Search

Aims Evaluate whether UK National Institute for Health & Care Excellence (NICE) chronic heart failure (HF) guidelines can be safely and effectively refined through specialist referral management. Methods and results All referrals to a UK centre 1/3/2019–30/5/2019 and 1/6/2020–31/7/2020 were reviewed by HF specialists. Patients were triaged to specialist assessment in HF clinic, according to the NICE HF diagnostic pathway [urgency based on N‐terminal pro brain natriuretic peptide (NTproBNP) levels], or the referrer given remote Advice & Guidance (A&G), to aid primary care management. Standardized triage criteria for recommending primary care management were (i) presentation inconsistent with HF, (ii) competing comorbidity/frailty meant specialist assessment in clinic not in patient's best interests, (iii) recent assessment for same condition, or (iv) patient had known HF. Following triage patients managed in the primary care were categorized as low or high risk of adverse outcomes. Outcome measures were 90 day all‐cause and HF hospital admission and mortality rates. Four hundred and eighty‐six patients had the median age of 80 (74–86) years, and 253 (52%) were male. Two hundred and six (42%) had NTproBNP > 2000 pg/mL. Primary care management was recommended for 128 patients (26%): 105 (22%) A&G alone and 23 input from community HF nurse specialists. Primary care management was recommended due to the following: presentation inconsistent with HF 53 (42%), more important competing comorbidity/frailty 35 (27%), recent assessment 17 (13%), and known HF 23 (18%). Patients managed in primary care had higher rates of all‐cause hospitalization (30% vs. 19%; P = 0.018) and death (7% vs. 2%; P = 0.0054) than those seen in HF clinic. Of those managed in primary care, 50 (39%) were determined to be at low risk and 78 (61%) at high risk. High‐risk patients were older (87 vs. 80 years; P = 0.0026), had much higher NTproBNP (2666 vs. 697 pg/mL; P

ObjectiveTo describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines.MethodsNICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400–2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement.Results1271 patients (median age 80; IQR 73–85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (pConclusionsOutcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.

ObjectiveTo understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload.MethodsSingle centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance.Results264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred.ConclusionsIn this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.

Definition and classification—heart failure is a clinical syndrome caused by cardiac dysfunction, most commonly left ventricular systolic dysfunction (LVSD). Many epidemiological studies focus on characterizing the incidence and/or prevalence of LVSD, using cut off points ranging from less than 30% to less than 50%. Patients with heart failure symptoms or signs and normal or near normal LV function are often classified as having heart failure with preserved ejection fraction (HF-PEF), but there is no clear and generally accepted definition of this condition. Epidemiology—estimates of incidence and prevalence are heavily influenced by definition. An echocardiographic study of a random sample of the general population aged 25–74 years in Glasgow (Scotland) estimated a prevalence of heart failure of 1.5%, with a further 1.4% having asymptomatic LVSD. Prevalence rises significantly with age, with a median age of first presentation in the mid seventies. Longitudinal data suggests that the incidence of heart failure has remained fairly stable over the last few decades, but prevalence is increasing as more people survive cardiovascular disease earlier in life. Aetiology—determining the aetiology of heart failure in epidemiological studies is difficult: the commonest cause in the developed world is coronary artery disease, followed by hypertension, which predominates in those with a diagnosis of HF-PEF. Prognosis and morbidity—data from the United States of America and the United Kingdom show the death rates of those admitted to hospital with a diagnosis of heart failure have a mortality of over 30% at one year. The outcome has improved in recent years, perhaps linked to the increased usage of angiotensin inhibitors and β‎-blockers. Heart failure accounts for around 5% of all adult general medical admissions, and in developed countries the condition consumes 1 to 2% of health care budgets.

Purpose: To determine the prognostic implications of changes towards hyponatremia at varying time-points in the treatment of patients undergoing cardiac resynchronisation therapy (CRT). Methods: A retrospective series of 249 patients was studied from 2002 to 2013. The population was categorized on the basis of serum sodium profile at baseline, at 1 month and at 6 month follow up visits following successful CRT implantation. The composite endpoint was all-cause mortality and heart failure hospitalisation (defined by the need for intravenous diuretic therapy) following CRT implantation. Results: A total of 249 patients (67.8 ± 12.5 years; NYHA class III/IV 75; LVEF 27.2 ± 8.8%) were followed up for a median of 5.5 years. Hyponatremia at baseline, 1 month or 6 months follow up did not predict the composite endpoint. 26% of patients showed hyponatremia at baseline prior to CRT implantation, while it was present in 19.9% of patients 1 month (p = 0.003) and in 16% (p 7.0 mmol/l) (HR 1.61 [1.05–2.46], p = 0.03) at baseline were associated with an increased risk of unplanned heart failure hospitalisation and all-cause mortality after CRT implantation. Conclusions: A change towards hyponatremia when observed 6 months after CRT implantation may predict a worse clinical outcome. Additionally, renal impairment and higher diuretic doses are associated with an increased risk of mortality in the population analysed.

