Recent Submissions

  • Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries

    Jan, A; Riaz, A; Gill, M; Sewell, T A (Atherosclerosis, 2019-06)
    Background and aims: One of the objectives of the ESC-EORP EUROASPIRE V survey is to determine how well European guidelines on the management of dyslipidaemias are implemented in coronary patients. Methods: Standardized methods were used by trained technicians to collect information on 7824 patients from 130 centers in 27 countries, from the medical records and at a visit at least 6 months after hospitalization for a coronary event. All lipid measurements were performed in one central laboratory. Patients were divided into three groups: on high-intensity LDL-C-lowering-drug therapy (LLT), on low or moderate-intensity LLT and on no LLT. Results: At the time of the visit, almost half of the patients were on a high-intensity LLT. Between hospital discharge and the visit, LLT had been reduced in intensity or interrupted in 20.8% of the patients and had been started or increased in intensity in 11.7%. In those who had interrupted LLT or had reduced the intensity, intolerance to LLT and the advice of their physician were reported as the reason why in 15.8 and 36.8% of the cases, respectively. LDL-C control was better in those on a high-intensity LLT compared to those on low or moderate intensity LLT. LDL-C control was better in men than women and in patients with self-reported diabetes. Conclusions: The results of the EUROASPIRE V survey show that most coronary patients have a less than optimal management of LDL-C. More professional strategies are needed, aiming at lifestyle changes and LLT adapted to the need of the individual patient.
  • Advancements in Gene Therapy approaches for Atrial Fibrillation: Targeted delivery, Mechanistic Insights and Future Prospects

    Toru, Hamza Khan (Current Problems in Cardiology, 2024-04)
    Atrial fibrillation (AF) remains a complex and challenging arrhythmia to treat, necessitating innovative therapeutic strategies. This review explores the evolving landscape of gene therapy for AF, focusing on targeted delivery methods, mechanistic insights, and future prospects. Direct myocardial injection, reversible electroporation, and gene painting techniques are discussed as effective means of delivering therapeutic genes, emphasizing their potential to modulate both structural and electrical aspects of the AF substrate. The importance of identifying precise targets for gene therapy, particularly in the context of AF-associated genetic, structural, and electrical abnormalities, is highlighted. Current studies employing animal models, such as mice and large animals, provide valuable insights into the efficacy and limitations of gene therapy approaches. The significance of imaging methods for detecting atrial fibrosis and guiding targeted gene delivery is underscored. Activation mapping techniques offer a nuanced understanding of AF-specific mechanisms, enabling tailored gene therapy interventions. Future prospects include the integration of advanced imaging, activation mapping, and percutaneous catheter-based techniques to refine transendocardial gene delivery, with potential applications in both ventricular and atrial contexts. As gene therapy for AF progresses, bridging the translational gap between preclinical models and clinical applications is imperative for the successful implementation of these promising approaches.
  • Beyond Symptoms: Unlocking the Potential of Coronary Calcium Scoring in the Prevention and Treatment of Coronary Artery Disease

    Mahmoud, Hassan Ali Ahmed
    Coronary Artery Disease (CAD) represents a persistent global health menace, particularly prevalent in Eastern European nations. Often asymptomatic until its advanced stages, CAD can precipitate life-threatening events like myocardial infarction or stroke. While conventional risk factors provide some insight into CAD risk, their predictive accuracy is suboptimal. Amidst this, Coronary Calcium Scoring (CCS), facilitated by non-invasive computed tomography (CT), emerges as a superior diagnostic modality. By quantifying calcium deposits in coronary arteries, CCS serves as a robust indicator of atherosclerotic burden, thus refining risk stratification and guiding therapeutic interventions. Despite certain limitations, CCS stands as an instrumental tool in CAD management and in thwarting adverse cardiovascular incidents. This review delves into the pivotal role of CCS in CAD diagnosis and treatment, elucidates the involvement of calcium in atherosclerotic plaque formation, and outlines the principles and indications of utilizing CCS for predicting major cardiovascular events.

