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Clinical articles

February 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.006 Online First

A retrospective single-centre study on determinants of high-risk coronary artery calcium (CAC) score in women

Saskia D Handari, Naesilla, Annisya Dinda Paramitha

Abstract

One of the assessments for coronary atherosclerosis during cardiac computed tomography (CT) is coronary artery calcium (CAC) scoring. We conducted analysis on the determinants of high-risk coronary calcification, represented by CAC score, among women as a step to improve their outcomes and prognosis. This study involved a total of 1,129 female patients from a single centre. There were 127 patients (11.2%) classified as high risk (CAC ≥400). We found that a history of hypertension and diabetes are independent determinants of having a high-risk CAC score. Furthermore, this study demonstrated protective effects associated with physical activity and diastolic blood pressure. In conclusion, a history of hypertension, diabetes, and high uncontrolled systolic blood pressure might be used as cues for physicians to prioritise CAC assessment in women, despite the absence of chest pain or atypical symptoms.

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February 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.007 Online First

Transcatheter versus surgical valve replacement in patients with bicuspid aortic valves: an updated meta-analysis

Peter S Giannaris, Viren S Sehgal, Branden Tejada, Kenzy H Ismail, Roshan Pandey, Eamon Vega, Kathryn Varghese, Ahmed K Awad, Adham Ahmed, Irbaz Hameed

Abstract

Patients with bicuspid aortic valves (BAV) are predisposed to the development of aortic stenosis. We performed a pairwise meta-analysis, comparing the efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with BAV.

Medical databases were queried to pool comparative studies of interest. Single-arm studies, conference presentations, animal studies, and studies that involved patients with tricuspid aortic morphology were excluded. Outcomes were pooled as risk ratios (RRs) with their 95% confidence intervals (CI) using the random effects model in R.

There were 60,858 patients with BAV (7,565 TAVR, 53,293 SAVR) included. Compared with SAVR, TAVR was associated with a significantly lower risk of 30-day major bleeding (RR 0.29, 95%CI 0.13 to 0.63, p=0.01) but a higher risk of new permanent pacemaker placement (RR 2.17, 95%CI 1.03 to 4.58, p=0.04). No significant differences were seen with other explored outcomes, including 30-day/mid-term mortality, stroke, acute kidney injury, major vascular complications, paravalvular leak, and conduction abnormalities.

In conclusion, in patients with BAV, TAVR is associated with a lower risk of 30-day major bleeding but has an increased risk for permanent pacemaker implantation when compared with SAVR. Future large-scale randomised trials comparing both the short- and long-term outcomes of SAVR and TAVR in patients with BAV are needed to assess the efficacy of each modality in a controlled population across long follow-up durations.

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February 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.008 Online First

Solving problems at the cath lab

Rita Caldeira da Rocha, Alejandro Diego Nieto, Jesus Garibi, Ignacio Cruz-Gonzalez

Abstract

We describe a case of aortic rupture following transcatheter aortic valve implantation that was managed percutaneously.

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January 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.001 Online First

Dishing out the meds

David Mulcahy, Palwasha Khan

Abstract

Twenty years ago, Wald and Law1 hypothesised that, if a combination pill could be made including aspirin, folic acid, a statin, and a low-dose diuretic, beta blocker and angiotensin-converting enzyme (ACE) inhibitor (thus, allowing for the simultaneous modification of four different risk factors: low-density lipoprotein [LDL]-cholesterol, blood pressure, homocysteine, and platelet function), and administered to everyone with existing cardiovascular disease and everyone over 55 years old, there would be an 88% reduction in ischaemic heart disease events, and an 80% reduction in stroke. One third of people over the age of 55 years would benefit by gaining an average of 11 years free from a cardiac event or stroke (subsequently termed the vaccination approach). They called this pill the ‘Polypill’, and concluded that treatment would be acceptably safe and, with widespread use, would have a greater impact on the prevention of disease in the Western world than any other single intervention. They noted that, while such a preventative strategy was radical, if such a formulation existed that prevented cancer and was safe, it would be widely used. “It is time to discard the view that risk factors need to be measured and treated individually if found to be abnormal. There is much to gain and little to lose by the widespread use of these drugs.” While subsequent works have shown that folic acid is not prognostically beneficial in preventing cardiovascular disease,2 and that aspirin may not be beneficial overall in primary prevention settings,3 the concept of the combination pill was awakened in the public eye.