Introduction Chronic heart failure (HF) represents a substantial and growing public health and financial burden and has a poor prognosis. National Institute for Health and Care Excellence (NICE) guidelines and quality standards recommend timely specialist assessment for patients with suspected HF and raised natriuretic peptides. However, data on the outpatient population assessed, diagnostic rates of HF and outcomes for patients on this pathway are not known. This is in contrast to patients hospitalised with acute HF who are well described in the UK. Our aim is to describe real world data from a large patient cohort with suspected HF investigated according to NICE protocols. Methods All patients with suspected HF and elevated NTproBNP referred to a dedicated HF clinic between January 2014 – December 2016 were included. Patients underwent specialist assessment, echocardiography and diagnosis in a one-stop clinic within 2 weeks (NTproBNP>2000pg/ml) or 6 weeks (NTproBNP 400–2000pg/ml) in accordance with NICE guidelines. Patient baseline characteristics and co-morbidities were recorded prospectively. 1 year all-cause hospitalisation (1 or more admissions) and mortality rates were retrospectively calculated from the date of NTproBNP measurement using hospital coding data and electronic patient records. Outcomes were compared between those referred on the 2 and 6 week pathways; and between those diagnosed with Heart Failure (HF) vs. Not Heart Failure (NHF) after specialist assessment. Results Out of 1042 consecutive patients referred, 1013 had NTproBNP measured and were included. 544 (54%) were on the 2-week and 469 (46%) on the 6-week pathway. 543 (54%) were diagnosed with HF; 300 (55%) with Heart Failure with reduced Ejection Fraction (HFrEF) and 243 (45%) with Heart Failure with preserved Ejection Fraction (HFpEF). 454 (45%) were diagnosed as NHF. A diagnosis of HF was made in 383 (70%) in the 2-week and 160 (34%) in the 6-week pathway (p For the entire population the 1-year hospitalisation rate was 324/1013 (32%) and mortality 112/1013 (11%). There were significantly higher rates of both mortality (88 [16%] vs 24 [5%] p Conclusion The prognosis is relatively poor for outpatients with suspected chronic HF and raised natriuretic peptides, with high rates of adverse outcomes observed despite specialist investigation in accordance within NICE timeframes. This is regardless of the final diagnosis, as mortality is comparable between HF and NHF groups. The proportion of patients diagnosed with HF in the 2-week pathway was high. As expected, patients referred via the 2-week pathway had significantly higher rates of both mortality and hospitalisation. This study provides valuable real world data and insight into an important population, which will help inform discussions with patients and shape chronic HF services. Conflict of Interest None

Purpose To understand factors contributing to disturbances during cardiac procedures, including frequency and nature of distractions, along with assessment of operator ‘work-load’ through NASA Task-load indices. Methods A single centre prospective observational study was conducted on 194 consecutive patients undergoing cardiac procedures in 3 adult cardiac CL’s over a period of 4 weeks. A distraction pro-forma was completed for each case by CL team members (predominantly physiologists), documenting procedural logistics and referring both to the level of risk of the procedure at that time (table 1) and frequency, nature and magnitude of each distraction/interruption (table 2). The primary operator completed a NASA Task-load questionnaire rating parameters to include mental and physical effort, level of frustration, time–urgency, and overall effort and performance on a scale of 1 – 21. Results 264 distractions occurred in 106 procedures (55% of total); 80% were not relevant to the case being undertaken; 13% were due to emergencies occurring in the ‘Hot- Lab’ predominantly to discuss potential ST-elevation myocardial infarction requiring emergency angioplasty. Frequency of distractions per case ranged from 1 to 16, with an average of 2.5; 16% (n=43) of these were documented to occur during high-risk stages (categories 3 or 4) of the procedure. Operator rating of NASA task-load parameters demonstrated higher levels of ‘mental’ and ‘physical’ workload and ‘effort’ when distractions occurred (figure 1). Conclusion In this first description of human factors in the adult cardiac CL we have shown that less than half of all procedures are completed without interruption/distraction. The vast majority of these are unnecessary and without relation to the case or list. We therefore propose the introduction of a ‘sterile cockpit’ environment in the CL, as has been adapted from the aviation industry within surgical operating theatres, to minimise non-emergent interruptions and disturbances, in an attempt to improve operator conditions and overall patient safety. Conflict of Interest Nil

