搜索结果：The British journal of cardiology

We performed a cross-sectional study to determine the frequency of use of proton-pump inhibitors (PPIs) in acute coronary syndrome (ACS) patients on dual antiplatelet therapy (DAPT) within 24 hours of hospital admission, and their effectiveness in reducing bleeding complications. This cross-sectional study included a total of 83 patients admitted via the medical take to Queen Elizabeth Hospital, Lewisham and Greenwich Trust (LGT), London, with ACS from May 2022 to June 2022. The data of these patients were analysed to see whether ACS patients on DAPT were given PPIs within 24 hours of their hospital admission. These patients were further assessed for any bleeding event during their hospital admission and its association with the prescription of PPIs. A significant number of ACS patients (26, 32.1%) were not prescribed PPIs within 24 hours of hospital admission. However, 55 (67.9%) patients were prescribed PPIs within 24 hours of their hospital admission. Of the 26 ACS patients not given PPIs within 24 hours of their hospital admission, three patients developed bleeding complications during their admission. Two out of the three patients developed gastrointestinal (GI) bleeding (melena) with a significant drop in their haemoglobin levels, while one patient developed haematuria. In conclusion, a large number of patients admitted with ACS and started on DAPT did not receive a concomitant PPI within 24 hours of admission to the hospital in accordance with European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines, and, as such, were at significant risk of bleeding events.

There is a paucity of data on arrhythmia burden in patients with congenitally corrected transposition of the great arteries (ccTGAs). The present study sought to quantify the incidence of atrial arrhythmia (AA), ventricular arrhythmia (VA), and complete atrioventricular block (CAVB) in patients with ccTGA and identify associated factors. An international, multi-centre, retrospective cohort study was conducted in 29 tertiary hospitals (six countries) between 1990 and 2018. Primary analyses consisted of determining the incidence of a combined outcome consisting of AA, VA, or CAVB, along with its individual components. Factors associated with the different types of arrhythmias were assessed by uni-variable and multi-variable Cox regression analyses. A total of 1131 patients with ccTGA were followed for 9.0 (interquartile range 4.0-17.2) years. Cumulative rates of the primary endpoint at 10, 15, and 20 years were 44.5%, 51.0%, and 58.8%, respectively. AA, VA, and CAVB occurred in 2.1, 1.4, and 2.0 cases per 100 person-years, respectively. In multi-variable analyses, surgery/intervention conferred a greater than three-fold higher risk of AA [hazard ratio (HR) 3.01, 95% confidence interval (CI) 1.90-4.78, P < .001]. Furthermore, surgery/intervention was significantly associated with a greater risk of VA (HR 1.73, 95% CI 0.98-3.05, P = .003) and CAVB (HR 3.65, 95% CI 2.20-6.05, P < .001). The left bundle branch block was associated with a higher risk of VA (HR 4.03, 95% CI 1.59-10.23, P = .003) and the right bundle branch block with a higher risk of CAVB (HR 3.71, 95% CI 1.81-7.63, P < .001). The arrhythmia burden in patients with ccTGA is substantial, with a high incidence of AA, VA, and CAVB.

Cardiotoxicity, including left ventricular (LV) dysfunction, is a dreaded side-effect of selected drugs that are widely used in oncology. Guidelines recommend the assessment of LV systolic function, primarily by echocardiography, before and during exposure to cardiotoxic medications. However, apart from LV ejection fraction (LVEF), echocardiography reports include dozens of numerical data points and other detailed information familiar to cardiologists, but which may not be familiar to other specialties. With a rising need for echo in oncology patients, and with no cardio-oncology service within our hospital, we assessed what is understood by oncologists regarding the information provided within an echocardiographic report, and what action they take subsequent to the report. Morriston Cardiac Centre provides tertiary care to a population of 1.2 million and conducts 12,000 transthoracic echocardiograms (TTE) annually. We ran a survey of all consultant clinical oncologists in Wales, using a set of multiple-choice questions via Google Forms. We presented the responders to our questionnaire with a set of hypothetical echocardiographic findings, drawn from common clinical scenarios, and asked what they would do if they received a report containing such a finding. Our questionnaire was completed by 14 of 19 (74%) oncology consultants. Only a little better than half reported low-to-moderate confidence in interpreting the findings that echo reported. Oncologists varied in their level of confidence and understanding of what TTE findings meant, and the responses to commonly reported echocardiographic findings (e.g. actions they would take if echo report stated low-normal ejection fraction) had inhomogeneity. Our work supports the utility of a dedicated cardio-oncology clinical pathway or service, which would assist with these queries, and may even obviate them, by providing the echo report directly to a cardio-oncologist.

