Clinical articles

Palpitations are a common presentation in general practice(1) and a frequent reason for cardiology referrals. This symptom often causes considerable distress and anxiety for the patient(2) and can evoke a similar feeling in the consulted healthcare professional. However, palpitations are often benign.(3) Less than half of patients with palpitations suffer from an arrhythmia and not every identified arrhythmia is of clinical or prognostic significance.(4 )There is also a high incidence of anxiety disorders among patients presenting with palpitations.(5)

The skill lies in identifying patients with a significant heart rhythm abnormality who can be either helped by treatment or are at risk of adverse outcome. This can be achieved in primary care by taking a careful history and simple investigations.(5)

The provision of services for patients with arrhythmic illness has lagged behind those who suffer from coronary heart disease (CHD). This has been recognised by the addition of Chapter 8 to the National Service Framework for CHD.(6) Timely access to appropriate clinicians and patient support are among the quality requirements, which have been much welcomed by patients.

Considerable variation exists in adherence to and implementation of post-myocardial infarction (post-MI) clinical guidelines in the UK. The Follow Your Heart Steering Group has consolidated existing clinical evidence and published guidance into a consensus of succinct recommendations for optimal post-MI management, which includes separate healthcare professional and patient-focused components. This guidance should help encourage two-way dialogues between patients and healthcare professionals, reduce practice variation, raise standards of care, maximise healthcare resource utilisation and improve outcomes in post-MI patients. It is our intention to develop and widely disseminate a simple algorithm for healthcare professionals and for patients that summarises the guidance.

In the case of coronary artery disease the glut of diagnostic terms like Q-wave infarction, non-Q infarction, ST elevation infarction, non-ST elevation infarction, intermediate syndrome, unstable angina, stable angina, silent ischaemia, and exertional angina do not reflect the present day realities and are neither rational nor systematic. The term ‘acute coronary syndrome’ is too vague. A diagnostic term should be based on the cause rather than the effects. The present terms are symptom and effect based. These were relevant when there was no effective treatment. With the availability of powerful treatments these terms have become outdated. Terminology relating to the present day realities is required. In this paper I propose a system of terminology based on the assumed pathology.

Most people do not wish to die in hospital, yet most people do. Patients with chronic heart failure (CHF) appear to be particularly disadvantaged in this regard, partly because it can be difficult to recognise when the issue should be broached. This review by two integrated cardiology–palliative care services of 235 CHF deaths, shows that only about a third of patients died in an acute hospital bed. End-of-life discussions were possible, with the majority of patients given the opportunity to express a preferred place of dying achieving their wish.

The authors describe a case of Takotsubo-like syndrome in a 59-year-old Caucasian woman.

A 37-year-old man presented with palpitations and recurrent episodes of pre-syncope. He had a past medical history of atrial septal defect (ASD) repair aged seven.

The management of acute coronary syndromes (ACS) has changed greatly over recent years. Trial evidence encouraged clinicians to consider early invasive management in high-risk patients and this has created a large clinical burden. We instituted a comprehensive system of nurse-led diagnosis and management of ACS. In-patients are seen by a cardiac outreach nursing team and depending on their risk profile may be managed in a designated acute cardiac unit (ACU) by cardiologists. We also piloted an ‘ACS clinic’ where patients with higher risk are seen within two weeks of discharge. We conducted audits to assess the impact of these new services.

A total of 158 consecutive patients from ACU with unstable angina or non-ST elevation myocardial infarction (NSTEMI) were identified. The in-patient coronary angiography rate was 48%, percutaneous coronary intervention (PCI) rate 15% and coronary artery bypass graft (CABG) rate 4%. The six-month re-admission rate was 28.5%, of whom 44.4% were within one month of discharge. In-patient coronary angiography almost halved the rate of re-admission (20.0% vs. 36.6%; p=0.026). We also audited the first 12 months of the ACS clinic. The six-month re-admission rate was 14.2%, a significant reduction compared with the first audit (p=0.0002). In conclusion, the strategy of nurse-led identification and follow-up of ACS patients promotes effective use of resources and reduces re-admissions.

The transradial approach is increasingly used in a wide range of percutaneous coronary interventions (PCIs) with few reported complications. It is established as a safe procedure with improved patient comfort and early mobilisation.1-3 This has translated into early discharge with reduced procedural cost leading to out-patient day-case PCI.4,5 However, with this increasing use, unusual and new complications will be recognised.

Research has shown that, following angiogram with femoral puncture, prolonged bed rest increases patient discomfort during recovery. This audit aimed to measure the effects of reducing the period of immobilisation from the local standard of four hours to only two hours. Almost 500 consecutive patients were selected for early ambulation at two hours post-angiogram. Overall, 86.8% of patients suffered no vascular complications. In addition to the beneficial effects on patient comfort, earlier ambulation will enable cardiology units to treat more patients, thereby maximising efficiency and income generation.

Vascular surgery is associated with a substantial risk of cardiovascular events and death. Cardiac troponin I (cTnI) is a contractile protein that is a highly sensitive and specific marker of myocardial necrosis. This case series examines the clinical course of 10 patients who had an asymptomatic pre-operative elevation in cTnI and underwent a vascular surgical procedure.

A prospective, two-year, observational, single-centre cohort study of all patients undergoing a vascular procedure with an expected cardiac event rate of >5% was performed. Pre-operative cTnI was carried out (cTnI >0.02 ng/ml positive). Post-operative screening for cardiac events at post-operative days two and five was performed.

Two-hundred and thirteen patients were recruited, of whom 11 (5.2%) had an asymptomatic elevated pre-operative cTnI. Ten patients in whom the pre-operative cTnI was not known prior to surgery, or in whom a procedure could not be delayed proceeded with the operation. One patient had surgery deferred. Four patients suffered a post-operative cardiac event and five died.

The outcome in this case series was poor with death in 50% of those taken to theatre and cardiac events in 40%. An elevated pre-operative cTnI in an otherwise asymptomatic patient identifies a very high-risk group of patients.