Ivabradine, acting on the funny channel (If) in the sino-atrial node, reduces myocardial oxygen demand without inducing hypotension. It was developed as a specific bradycardic agent in the 1980s, avoiding the adverse effects of more traditional antianginal agents (beta-blockers and calcium channel antagonists). This has seen significant interest in this first-in-class treatment, and is perceived as a promising drug in the management of ischaemic heart disease and heart failure. There has been much clinical research conducted exploring its role in these fields, to try to elucidate potential benefits and target patient group. The side effect profile of ivabradine ensures it is well tolerated, and consistently leads to a reduction in heart rate. This review discusses the drug development and trial data in ischaemic heart disease and chronic left ventricular systolic dysfunction. Key clinical trials and observational studies are discussed in depth to examine potential explanations of unexpected or diverging results. The emerging role of ivabradine in acute decompensated heart failure is explored with recent trial data, providing a potential novel treatment avenue in this difficult to manage patient cohort. The role of intravenous ivabradine, as a beneficial tool in the acute hospital setting, when oral medication is not ideal, or where fast onset of action is required, in cardiac computerised tomography for example, is also discussed. Future directions for research are highlighted, including options for further elucidating unexplained results from previous studies.

Developments within the field of heart failure have steadily advanced over the last four decades. Techniques to diagnose, manage, and improve the plight of a patient with heart failure have been revolutionized during this time period. In addition, there has been a wealth of epidemiological data accompanying these scientific achievements. This has led to an enhanced understanding of the disease on a population basis. The burden of heart failure has meant that robust pertinent data are now available on its incidence, prevalence, impact on health resources, and prognosis. This chapter gives a brief overview of the field and hopefully will stimulate further interest.

Introduction Natriuretic peptides, including NTproBNP, are elevated in heart failure (HF) and correlate with prognosis. They also predict the development of HF and are associated with an adverse outcome in patients without overt HF. NICE CG108 mandates that patients with potential HF and elevated natriuretic peptides are evaluated with echocardiography and specialist assessment. There are few data on how outcomes compare based on whether the final diagnosis is HF or not after assessment. Furthermore, the incidence of subsequent HF in patients where the diagnosis is initially rejected is unknown. Methods All patients with possible HF and raised NTproBNP referred to a single centre specialist HF clinic in a 1 year period from March 2014 were identified. Patients were seen within 2 (NTproBNP >2000 pg/ml) or 6 (NTproBNP 400­2000 pg/ml) weeks of referral in line with NICE CG108. Hospital coding data and electronic patient records were used to identify all-cause unplanned hospital admissions and mortality over a minimum follow up period of 2 years. Event rates were compared between patients with a final diagnosis of HF and those without (no heart failure-NHF). We also recorded how many NHF patients went on to develop HF. Results 235 patients were seen and form the study population. Mean follow up was 29±4 months. 133 (56%) patients were diagnosed with HF; 63 (47%) with HF with Reduced Ejection Fraction (HFREF) and 70 (53%) with HF with Preserved Ejection Fraction (HFPEF). 102 (43%) were diagnosed as NHF. Comorbidities in the NHF group are shown in table 2. Patients in the two groups were similar in age. HF patients had much higher NTproBNP levels and higher rates of AF and diabetes (table 1). Despite this, there were no differences in either mortality (HF 23% and NHF 22%; p=0.75) or hospitalisations (HF 41% and NHF 40%; p=0.95) between the groups; figure 1. 7 (7%) of NHF patients were subsequently diagnosed with HF. Negative predictive value of a NHF diagnosis was 93%. Conclusions Patients with suspected HF and raised natriuretic peptides are at high risk of adverse outcomes regardless of the final diagnosis after specialist evaluation. Much higher NTproBNP levels and higher rates of diabetes and AF in the HF group did not translate into a worse prognosis. This may be due to the fact that patients with a HF (in particular HFREF) diagnosis were considered for evidence based therapies. The adverse outcome in the NHF group is not explained by unrecognised HF at assessment as subsequent presentations with HF were uncommon. These findings should be taken into consideration when framing our discussions with all patients with elevated NTproBNP regarding their prognosis.

