Clinical articles

Wellens’ syndrome, characterised by specific T-wave changes on electrocardiogram (ECG), indicates critical proximal left anterior descending (LAD) stenosis and high acute myocardial infarction risk. While revascularisation is the standard treatment, it may be unsuitable for elderly patients with comorbidities. We present a case of successful medical management of Wellens’ syndrome type B in a 94-year-old woman deemed unfit for invasive interventions. The patient was treated with dual antiplatelet therapy, high-intensity statin, and anti-anginal medications. Symptom control was achieved, and serial ECGs and cardiac biomarkers remained stable. This case demonstrates that aggressive medical management can be a viable alternative in elderly patients with Wellens’ syndrome type B, unsuitable for invasive procedures.

Heart failure (HF) is a significant problem in the UK with variation in services across the country. Here we describe the findings from a cross-sectional survey of HF services in the UK performed between September 2021 and February 2022.

Seventy-nine responses describing hospital-based HF services from all devolved countries were received. The clinical lead in 82% of hospitals was a cardiologist with specialist interest in HF. Just over half of HF hospital services had a one-stop diagnostic clinic with a median of two clinics per week. A two-week pathway and six-week pathway were present in 78.5% and 75%, respectively. Only 4% of services met referral waiting time targets 100%, and 15% never met targets. The majority of inpatient HF services reviewed patients with primary (96%) or secondary (89%) admission for HF with reduced ejection fraction (HFrEF), corresponding percentages for HF with preserved ejection fraction (HFpEF) were 68% and 51%, respectively. HF services reported a median of two HF consultant cardiologists, five non-HF consultant cardiologists, one palliative care consultant, two band seven and one band six HF specialist nurses.

In conclusion, considerable variation in hospital-based HF services across the UK exist, which may not meet the needs of patients.

Cardiovascular disease (CVD) is a leading cause of global mortality, necessitating extensive research efforts. In Scotland, the NHS Research Scotland (NRS) Cardiovascular Network plays a pivotal role in coordinating cardiovascular research. Patient and public involvement (PPI) is crucial for shaping meaningful research strategies, yet barriers to such engagement persist.

We organised a hybrid PPI event, bringing together patients, researchers, and stakeholders. Interactive sessions explored barriers and enablers of PPI. Qualitative and quantitative data were collected, focusing on communication, commitment, and value as key themes.

Participants highlighted communication challenges, emphasising the need for clear, accessible information about research involvement. Commitment barriers included costs, travel, and time constraints. Feeling valued as research participants was essential, emphasising recognition of diverse experiences. Running the event as a hybrid facilitated broader participation, employing professional notetakers, British sign language (BSL) interpreters, and moderators.

In conclusion, holding this event emphasised the importance of PPI in cardiovascular research, outlining communication, commitment, and value as key facets. Hybrid events enhance inclusivity but demand careful planning. Meaningful PPI, as exemplified in this study, informs and enhances research quality, underscoring the need for continued investment in patient involvement initiatives.

Previous studies have shown mixed results comparing short-term mortality in patients undergoing urgent transcatheter aortic valve implantation (Urg-TAVI) compared with elective procedures (El-TAVI) for severe aortic stenosis (AS). This study aimed to explore the predictors of requirement for Urg-TAVI versus El-TAVI, as well as compare differences in short- and intermediate-term mortality.

This single-centre, retrospective cohort study investigated 358 patients over three years. Baseline demographic data were collected for patients undergoing elective and urgent procedures, and mortality outcomes at one-month, one-year and three-year follow-up were compared.

Urg-TAVI was required in 131 (36.6%) patients. Patients undergoing Urg-TAVI were significantly more likely to be female, have poor left ventricular (LV) function, with higher baseline creatinine and higher clinical frailty score (CFS). Higher rates of vascular complications were independently associated with increased mortality at one month. Mortality at one year was associated with higher creatinine level (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00 to 1.01, p=0.0013) and an urgent procedure (OR 2.25, 95%CI 1.28 to 3.97, p=0.0048). There remained a higher mortality in the urgent patients at three-year follow-up.

In conclusion, undergoing TAVI urgently did not have a statistically significant effect on 30-day mortality. However, over long-term follow-up of one year, it was associated with worse mortality than elective TAVI, and this persisted out to three years.

Fabry disease (FD), resulting from alpha-galactosidase A enzyme deficiency, remains underdiagnosed despite readily available methods for diagnosis. This multi-centre prospective survey across six tertiary centres aimed to determine the level of consideration of FD in patients presenting with left ventricular hypertrophy (LVH). LVH was defined according to the guidelines of the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA) for the management of cardiomyopathies, where LVH is diagnosed if the left ventricular wall thickness exceeds 15 mm in any segment or exceeds 13 mm in the presence of a known diagnosis in a first-degree relative. Of 143 patients surveyed, only three with LVH underwent diagnostic testing for FD, all testing negative. Moreover, 44% of patients with LVH had an ambiguous aetiology, highlighting possible missed FD diagnostic opportunities. A discrepancy was observed between electrocardiogram (ECG) results and echocardiography or cardiac magnetic resonance (CMR) in diagnosing LVH, emphasising the need for comprehensive cardiac imaging. This project highlights the urgent requirement to amplify FD awareness, especially in patients with LVH, to ensure early intervention and better patient outcomes.

