Clinical articles

Cardiac disease remains the commonest cause of maternal death in the UK. While some deaths are unavoidable, pre-pregnancy counselling for women with acquired or congenital heart disease is important and counselling should be viewed as the mainstay of clinical practice. It provides women with information about the risk a pregnancy may pose to their health and to that of a foetus and provides an opportunity for an up-to-date assessment of the cardiac condition and a medication review. All cardiologists should recognise the need to raise the issue of pregnancy whenever a diagnosis of acquired heart disease is made in a woman of childbearing age. Although women with heart disease are at increased risk during pregnancy, the majority of women will have a good outcome with careful management.

Troponin levels are used in the diagnosis of acute coronary syndromes (ACS), however, levels may be elevated in many other conditions. A significant proportion of patients with stable heart failure (HF) have detectable levels of troponin using standard assays, however, the incidence of detectable levels of high-sensitivity troponin T (hsTnT) in HF patients is not extensively studied.

The majority of patients with stable HF will have detectable levels of troponin T using new high-sensitivity assays. A significant proportion of these will be above the cut-off point used for diagnosis of ACS. If these patients present to hospital, modest elevations in hsTnT do not necessarily indicate recent ACS, and serial measurements should be undertaken if clinically indicated. 

Effective communication is known to increase patient satisfaction and correlates with improved health outcomes. Efforts have been made in recent years to improve communication skills through the use of less complex terminology. This study tests the hypothesis that patient understanding of more simplified terms can be limited and overestimated by doctors. 

In conclusion, the cardiology terms chosen were poorly understood by the surveyed patient population, and understanding was frequently overestimated. Caution should be used when using these terms without further clarification. 

W e continue our series looking at pacing in patients with congenital heart disease. In this final article, we discuss the challenge of device implantation in patients with more complex congenital structural cardiac defects.

Statins are ‘HMG-CoA reductase’ (3-hydroxy-3-methylglutaryl-CoA reductase) inhibitors and attenuate the intracellular levels of cholesterol. By virtue of their multiple pleiotropic modes of action in cardiovascular diseases, statins have also been considered and used for treating various other disorders, with convincing beneficial results, though a few contradictory reports do exist. Taking into account the positive and negative effects of statins, the data need to be viewed with a ‘pinch of salt’ for statins to be labelled as wonder drugs. 

In a retrospective, case-controlled study, we examined the influence of diagnostic cardiac catheterisation (DCC) on the management of a cohort of very elderly patients (aged over 80 years). Peri-procedure complications were also determined. Study and control patients (aged less than 70 years) were randomly selected from patients who had undergone DCC over the previous five years. Data were collected on the primary treatment outcome (immediately following DCC) and the secondary outcome – the treatment the patient eventually received. We found that, while those in the very elderly group (n=100) were more likely to be referred for surgical intervention as a primary outcome, there was no overall difference in secondary outcome between the two groups. There was no difference in peri-procedural complications between the two groups. We observed that, in very elderly patients, DCC is both safe and contributes to clinical management to a similar degree compared with younger patients.

Anticoagulation prior to direct current cardioversion (DCCV) is mandatory to reduce the risk of thromboembolism. We examined the impact of the use of dabigatran as an alternative to warfarin on the efficiency of an outpatient DCCV service. A total of 242 DCCVs performed on 193 patients over a 36-month period were analysed. Patients were divided into two cohorts; cohort A included cases in the 22-month period before the introduction of dabigatran and cohort B included cases in the 14-month period after the introduction of dabigatran. All patients in cohort A received warfarin. In cohort B, 48.4% received dabigatran. A larger number of patients from cohort A were rescheduled due to subtherapeutic international normalised ratios (INRs) compared with cohort B (42.1% vs. 15.6%, p<0.001). Those who received dabigatran had significantly lower rates of rescheduling compared with those who received warfarin (9.7% vs. 34.4%, p<0.001). The length of time between initial assessment and DCCV was 24 days shorter in cohort B than cohort A (p<0.001) and 22 days shorter with those who took dabigatran than warfarin (p=0.0015). Outcomes in achieving and maintaining sinus rhythm were comparable in both cohorts and anticoagulants (all p>0.05). This study demonstrates that the use of dabigatran can improve the efficiency of an elective DCCV service.

Hypertension is a growing clinical burden associated with significant morbidity and mortality. Those patients who remain with uncontrolled blood pressure despite multiple appropriate tablets are labelled as resistant hypertension. This cohort faces the highest risk. A key driving factor in resistant hypertension is an abnormally elevated sympathetic nervous system (SNS). It is now possible to attenuate this non-pharmacologically by performing radiofrequency ablation to the renal sympathetic nerves using a transcatheter approach. Currently available trial data show impressive blood pressure reductions with this therapy and, more importantly, its relative safety. The National Health Service (NHS) experience with this procedure is at an early stage, but is likely to grow with guidance already published by the joint British Societies and National Institute for Health and Care Excellence (NICE).

A 34-year-old Filipino computer engineer with no previous medical history presented to the emergency department with sudden onset exertional breathlessness and intermittent palpations for 10 days. He had no associated dizziness, syncope or chest pain, and no significant family history or recent travel. Blood pressure was 126/69 mmHg and pulse 104 bpm, regular with normal volume and character. The jugular venous pressure was normal. A 4/6 continuous murmur with diastolic accentuation was heard loudest at the left lower sternal edge, associated with a diastolic thrill. Electrocardiogram (ECG) showed sinus tachycardia and no other abnormality.

 A 68-year-old male with a background fhistory of squamous cell carcinoma of the epiglottis presented with recurrent syncope. During a witnessed collapse in Accident and Emergency (A&E), his heart rate decreased to 38 bpm and blood pressure dropped to 74/50 mmHg. Electrocardiogram (ECG) confirmed sinus bradycardia. Magnetic resonance imaging (MRI) of his neck revealed disease recurrence with a mass encasing the left internal carotid artery. He was diagnosed with reflex syncope secondary to mechanical stimulation of the carotid sinus. He had a dual-chamber pacemaker inserted, and re-presented with one further episode of collapse shortly afterwards. This report discusses the different options in managing this rare but debilitating symptom in head and neck cancers invading the carotid sinus.