Clinical articles

This editorial series provides an in-depth exploration of research avenues in UK cardiology. It underscores the pivotal role of research in cardiology training and addresses the challenges faced by trainees in identifying apt research opportunities. This second article categorises available research roles, weighing their pros and cons, and outlines various supervisory styles to guide trainees in finding the optimal fit. It also summarises the primary research degrees, namely MPhil, MSc, MD, and PhD, tailored to diverse research goals.

International guidelines recommend ‘heart teams’ as the preferred method for decision-making. Heart team processes, mandatory attendees and investigations vary significantly between hospitals. We assessed outcomes following mitral valvular surgery in a tertiary referral centre with a dedicated mitral multi-disciplinary team (MDT).

This was a single-centre retrospective review of prospectively collected data within the ‘mitral database’ of mitral valvular disease patients. The ‘mitral MDT’ meeting involved pre-operative imaging and clinical data review, including mandatory transoesophageal echocardiography; recommendation for planned procedure, as well as an appropriate surgeon; and review of echocardiography images and clinical outcomes after surgery had been performed.

Between 2016 and 2020, 395 patients with mitral valvular disease were discussed at MDT. Of these, 310 patients underwent surgery. During the same time interval, 75 patients had surgery without MDT discussion: 84% of patients not discussed were urgent or emergent procedures and, in these, the most common pathology was degenerative mitral regurgitation (DMR, 46%) followed by infective endocarditis (30%). Of those discussed at MDT the pathology was: DMR 65%; mitral stenosis 14%; functional mitral regurgitation (MR) 5%; rheumatic MR 4%; endocarditis 4%; ischaemic MR 4%; and other pathologies 4%. For patients with DMR having elective surgery, the repair rate was 93% with mortality 2% and median (IQR) length of stay 5 (4–6) days. Postoperative transthoracic echocardiography demonstrated 99% of elective DMR patients had ≤2+ MR and <1% severe (3+) MR.

In conclusion, a dedicated ‘mitral MDT’ can enhance the safe delivery of care with consistently high repair rates for DMR patients with excellent outcomes.

One of the assessments for coronary atherosclerosis during cardiac computed tomography (CT) is coronary artery calcium (CAC) scoring. We conducted analysis on the determinants of high-risk coronary calcification, represented by CAC score, among women as a step to improve their outcomes and prognosis. This study involved a total of 1,129 female patients from a single centre. There were 127 patients (11.2%) classified as high risk (CAC ≥400). We found that a history of hypertension and diabetes are independent determinants of having a high-risk CAC score. Furthermore, this study demonstrated protective effects associated with physical activity and diastolic blood pressure. In conclusion, a history of hypertension, diabetes, and high uncontrolled systolic blood pressure might be used as cues for physicians to prioritise CAC assessment in women, despite the absence of chest pain or atypical symptoms.

Patients with bicuspid aortic valves (BAV) are predisposed to the development of aortic stenosis. We performed a pairwise meta-analysis, comparing the efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with BAV.

Medical databases were queried to pool comparative studies of interest. Single-arm studies, conference presentations, animal studies, and studies that involved patients with tricuspid aortic morphology were excluded. Outcomes were pooled as risk ratios (RRs) with their 95% confidence intervals (CI) using the random effects model in R.

There were 60,858 patients with BAV (7,565 TAVR, 53,293 SAVR) included. Compared with SAVR, TAVR was associated with a significantly lower risk of 30-day major bleeding (RR 0.29, 95%CI 0.13 to 0.63, p=0.01) but a higher risk of new permanent pacemaker placement (RR 2.17, 95%CI 1.03 to 4.58, p=0.04). No significant differences were seen with other explored outcomes, including 30-day/mid-term mortality, stroke, acute kidney injury, major vascular complications, paravalvular leak, and conduction abnormalities.

In conclusion, in patients with BAV, TAVR is associated with a lower risk of 30-day major bleeding but has an increased risk for permanent pacemaker implantation when compared with SAVR. Future large-scale randomised trials comparing both the short- and long-term outcomes of SAVR and TAVR in patients with BAV are needed to assess the efficacy of each modality in a controlled population across long follow-up durations.

We describe a case of aortic rupture following transcatheter aortic valve implantation that was managed percutaneously.

Twenty years ago, Wald and Law¹ hypothesised that, if a combination pill could be made including aspirin, folic acid, a statin, and a low-dose diuretic, beta blocker and angiotensin-converting enzyme (ACE) inhibitor (thus, allowing for the simultaneous modification of four different risk factors: low-density lipoprotein [LDL]-cholesterol, blood pressure, homocysteine, and platelet function), and administered to everyone with existing cardiovascular disease and everyone over 55 years old, there would be an 88% reduction in ischaemic heart disease events, and an 80% reduction in stroke. One third of people over the age of 55 years would benefit by gaining an average of 11 years free from a cardiac event or stroke (subsequently termed the vaccination approach). They called this pill the ‘Polypill’, and concluded that treatment would be acceptably safe and, with widespread use, would have a greater impact on the prevention of disease in the Western world than any other single intervention. They noted that, while such a preventative strategy was radical, if such a formulation existed that prevented cancer and was safe, it would be widely used. “It is time to discard the view that risk factors need to be measured and treated individually if found to be abnormal. There is much to gain and little to lose by the widespread use of these drugs.” While subsequent works have shown that folic acid is not prognostically beneficial in preventing cardiovascular disease,² and that aspirin may not be beneficial overall in primary prevention settings,³ the concept of the combination pill was awakened in the public eye.