Heart failure remains a widespread commonly encountered clinical condition. It is responsible for increased healthcare expenditure, driven by frequent and often prolonged hospital admissions associated with an increased mortality. A clinically useful classification of the syndrome is, patients with left ventricular systolic impairment (Heart Failure and reduced ejection fraction, HFREF) and patients with preserved left ventricular systolic function (HFPEF). The pharmacological treatment for patients with HFREF has evolved over the last twenty five years, focusing on modulation of the neurohormonal activation which represents a hallmark of this condition. This has led to the development of a stepwise treatment algorithm predominately based on inhibition of the renin angiotensin aldosterone pathway and counteracting sympathetic over-activation. In particular since the early trials in chronic heart failure (CHF) demonstrated a significant mortality benefit with ACE-inhibitors, subsequent studies have been conducted in conjunction with these drugs. The rationale being that it would be unethical to trial any new agent without the concomitant use of ACE-inhibitors. The recent publication of the PARADIGM -HF study has challenged this convention by trialling a novel pharmacological agent against an ACE-inhibitor in a landmark trial. The review sets out the current pharmacological treatment for patients with heart failure and discusses the recent findings with this novel class of medication.

Cardiac resynchronisation therapy (CRT) is an established treatment for selected patients with symptomatic left ventricular (LV) systolic dysfunction. Heart failure (HF) is primarily a disease of the elderly; however, these patients are underrepresented in CRT trials. Our aim was to evaluate the impact of age on clinical outcomes following CRT. A consecutive series of 177 patients was identified and divided into those aged ≤75 years (n = 131, mean ± SD 62.1 ± 11.2 years) and those aged >75 years (n = 46, mean ± SD 80.7 ± 4.1 years). The primary end point was a composite of all-cause mortality or HF hospitalisation. During a median ± IQR follow up of 28.5 ± 33.7 months, the event rate for the primary end point was significantly higher in the elderly compared to younger patients (20.1 vs. 11.1 %, respectively, logrank p = 0.020). This was mainly driven by an excess mortality rate among those aged >75 years (10 vs. 4.7 %, respectively, logrank p = 0.018) whereas HF hospitalisation rates were similar between groups (10 vs. 6.4 %, respectively, logrank p = 0.301). After adjusting for comorbidities and ICD status, the difference in the composite end point rates was attenuated and no longer significant (HR 1.580, 95 % CI 0.899–2.778; p = 0.112 for >75 vs. ≤75 years). Notably, both groups demonstrated similar response rates to CRT in terms of symptomatic improvement, reverse LV remodelling and neurohormonal activation. CRT is equally effective in the elderly as in younger patients to reduce adverse clinical outcomes. For those who fulfil the prerequisite selection criteria, it should be considered as a valid therapeutic option.

Background— Cardiovascular magnetic resonance is the gold-standard technique for the assessment of ventricular function. Although left ventricular volumes and ejection fraction are strong predictors of outcome in dilated cardiomyopathy (DCM), there are limited data regarding the prognostic significance of right ventricular (RV) systolic dysfunction (RVSD). We investigated whether cardiovascular magnetic resonance assessment of RV function has prognostic value in DCM. Methods and Results— We prospectively studied 250 consecutive DCM patients with the use of cardiovascular magnetic resonance. RVSD, defined by RV ejection fraction ≤45%, was present in 86 (34%) patients. During a median follow-up period of 6.8 years, there were 52 deaths, and 7 patients underwent cardiac transplantation. The primary end point of all-cause mortality or cardiac transplantation was reached by 42 of 86 patients with RVSD and 17 of 164 patients without RVSD (49% versus 10%; hazard ratio, 5.90; 95% confidence interval [CI], 3.35–10.37; P P P P =0.006). Assessment of RVSD improved risk stratification for all-cause mortality or cardiac transplantation (net reclassification improvement, 0.31; 95% CI 0.10–0.53; P =0.001). Conclusions— RVSD is a powerful, independent predictor of transplant-free survival and adverse heart failure outcomes in DCM. Cardiovascular magnetic resonance assessment of RV function is important in the evaluation and risk stratification of DCM patients.

