Clinical articles

Temporary epicardial pacing is a cornerstone of postoperative cardiac care, but improper management, particularly of atrial pacing, may contribute to the onset of postoperative atrial fibrillation (POAF). In this article we review the challenges involved in identifying atrial lead malfunction and the associated arrhythmogenic risk. As well as implementing strategies to reduce risk, the development of advanced technology capable of detecting and correcting atrial pacing dysfunction in real time should be a priority.

Reduction in low-density lipoprotein-cholesterol (LDL-C) in patients with hypercholesterolaemia is associated with a lower risk of cardiovascular (CV) events. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibiting therapy is approved by the National Institute for Health and Care Excellence (NICE) and the Scottish Medicines Consortium (SMC) for use in high-risk patients who are unable to achieve the LDL-C target levels, despite other maximum tolerated lipid-lowering therapies. Our prior publication analysed the records of patients in a large Scottish health board with familial hypercholesterolaemia and high CV risk and confirmed the real-world efficacy of PCSK9 inhibiting monoclonal antibodies (mAbs) in routine clinical care.

In this follow-up study, we examined the comparative efficacy of inclisiran, a small-interfering ribonucleic acid (siRNA) therapeutic, in a similar patient cohort to provide real-world data that can guide clinicians in optimising lipid-lowering strategies.

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management.

Saphenous vein grafts (SVGs) are frequently used for coronary artery bypass grafting (CABG) of severe coronary artery disease; however, re-stenosis is common. Restoration of blood flow to the SVG is uncommonly achieved via revascularisation of the native vessel. A man in his 70s with previous CABGs presented with prolonged chest pain at rest. The left anterior descending (LAD) and left circumflex arteries had chronic total occlusions (CTO), and the SVG and left internal mammary artery, previously used to bypass the LAD, were severely diseased with sluggish flow and an inability to pass a balloon or microcatheter. Rotational atherectomy was successfully performed to cross the LAD CTO, with good flow post-stenting. He remained asymptomatic one year later. Where management of calcified venous grafts precludes passage with balloon or microcatheter, rotational atherectomy of the native coronary may represent an alternative method of restoring blood flow.

Habitual physical activity improves cardiovascular health but there is a higher risk of atrial fibrillation (AF) in endurance athletes. The physiological processes underlying this observation are not fully understood, but adaptations to exercise, such as bradycardia and atrial dilatation, may contribute to arrhythmia susceptibility. Further data on long-term implications and individualised management strategies in athletes with AF are required.

Platypnea-orthodeoxia syndrome (POS) is a rare condition which presents with positional dyspnoea and deoxygenation on an orthopneic position which resolves when supine. We present a rare presentation of POS in a 75-year-old man, who initially presented with mixed symptomology including dyspnoea on exertion and syncope. He was found to have intermittent symptomatic hypoxia and initial investigations ruled out infection, pulmonary embolism and interstitial lung disease. Pulse oximetry confirmed positional variations in oxygenation. A transthoracic echocardiogram and a transoesophageal bubble echocardiogram with positional manoeuvres confirmed the presence of a large patent foramen ovale (PFO) with shunting. The patient was referred to the tertiary centre for PFO closure which resulted in resolution of his symptoms. This case report highlights the importance of recognising POS as a rare differential in causes of unexplained dyspnoea and utilising multiple imaging techniques to confirm the diagnosis.

Cardiac sarcoidosis is a rare but potentially deadly complication of systemic sarcoidosis, in which the heart is affected by immune dysregulation and granulomatous infiltration. We present a case of a 65-year-old woman who presented with worsening breathlessness and bradycardia secondary to complete heart block. Workup with cardiovascular magnetic resonance imaging showed an increased signal on late gadolinium enhancement sequences in the anteroseptum and inferoseptum consistent with active infiltration from cardiac sarcoidosis. High-resolution computed tomography of the chest showed multifocal ground-glass opacities with a peribronchovascular distribution in keeping with sarcoidosis. A dedicated CT scan of the chest showed bilateral hilar lymphadenopathy. A further positive emission tomography scan confirmed the diagnosis of cardiac sarcoidosis in the left ventricle. The findings were discussed in the cardiology multidisciplinary team meeting and it was decided the patient needed an implantable cardioverter defibrillator with further follow-up with the respiratory and cardiology team.

Physiological adaptation to exercise results in a series of electrical, structural, and functional cardiac changes, broadly named ‘athlete’s heart’. Symmetrical enlargement of all cardiac chambers and mild increase in wall thickness are common findings in highly trained athletes. Typical electrocardiogram (ECG) features include sinus bradycardia, first-degree atrioventricular (AV) block, isolated voltage criteria for right and left ventricular hypertrophy and early repolarisation. Cardiac remodelling may be marked in some athletes, and it may be challenging to distinguish physiological adaptation from cardiac conditions at risk of sudden cardiac death (SCD), such as cardiomyopathies. Differential diagnosis often requires a comprehensive assessment starting from a detailed personal and family history to baseline tests, such as ECG and echocardiogram. In some cases, second-line tests, such as prolonged ambulatory ECG monitoring, exercise tolerance test and cardiovascular magnetic resonance are required.

In this narrative review, we will explore the key features of physiological cardiac adaptation to exercise, and we will focus on differential diagnosis between ‘athlete’s heart’ and cardiomyopathies.

Sickle cell disease (SCD) is an inherited haematologic disorder with cardiac-related complications. Cardiac magnetic resonance (CMR) imaging allows us to assess the cardiac morphology and function of this population. Our aim was to better characterise phenotypic variations among SCD patients utilising CMR data.

This retrospective study included 72 patients with SCD who underwent CMR between May 2013 and July 2023. We recorded baseline characteristics, medical history, and indication and setting of CMR. CMR parameters relating to morphology and function were collected. Patients were placed into the following groups based on cardiac parameters on CMR: high output, pulmonary hypertension (PH; defined by mean pulmonary artery pressure >20 mmHg on right heart catheterisation or elevated tricuspid regurgitation velocity >3.4 m/s on echocardiogram), left ventricular (LV) dysfunction, or normal size and function. Between- and within-group comparisons were performed.

Demographic data were similar among groups. The PH group was more likely to have a history of smoking, chronic hypoxia, lower baseline haemoglobin, and need for blood transfusion (p<0.05 for all). There were significant between-group differences in CMR structural and function parameters.

In conclusion, sickle cell patients present with different cardiac phenotypes. Patients with PH are associated with significantly higher morbidities.

Low-density lipoprotein-cholesterol (LDL-C) is accepted as a causal risk factor for development of atherosclerotic cardiovascular disease (CVD) and acute coronary syndromes (ACS). In individuals aged 40–75 years, reducing LDL-C constitutes a main treatment target for prevention of atherosclerotic CVD in all international guidelines. Furthermore, diabetes mellitus (DM) confers a two-fold excess risk of vascular outcomes (coronary heart disease, ischaemic stroke, and vascular deaths), independent of other risk factors. Our audit project identified a deficit in current standards following an audit of adherence to lipid profile and glycated haemoglobin (HbA1c) testing in the high-risk chest pain population in our city hospital setting. We found only 49% of patients had LDL-C checked during their inpatient stay, and only 45% had HbA1c checked, of our targeted 100% of patients. This allowed the introduction of a planned intervention to improve admission testing and re-auditing demonstrated an improvement in testing, mainly driven by improved LDL-C testing. Despite this, a deficit still exists and more work is needed to meet our target of 100% compliance.