This study aimed to understand the national echocardiography assessment pathway in heart donation. We carried out a prospective national specialist nurses in organ donation (SNOD) audit of UK donor offers between 20 August and 31 November 2022, and a prospective national recipient transplant centre audit of all donor offers between 22 September and 19 December 2022.

The SNOD audit identified median time delay between requesting and performing an echocardiogram of 17.9 hours (interquartile range [IQR] 13.9–33.2). The staff group performing the echo were a cardiac physiologist in 57% (17/30) of cases and a medical doctor in 43% (13/30) of cases. Only 30% (9/30) of providers held comprehensive accreditation, 13% (4/30) were focused accredited, 33% (10/30) had no accreditation, and 23% (7/30) were unknown. Only 50% (15/30) of images were transferred for review to the transplant centre. Images were transferred via email (10/15, 67%), WhatsApp (4/15, 27%) and a standard picture archiving system (PACS) (1/15, 3%).

The transplant centre audit revealed that in 21% of donors, the transplant team felt that the echo performed at the referring centre contained inadequate information, and in 11% of donors, no echo was performed at all. Only 52% of potential donors had echo images available for direct review by the transplant centre. In 17% of cases, the transplant team felt that if good quality echo data and imaging had been available, the decision regarding mobilising the retrieval team may have been altered.

In conclusion, to improve donor heart utilisation rates we believe there is a need to recognise the contribution of focused echo and improve guidance for echo image acquisition. There is also a need for a robust system for image transfer to transplant centres.

Protection against the increased risk of sudden cardiac death (SCD) due to ventricular arrhythmias is offered by the implantation of cardiac defibrillators. A life-expectancy of less than one year is usually a contraindication to the implantation of these devices. We evaluated the outcomes of all those who received defibrillator implantation for any clinical indication at our centre in the same year that early (<12 months) death notifications occurred.

This is a single-centre retrospective study on the outcomes of all patients who had a transvenous defibrillator implant in 2015. All transvenous defibrillator devices implanted for both primary and secondary prevention of SCD were included. Patient demographic data and device data were studied.

Data from 235 patients were analysed. In a follow-up period of 66.2 ± 3.8 months, 77 (32.8%) of the study cohort died; 20 (8.5%) of these patients died less than 12 months post-implant. None of the deaths were directly arrhythmia related. Factors that were significant in predicting mortality included age and ejection fraction <35% (p<0.01). From a pre-procedure biomarker perspective, an increased red cell distribution width (RDW) was strongly associated with early mortality risk on univariate and multi-variate analysis (p<0.001). Receiver operator characteristics (ROC) curve analysis found that the optimal cut-off for RDW was 14.75% (area under curve 0.75; sensitivity 0.69; specificity 0.77; p<0.001).

In conclusion, there are limitations in fully assessing patient prognosis despite current guidance. Universal clinical frailty scores that incorporate biomarkers may be helpful in enhancing this pre-assessment process to improve the evaluation of the risk of early non-arrhythmic-related death for implantable cardioverter defibrillator candidates.

Atrioventricular nodal (AVN) ablation with permanent pacemaker implantation – ‘pace and ablate’ – may be considered for patients with symptomatic atrial fibrillation (AF) for whom rhythm control has been unsuccessful. This creates concerns about inducing pacemaker dependence and potential pacemaker-induced cardiomyopathy (PICM). Conduction-system pacing mitigates PICM, so we expect a greater uptake of AVN ablation going forward.

We conducted a retrospective multi-centre review of our patients who underwent AVN ablation over a one-year period. AVN ablation was successful with durable lesions at one year. Radiofrequency energy was utilised in all patients, with a median application time of 2.67 minutes. Median procedure time was found to be 55.5 minutes and fluoroscopy median of 3.5 minutes. Median radiation dose was 11 mGy. We found no acute or subacute complications up to three months.

In conclusion, our right-sided approach for ablation, staged post-device insertion demonstrated results in keeping with other centres in the UK and Europe. We expect our current practice to become more widespread, given the increased risk of lead-related complications or failures associated with physiological pacing compared with standard pacing methods.

The combination of atrioventricular (AV) block – specifically high-grade AV block– within the setting of myocarditis, is a rarely encountered clinical phenomenon. It is commonly encountered in infiltrative cardiomyopathies but may be associated with myocarditis.

Beyond conventional investigation and consideration of endomyocardial biopsy, there is a paucity of data to guide clinicians with regards to the issue of heart rhythm disorder. Options include a ‘watch-and-wait’ policy, anti-arrhythmic drugs, consideration of a permanent pacemaker or, alternatively, a wearable or implantable cardioverter-defibrillator (ICD).

The case encapsulates the difficulties facing clinicians with such pathology and the need to further investigate and risk stratify such patients.

Endomyocardial fibrosis is a common cause of restrictive cardiomyopathy worldwide, but rarely occurs in patients living outside tropical regions.¹ Herein is the first published case report of a 48-year-old woman with endomyocardial fibrosis due to hypereosinophilia secondary to a rare chromosome 8 and 9 PCM1-JAK2 translocation.