Aims Echocardiographic studies have shown that left atrial volume (LAV) predicts adverse outcome in small heart failure (HF) cohorts of mixed aetiology. However, the prognostic value of LAV in non-ischaemic dilated cardiomyopathy (DCM) is unknown. Cardiovascular magnetic resonance (CMR) allows accurate and reproducible measurement of LAV. We sought to determine the long-term prognostic significance of LAV assessed by CMR in DCM. Methods and results We measured LAV indexed to body surface area (LAVi) in 483 consecutive DCM patients referred for CMR. Patients were prospectively followed up for a primary endpoint of all-cause mortality or cardiac transplantation. During a median follow-up of 5.3 years, 75 patients died and 9 underwent cardiac transplantation. After adjustment for established risk factors, LAVi was an independent predictor of the primary endpoint [hazard ratio (HR) per 10 mL/m2 1.08; 95% confidence interval (CI) 1.01–1.15; P = 0.022]. LAVi was also independently associated with the secondary composite endpoints of cardiovascular mortality or cardiac transplantation (HR per 10 mL/m2 1.11; 95% CI 1.04–1.19; P = 0.003), and HF death, HF hospitalization, or cardiac transplantation (HR per 10 mL/m2 1.11; 95% CI 1.04–1.18; P = 0.001). The optimal LAVi cut-off value for predicting the primary endpoint was 72 mL/m2. Patients with LAVi >72 mL/m2 had a three-fold elevated risk of death or transplantation (HR 3.00; 95% CI 1.92–4.70; P < 0.001). LAVi provided incremental prognostic value for the prediction of transplant-free survival (net reclassification improvement 0.17; 95% CI 0.05–0.29; P = 0.002). Conclusions LAVi is a powerful independent predictor of transplant-free survival and HF outcomes in DCM. Assessment of LAV improves risk stratification in DCM and should be incorporated into routine CMR examination.

The National Institute for Health and Care Excellence (NICE) updated its guidelines for chronic heart failure (HF) in 2010. This re-audit assessed interim improvement as compared with an audit in 2011. Patients with HF (preserved and reduced ejection fraction) attending a tertiary cardiac centre over a 2-year period (January 2013–December 2014) were audited. The data collected included demographics, HF aetiology, medications, clinical parameters and cardiac rehabilitation. In total, 513 patients were audited. Compared with 2011, male preponderance (71%) and age (68±14 years, (Mean ± SD)) were similar. 73% of patients lived outside of London. HF aetiologies included ischaemic heart disease (37% versus 40% in 2011), dilated cardiomyopathy (26% versus 20%) primary valve disease (13% versus 12%). For patients with left ventricular systolic dysfunction (n=434, 85% of patients audited) 89% were taking beta-blockers (compared with 77% in 2011), 91% an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (86% in 2011) and 56% a mineralocorticoid receptor antagonist (44% in 2011); 6% were prescribed ivabradine. All patients were reviewed at least 6-monthly. Although 100% of patients were educated about exercise, only 21 (4%) enrolled in a supervised exercise programme. This audit demonstrated high rates of documentation, follow-up and compliance with guideline-based medical therapies. A consistent finding was poor access to cardiac rehabilitation.

This review provides a concise overview of the current understanding of chronic heart failure, focusing on the landmark clinical trials that form the basis of clinical management of patients with left ventricular systolic dysfunction.

V tomto clanku popisujeme dosud nepopsaný připad, a to pacientky, ktera přežila akutni aortalni syndrom bez chirurgicke intervence.

Dosing of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) may affect long-term outcomes. Retrospective data were collected at baseline and follow-up for consecutive patients who had CRT implanted and attended the institutional specialist HF pacing clinic. The study end point was death from any cause or hospitalization for worsening HF 24 months after implantation. Ninety-one patients (72 men, 68 ± 12 years old) with decreased left ventricular ejection fraction (24 ± 6%) were included. At baseline 85 patients (93%) were on ACE inhibitors/ARBs. At 6 months 3 patients had died and 86 of 88 (98%) were on ACE inhibitors/ARBs. Doses were uptitrated from 55 ± 35% of target dose (TD) at baseline to 62 ± 31% TD at month 6 (p = 0.018), whereas blood pressure was unchanged. Patients treated with50% TD of ACE inhibitors/ARBs (n = 20) at month 6 had worse 24-month event-free survival than those on 50% to 99% TD (n = 38, p = 0.011, log-rank test) or ≥100% TD (n = 30, p = 0.007, log-rank test). Failure to achieve a dose ≥50% TD of ACE inhibitors/ARBs at 6 months after CRT implantation was an independent predictor of all-cause mortality or hospitalization (hazard ratio 3.99, 95% confidence interval 1.66 to 9.62, p = 0.002) after adjustment for potential confounders including age, estimated glomerular filtration rate, diabetes and New York Heart Association class. In conclusion optimal dosing of ACE inhibitors/ARBs is an independent predictor of prognosis in patients with HF treated with CRT and it can be achieved by a structured follow-up within a specialized HF pacing clinic.