    Aye, Thandar; Appalanaidu, Nageswary (Heart, 2023-06)
    Introduction The 2021 ESC guidelines emphasise the importance of appropriate diagnosis and management of heart failure as it represents a condition with significant heterogeneity. Based on the NICOR heart failure audit 2021, the mortality rates are high with 40% of newly diagnosed patient are dying within a year and 50% of patients are either readmitted to hospital or dying within a year of admission to hospital. Pharmacotherapies such as beta blockers, angiotensin-converting enzyme inhibitors (ACEi) / angiotensin receptor neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLTi) and mineralocorticoid receptor antagonists (MRA) have proven to show marked reduction in mortality and morbidity. It is the cornerstone prior to considering non-pharmacological interventions such as device therapy. The aim of our study is to assess prescribing practice in commencing appropriate medications in patients with heart failure with reduced ejection fraction (HFrEF) in a district general hospital setting. Method A retrospective analysis based on data from NICOR of patients presenting to Kings Mill Hospital with diagnosis of heart failure between December 2020 – December 2021 was performed. We looked into parameters such as co-morbidities including a diagnosis of pre-existing heart failure, echocardiography results, heart failure medications on admission and on discharge, blood tests (potassium levels and eGFR) and haemodynamic (blood pressure and heart rates) were collected and collated. Results A total of 219 patients with diagnosis of heart failure were admitted. The mean age is 80 years old with a slight predominance of female patients at 51%. It was noted that 55% of these admissions had pre-existing diagnosis of HFrEF. 51% of the patients had echocardiogram during the admission and 40.2% have HFrEF. The calculated mortality is 26.5% in this cohort. Patients with new diagnosis of HFrEF were better optimised with medications (Figure 1) compared to the ones with pre-existing diagnosis. Substandard heart failure medication optimisations are due to medication intolerance, worsening renal function / hyperkalemia and haemodynamic effects such as hypotension. Only 2% of patients were on SGLT2i and ARNI compared to ACEi/ARB due to lack of familiarity of indication for prescribing. All patients had appropriate potassium levels as well as establishment of optimal heart rate and blood pressure control prior to discharge. Conclusion This analysis highlights that patients are not fully optimized on oral heart failure therapies prior to hospital discharge. Robust measures must be taken in commencing on SGLT2i and ARNI. We need to take opportunities to optimise the medications of patients with established diagnosis. These findings will form the basis of our quality improvement project on heart failure medications optimization and more analysis will follow in future.
  • Reminder to quote myocardial infarction and emergency angioplasty when consenting for dobutamine stress echo – a rare case

    Aye, Thandar; Appalanaidu, Nageswary (Heart, 2023-06)
    Background Dobutamine stress echocardiogram (DSE) is a widely used diagnostic tool for patients with new onset chest pain in whom angina cannot be ruled out by clinical assessment alone. It is also used for risk stratification to guide coronary revascularization for patients with known ischaemic heart disease. It is a low-risk procedure and myocardial infarction is quoted as a rare complication of the test. Case Summary A 38-year-old gentleman presented to chest pain clinic for symptoms of atypical chest pain. He has been getting a central throbbing discomfort with no radiation. His pain was normally exacerbated on exertion lasting for 20 minutes and eased with rest; associated with feeling hot and sweatiness. Similar symptoms could also occur at rest with some episodes lasting for a few hours; associated with nausea as well as pins and needles. In view of these atypical symptoms, he had Spider flash monitor, echocardiography and dobutamine stress echocardiography for further assessment. The Spiderflash did not capture arrhythmias and echocardiogram showed normal left ventricular systolic function. He attended DSE which showed no evidence of regional wall motion abnormality nor ischaemic changes at any stages of the test including peak stress. He later developed vasovagal response to high dose of Dobutamine (40mcg/Kg/min) with blood pressure dropping to 58/39 mmHg. He had chest discomfort at this stage but there was no regional wall motion abnormality or ECG changes. This all resolved after stopping Dobutamine and systolic blood pressure returned to >90mmHg. As per practice, the patient was kept outside to monitor for delayed complications. A few minutes later, he experienced severe chest discomfort, sweatiness, and clamminess. He was promptly assessed, and subsequent echo showed new hypokinesia at inferoseptum and inferior walls. 12 lead ECG showed inferolateral ST elevation with new LBBB (Figure 1). He was then transferred to the primary PCI centre. Coronary angiogram revealed complete occlusion of distal segment of the right coronary artery (Figure 2) which was successfully treated with angioplasty and drug eluting stent. Recovery was uneventful and he was discharged with dual antiplatelets and secondary prevention therapies. Conclusion and Discussion In our case, the clinical timeline and imaging features suggest that initial DSE was normal, however, the test may have contributed to endothelial shear stress and plaque rupture leading to ST elevation acute myocardial infarction. Although the occurrence of acute coronary syndrome after dobutamine administration during stress testing may be coincidental, clinicians should be aware of the possible rare complications and should educate patients when ordering stress tests. Such risk should be clearly mentioned when consenting patients for DSE.

