Clinical articles

Takotsubo syndrome – also known as broken-heart syndrome, Takotsubo cardiomyopathy, and stress-induced cardiomyopathy – is a recently discovered acute cardiac disease first described in Japan in 1991. This review aims to update understanding on the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of Takotsubo syndrome, highlighting aspects of interest to cardiologists and general practitioners.

We describe two cases of Takotsubo syndrome and discuss the issues relating to diagnosis and patient communication that they raise.

The incremental shuttle walk test (ISWT) is a valid, reliable submaximal exercise test used in the assessment of patients prior to cardiac rehabilitation (CR). Simultaneous electrocardiogram (ECG) measurements would provide important information on the safety of the test, and adequacy of subsequent cardiac risk stratification. Risk stratification is recommended to assess patients’ suitability for cardiac rehabilitation. For example, ST-segment depression >2 mm from baseline during testing would place a person in a high-risk category. However, such ECG measurements are rarely undertaken in clinical practice. The aim of the study was to investigate the incidence of ECG changes during an ISWT, and report on the possible impact of these findings on subsequent cardiac risk stratification.

A retrospective case note review was undertaken for the year 2017. Baseline clinical characteristics from eligible patients were gathered including those with ischaemic heart disease, heart failure, transplant and valve replacement, along with ECG measurements during the ISWT. The impact of ECG findings on cardiac risk stratification was calculated, based on risk stratification developed by the American Association of Cardiovascular and Pulmonary Rehabilitation. The safety of the ISWT was measured by the absence of major ECG changes.

Data were gathered for 295 patients. Minor ECG changes were identified during the ISWT in 189 patients (64.1%), with no major changes. The presence of silent myocardial ischaemia (ST-segment depression) had an impact on cardiac risk stratification in 27 patients. There was a statistically significant positive association between ST-segment depression with cardiac risk stratification (p<0.001).

In conclusion, the ISWT is safe in terms of ECG changes. The impact of ECG findings on cardiac risk stratification is significant and worthy of further consideration.

The coronavirus disease 2019 (COVID-19) pandemic has produced a dramatic shift in how we practise medicine, with changes in working patterns, clinical commitments and training. Cardiology trainees in the UK have experienced a significant loss in training opportunities due to the loss of specialist outpatient clinics and reduction in procedural work, with those on subspecialty fellowships perhaps losing out the most. Training days, courses and conferences have also been cancelled or postponed. Many trainees have been redeployed during the crisis, and routes of career progression have been greatly affected, prompting concerns about extensions in training time, along with effects on mental health.

With the pandemic ongoing and its effects on training likely long-lasting, we examine areas for improvement and opportunities for change in preparation for the ‘new normal’, including how other specialties have adapted. The increasingly routine use of video conferencing and online education has been a rare positive of the pandemic, and simulation will play a larger role. A more coordinated, national approach will need to be introduced to ensure curriculum components are covered and trainees around the country have equal access to ensure cardiology training in the UK remains world class.

Social distancing/isolation is vital for infection control but can adversely impact on mental health. As the spread of COVID-19 is contained, mental health issues will surface with particular concerns for elderly, isolated populations. We present a case of Takotsubo cardiomyopathy related to lockdown anxiety.

We describe a case of pneumopericardium following emergency pericardiocentesis in a patient with coronavirus disease 2019 (COVID-19).

Atrial fibrillation (AF) increases cardio-embolic stroke risk, yet AF diagnosis and subsequent prophylactic anticoagulant prescription rates are suboptimal globally. This project aimed to increase AF diagnosis and subsequent anticoagulation prescription rates in East Midlands Clinical Commissioning Groups (CCGs).

This service improvement evaluation of the East Midlands AF Advance programme investigated the implementation of mobile AF detection devices (Kardia, AliveCor) into primary-care practices within East Midlands CCGs, along with audit tools and clinician upskilling workshops designed to increase AF diagnosis and anticoagulation prescription rates. AF prevalence and prescription data were collected quarterly from July to September (Q3) 2017/18 to April to June/July to September (Q2/3) 2018/19.

AF prevalence increased from 1.9% (22,975 diagnoses) in Q3 2017/18 to 2.4% (24,246 diagnoses) in Q2 2018/19 (p=0.026), while the percentage of high-risk AF patients receiving anticoagulants increased from 80.5% in Q3 2017/18 to 86.9% in Q3 2018/19 (p=0.57), surpassing the Public Health England 2019 target of 85%.

The East Midlands AF Advance programme increased AF diagnosis and anticoagulation rates, which is expected to be of significant clinical benefit. The mobile AF detection devices provide a more practical alternative to traditional 12-lead electrocardiograms (ECGs) and should be incorporated into routine clinical practice for opportunistic AF detection, in combination with medication reviews to increase anticoagulant prescription.

Regular physical activity for secondary prevention in cardiovascular disease has many well-recognised benefits, with declines in physical activity being associated with worsening cardiovascular disease, suboptimal treatment or worsening comorbidities that might be rectified by early intervention. Most cardiovascular implantable electronic devices (CIED) now have the ability to detect, analyse and interpret physical activity data through an inbuilt accelerometer. Currently, these data are not being utilised to their full potential. We present three cases that demonstrate some of the possible uses of CIED-collected physical-activity data. These data have the potential to detect a deteriorating patient, to monitor the effects of an intervention, and/or provide motivational feedback to a patient. However, for the data to be used in this manner in the future, greater transparency from manufacturers and robust validation studies will be needed.

Stroke prophylaxis in atrial fibrillation is an important consideration in patients with cancer. However, there is little consensus on the choice of anticoagulation, due to the numerous difficulties associated with active cancer. Direct oral anticoagulants (DOACs) have been shown to be a promising option. Here, we conduct a simple cross-sectional analysis of 29 cancer patients receiving DOACs for stroke prophylaxis in atrial fibrillation at a tertiary-care institution in London. Our study demonstrates an encouraging efficacy and safety profile of DOACs used in this setting. We conclude by suggesting that, while DOACs may be useful, anticoagulation in cancer patients should continue to be individualised.

Data for low-risk ST-elevation myocardial infarction (STEMI) patients in the Essex cardiothoracic centre (CTC) during a three-month period were evaluated and the average duration of admission was calculated to be 67.2 hours. The data were sifted by applying Second Primary Angioplasty in Myocardial Infarction (PAMI-II) criteria for low-risk STEMI patients who could be safely discharged after 48 hours. After application of a proforma as a quality improvement intervention tool, data were re-assessed and the average time of admission observed for a similar cohort of patients dropped down to an average of 55.2 hours. Overall, there was a 13% average increase in rate of early discharge for low-risk STEMI patients.