A 61-year-old gentleman was admitted to his local hospital with a 5-h history of central chest pain. He was an ex-smoker with no other cardiac risk factors or history of ischaemic heart disease. ECG on presentation demonstrated ST elevation in leads 1 and aVL consistent with acute myocardial infarction (MI) and he was therefore thrombolysed with tenecteplase. Following thrombolysis, his ST segment elevation resolved and his chest pain subsided completely. Peak CK was 1015 U/l (24–173 U/l) and troponin T 3.65 ug/l (0–0.10 ug/l). A routine PA chest radiograph revealed a widened superior mediastinum, raising the possibility of aortic dissection (Figure 1). An urgent contrast enhanced CT scan was therefore requested which demonstrated a type A aortic dissection with an aneurysmal ascending aorta (Figure 2). Figure 1. PA chest radiograph shows widening of the mediastinum and ectasia of the descending thoracic aorta. The lung fields are clear. Figure 2. CT aorta demonstrates type A aortic dissection. In the dilated ascending aorta there is thrombus within the false lumen (asterisk). The dissection can be seen to extend into the descending thoracic aorta (arrow). T = true lumen. Despite the CT findings, the patient remained well following thrombolysis with no subsequent clinical sequelae of acute aortic dissection. Further investigation with transthoracic echocardiography revealed good left ventricular function with no pericardial effusion. There was mild central aortic regurgitation but …

Left ventricular non-compaction (LVNC) is a genetic cardiomyopathy often familial and autosomal dominant. It is characterized by morphological abnormalities affecting the left ventricular myocardium with prominent trabeculations of the inner surface of the ventricle, often extending deep into the ventricular wall. There are no pathognomonic histological findings with normal myocytes being interspersed with areas of fibrosis. Both familial and sporadic forms of non-compaction have been described, the prevalence being estimated to be between 0.01% and 0.27%.1 The diagnosis of LVNC calls for multimodal imaging. Echocardiography, being the most widely available cardiac imaging modality, may raise the initial suspicion of LVNC and can also provide physiological data. See Table 1. Cardiac Magnetic Resonance Imaging (CMR) offers detailed visualization of the extent of non-compaction and supplemental morphological information.4 It should be noted that the current criteria for this condition may result in over diagnosis. View this table: Table 1 Criteria for the diagnosis of isolated left ventricular non-compaction A correct diagnosis is important both for subsequent treatment and also to enable appropriate genetic counselling and familial screening. It is suggested that first degree relatives should be screened. CMR is the best imaging modality currently, though other techniques in the future may be able to improve on diagnostic accuracy. LVNC is associated with LV systolic dysfunction, due to subendocardial hypoperfusion and microcirculation dysfunction, and at a lesser extent to diastolic dysfunction, ventricular arrhythmias, sudden cardiac death and systemic embolism. There is no specific treatment for LVNC at present, with the …

The 12th Annual Meeting of the British Society of Heart Failure was held in London (UK). As heart failure has evolved into an accredited subspecialty in its own right, the conference has become increasingly well attended. This year there were over 400 delegates from around the world. As per clinical practice, there were large numbers of multidisciplinary members including a strong representation from the heart failure specialist nurse division.

Acute heart failure (AHF) is a leading cause of hospitalisation in developed nations with stubbornly poor outcomes in both the short and long term. Furthermore, alongside an ageing population the incidence continues to increase. Contemporary practice guidelines accordingly emphasise the importance of early recognition of heart failure in the acute setting to facilitate the timely instigation of key investigations, appropriate management and access to specialist care; all of which improve outcome. However, the diagnosis of AHF is often challenging, with no gold standard diagnostic test and presenting clinical features that may be non-specific, particularly in the elderly where they may be atypical, or masked by co-morbidity. This short review explores the main clinical signs and radiographic changes in patients with AHF relevant to clinical practice in accordance with the best available evidence.

