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Clinical articles

July 2022 Br J Cardiol 2022;29(3) doi :10.5837/bjc.2022.023

Age and the power of zero CAC in cardiac risk assessment: overview of the literature and a cautionary case

John P Sheppard, Suvasini Lakshmanan, Seth J Lichtenstein, Matthew J Budoff, Sion K Roy

Abstract

The coronary artery calcium (CAC) score is a marker of advanced coronary atherosclerosis. Numerous prospective cohorts have validated CAC as an independent marker that improves prognostication in atherosclerotic cardiovascular disease (ASCVD) beyond traditional risk factors. Accordingly, CAC is now incorporated into international cardiovascular guidelines as a tool to inform medical decision-making. Particular interest concerns the significance of zero CAC score (CAC=0). While many studies report CAC=0 to virtually exclude obstructive coronary artery disease (CAD), non-negligible rates of obstructive CAD despite CAC=0 are reported in certain populations. Overall, the current literature supports the power of zero CAC as a strong downward risk classifier in older patients, whose CAD burden predominantly involves calcified plaque. However, with their higher burden of non-calcified plaque, CAC=0 does not reliably exclude obstructive CAD in patients under 40 years. Illustrating this point, we present a cautionary case of a 31-year-old patient found to have severe two-vessel CAD despite CAC=0. We highlight the value of coronary computed tomography angiography (CCTA) as the gold-standard non-invasive imaging modality when the diagnosis of obstructive CAD is in question.

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July 2022 Br J Cardiol 2022;29(3) doi :10.5837/bjc.2022.024

Pain after pacemaker/ICD implants

Selwyn Brendon Goldthorpe

Abstract

A retrospective study of 322 patient experiences of post-operative pain, short term and long term, following a cardiac implantable electronic device (CIED) procedure. Pain from pacemaker and ICD (implantable cardioverter-defibrillator) implant surgery remains a problem both in terms of severity and longevity. There is a subset of patients receiving implants that have severe pain that may be of a long duration. Patient advice needs to be appropriate to these findings.

This study illustrates a need for better pain management by physicians, support, and realistic communication with their patients.

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July 2022 Br J Cardiol 2022;29(3) doi :10.5837/bjc.2022.025

Infective endocarditis: acne to zoonoses on the valve, an A to Z perspective

Mark Boyle, Charlene Tennyson, Achyut Guleri, Antony Walker

Abstract

Cutibacterium acnes (C. acnes), previously known as Propionibacterium acnes, is a rare cause of infective endocarditis (IE). We provide a review of the literature and describe two recent cases from a single centre to provide insight into the various clinical presentations, progression and management of patients with this infection.

The primary objective of our review is to highlight the difficulty in the initial assessment of these patients with an aim to improve the time and accuracy of diagnosis and expedite subsequent treatment. There are currently no guidelines in the literature specific to the management of IE caused by C. acnes. Our secondary objectives are to disseminate information about the indolent course of the disease and add to the growing body of evidence around this rare, yet complex, cause of IE.

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July 2022 Br J Cardiol 2022;29(3) doi :10.5837/bjc.2022.026

High-output heart failure due to arteriovenous malformation treated by endovascular embolisation

Federico Liberman, Roberto Cooke, María J Cabrera, Santiago Vigo, Guillermo Allende, Luciana Auad, Juan P Ricarte-Bratti

Abstract

High-output heart failure (HF) is an uncommon condition. This occurs when HF syndrome patients have a cardiac output higher than eight litres per minute. Shunts, such as fistulas and arteriovenous malformations are an important reversible cause. We present the case of a 30-year-old man who presented to the emergency department due to decompensated HF. Echocardiogram showed dilated myocardiopathy with high cardiac output (19.5 L/min calculated on long-axis view). He was diagnosed with arteriovenous malformation by computed tomography (CT) and subsequent angiography, and a multi-disciplinary team decided to perform endovascular embolisation with ethylene vinyl alcohol/dimethyl sulfoxide at different times. The transthoracic echocardiogram showed a significant decrease in cardiac output (9.8 L/min) and his general condition improved significantly.

