Clinical articles

Focused cardiac ultrasound using a pocket-sized imaging device (V scan) is increasingly being used to screen patients in the emergency setting for structural heart disease. We describe a patient who presented with light-headedness and pallor with elevated high-sensitivity troponin T (hs-TnT) and was initially thought to have acute coronary syndrome. A screening focused cardiac ultrasound revealed a dilated right ventricle with normal left ventricular function, and a computerised tomography pulmonary angiogram (CTPA) demonstrated a large saddle pulmonary embolus. The case highlights the application and utility of focused cardiac ultrasound and provides an overview of its current role in the acute setting reinforced by current guidelines from the European Society of Cardiology.

People with chronic heart failure (CHF) often experience exacerbations of their symptoms that require hospitalisation. The feasibility, safety and efficacy of early post-exacerbation rehabilitation are largely unknown in this population. 

This was a single-centre, feasibility trial of early rehabilitation versus usual care. Those assigned to the intervention started rehabilitation within 10 days of discharge and attended supervised sessions twice per week for eight weeks. The primary outcomes were feasibility of uptake and safety. Assessments were performed at baseline and three months: exercise tolerance (shuttle walking tests) and health status (questionnaire).

There were 1,298 patients screened, 16 patients recruited (<1% of those screened) and 11 randomised (five rehabilitation, six control). The primary reasons for exclusion were contraindication to exercise and normal ejection fraction. There were improvements in exercise tolerance and health status in both groups at three months; however, the study was not powered to report any within- or between-group significance. The early rehabilitation intervention was safe with no adverse events reported.

In conclusion, early rehabilitation, for patients with CHF, was unfeasible. The 10-day recruitment target was too restrictive in this population. This is important because there has been a drive towards early rehabilitation in CHF guidelines.

The proportion of patients with heart failure with preserved ejection fraction (HFPEF), compared with those with reduced ejection fraction (HFREF), is significant and rising. Studies have used an ejection fraction (EF) >50% as the sole criteria for identifying patients with HFPEF. However, European Society of Cardiology (ESC) guidelines include the diagnostic criteria of EF >50% and evidence of diastolic dysfunction.

In this retrospective cohort study based on admissions in 2012; we compared characteristics, treatment and outcomes between HFPEF and HFREF patients. One year readmission and survival rate was also assessed.

Overall, 41 (17%) patients had HFPEF (EF >50% and either medial or lateral E/E’ >15) compared with 200 (83%) with HFREF. Age was similar between the two groups (HFPEF: 84 ± 9 vs. HFREF: 82 ± 14, p=0.106). HFPEF patients were significantly more likely to be female (71% vs. 41.5%, p=0.001) and significantly less likely to have ischaemic heart disease (34% vs. 52%, p=0.043). Patients with HFPEF were significantly less likely to be taking loop diuretics, potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors and aspirin on discharge. Ischaemic heart disease was a significant predictor of mortality in HFPEF patients (hazard ratio [HR] 7.14; 95% confidence interval [CI] 1.51–33.85, p=0.01). There was no difference in readmission and one-year survival rate (p=0.68 and p=0.551, respectively).

In conclusion, HFPEF patients are more likely to be female but less likely to have an ischaemic aetiology. There were significant differences in treatment of both phenotypes. Both groups have a similar poor prognosis.

Delays in achieving target international normalised ratio (INR) with warfarin after cardiac surgery can lead to suboptimal outcomes. The aims of the study are to determine the difference in warfarin dosage requirements, before and after cardiac surgery, needed to achieve therapeutic anticoagulation.

A single-centre, retrospective review was conducted from 2012 to 2014 in cardiac surgery patients who were on warfarin pre-operatively and who had warfarin therapy resumed postoperatively in hospital. The primary outcome was the difference in warfarin dosage needed to achieve target INR before and after cardiac surgery. 

Ninety-five patients were included in the study. The mean daily postoperative warfarin dose needed for achieving a therapeutic INR was 0.18 mg lower than the mean pre-operative dose (5.03 ± 2.10 vs. 4.85 ± 2.25 mg; p=0.358). 

In conclusion, there was no statistically significant difference in the warfarin dosage before and after cardiac surgery needed to achieve target INRs.

Conducting clinical research is an ambition of many cardiologists and academic clinicians. Over the last decade, the National Health Service (NHS) has indicated that research is a clear priority in improving healthcare for patients. The processes leading to permission to start a clinical trial in the UK are, however, poorly understood, labyrinthine and fraught with difficulty. In this article, we aim to share our knowledge of initiating a clinical trial using a case study, with a focus on the essential documents and the communication required with different organisations. 

In June 2014 the National Institute for Health and Care Excellence (NICE) released new guidelines (TA314) on the use of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy devices (CRTs) in the management of heart failure. These guidelines replaced the previous TA95 and TA120 guidelines. We evaluated the potential impact on implant rates in our institution.