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January 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.002 Online First

Assessment of the diagnostic value of NT-proBNP in heart failure with preserved ejection fraction

Hayley Birrell, Omar Fersia, Mohamed Anwar, Catherine Mondoa, Angus McFadyen, Christopher Isles

Abstract

Heart failure with preserved ejection fraction (HFpEF) is a common concern in the medical field due to its prevalence in an ageing western population. HFpEF is associated with significant morbidity and mortality not dissimilar to heart failure (HF) with reduced ejection fraction. N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and echocardiography are the guideline diagnostic indicators of HF and their use is being examined in this study, with the aim to consider NT-proBNP thresholds performance as a rule-out test.

The current National Institute for Health and Care Excellence (NICE) and European guidelines recommend a single NT-proBNP threshold of >400 ng/L and >125 ng/L, respectively, to trigger echocardiographic assessment of HF in the outpatient setting. NT-proBNP levels are known to increase with age and worsening renal function. Unsurprisingly, a single threshold significantly increases demand for echocardiography. NT-proBNP measurements and echocardiograms performed within six months of each other were included for 469 patients with suspected HF.

A significant relationship between NT-proBNP levels and diastolic dysfunction was established. NT-proBNP levels and age are significant predictors of diastolic dysfunction in uni-variant (odds ratio 1.251, 95% confidence interval [CI], p<0.001) and multi-variant analysis (odds ratio 1.174, 95%CI, p=0.002). High negative-predictive values (NPVs) were obtained in severe diastolic impairment with the NPV being 95% at the European NT-proBNP cut-off of 125 ng/L, 95% at the NICE cut-off of 400 ng/L, 93% at 1,000 ng/L and 92% at 2,000 ng/L.

There is a significant association between NT-proBNP and diastolic dysfunction. NT-proBNP and age can predict diastolic dysfunction, and age can predict NT-proBNP levels, thus, these variables should be considered when considering referral for an echocardiogram. Most importantly, at higher NT-proBNP cut-offs the NPVs remain above 90% suggesting that different thresholds for subpopulations could yield a more effective strategy and mitigate the increased demand for echocardiography.

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January 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.003 Online First

Inpatient initiation of sodium-glucose cotransporter-2 inhibitors: the prescribing learning curve

Charlotte Gross, Hiba Hammad, Thomas A Slater, Sam Straw, Thomas Anderton, Caroline Coyle, Melanie McGinlay, John Gierula, V Kate Gatenby, Vikrant Nayar, Jiv N Gosai, Klaus K Witte

Abstract

We aimed to describe the safety and tolerability of initiation of sodium-glucose cotransporter 2 inhibitors (SGLT2i) during hospitalisation with heart failure, and the frequency of, and reasons for, subsequent discontinuation.

In total, 934 patients who were not already prescribed a SGLT2i were hospitalised with heart failure, 77 (8%) were initiated on a SGLT2i a median of five (3–8.5) days after admission and two (0.5–5) days prior to discharge. During a median follow-up of 182 (124–250) days, SGLT2i were discontinued for 10 (13%) patients, most frequently due to deteriorating renal function. We observed reductions in body weight (mean difference 2.0 ± 0.48 kg, p<0.001), systolic blood pressure (mean difference 9.5 ± 1.9 kg, p<0.001) and small, non-significant reductions in estimated glomerular filtration rate (eGFR mean difference 2.0 ± 1.5 ml/min/1.73 m2, p=0.19) prior to initiation, with further modest reductions in weight (mean difference 1.2 ± 0.4 kg, p=0.006) but not systolic blood pressure (2.4 ± 1.5 mmHg, p=0.13) or eGFR following initiation of SGLT2i. At discharge the proportion prescribed a beta blocker (44% to 92%), angiotensin-receptor/neprilysin inhibitor (6% to 44%) and mineralocorticoid-receptor antagonist (35% to 85%) had increased.

In conclusion, inpatient initiation of SGLT2i was safe and well tolerated in a real-world cohort of patients hospitalised with worsening HF. We observed a 13% frequency of discontinuation or serious side effects.

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January 2024 Br J Cardiol 2024;31(1) doi :10.5837/bjc.2024.004 Online First

Pulmonary hypertension secondary to arteriovenous fistula: a case report

Karla Alejandra Pupiales-Dávila, David Jacobo Sánchez-Amaya, Rodrigo Zebadúa-Torres, Julio César López-Reyes, Nayeli Guadalupe Zayas-Hernández

Abstract

Pulmonary hypertension is a rare disease, associated with a significant deterioration in quality of life, usually not curable and with an ominous prognosis. It is classified into five groups according to similar pathophysiological, clinical, haemodynamic, and treatment options in each of them. However, group 5 is the least common, encompassing different types of aetiological, semiological, and management conditions. We present the case of a patient diagnosed with precapillary component pulmonary hypertension, with the finding of an arteriovenous fistula at the peripheral level. Interventional exclusion was performed, achieving remission of her disease.