Cardiac rehabilitation (ExCR) is an essential, evidence-based part of the management of people with chronic heart failure (CHF), but research indicates it is underused. This retrospective audit explores the eligibility of heart failure inpatients for ExCR, according to the European Society of Cardiology (ESC) consensus statement, and the impact of frailty on referral rates. The first 100 patients admitted with a diagnosis of CHF from 1 February 2020 within one hospital trust were included in the audit. Only 54% of patients were eligible for ExCR at discharge and, of them, 43% were referred. Most patients (69%) admitted to cardiology wards were eligible for ExCR compared with 14% of those admitted to non-specialist care. Frail patients were less likely to be admitted to cardiology wards (43%) than their non-frail counterparts (93%). Not all patients admitted to hospital with heart failure are eligible for ExCR, and assessing eligibility is important in identifying the true referral rate to allow national benchmarking. Interventions to improve referral are still important, but focus also needs to be directed to developing interventions for those individuals currently not eligible for standard ExCR programmes.

Hyperbaric oxygen therapy (HBOT) is successfully implemented for the treatment of several disorders. HBOT is a promising treatment modality for coronary artery disease (CAD), where outcomes are frequently poor despite early revascularisation. The aim of this study is to investigate the effect of HBOT on the left ventricular function of patients with CAD after reperfusion. Electronic journal searching was performed in PubMed, ScienceDirect, and Cochrane to find studies that investigate the effect of HBOT on the myocardial function of patients with CAD. The primary outcomes were left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and left ventricular ejection fraction (LVEF). Meta-analyses were performed on included studies and mean differences (MD) and 95% confidence intervals (CI) were estimated using Review Manager v5.4. A total of three observational studies enrolling 195 participants were included in our analysis. HBOT significantly increased LVEF by 4.16% in patients with CAD after revascularisation compared with non-HBOT (MD=4.16, 95%CI 0.97 to 7.34, p=0.01). There was no statistical significance observed in the HBOT versus non-HBOT comparison on LVEDV (MD=-1.63, 95%CI -6.52 to 3.26, p=0.51) and LVESV (MD=- 1.58, 95%CI -4.06 to 0.90, p=0.21). In general, this meta-analysis shows HBOT significantly increased LVEF in patients with CAD after revascularisation compared with non-HBOT. There were no significant changes in LVEDV and LVESV in the HBOT group and non-HBOT group.

Cardiovascular disease incidence is increasing worldwide, rendering it the most common cause of death worldwide. As such, nanomedicine has emerged in the context of overcoming these biological barriers. In this review, novel technologies are illustrated on two levels: molecular imaging and nanotechnology in atherosclerosis and therapeutic options in atherosclerosis. The former includes many diagnostic techniques, such as fluorescence imaging, computed tomography angiography (CTA), magnetic resonance imaging (MRI), photoacoustic imaging, contrast-enhanced ultrasound (CEUS), and multi-modality imaging. The latter is divided into two main subgroups: the first group includes inflammation-targeted therapies involving the endothelial cells and macrophages, and the second group includes nanoparticle transporters, like liposomes, micelles, dendrimers, polymeric nanoparticles (NPs), gel-like NPs, carbon nanotube, magnetic NPs, iron oxide NPs and gold NPs, and nanocoating (stent polymeric coatings to nanotextured ceramic coatings). In conclusion, nanoparticles show promise in enhancing the early diagnosis and targeted treatment of coronary artery disease. While several imaging and therapeutic techniques have demonstrated efficacy in preclinical models, only a few have progressed to human trials or clinical use.