Clinical records of 396 consecutive patients were reviewed, with 100 patients included in the final analysis. Device indications and associated costs were calculated using both existing and new criteria.

NICE TA95/TA120 criteria recommended 37 devices: 20 ICDs, 9 CRTs with pacing (CRT-Ps), and 8 CRTs with defibrillator (CRT-Ds). The new NICE 2014 criteria recommended 97 devices: 56 ICDs, 7 CRT-Ps, and 34 CRT-Ds. Comparison of the new and old guidelines suggested a significant increase in total devices (p<0.0001). This corresponded primarily to an increase in ICDs and CRT-Ds, with an associated £661,708 increase in total spend (£407,205 increase per annum).

This study confirms the significant increase in ICDs and CRT-Ds indicated by NICE. This will have significant financial and workforce implications.

The UK population is getting older and the amount of cardiovascular disease is increasing significantly, fuelled by a steep rise in the incidence of obesity and diabetes. Heart failure is increasing in incidence because of improved survival rates following myocardial infarction and more effective treatments, with an estimated 500,000 sufferers.¹ People with heart failure are more at risk of sudden cardiac death and many can benefit from cardiac devices such as implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation devices (CRT-D/Ps). This increasing need was recognised by the National Institute of Health and Care Excellence (NICE) in 2014 with the publication of the revised guidelines for the use of such devices.² Nevertheless, the UK remains well below the European average for ICD implants, although is improving in terms of CRT devices;³ the latter due to a higher than average implant rate of CRT pacemakers. However, the rate of implantation of all high-energy devices (ICD + CRT-D) is only slightly more than half the European average.

Cardiopulmonary exercise testing (CPEX) is a valuable clinical tool that has proven indications within the fields of cardiovascular, respiratory and pre-operative medical care. Validated uses include investigation of the underlying mechanism in patients with breathlessness, monitoring functional status in patients with known cardiovascular disease and pre-operative functional state assessment. An understanding of the underlying physiology of exercise, and the perturbations associated with pathological states, is essential for healthcare professionals to provide optimal patient care. Healthcare professionals may find performing CPEX to be daunting, yet this is often due to a lack of local expertise and guidance with testing. We outline the indications for CPEX within the clinical setting, present a typical protocol that is easy to implement, explain the key underlying physiological changes assessed by CPEX, and review the evidence behind its use in routine clinical practice. There is mounting evidence for the use of CPEX clinically, and an ever-growing utilisation of the test within research fields; a sound knowledge of CPEX is essential for healthcare professionals involved in routine patient care. 

This is an audit of 10 Anglia region cardiac rehabilitation (CR) programmes against the British Association of Cardiovascular Prevention and Rehabilitation (BACPR) seven core standards. Methods included a questionnaire that encapsulated these standards, a SWOT (strengths, weaknesses, opportunities, threats) analysis and assessment of local outcomes.  

Overall, all 10 CR services were compliant with the vast majority of basic standards set by BACPR but the audit also highlighted gaps in ideal care processes, such as a shortage of psychologists, occupational therapists and pharmacists, and inadequate audit processes. Local strengths were highlighted that will encourage future cross-pollination across the network. Outcomes were collected variably ad hoc but there was some consistency that CR across the region improved exercise tolerance, reduced anxiety and reduced smoking, but had little effect on blood pressure and body mass index, comparable to the national audit. 

Anglia CR services were shown to be fit-for-purpose and there were local areas of excellence, but local areas of need and gaps in CR were highlighted that will cross-pollinate to improve all CR services in East Anglia. 

High-risk atherosclerotic cardiovascular disease (ASCVD), including recent history of acute coronary syndrome, cerebrovascular atherosclerotic disease, peripheral arterial disease, and coronary artery disease with diabetes mellitus, requires lipid-level monitoring and treatment. Data for patients with high-risk ASCVD from 2008–2011 were obtained from the UK Clinical Practice Research Datalink. Across two years of follow-up, analyses examined lipid-altering drug use, statin adherence (medication possession ratio [MPR]), and persistence (continuous time on drug). Initial statin dose, upward dose titration, and use of high-intensity statins were also studied. Lipid levels were examined overall and by statin use. A total of 131,603 high-risk ASCVD patients were included. Within six months of diagnosis, 63.1% of patients received a statin prescription. Patients typically remained on the initial statin (MPR ≥80% for 71.3% of patients at two years) and dose; 16.4% of patients used high-intensity statins. During the first year of follow-up, 69.3% of patients were either at the low-density lipoprotein cholesterol goal of <2.5 mmol/L or using a high-intensity statin. Considerable room for improvement remains with respect to optimal management of patients with ASCVD.