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June 2022 Br J Cardiol 2022;29(3) doi :10.5837/bjc.2022.021

Evolution of a circulatory support system with full implantability: personal perspectives on a long journey

Stephen Westaby

Abstract

Implantable mechanical circulatory support systems have evolved dramatically over the last 50 years. The objective has been to replace or support the failing left ventricle with a device that pumps six litres of blood each minute, a massive 8,640 litres per day. Noisy cumbersome pulsatile devices have been replaced by smaller silent rotary blood pumps that are much more patient friendly. Nonetheless, the tethering to external components, together with the risks of power line infection, pump thrombosis and stroke, must be addressed before widespread acceptance. Infection predisposes to thromboembolism, so elimination of the percutaneous electric cable has the capacity to transform outcomes, reduce costs and improve quality of life.

Developed in the UK, the Calon miniVAD is powered by an innovative coplanar energy transfer system. As such, we consider it can achieve those ambitious objectives.

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May 2022 Br J Cardiol 2022;29:46–51 doi :10.5837/bjc.2022.015

Clinical and health economic evaluation of a post-stroke arrhythmia monitoring service

David Muggeridge, Kara Callum, Lynsey Macpherson, Nick Howard, Claudia Graune, Ian Megson, Adam Giangreco, Susan Gallacher, Linda Campbell, Gethin Williams, Ashish Macaden, Stephen J Leslie

Abstract

Atrial fibrillation (AF) is a major cause of recurrent stroke and transient ischaemic attack (TIA) in the UK. As many patients can have asymptomatic paroxysmal AF, prolonged arrhythmia monitoring is advised in selected patients following a stroke or TIA. This service evaluation assessed the clinical and potential health economic impact of prolonged arrhythmia monitoring post-stroke using R-TEST monitoring devices.

This was a prospective, case-controlled, service evaluation in a single health board in the North of Scotland. Patients were included if they had a recent stroke or TIA, were in sinus rhythm, and did not have another indication for, or contraindication to, oral anticoagulation. A health economic model was developed to estimate the clinical and economic value delivered by the R-TEST monitoring. Approval to use anonymised patient data in this service evaluation was obtained.

During the evaluation period, 100 consecutive patients were included. The average age was 70 ± 11 years, 46% were female. Stroke was the presenting complaint in 83% of patients with the other 17% having had a TIA. AF was detected in seven of 83 (8.4%) patients who had had a stroke and one of 17 (5.9%) patients with a TIA. Health economic modelling predicted that adoption of R-TEST monitoring has a high probability of demonstrating both clinical and economic benefits.

In conclusion, developing a post-stroke arrhythmia monitoring service using R-TEST devices is feasible, effective at detecting AF, and represents a probable clinical and economic benefit

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May 2022 Br J Cardiol 2022;29:60–3 doi :10.5837/bjc.2022.017

Total ischaemic time in STEMI: factors influencing systemic delay

Cormac T O’Connor, Abdallah Ibrahim, Anthony Buckley, Caoimhe Maguire, Rajesh Kumar, Jatinder Kumar, Samer Arnous, Thomas J Kiernan

Abstract

Total ischaemic time in ST-elevation myocardial infarction (STEMI) has been shown to be a predictor of mortality. The aim of this study was to assess the total ischaemic time of STEMIs in an Irish primary percutaneous coronary intervention (pPCI) centre. A single-centre prospective observational study was conducted of all STEMIs referred for pPCI from October 2017 until January 2019.

There were 213 patients with a mean age 63.9 years (range 29–96 years). The mean ischaemic time was 387 ± 451.7 mins. The mean time before call for help (patient delay) was 207.02 ± 396.8 mins, comprising the majority of total ischaemic time. Following diagnostic electrocardiogram (ECG), 46.5% of patients had ECG-to-wire cross under 90 mins as per guidelines; 73.9% were within 120 mins and 93.4% were within 180 mins. Increasing age correlated with longer patient delay (Pearson’s r=0.2181, p=0.0066). Women exhibited longer ischaemic time compared with men (508.96 vs. 363.33 mins, respectively, p=0.03515), driven by a longer time from first medical contact (FMC) to ECG (104 vs. 34 mins, p=0.0021).