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November 2023 Br J Cardiol 2023;30:139–43 doi :10.5837/bjc.2023.040

Drug therapies for stroke prevention

Nimisha Shaji, Robert F Storey, William A E Parker

Abstract

Stroke is a major cause of mortality, morbidity and economic burden. Strokes can be thrombotic, embolic or haemorrhagic. The key risk factor for cardioembolic stroke is atrial fibrillation or flutter, and oral anticoagulation (OAC) is recommended in all but the lowest-risk patients with evidence of these arrhythmias. Risk factors for thrombotic stroke overlap strongly with those for other atherosclerotic cardiovascular diseases (ASCVDs). Antiplatelet therapy (APT) should be considered in patients with established ASCVD to reduce risk of cardiovascular events, including stroke. Intensification from single to dual APT or a combination of APT with low-dose OAC can reduce ischaemic stroke risk further, but increases bleeding risk. Blood pressure and lipid profile should be controlled appropriately to guideline targets. In patients with diabetes, good glycaemic control can reduce stroke risk. Inflammation is another emerging target for stroke prevention. Overall, comprehensive assessment and pharmacological modification of risk factors are central to stroke prevention.

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November 2023 Br J Cardiol 2023;30:150 doi :10.5837/bjc.2023.041

CMR is vital in the management of cardiology inpatients: a tertiary centre experience

Rumneek Hampal, Kristopher D Knott, Aristides Plastiras, Nicholas H Bunce

Abstract

To review the utility of cardiovascular magnetic resonance (CMR) in the management of hospital inpatients, we performed a retrospective review of all inpatient CMR scans performed over a six-month period at a tertiary referral cardiology centre. Patient demographics, indication for CMR imaging, results of the CMR scans and whether the results changed patient management were recorded. Change in management included medication changes, subsequent invasive procedures, or avoidance of such, and hospital discharge.

Overall, 169 patients were included in the study cohort, 66% were male, mean age was 57.1 years. The most common indication for inpatient CMR was to investigate for cardiomyopathy (53% of patients). The most prevalent diagnosis post-CMR in our cohort was ischaemic heart disease, including ischaemic cardiomyopathy and coronary artery disease. There was a complete change in diagnosis or additional diagnosis found in 29% of patients following CMR. Overall, inpatient CMR led to a change in management in 77% of patients; the most common being changes to medication regimen. CMR was well tolerated in 99% of patients and image quality was diagnostic in 93% of cine scans performed.

In conclusion, CMR is vital for the management of cardiology inpatients, having an impact that is at least as significant as in the management of outpatients.

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November 2023 Br J Cardiol 2023;30:144–7 doi :10.5837/bjc.2023.042

Myocardial revascularisation in complex patients: does it happen as prescribed by the heart team?

Montasir Ali, Abdul R A Bakhsh, Omer Elsayegh, Hussain Al-Sadi, Adrian Ionescu

Abstract

Guidelines recommend decision-making using the heart team (HT) in complex patients considered for myocardial revascularisation, but there are little data on how this approach works in practice. We data-mined our electronic HT database and selected patients in whom the clinical question referred to revascularisation, and documented HT recommendations and their implementation.

We identified 154 patients (117 male), mean age 68.9 ± 11.4 years, discussed between February 2019 and December 2020. The clinical questions were coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) (141 cases, 91%), and medical treatment versus revascularisation by PCI (eight cases, 6%) or by CABG (five cases, 3%).

HT recommended CABG in 55 cases (35%), PCI in 43 (28%), medical treatment in 15 (10%), and equipoise in seven (5%) and further investigations in 34 (22%): non-invasive imaging for ischaemia in 11 (32%), invasive coronary physiology studies in eight (24%), further clinical assessment in seven (20%), structural imaging for five (15%), invasive coronary angiography in two (6%), and an electrophysiology opinion in one case (3%).

Decisions were implemented in 135 cases (89%). The average time between the HT and the implementation of its decision was 80.5 ± 129.3 days. There were 17 deaths: 10 cardiac, six non-cardiac and one of unknown cause. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p = 0.03).

In conclusion, almost 90% of the decisions of the HT on myocardial revascularisation are implemented, while ischaemia testing is the main investigation required for decision-making. Recent data on the futility of such an approach have not yet permeated clinical practice.

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