy. We reviewed electronic health records to capture demographics, changes in medication use, and patient-related outcome measures (Seattle Angina Questionnaire [SAQ] and Hospital Anxiety and Depression Scale) before and after enrolment.

One hundred and ninety patients were referred to our service. Pre- and post-questionnaire data were available in 83 patients. Anxiety and depression scores significantly improved (p<0.05) as well as quality of life and all subcategories of the SAQ (p<0.0001). Patients were most commonly on three or four anti-anginal drugs. In patients with no demonstrable reversible ischaemia, there was a significant reduction in anti-anginal usage (mean reduction of two drugs) after completion of our pathway (p<0.025).

In conclusion, a dedicated multi-disciplinary pathway for RA is associated with improvements in quality of life, mental health and polypharmacy. An ischaemia-driven method to rationalise medication may reduce polypharmacy in patients with RA, particularly in patients with no demonstrable ischaemia.

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May 2020 Br J Cardiol 2020;27:71 doi :10.5837/bjc.2020.013

Ezekiel’s heart

JJ Coughlan, Max Waters, David Moore, David Mulcahy

Abstract

“I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh” – Ezekiel 36:26

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May 2020 Br J Cardiol 2020;27:72–3 doi :10.5837/bjc.2020.014

Can a giant U-wave be innocent?

Sinead Curran, Waleed Arshad, Arvinder Kurbaan, Han B Xiao

Abstract

The U-wave on electrocardiogram (ECG) is a small deflection following the T-wave, the sixth wave. It is 25% or less of the preceding T-wave in amplitude.1,2 While the genesis of the U-wave is uncertain, it is said to represent repolarisation of the Purkinje fibres.1,2 Disproportionally large U-waves may indicate underlying cardiac or non-cardiac pathology. A relatively frequent cause for a large U-wave is hypokalaemia. It is observed in patients with bradycardia, ventricular hypertrophy, hypothyroidism, hypocalcaemia, hypomagnesaemia, mitral valve prolapse, hypothermia, increased intracranial pressure, or patients on anti-arrhythmic medicine.2 A negative U-wave, on the other hand, may represent early myocardial ischaemia, specifically in the context of a lesion in the left main or proximal left anterior descending coronary artery.2,3

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March 2020 Br J Cardiol 2020;27:27–30 doi :10.5837/bjc.2020.006

Rise of the machines: will heart failure become the first cyber-specialty?

Shirley Sze

Abstract

Digital healthcare is being introduced to the management of heart failure as a consequence of innovations in information technology. Advancement in technology enables remote symptom and device monitoring, and facilitates early detection and treatment of heart failure exacerbation, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems. Although promising, there is, as yet, insufficient evidence to support the widespread implementation of digital healthcare. Patient-related barriers include user characteristics and health status; privacy and security concerns; financial costs and lack of accessibility of digital resources. Physician-related barriers include the lack of infrastructure, incentive, knowledge and training. There are also a multitude of technical challenges in maintaining system efficiency and data quality. Furthermore, the lack of regulation and legislation regarding digital healthcare also prevents its large-scale deployment. Further education and support and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure.

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