Clinical articles

Primary percutaneous coronary intervention (PCI) has become treatment of choice for ST-elevation myocardial infarction (STEMI) in England. The assumption in most trials, and in their translation into clinical practice, is that centralisation of primary PCI for STEMI into large facilities is inevitable and essential. We feel that a successful and preferable primary PCI service can be delivered in a medium-sized district general hospital (DGH).

We performed a retrospective analysis of the first 18 months of primary PCI for STEMI in our unit. We compared our results with standards set out in the National Infarct Angioplasty Project report. Our median call-to-balloon time was 95 minutes and median door-to-balloon time was 50 minutes. Door-to-balloon times were shorter during working hours than out of hours, and were shorter for patients taken directly to the catheterisation laboratory than those admitted via A&E. During the period of assessment, 14% of patients experienced a major adverse cardiovascular and cerebrovascular event (MACCE). The overall mortality rate was 6.7%. No patients were transferred to our surgical centre for emergency treatment. 

We believe our data demonstrate that a system utilising regional Heart Attack Centres is not essential for satisfactory clinical outcomes, and may not be the preferred choice for patients and their ongoing post-myocardial infarction care. Expansion of PCI services in well-organised DGHs may be an equally good solution.

Diagnostic coronary angiography (CA) remains the gold-standard assessment of coronary artery disease (CAD). Transfemoral access remains a commonly used approach. Arterial tortuosity can lead to difficulties in coronary engagement, particularly when intubating the right coronary artery (RCA). Excessive catheter manipulation may result in knotting. 

Eliminate non-cardiac chest pain. Or rather, eliminate the expression. Cumulative irritation over several years leads me to comment on the readiness of doctors to use this, and ‘atypical chest pain’, as a diagnosis, and even carry out trials to assess treatment. To study a condition defined by what it is not seems weird; perhaps some people also describe non-brain head pain or atypical abdominal pain? 

Current European Society of Cardiology guidelines state that in troponin-negative acute coronary syndrome with no ST-segment change on electrocardiogram (ECG), a stress test is recommended. In the UK, exercise tolerance testing (ETT) is currently the most common first-line test. The high proportion of false-positive and inconclusive results often mandates second-line tests. We compared the diagnostic accuracy and cost implication
of computed tomography coronary angiography (CTCA) as first-line investigation compared with ETT. We hypothesised that CTCA would outperform ETT because of its excellent negative-predictive value. 

Our results suggest that it is feasible to use CTCA to investigate patients with acute low-to-intermediate likelihood chest pain in place of ETT at no extra cost. Moreover, this cost analysis only took into consideration the actual cost of investigation. Three US clinical trials have shown that CTCA in the emergency room can substantially reduce patient length of stay, reducing overall cost further. CTCA also recognises non-obstructive coronary atheroma, which, combined with clinical risk factors, may prompt the physician to initiate secondary prevention medication earlier.

An observational study was conducted on patients with pre-existing coronary heart disease who were re-admitted to an acute district general hospital with a further acute coronary event. Their demographics, admission drug therapies and cardiovascular risk factor parameters were recorded and analysed. Of the 100 patients admitted over a nine-month period, more than a quarter of them were taking suboptimal secondary prevention drug therapies. Furthermore, a proportion of patients were not achieving adequate cholesterol, blood pressure and heart rate targets, which, in turn, may be a major contributory factor for their re-presentation to hospital. 

We conducted an observational study within a cardiology tertiary centre with the aim of increasing the primary prevention implantable cardioverter defibrillator (ICD) implantation rate in line with Heart Rhythm UK (HRUK) national target.

A total of 326 patients experienced ST-elevation myocardial infarction (STEMI) over a 14-month time period and were offered incidence screening for implantation of a primary prevention ICD at six weeks according to National Institute for Health and Clinical Excellence (NICE) guidelines (TA095). There were 273 (84%) patients who completed the screening process; 26 (8%) had an ejection fraction (EF) of <35%. Two patients had an EF of <30% with a QRS duration >120 msec. Two of 22 subjects had evidence of non-sustained ventricular tachycardia on 24-hour Holter monitoring; one had a positive ventricular tachycardia stimulation test. Overall, three patients received an ICD (0.9%).