The majority of total ischaemic time is due to patient delay, and this increases as age increases. Women had longer ischaemic time compared with men and longer wait from FMC until diagnostic ECG. This study suggests that improved awareness for patients and healthcare staff will be paramount in reducing ischaemic time.

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May 2022 Br J Cardiol 2022;29:64–6 doi :10.5837/bjc.2022.018

Evaluation of the prognostic value of the admission ECG in COVID-19 patients: a meta-analysis

Mateusz Wawrzeńczyk, Marcin D Grabowski

Abstract

The assessment of the prognostic value of the admission electrocardiography (ECG) (specifically of the duration of the PR and QTc intervals, the QRS complex and the heart rate [HR]) in COVID-19 patients on the basis of nine observational studies (n=1,424) indicates that relatively long duration of the QTc interval and QRS complex, as well as higher HR, are linked to a severe course of COVID-19, which may be of use in risk stratification. Since there are important differences in suggested indicators of adverse prognosis between observational studies, further research is necessary to clarify high-risk criteria.

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May 2022 Br J Cardiol 2022;29:73–6 doi :10.5837/bjc.2022.019

The use of PYP scan for evaluation of ATTR cardiac amyloidosis at a tertiary medical centre

Joshua Dower, Danai Dima, Mumtu Lalla, Ayan R Patel, Raymond L Comenzo, Cindy Varga

Abstract

Cardiac transthyretin amyloidosis (ATTR) is an often underdiagnosed disease that can lead to significant morbidity and mortality for patients. In recent years, technetium-99m pyrophosphate scintigraphy (PYP) imaging has become a standard of care diagnostic tool to help clinicians identify this disease. With newly emerging therapies for ATTR cardiomyopathy, it is critical to identify patients who are eligible for therapy as early as possible. At our institution, we sought to describe the frequency of PYP scanning and how it has impacted the management of a patient suspected to have amyloid cardiomyopathy.

Between 1 January 2017 and 31 December 2020, we identified 273 patients who completed PYP scanning for evaluation of cardiac amyloidosis at Tufts Medical Center, a tertiary care centre. We reviewed pertinent clinical data for all study subjects. A PYP scan was considered positive when the heart to contralateral lung ratio was greater than or equal to 1.5, with a visual grade of 2 or 3, and confirmation with single-photon emission computerised tomography (SPECT) imaging.

In total there were 55 positive, 202 negative, and 16 equivocal PYP scans. Endomyocardial biopsies were rarely performed following PYP results. Of the seven patients with a positive PYP scan who underwent biopsy, five were positive for ATTR amyloid; of the patients with a negative scan who were biopsied, none were positive for ATTR amyloidosis and two were positive for amyloid light-chain (AL) amyloidosis. The biomarkers troponin I, B-type naturietic peptide (BNP), and N-terminal pro-BNP (NT-proBNP), as well as the interventricular septal end-diastolic thickness (IVSd) seen on echocardiogram, were all found to be statistically higher in the PYP positive cohort than in the PYP negative cohort using Mann-Whitney U statistical analysis. In total, 27 out of the 55 patients with a positive PYP scan underwent therapy specific for cardiac amyloid.

In conclusion, this study reinforces the clinical significance of the PYP scan in the diagnosis and management of cardiac amyloidosis. A positive scan allowed physicians to implement early amyloid-directed treatment while a negative scan encouraged physicians to pursue an alternative diagnosis.

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May 2022 Br J Cardiol 2022;29:79–80 doi :10.5837/bjc.2022.020

Angina pain associated with isolated R-IIP modified Lipton classification coronary artery anomaly

Nicholas Coffey, Alexis Smith, Rich Pham, Mohammed Kazimuddin, Aniruddha Singh

Abstract

We report a case of a patient that presented with typical angina pain and associated risk factors for coronary artery disease (CAD). Subsequent cardiac catheterisation led to the discovery of an isolated R-IIP modified Lipton classification coronary artery anomaly with follow-up coronary computed tomography angiography (CCTA) confirmation. This case report includes images of the CCTA and left heart catheterisation results, along with a discussion of the potential for increased risk of atherosclerosis in our patient, and a proposed explanation of his presentation with prototypical angina pain, despite lack of apparent atherosclerosis.

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