Background Based on the PARADIGM-HF study trial, sacubitril/valsartan (SV) was approved by NICE in April 2016 (TA388) for patients with symptomatic heart failure. SV is recommended in patients with a left ventricular ejection fraction (LVEF) 35% despite a stable dose of ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB), and large numbers are potentially eligible for this first-in-class drug. However, there is a lack of real world experience of both drug tolerability and systems for initiation and monitoring in overstretched heart failure services. Methods Suitable patients were identified and started on SV by heart failure specialists. Dedicated, registrar-delivered monitoring and up titration clinics were established. Patients were reviewed 2–4 weekly. Symptoms, vital signs, biochemistry and hospital admissions were recorded at each visit. Once stable on optimal doses, patients were discharged to primary care, as pre-arranged with the District Prescribing Committee. Our initial 6 month experience has been analysed. Results 69 patients (mean age 63.2±11.6 years) were commenced on SV. Mean LVEF 27.5±6.7%; mean baseline eGFR 66.1±21.9 ml/min/1.73m2. Prior to initiation of SV, mean baseline ACEi/ARB dose was equivalent to 16.3±6.7 mg enalapril daily. Overall 68/69 (98.6%) prescriptions of SV were NICE TA388 compliant (1 patient ACEi/ARB intolerant). 9 patients (13.0%) stopped the medication due to adverse effects (PARADIGM-HF 17.8%), whilst another 3 patients (4.3%) were down titrated to a tolerable lower dose. 15.9% of all patients experienced symptomatic hypotension (PARADIGM-HF 14.0%). No episodes of angioedema, nor significant deterioration in renal function (50% reduction in eGFR) were observed. Only 1 (1.4%) patient was hospitalised with decompensated heart failure symptoms, but 3 (4.3%) patients were admitted with syncope secondary to orthostatic hypotension. A total of 36 patients were discharged, with a median ?follow up time of 39 days (IQR 23) from commencement to?stable discharge dose each requiring 1 initiation consultation and a mean of 2.4±1.0 follow up consultations. The majority of patients 25 (69.4%) were discharged at the highest ?dose?–?97/?103 mg BD. 23 (63.9%) of those discharged reported a subjective improvement in symptoms and quality of life. Conclusions Initiation of SV and dose optimisation in clinical practice represents a significant burden of additional work for heart failure teams. Dedicated, registrar-led outpatient clinics to monitor patients commenced on SV by heart failure specialists can successfully address this. Prescribing within NICE TA388 guidelines in real world patients, there were similar drug tolerance and adverse event rates to those reported in PARADIGM-HF. However, the lower mean age within this particular population, who were carefully selected, may indicate that such findings are not representative of the entire heart failure population.

Risk stratification of patients with nonischemic dilated cardiomyopathy is primarily based on left ventricular ejection fraction (LVEF). Superior prognostic factors may improve patient selection for implantable cardioverter-defibrillators (ICDs) and other management decisions.To determine whether myocardial fibrosis (detected by late gadolinium enhancement cardiovascular magnetic resonance [LGE-CMR] imaging) is an independent and incremental predictor of mortality and sudden cardiac death (SCD) in dilated cardiomyopathy.Prospective, longitudinal study of 472 patients with dilated cardiomyopathy referred to a UK center for CMR imaging between November 2000 and December 2008 after presence and extent of midwall replacement fibrosis were determined. Patients were followed up through December 2011.Primary end point was all-cause mortality. Secondary end points included cardiovascular mortality or cardiac transplantation; an arrhythmic composite of SCD or aborted SCD (appropriate ICD shock, nonfatal ventricular fibrillation, or sustained ventricular tachycardia); and a composite of HF death, HF hospitalization, or cardiac transplantation.Among the 142 patients with midwall fibrosis, there were 38 deaths (26.8%) vs 35 deaths (10.6%) among the 330 patients without fibrosis (hazard ratio [HR], 2.96 [95% CI, 1.87-4.69]; absolute risk difference, 16.2% [95% CI, 8.2%-24.2%]; P.001) during a median follow-up of 5.3 years (2557 patient-years of follow-up). The arrhythmic composite was reached by 42 patients with fibrosis (29.6%) and 23 patients without fibrosis (7.0%) (HR, 5.24 [95% CI, 3.15-8.72]; absolute risk difference, 22.6% [95% CI, 14.6%-30.6%]; P.001). After adjustment for LVEF and other conventional prognostic factors, both the presence of fibrosis (HR, 2.43 [95% CI, 1.50-3.92]; P.001) and the extent (HR, 1.11 [95% CI, 1.06-1.16]; P.001) were independently and incrementally associated with all-cause mortality. Fibrosis was also independently associated with cardiovascular mortality or cardiac transplantation (by fibrosis presence: HR, 3.22 [95% CI, 1.95-5.31], P.001; and by fibrosis extent: HR, 1.15 [95% CI, 1.10-1.20], P.001), SCD or aborted SCD (by fibrosis presence: HR, 4.61 [95% CI, 2.75-7.74], P.001; and by fibrosis extent: HR, 1.10 [95% CI, 1.05-1.16], P.001), and the HF composite (by fibrosis presence: HR, 1.62 [95% CI, 1.00-2.61], P = .049; and by fibrosis extent: HR, 1.08 [95% CI, 1.04-1.13], P.001). Addition of fibrosis to LVEF significantly improved risk reclassification for all-cause mortality and the SCD composite (net reclassification improvement: 0.26 [95% CI, 0.11-0.41]; P = .001 and 0.29 [95% CI, 0.11-0.48]; P = .002, respectively).Assessment of midwall fibrosis with LGE-CMR imaging provided independent prognostic information beyond LVEF in patients with nonischemic dilated cardiomyopathy. The role of LGE-CMR in the risk stratification of dilated cardiomyopathy requires further investigation.

