Clinical articles

Angiography of internal mammary artery (IMA) grafts continues to be a common indication for upfront femoral access. This is particularly the case for bilateral pedicled IMAs, or when the left radial artery has been grafted. While the right radial artery is ideally suited in these situations for cannulation of the right IMA, accessing the left IMA (LIMA) by this route is often perceived as challenging and for ‘radial evangelists’ only. We describe a case series showing a simple technique for selective cannulation of the LIMA from the right radial artery using a single catheter that provides sufficient backup for percutaneous coronary intervention (PCI).

Gastrointestinal (GI) symptoms are common in patients with postural orthostatic tachycardia syndrome (PoTS). Our understanding of managing GI symptoms in PoTS is very limited. Our objectives were to evaluate common GI symptoms, diagnostic work-up, diagnosis and management strategy in patients with PoTS.

We retrospectively reviewed medical records of all patients referred to the gastroenterology clinic (2014 to 2017) with GI symptoms and known or suspected PoTS: 85 patients with PoTS and GI symptoms were seen in our clinic. Bloating (75%), constipation (74%) and abdominal pain (60%) were the most common GI symptoms. Endoscopy, high-resolution manometry, gastric-emptying studies and colonic-transit studies were commonly performed investigations. Over two-thirds of patients had confirmed or suspected GI dysmotility, 5.9% had organic GI disease (e.g. inflammatory and acid peptic disorders).

In conclusion, the majority of patients with PoTS have a functional disturbance and reduced GI motility, however, a small proportion have organic disease that needs systematic evaluation. Dietary modifications and laxatives are the main modalities of therapy.

False-negative results either from balanced ischaemia or from failure to induce optimal hyperaemia is a known limitation of vasodilator myocardial perfusion imaging (MPI). We sought to identify the prevalence of false-negative results in the kidney transplant population and to identify the risk factors predictive of false-negative MPI results at our institution.

We retrospectively studied 133 consecutive patients who were referred to us for pre-operative evaluation. Mean age was 56 years and 70% of the subjects were males. All patients who underwent vasodilator MPI and computed tomography coronary angiography (CTCA) were included.

In the studied population, false-negative vasodilator MPI test result prevalence was around 13%. In uni-variable and multi-variable analysis, diabetes and cardiovascular disease (CVD) were predictive of false-negative vasodilator MPI testing results. CTCA had a positive-predictive value (PPV) of 82%.

In conclusion, false-negative results, either from balanced ischaemia or from failure to induce optimal hyperaemia, are a major problem in the pre-operative evaluation of renal transplant patients when the vasodilator MPI test is used. CTCA could be a useful imaging modality in this patient population. We found that diabetes and CVD are significantly associated with false-negative MPI results.

Absence of the pericardium is a rare defect that can be both congenital and acquired. Defects occur through abnormal development of the pleuro-pericardial membranes, which should fuse at the midline and separate the pericardial and pleural cavities.¹ Congenital incidence is thought to be less than one in 10,000,² however, prevalence is uncertain due to the incidental findings of many diagnoses. With increasing use of cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CT), diagnosis of pericardial absence is becoming more frequent, however, little is known about the long-term management of these patients.

Studies have suggested that acute coronary syndrome (ACS) may be excluded by a single undetectable high-sensitivity troponin (hs-TnT) taken at least three hours after the onset of symptoms in patients with non-pleuritic chest pain whose electrocardiogram (ECG) is non-ischaemic.

During a six-month period between April and September 2015, we identified 147 consecutive patients with non-pleuritic chest pain and non-ischaemic ECG whose first hs-TnT was less than 5 ng/L at least three hours after the onset of symptoms. We used the Elecsys hs-TnT assay, which has a lower limit of detection of 5 ng/L and a 99^th centile of <14 ng/L.

Sixty-seven of 147 (46%) patients were male. The average age of our cohort was 52 years, range 19–83 years. Coronary heart disease (CHD) was known to have been present in 24 (16%) before the index admission. Median length of hospital stay was 15.4 hours (mean 22.5 hours) with 86 (59%) patients spending more than 12 hours in hospital. We referred 60 (41%) patients to cardiology for further assessment, either during or after admission, in order to rule out unstable angina. No patient was readmitted with hs‑TnT positive ACS, one patient underwent elective revascularisation and no patient died during one year of follow-up. Only one patient was lost to follow-up.

In conclusion, patients with non-pleuritic chest pain, non-ischaemic ECG and undetectable hs-TnT at least three hours after the onset of symptoms have a low risk of hs-TnT positive ACS, revascularisation and death during one year of follow-up. Most such patients could safely be discharged from hospital after a few hours of observation, without the need for a second hs-TnT.

