Clinical articles

 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.

In this new regular series ‘ECGs for the fainthearted’ Dr Heather Wetherell will be interpreting ECGs in a non-threatening and simple way. She hopes this will help keep the art alive in primary care. In this first article, she looks at ECG methodical analysis

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

Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is recommended for up to one year following acute coronary syndrome (ACS). Gastrointestinal bleeding is the main hazard of this treatment and proton pump inhibitors (PPIs) are often prescribed in selected patients to reduce this risk. The main purpose of this study was to analyse the effect of PPIs in reducing the subsequent risk of gastrointestinal bleeding. 

The medical records of 177 consecutive patients treated with DAT following ACS, were specifically reviewed for the study parameters over a 12-month period. 

The mean age was 66 years (range 24–96) with a median value of 68 years; 67% were males and 33% females, 74% Caucasians and 26% Asians. Patients were divided into two groups: the PPI group (patients on DAT and PPIs, n=91) and the control group (patients on DAT only, n=86). In the PPI group, 55% were on lansoprazole, 34% on pantoprazole and 11% on omeprazole. 

Out of the 177 patients, evidence of upper gastrointestinal bleeding was found in 10 patients, with the mean age of these patients being 77 years in the PPI group and 53 years in the control group. In the PPI group, endoscopy findings from six patients (6.6%) revealed gastritis in four, bleeding angiodysplasia in one, and bleeding oesophagitis in one; while the findings for the four patients in the control group (4.6%) showed gastritis in two, gastric ulcer in one and Mallory Weiss tear in one (odds ratio: 1.45, 95% confidence interval 0.39–5.32, p=0.58). None of these patients had a previous history of gastrointestinal bleeding.

In conclusion, empirical prophylactic prescription of PPIs for patients on DAT following ACS is of no significant benefit in reducing their predisposition to upper gastrointestinal bleeding. However, studies utilising larger populations are warranted to confirm this conclusion. 

Cardiovascular magnetic resonance (CMR) imaging is a rapidly developing subspecialty with a clear training structure and good career prospects. Demand for CMR demand is growing rapidly, with an 85% increase in cases scanned nationally in only two years, and this demand is predicted to continue with the British Cardiovascular Society working group predicting a further trebling of demand in the five years from 2010 to 2015. The most recent British Junior Cardiology Association survey identified cardiovascular imaging as an increasing preference for subspecialty training with 22% of trainees choosing imaging in 2012 (up from 10% in 2005) and CMR as the preferred imaging modality (selected by 45%). However, it was highlighted that there were still difficulties in accessing training by around one third of trainees. We describe the common indications for CMR, what CMR training involves (including the accreditation process), as well as how trainees can access current training opportunities.

New high-sensitivity troponin assays will reduce the threshold for the diagnosis of myocardial infarction (MI), as specified in the 2012 third Universal Definition of MI. They will also allow earlier diagnosis of MI, but serial testing is required for adequate specificity. They convey prognostic information in both MI and in other acute conditions. Interpretation of troponin results must be in combination with a full assessment of the clinical context.

This review discusses these concepts and developments in this area.

Monitoring renal function is essential in chronic heart failure (CHF) patients on the combination of aldosterone antagonists (AA) and either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). The National Institute for Health and Care Excellence (NICE) recommends renal monitoring at weeks 1, 4, 8, 12 and then every three months. We audited the compliance of discharge notes to general practitioners (GPs) by hospital staff with NICE’s safety recommendation. We reviewed the notes of all consecutive CHF patients who were discharged in two periods (1st October to 20th November 2011 and 1st June to 30th June 2012) on the above combination therapy.

In the first audit, of 83 patients discharged on the combination (21 patients were commenced on it in the index admission), 43% met the audit standard. In the re-audit, 51 patients were discharged on the combination (12 had it commenced during the index admission), and 58% met the audit standard (p=not significant). In both audits, no advice at all was made to monitor renal function in 28% of the discharge notes.

Despite a trend of improvement in the rate of adherence to NICE’s safety recommendation between the two audits, almost a third of the patients were discharged without advice to the GP to monitor renal function.

Only a small proportion of patients requiring pacemaker or defibrillator implantation have congenital cardiac abnormalities. Patients with such anomalies can be divided into two categories: those with undiscovered congenital abnormalities, which had not given rise to symptoms or other obvious physical signs, and those known to have congenital abnormalities having had surgical intervention or not.

Pacemaker implantation in these two groups of patients may give rise to practical challenges and the implanting physician should be familiar with them so that potential problems can readily be recognised. In this, and the subsequent articles, we will cover the most common congenital cardiac anomalies with relevance to cardiac device implantation.