Saphenous vein grafts (SVGs) are frequently used for coronary artery bypass grafting (CABG) of severe coronary artery disease; however, re-stenosis is common. Restoration of blood flow to the SVG is uncommonly achieved via revascularisation of the native vessel. A man in his 70s with previous CABGs presented with prolonged chest pain at rest. The left anterior descending (LAD) and left circumflex arteries had chronic total occlusions (CTO), and the SVG and left internal mammary artery, previously used to bypass the LAD, were severely diseased with sluggish flow and an inability to pass a balloon or microcatheter. Rotational atherectomy was successfully performed to cross the LAD CTO, with good flow post-stenting. He remained asymptomatic one year later. Where management of calcified venous grafts precludes passage with balloon or microcatheter, rotational atherectomy of the native coronary may represent an alternative method of restoring blood flow.

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management.

Reduction in low-density lipoprotein-cholesterol (LDL-C) in patients with hypercholesterolaemia is associated with a lower risk of cardiovascular (CV) events. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibiting therapy is approved by the National Institute for Health and Care Excellence (NICE) and the Scottish Medicines Consortium (SMC) for use in high-risk patients who are unable to achieve the LDL-C target levels, despite other maximum tolerated lipid-lowering therapies. Our prior publication analysed the records of patients in a large Scottish health board with familial hypercholesterolaemia and high CV risk and confirmed the real-world efficacy of PCSK9 inhibiting monoclonal antibodies (mAbs) in routine clinical care. In this follow-up study, we examined the comparative efficacy of inclisiran, a small-interfering ribonucleic acid (siRNA) therapeutic, in a similar patient cohort to provide real-world data that can guide clinicians in optimising lipid-lowering strategies.

Retinal ischaemic perivascular lesions (RIPL) are characterised on spectral domain optical coherence tomography (SD-OCT) as focal thinning of the inner nuclear layer (INL) associated with outer nuclear layer (ONL) upward expansion. We present a small case series of 11 patients and reviewed all relevant original research on RIPL and its association with cardiovascular diseases (CVD). All 11 patients had RIPL incidentally identified on SD-OCT by two consultant ophthalmologists during a routine medical retina clinic. We obtained a thorough medical history to identify risk factors and CVD. The most common risk factor was type 2 diabetes mellitus (90.9%), followed by hypertension (81.9%). A diagnosis of arrhythmia was determined in 36.4% patients, coronary artery disease in 27.3%, cerebrovascular events in 36.4%, peripheral vascular disease in 27.3% and carotid artery stenosis in 8.3%. A literature search was conducted using PubMed, Google Scholar and Scopus, using all relevant key words. Seven pieces of original research were described in the literature. Six of these described a RIPL prevalence ranging from 34.62% to 91%. One paper described a case series with an incidence of 72.7% new diagnosis of CVD in their cohort who were identified to have RIPLs. The ophthalmologists' role in detecting RIPLs could be used to assess cardiovascular risk status, supporting a multi-disciplinary approach in managing CVD.