Heart failure with preserved ejection fraction (HFpEF) is a common concern in the medical field due to its prevalence in an ageing western population. HFpEF is associated with significant morbidity and mortality not dissimilar to heart failure (HF) with reduced ejection fraction. N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and echocardiography are the guideline diagnostic indicators of HF and their use is being examined in this study, with the aim to consider NT-proBNP thresholds performance as a rule-out test.

The current National Institute for Health and Care Excellence (NICE) and European guidelines recommend a single NT-proBNP threshold of >400 ng/L and >125 ng/L, respectively, to trigger echocardiographic assessment of HF in the outpatient setting. NT-proBNP levels are known to increase with age and worsening renal function. Unsurprisingly, a single threshold significantly increases demand for echocardiography. NT-proBNP measurements and echocardiograms performed within six months of each other were included for 469 patients with suspected HF.

A significant relationship between NT-proBNP levels and diastolic dysfunction was established. NT-proBNP levels and age are significant predictors of diastolic dysfunction in uni-variant (odds ratio 1.251, 95% confidence interval [CI], p<0.001) and multi-variant analysis (odds ratio 1.174, 95%CI, p=0.002). High negative-predictive values (NPVs) were obtained in severe diastolic impairment with the NPV being 95% at the European NT-proBNP cut-off of 125 ng/L, 95% at the NICE cut-off of 400 ng/L, 93% at 1,000 ng/L and 92% at 2,000 ng/L.

There is a significant association between NT-proBNP and diastolic dysfunction. NT-proBNP and age can predict diastolic dysfunction, and age can predict NT-proBNP levels, thus, these variables should be considered when considering referral for an echocardiogram. Most importantly, at higher NT-proBNP cut-offs the NPVs remain above 90% suggesting that different thresholds for subpopulations could yield a more effective strategy and mitigate the increased demand for echocardiography.

We aimed to describe the safety and tolerability of initiation of sodium-glucose cotransporter 2 inhibitors (SGLT2i) during hospitalisation with heart failure, and the frequency of, and reasons for, subsequent discontinuation.

In total, 934 patients who were not already prescribed a SGLT2i were hospitalised with heart failure, 77 (8%) were initiated on a SGLT2i a median of five (3–8.5) days after admission and two (0.5–5) days prior to discharge. During a median follow-up of 182 (124–250) days, SGLT2i were discontinued for 10 (13%) patients, most frequently due to deteriorating renal function. We observed reductions in body weight (mean difference 2.0 ± 0.48 kg, p<0.001), systolic blood pressure (mean difference 9.5 ± 1.9 kg, p<0.001) and small, non-significant reductions in estimated glomerular filtration rate (eGFR mean difference 2.0 ± 1.5 ml/min/1.73 m², p=0.19) prior to initiation, with further modest reductions in weight (mean difference 1.2 ± 0.4 kg, p=0.006) but not systolic blood pressure (2.4 ± 1.5 mmHg, p=0.13) or eGFR following initiation of SGLT2i. At discharge the proportion prescribed a beta blocker (44% to 92%), angiotensin-receptor/neprilysin inhibitor (6% to 44%) and mineralocorticoid-receptor antagonist (35% to 85%) had increased.

In conclusion, inpatient initiation of SGLT2i was safe and well tolerated in a real-world cohort of patients hospitalised with worsening HF. We observed a 13% frequency of discontinuation or serious side effects.

Pulmonary hypertension is a rare disease, associated with a significant deterioration in quality of life, usually not curable and with an ominous prognosis. It is classified into five groups according to similar pathophysiological, clinical, haemodynamic, and treatment options in each of them. However, group 5 is the least common, encompassing different types of aetiological, semiological, and management conditions. We present the case of a patient diagnosed with precapillary component pulmonary hypertension, with the finding of an arteriovenous fistula at the peripheral level. Interventional exclusion was performed, achieving remission of her disease.

Stroke is a major cause of mortality, morbidity and economic burden. Strokes can be thrombotic, embolic or haemorrhagic. The key risk factor for cardioembolic stroke is atrial fibrillation or flutter, and oral anticoagulation (OAC) is recommended in all but the lowest-risk patients with evidence of these arrhythmias. Risk factors for thrombotic stroke overlap strongly with those for other atherosclerotic cardiovascular diseases (ASCVDs). Antiplatelet therapy (APT) should be considered in patients with established ASCVD to reduce risk of cardiovascular events, including stroke. Intensification from single to dual APT or a combination of APT with low-dose OAC can reduce ischaemic stroke risk further, but increases bleeding risk. Blood pressure and lipid profile should be controlled appropriately to guideline targets. In patients with diabetes, good glycaemic control can reduce stroke risk. Inflammation is another emerging target for stroke prevention. Overall, comprehensive assessment and pharmacological modification of risk factors are central to stroke prevention.