In conclusion, this process was labour intensive and had a lower than expected yield.

The objective of our study was to evaluate the impact of atrial fibrillation (AF) on secondary care costs in Scotland. Patient hospitalisation data from the Information and Statistics Division (ISD) of the Scottish National Health Service (NHS) from 2004 to 2008 were analysed to estimate trends in hospital episodes in the 5.2 million population of Scotland. The associated costs were estimated using the tariff prices in Scotland for the respective years. 

Over the five-year period, AF-related hospital discharges increased by 33% compared with 20% for all cardiovascular discharges (29 and 37 per 1,000 population respectively). There were increases of: 21% in number of patients hospitalised; 27% in AF-related hospital admissions; and 15% in total patient bed days. Despite decreasing trends, mean length of inpatient stay for AF remained higher than for total cardiovascular conditions (10.9 vs. 8.7 days), as did inpatient cost per patient (£6,009 vs. £5,586). AF-related hospital costs increased from £138.9 million in 2004 to £162.5 million in 2008, accounting for 24% of all cardiovascular hospital costs. Overall, the burden of AF was higher among women and increased progressively with age. 

In conclusion, AF presents a significant and increasing burden on hospital care in Scotland. At 25% of the total cardiovascular burden, AF costs are increasing relatively faster. 

Improving patient access and implementation of the European Working Time Directive has proved a challenge for the National Health Service (NHS), particularly adding to workforce pressures and reducing continuity of care for patients. Innovative service and workforce redesign led to the introduction of new and extended roles based on service need. This paper outlines the introduction of one such new role, physician assistant (PA), introduced in the NHS in 2006, based on the established US PA model. UK-trained PA graduates are taking up newly created posts in primary and acute healthcare trusts and the aim of this paper is to share the first-year experience of introducing a newly qualified UK-trained PA within a busy district general hospital cardiology department, describing the internship year, achievements, limitations and how the role has evolved in line with service need. We believe the role has ideal potential in a cardiology department and, in particular, in the management of long-term chronic conditions, such as heart failure, where the number of specialist contacts with the patient can directly impact admissions, re-admissions, length of stay, adherence to medications and protocols of care positively.

A new heart failure service was established in Sheffield in 2008. The service provides specialist advice on the management of inpatients with heart failure, and optimises their medical therapy in a heart failure clinic led by heart failure nurse specialists. We undertook a survey of patients’ perception of the service provided by these clinics.

A postal survey was sent to the patients who attended the nurse-led heart failure clinics more than once in the first two years of the service. There were two types of questions: multiple-choice questions and those allowing free text answers. We approached 228 patients. We received responses from 192 (84%). Of these patients, the majority (80–90%) responded positively to most of the questions. The vast majority of patients regarded the service as providing excellent care, that the staff were courteous and professional, and they were able to establish a good relationship. The negative remarks were related to facilities such as parking spaces in the hospital, and to the label of heart failure. The team endeavours to make improvements to the service. 

In conclusion, the nurse-led heart failure clinic was positively received by heart failure patients.

A 26-year-old man presented with T4 adenocarcinoma of sigmoid colon, which was initially treated with a covering ileostomy and neoadjuvant chemotherapy with oxaliplatin and infusional 5-fluorouracil delivered through a right subclavian Hickman line. While receiving chemotherapy, he developed a massive right atrial thrombus, adherent to the inferior venacaval opening and the adjoining right atrial wall, mimicking a metastatic deposit, which was removed surgically on cardiopulmonary bypass. The patient subsequently underwent successful high anterior resection of the sigmoid cancer followed by adjuvant chemotherapy with oxaliplatin and capecitabine. The unusual features of this patient’s presentation include the extremely rapid growth of thrombus despite aggressive anticoagulation, the unusual site of thrombus on the inferior vena caval opening rather than around the Hickman line, and possible facilitation of thrombus formation by chemotherapeutic agents. We also discuss the diagnostic and therapeutic dilemmas in a patient with a concurrent malignancy and a right atrial mass.