Adults with Fontan palliation face variable risks of thrombosis and bleeding. The optimal thromboprophylaxis strategy remains unclear. There is a balance between the risk of thromboembolism and bleeding with thromboprophylaxis. Recent studies suggest direct oral anticoagulants (DOACs) may provide effective thromboembolism prevention, but concerns regarding bleeding risk, hepatic impairment, and lack of robust data persist. This study investigates thromboprophylaxis practices among UK adult congenital heart disease (ACHD) specialists, focusing on the use of DOACs in Fontan patients. An electronic survey was distributed to UK National ACHD Consultant Group members from February to March 2023. Based on hypothetical clinical scenarios, the survey collected demographic data, familiarity with DOACs, and preferred thromboprophylaxis strategies. Responses were analysed using descriptive statistics to identify patterns in practice. There was a maximum response rate of 42%, with 32 respondents participating, primarily consultants from level 1 ACHD centres. Thromboprophylaxis strategies varied significantly: DOACs, warfarin, and aspirin were used with varying frequency, depending on clinical factors, such as arrhythmias, thrombosis history, and patient-specific challenges. While 35% of respondents were comfortable prescribing DOACs, 42% expressed reservations, citing limited evidence and concerns about risks. This study highlights wide variability in thromboprophylaxis strategies for Fontan patients in the NHS, underscoring significant gaps in evidence. Hepatic considerations, patient-specific challenges, and the lack of DOAC licensing for certain scenarios contribute to the complexity of clinical decision-making. Prospective studies are essential to guide practice, and patient involvement in shared decision-making is critical in the interim.

In recent years, artificial intelligence (AI) has been used to improve the precision of valvular heart disease diagnosis and treatment. It has the ability to identify and risk stratify patients with valvular heart disease and holds promise in improving the innovation of new treatments through shorter, safer and more effective clinical trials. AI can help to guide the treatment of patients with valvular heart disease, by aiding in optimal device selection for transcatheter valvular interventions and, potentially, predicting the risk of specific complications. This review article explores the various potential applications of AI in the diagnosis and treatment of valvular heart disease in more detail.

Low-density lipoprotein-cholesterol (LDL-C) is accepted as a causal risk factor for development of atherosclerotic cardiovascular disease (CVD) and acute coronary syndromes (ACS). In individuals aged 40-75 years, reducing LDL-C constitutes a main treatment target for prevention of atherosclerotic CVD in all international guidelines. Furthermore, diabetes mellitus (DM) confers a two-fold excess risk of vascular outcomes (coronary heart disease, ischaemic stroke, and vascular deaths), independent of other risk factors. Our audit project identified a deficit in current standards following an audit of adherence to lipid profile and glycated haemoglobin (HbA1c) testing in the high-risk chest pain population in our city hospital setting. We found only 49% of patients had LDL-C checked during their inpatient stay, and only 45% had HbA1c checked, of our targeted 100% of patients. This allowed the introduction of a planned intervention to improve admission testing and re-auditing demonstrated an improvement in testing, mainly driven by improved LDL-C testing. Despite this, a deficit still exists and more work is needed to meet our target of 100% compliance.

National Institute for Health and Care Excellence (NICE) guidance recommends routine early inpatient invasive coronary angiography (ICA) for patients presenting with non-ST-elevation acute myocardial infarction acute coronary syndrome (NSTEMI-ACS) within 72 hours of hospital admission. For patients admitted to hospitals without invasive cardiac facilities, completing interhospital transfer and investigation within this timeframe is challenging. This retrospective cohort study evaluated factors influencing time to ICA, diagnosis and treatment allocation decisions in 4,087 NSTEMI-ACS patients referred from five district general hospitals to the Royal Infirmary of Edinburgh over four years. The mean time from admission to coronary angiography was 5.0 &#xb1; 3.0 days, with the majority waiting longer than the 72-hour NICE target. Admission towards the end of the week, defined as Wednesday to Saturday, was associated with longer delay. Coronary revascularisation was not required in 34% of patients. The presence of obstructive coronary disease and use of coronary revascularisation varied with age and sex, with younger female patients more likely to have normal coronary arteries or mild non-obstructive plaque disease. Use of percutaneous coronary intervention (PCI) varied with supervising consultant operator. These findings highlight disparity between clinical practice and NICE guideline recommendations for NSTEMI-ACS patients admitted to hospitals without invasive cardiac facilities, and highlight the need for the development of treatment pathways that reduce delay and better identify patients who will benefit from coronary revascularisation.

