Clinical articles

The number of patients with aortic stenosis (AS) in the UK is increasing. Patients with non-significant AS can be safely reviewed in technician-led clinics. The potential impact of this on healthcare services is unreported. The aim of this study was to describe the impact of establishing an AS surveillance clinic in a district general hospital setting and consider the potential impact of widespread implementation.

In recent years a large amount of research has focused on developing both invasive and non-invasive methods of assessing atherosclerosis. In this regard, magnetic resonance imaging (MRI) is safe, non-invasive, requires no ionising radiation, and is capable of giving high-resolution images of atherosclerotic plaque. As a result, MRI has been extensively applied to imaging of the vascular system – in particular, the carotid arteries – where it has been shown to have the ability to not only accurately quantify the extent of atherosclerotic plaque disease, but also to identify several compositional features suggestive of plaque vulnerability. Imaging of the relatively small coronary arteries has, until now, been limited by the problems of cardiac and respiratory motion, however, more recently, technological advancements have allowed more detailed plaque information to be acquired. This article will review the origins of MRI imaging of atherosclerotic disease, its current status, and its potential future applications.

A 66-year-old male presented with increasing dyspnoea. He was an ex-smoker and had been diagnosed with stage IV undifferentiated large cell carcinoma of the left lung two months previously. Clinical examination revealed signs consistent with cardiac tamponade. Cardiac tamponade, a life-threatening condition, is a continuum of haemodynamic compromise, initiated by a collection of fluid in the pericardial space causing an increase in intra-pericardial pressure and cardiac compression. Transthoracic echocardiography confirmed the presence of a large global pericardial effusion with echocardiographic signs of cardiac tamponade (figure 1A and 1B).

Cerebrogenic control of cardiac function is well recognised and acute neurological events, including epileptic seizures, may cause a disturbance of cardiac function even in the absence of significant cardiac structural or electrophysiological abnormalities. Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in patients with epilepsy. Cardiac dysrhythmias are a potential cause of SUDEP.

Metformin is one of the oldest oral treatments to reduce hyperglycaemia in people with diabetes. Gastrointestinal side effects are common, and metformin should be used with caution in patients with renal impairment because of the slight risk of lactic acidosis. In the United Kingdom Prospective Diabetes Study (UKPDS) patients treated with metformin had a significant reduction in myocardial infarction and mortality that was not demonstrated in patients treated with sulphonylureas or insulin. The fact that metformin significantly reduces cardiovascular events plus reduces weight has meant that metformin is the drug of first choice in guidelines for the treatment of type 2 diabetes. There are no longer concerns about using metformin in patients with chronic heart failure, other than in patients with associated renal failure, or during episodes of acute left ventricular failure when metformin should be temporarily stopped. 

The role of cardiac computed tomography (CT) in clinical practice is constantly evolving. Early machines were only capable of measuring coronary calcification. Advances in temporal and spatial resolution, especially the introduction of 64-detector rows, now mean that high-quality non-invasive angiograms are possible in most patients. This review will outline the capabilities and limitations of coronary artery imaging with CT, and also highlight areas that differentiate CT from X-ray angiography, including direct plaque visualisation and potential vulnerable plaque identification.

Ventricular fibrillation (VF) is induced at the time of implantable cardioverter defibrillator (ICD) implantation in the UK, typically at least twice, with defibrillation ≥10 J below the maximum output. With the advent of modern leads/devices a single test may be sufficient.

A 72-year-old man, who underwent coronary artery bypass grafting 14 years previously, presented with sharp posterior chest pain and presyncope.

Ictal bradycardia/asystole is a poorly recognised cause of collapse late in the course of a typical complex partial seizure. Its recognition is important as it might potentially lead to sudden unexpected death in epilepsy (SUDEP). We present five patients with intractable complex partial seizures who had associated ictal bradycardia/asystole. All the patients underwent cardiac pacing to potentially prevent SUDEP. It is important to recognise and treat ictal asystole early, and to achieve this there is need for both an increase in epilepsy monitoring beds and a recognition of the potential role of implantable loop recorders in the evaluation of patients with epilepsy who clinically appear to be at increased risk for ictal asystole.

Depression and anxiety are commonly experienced by cardiac patients and are associated with reduced quality of life and mortality, but the evidence for the effectiveness of medical and psychological treatments for depression has been mixed.