    Kyaw, Myat; Aye, Thandar
    Background Association between the heart and the thyroid gland has been well-known for 200 years, from hyperthyroidism leading to cardiac arrhythmias and high-output heart failure to cardiovascular diseases in hypothyroidism through accelerated atherosclerosis and endothelial dysfunction. We present a case which demonstrates another conjunction between the heart and the thyroid. Case Presentation A 32-year-old female presented to the A&E department with chest pain, vomiting, and generalized unwellness. She has been well previously, without any underlying medical disease. Her EWS score was 7 with tachycardia and high fever. Blood results showed microcytic anaemia, leucocytosis and raised C-reactive protein. She was treated for sepsis which later turned out to be infective endocarditis. Blood culture was positive for Staph aureus. The subsequent echocardiogram showed a vegetation of 1.2cm x 0.8cm at the posterior mitral valve (figure 1). Interestingly, she was found to be hyperthyroid from thyroid screening prompted by tachycardia presentation. Thyroid stimulation hormone (TSH) was high <0.01 (0.5–5 μIU/mL). TSH receptor antibodies and thyroid peroxidase (TPO) antibodies were also high. Carbimazole and beta-blocker were initiated. Despite antibiotic therapy, the patient required mitral valve replacement because of the vegetation size, persistently raised inflammatory markers and incompetent mitral valve. Surgical findings include large vegetation on P2 segment of the mitral valve, with deep abscess cavity underneath. She was discharged without further complications and her thyroid status normalized 3 months later with carbimazole. Discussion Although thyrotoxicosis together with infective endocarditis is a rare presentation, any organ involvement is possible with endocarditis. There have been a few case reports of suppurative thyroiditis or thyroid abscess in infective endocarditis. In our case, there have been no symptoms such as neck pain or swelling and thyroid gland appears normal from CT scan. Presence of TSH receptor antibodies and TPO antibodies suggest autoimmune thyroiditis nature. Association between autoimmune thyroiditis and infected cardiac valves can be explained by several mechanisms. In Graves’ disease, circulating TSH receptor autoantibodies activate mucopolysaccharide-secreting endothelial cells leading to thickening and myxomatous changes with likelihood of endocarditis in transient bacteremia. Conversely, various infections are suggested to trigger autoimmune thyroid disorders due to the release of sequestered antigens from inflammation and molecular mimicry of the infective organisms. Psychological stress is also a factor known to precipitate autoimmunity. Infective endocarditis reflects both. Conclusion This case highlights the importance of thyroid investigation in the management of infective endocarditis. It also illustrates the possible association between autoimmune thyroid disease and infective endocarditis.
  • Effects of haemodynamically atrio-ventricular optimized His-pacing on heart failure symptoms and exercise capacity: The His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) randomised, double-blind, cross-over trial

    Bassi, Sukhbinder
    Aims: Excessive prolongation of PR interval impairs coupling of AV contraction, which reduces left ventricular pre-load and stroke volume, and worsens symptoms. His-bundle pacing allows AV-delay shortening while maintaining normal ventricular activation. HOPE-HF evaluated whether AV-optimized His pacing is preferable to no-pacing, in double-blind cross-over fashion, in patients with heart failure, left ventricular ejection fraction (LVEF) ≤40%, PR interval ≥200ms and either QRS ≤140ms or right BBB. Methods and Results: Patients had atrial and His-bundle leads implanted (and an ICD lead if clinically indicated) and were randomized, to 6-months of pacing and 6-months of no-pacing utilizing a cross-over design. The primary outcome was peak oxygen uptake during symptom-limited exercise. Quality of life, LVEF and patients' holistic symptomatic preference between arms were secondary outcomes. 167 patients were randomized: 90% men, 69±10 years, QRS duration 124±26ms, PR interval 249±59ms, LVEF 33±9%. Neither peak VO 2 (+0.25 ml/min/kg, 95% CI -0.23 to +0.73, p=0.3) nor LVEF (+0.5%, 95% CI -0.7 to 1.6, p=0.4) changed with pacing but Minnesota Living with Heart Failure quality of life improved significantly (-3.7, 95% CI -7.1 to -0.3, p=0.03). 76% of patients preferred His-bundle pacing-on and 24% pacing-off (p<0.0001). Conclusion: His-bundle pacing did not increase peak oxygen uptake but, under double-blind conditions, significantly improved quality of life and was symptomatically preferred by the clear majority of patients. Ventricular pacing delivered via the His bundle did not adversely impact ventricular function during the 6 months
  • Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial

    Fazal, Iftikhar (Circulation, 2022-08)
    Background: Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. Methods: We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non-ST-segment-elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. Results: In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3-5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613-£7015); and angiography+FFR, £4510 (£2721-£7415; P=0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60-87); and angiography+FFR, 75 (interquartile range, 60-90; P=0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR (P=0.64). Conclusions: A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life.
  • Invasive coronary physiology assessment - safety of pressure wire study as a diagnostic tool at a district general hospital

    Dardas, Sotirios; Jesudason, Daniel (Heart, 2022-06)
    Introduction Pressure wire study (PWS) is a well-established tool for the assessment of the haemodynamic significance of intermediate coronary artery stenoses (40–90%). This, according to the 2018 ESC myocardial revascularization guidelines, has Class IA indication when evidence of ischaemia is not present. It can be used to calculate the fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) or resting full cycle ratio (RFR) to guide revascularization decisions, with similar diagnostic accuracy between the tests. Despite the above, the utilization of PWS varies across the U.K., as reflected in the recent BCIS annual data. One possible explanation might be the fact that there are still numerous centres in the U.K, where diagnostic only coronary angiography lists take place, precluding the use of PWS at the same sitting. In our study, we aimed to review the safety of PWS as an invasive diagnostic tool and determine whether it could be incorporated in diagnostic only lists for the assessment of coronary stenoses.
  • Atypical presentation of ventricular tachycardia

    Malik, F; Khaing, T; Adlakha, S; Aye, T (2020-05)
    Cardiac syncope and epileptic seizure are two very similar presentations and difficult to differentiate without a proper history, physical examination and investigations. In a former study, 10 out of 22 episodes of induced ventricular tachycardia or fibrillation can result in stereotypical tonic-clonic movement with varied electroencephalography changes. We present a case which was diagnosed as ventricular tachycardia from seizure-like attack. It is to emphasise the importance of including ventricular tachycardia among other differential diagnoses of seizure-like activity in a patient with cardiovascular risks.
  • Atrial flutter with flecainide-induced 1:1 conduction at a rate <200 b.p.m. at rest: a case report

    Dardas, Sotirios; Khan, Asif (European Heart Journal. Case Reports, 2021-10)
    Background : Class IC antiarrhythmic drug flecainide is commonly used in the management of atrial arrhythmias and in particular atrial fibrillation (AF). Although previously reported as a potential complication, atrial flutter (AFL) with 1:1 atrioventricular (AV) conduction is rare, with only few cases reported so far, most of which related to physical activity. In all previous reported cases, 1:1 conduction resulted in ventricular rates of >200 b.p.m. Case summary : We report the case of a 60-year-old woman, who presented to our local emergency department with palpitations related to acute onset AF. The patient developed symptomatic 1:1 AFL with a rate of 192 b.p.m., shortly after administration of intravenous flecainide, which spontaneously converted back to AF and subsequently to sinus rhythm, with further administration of amiodarone and beta-blocker. Discussion : The case raises awareness of this rare but potentially life-threatening complication to those using flecainide for pharmacological cardioversion of AF. QRS complex widening can be seen in the context of very rapid ventricular rates, posing additional diagnostic challenge, especially with rates of <200 b.p.m. Prescribing an AV nodal blocking agent, such as a beta-blocker, together with flecainide reduces significantly the risk of 1:1 conduction and should always be considered.
  • His bundle pacing, learning curve, procedure characteristics, safety and feasibility: insights from a large international observational study

    Bassi, Sukhbinder (2019-10)
    Background: His‐bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques' feasibility; however, data have come from a limited number of centers. Objectives: We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes. Methods: This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated. Results: A total of 529 patients underwent attempted HBP during the study period (2014‐19) with a mean follow‐up of 217 ± 303 days. Most implants were for bradycardia indications. In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases. All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His‐bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check. HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants. There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30‐50 cases. Conclusion: We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30‐50 cases.