A 79-year-old woman presents to the hospital with dyspnoea, fever, and hypotension, and is diagnosed with community-acquired pneumonia and septic shock. Resuscitation is initiated with fluids and vasopressors, and a central venous catheter is placed. However, during the procedure, the guide experiences resistance and cannot be removed, becoming trapped. This is confirmed with tomography and reconstruction, demonstrating intravascular position. The patient is then sent to interventional cardiology for extraction, which is successfully performed using the EN Snare (Merit Medical). The significance of this case lies in the complications of not guiding procedures with ultrasound and how to resolve them, such as the guide being trapped in this patient.

In this four-part editorial series, we have looked at the significance of research within cardiology training in the UK. The first three instalments explored the impact of research on a career in cardiology, identified the diverse research avenues, and provided guidance on navigating the application process. In the final part of this series, our focus shifts to post-higher degree opportunities within the field, and discuss the skills developed in research that can be applied to clinical practice.

Ejection fraction (EF) offers a remarkable approach to assess ventricular and atrial pumping capacity. Its value can easily be calculated, and it seems to reflect performance. However, EF is a non-preferred candidate from a conceptual point of view. To fully understand the weakness of the EF metric, it is necessary to appreciate that its numerical value (by its definition) solely depends on end-systolic volume (ESV) and end-diastolic volume (EDV). This tight mathematical connection can best be graphically represented in the ventricular volume domain while relating ESV to EDV, leading to straight conclusions about EF. No previous paper has addressed the curious tradition of applying EF in cardiology in terms of the indirect reasons for its popularity, as well as the intrinsic shortcomings, alongside the statistical irregularities involved. This review highlights the misleading attractiveness of EF, while also offering logical alternatives without invoking the need for relying on additional data beyond standard measurements.

Heart failure (HF) is a prevalent and complex condition that demands precise and efficient management. This paper delves into a critical, yet often under-recognised, challenge in HF care - the accurate coding of patients on HF registers. We explore how discrepancies in coding, including missing patients and incorrect HF type classifications, can significantly impact patient management. The experiences of our healthcare system's staff are examined to shed light on the real-world implications of these issues. Clinicians and administrative staff in primary care can play a pivotal role in identifying, monitoring, and ensuring the accuracy of patient coding. By sharing their insights, we uncover the intricacies of addressing coding discrepancies and strategies suggested to optimise patient management. Furthermore, we investigate the technology and systems in place to aid staff in this endeavour. This paper aims to contribute to the broader healthcare community's understanding of the challenges related to coding accuracy in HF registers and to offer insights into potential solutions. By rectifying these coding discrepancies, we can enhance patient care, minimise potential oversights, and ultimately improve outcomes for individuals living with HF. Our findings underscore the significance of ensuring that no HF patient is missed or misclassified, emphasising the need for continued improvement in this vital aspect of HF care.

Drug-eluting stents (DES) are a common treatment for acute coronary syndrome (ACS) but pose risks like bleeding, re-stenosis, stent thrombosis, and neo-atherosclerosis. Drug-coated balloons (DCB) may mitigate these risks. This study compares DCB therapy's effectiveness with DES in ACS patients with de novo lesions. A retrospective observational study was conducted on ACS patients undergoing percutaneous coronary intervention (PCI) with either DES or DCB from May 2019 to August 2022 at a single tertiary centre. Patients with left central trunk lesions were excluded. The primary end point was a composite of major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, and target lesion revascularisation, evaluated 12 months post-intervention. Statistical analysis was performed using R software with significance set at a two-tailed p value <0.05. Of 168 patients, 101 received DES and 67 received DCB. The DCB group had a mean age of 61.9 years, while the DES group averaged 63 years. The DCB group had more prior PCIs and myocardial infarctions. Baseline characteristics, including target and number of lesions, were comparable. MACE occurred in eight (11.9%) DCB patients and 11 (10.9%) DES patients, showing no significant difference (p=0.64). In conclusion, this study suggests that DCB therapy may be an effective alternative to DES for ACS. However, limitations, including a single-centre setting and short follow-up, warrant the need for more extensive, randomised trials to validate these findings.