Frailsafe was developed by the British Geriatrics Society as clinical criteria to accurately identify patients at risk of frailty-associated harm on admission to hospital. There is no single validated tool for assessing frailty in heart failure on admission to hospital. The aim is to determine the prevalence of frailty-associated harm and the outcomes of older persons admitted to hospital with decompensated heart failure using Frailsafe screening criteria.

A retrospective cohort study of consecutive patients aged 75 years and over, admitted to hospital with decompensated heart failure within a six-month period was performed. Frailsafe screening criteria were applied to each patient retrospectively and data on length of stay, inpatient mortality, six-month mortality and readmission at six months was collected for all patients. The outcomes were analysed using univariate analysis comparing the patients ‘at risk of frailty-associated harm’ with those ‘not at risk’.

There were 103 patients identified as 75 years or older and admitted with a primary diagnosis of heart failure, 27% (28) were identified as at risk of frailty-associated harm. This cohort had a significantly longer length of stay (3.5 days, p=0.0496), worse six-month mortality (57% vs. 33%, p=0.0274) and more frequent emergency readmissions (2.04 vs. 0.97, p=0.0031).

In conclusion, prevalence of patients at risk of frailty-associated harm measured by Frailsafe in an older population admitted with decompensated heart failure was 27%. Such patients had a longer length of stay, and were at increased risk of readmission and mortality within the following six months. Future research should include analysis of confounding variables, such as comorbidity, in a larger population to aim to identify how to improve outcomes in this particularly high-risk group.

Infective endocarditis (IE) is an increasingly common disease associated with significant morbidity and mortality. It is known that the incidence of IE has been rising globally, but the reasons for this rise are not fully understood. This study sought to investigate the epidemiology of IE in a UK population, with a review of mortality outcomes based on current clinical practice.

Body mass index (BMI) was first proposed in 1835 as a way to standardise body composition assessment for people of different heights, at a time when malnutrition was the main public health concern. BMI has been considered appropriately as a part of nutritional assessment in populations. It is not, however, a useful tool for assessment of individuals because there is so much individual variability in body composition and in its impact on health outcomes. Similarly, high BMI does not distinguish between excess body fat (bad for health) and large muscle mass (good). In contrast, we propose that individuals need to be assessed using clinical criteria, monitored over time to trigger different interventions. A diagnosis of obesity should be based on estimates of body fat (BMI, now being replaced by percentage body fat) at a particular age, and a clinical staging system.

Coronary physiology is the collective term for a group of indexes aimed at directly measuring the intracoronary haemodynamic changes that occur across a stenosis in order to guide revascularisation decision-making. Fractional flow reserve (FFR) uses pharmacological dilatation and miniaturised pressure-wires to measure coronary pressure proximal and distal to a stenosis, thereby estimating flow reduction across a stenosis. Several clinical trials have shown that FFR-guided revascularisation improves clinical outcomes, and that deferring revascularisation in patients shown by FFR to have non-haemodynamically significant lesions is safe. Instantaneous wave-free ratio (iFR) is a novel technique that measures the ratio of distal coronary to aortic pressure during a specific period in diastole that obviates the need for pharmacological vasodilatation. Recent randomised-controlled trials have shown iFR to be non-inferior to FFR with respect to major adverse cardiac events, while reducing adverse procedural symptoms and procedure duration.

Advanced nursing roles supported by competency-based training have been pioneered over the last 25 years, with emphasis on the development of specific medical skills. This has largely been influenced by increasingly complex medical needs, costs of healthcare and the significant reduction in available doctors. With this reduction of doctors in training and departmental support for expanding nursing roles, we devised a local initiative to train an experienced nurse to perform diagnostic coronary angiography. Our aim was to provide a safe and enhanced service and improve procedural efficiency within the cardiac day unit.

A prospective audit of 250 coronary angiography procedures was performed in the training period between 24 September 2014 and 9 October 2015. Post-training, 143 procedures were performed between 12 October 2015 and 20 July 2016. The prospective audit was performed to explore the safety, effectiveness and quality of nurse-delivered diagnostic coronary angiography. An audit form was created to assess each component of the procedure. This included, gaining patient consent, success in gaining arterial access, success in intubating the left and right coronary arteries, observation of haemodynamics, observation of complications and reporting the findings. Financial impact, patient satisfaction and staff perception outcomes were also audited.

When directly compared with contemporaries, nurse-delivered diagnostic coronary angiography resulted in successful and appropriate arterial access, successful intubation of both coronary arteries, safe monitoring throughout the procedure and correct reporting of each study, with a similar level of patient satisfaction.

In conclusion, this study demonstrates that nurses can, under the right supervision and governance, perform diagnostic coronary angiography to a safe, highly effective standard, which is equivalent to contemporaries.