Total isovolumic time (t-IVT) reflects left ventricular (LV) asynchrony (when the ventricle is neither ejecting nor filling). It is prolonged in left bundle branch block (LBBB). Cardiac resynchronisation therapy (CRT) is a treatment for patients with heart failure, reduced LV ejection fraction and LBBB. CRT shortens t-IVT, but the long-term clinical benefit of such reduction after CRT has not been studied in this patient group.Seventy-three patients who underwent CRT had t-IVT measured before and after CRT implantation. The study end-point was a composite of unplanned heart failure hospitalisation and all-cause mortality.Baseline t-IVT showed considerable scatter: 30 patients had t-IVT values longer than 15s/min (upper 95% limit of normal). The change in t-IVT with CRT was also variable: t-IVT shortened in 50 patients (from 16.2 ± 4.8s/min to 11.7 ± 3.7s/min: group A), and lengthened in 23 patients (from 11.7 ± 4.2s/min to 14.5 ± 4.33 s/min: group B). The magnitude of change in t-IVT with CRT negatively correlated with baseline t-IVT (r=-0.619, p0.001); thus t-IVT (significantly longer in group A than group B before CRT: 16.2 ± 4.8s/min vs. 11.7 ± 4.2s/min, p0.001) became significantly shorter in group A compared to group B after CRT (11.7 ± 3.7s/min vs. 14.5 ± 4.3s/min, p=0.005). After follow-up of 30 months, 70% group A patients had event-free survival compared to 39% group B patients. The presence of any fall in t-IVT after CRT was an independent predictor of event-free survival.T-IVT is a marker of global cardiac asynchrony that has predictive capacity on functional, symptomatic, and mortality endpoints in patients with advanced heart failure.

Modern medicine is awash with technological advance. Though the last three decades have witnessed countless pharmacological successes, the pace of novel drug development has slowed down. Since the dawn of the new century, medicine has embraced technological changes with a resultant increase in implantable devices. Though the attendant physician may feel that medical devices are the remit of the specialist, with the expanding indications for medical implants, it is likely that physicians will encounter unfamiliar devices in routine and emergency clinical practice. Corbett et al highlight such issues within the sphere of endoscopy.1 Using an initial case of nucleus stimulators, the authors describe a successful endoscopic examination using a multidisciplinary approach. The authors indicate that the number of neurological and cardiac devices is rising. The Heart Rhythm network data indicates an increase in cardiac pacing (both basic and complex) and cardiac defibrillators.2 This data has also been corroborated on a European-wide basis.3 With increasing elderly populations observed throughout primary and secondary care, it is likely that the number of medical devices will increase further. The concern with medical devices and endoscopy …

Background Cardiac resynchronization therapy (CRT) is an established treatment in advanced heart failure (HF). However, an important subset does not derive a significant benefit. Despite an established predictive role in HF, the significance of right ventricular (RV) dysfunction in predicting clinical benefit from CRT remains unclear. We investigated the role of RV function, assessed by cardiovascular magnetic resonance (CMR), in predicting response to and major adverse clinical events in HF patients undergoing CRT. Methods Sixty consecutive patients were evaluated with CMR prior to CRT implantation in a tertiary cardiac centre. The primary end-point was a composite of death from any cause or unplanned hospitalization for a major cardiovascular event. The secondary end-point was response to therapy, defined as improvement in left ventricular ejection fraction ≥ 5% on echocardiography at one year. Results Eighteen patients (30%) met the primary end-point over a median follow-up period of 26 months, and 27 out of 56 patients (48%) were considered responders to CRT. On time-to-event analysis, only atrial fibrillation (HR 2.6, 95% CI 1.02-6.84, p = 0.047) and RV dysfunction, either by a reduced right ventricular ejection fraction-RVEF (HR 0.96, 95% CI 0.94-0.99, p = 0.006) or tricuspid annular plane systolic excursion-TAPSE (HR 0.88, 95% CI, 0.80-0.96, p = 0.006), were significant predictors of adverse events. On logistic regression analysis, preserved RVEF (OR 1.05, 95% CI 1.01-1.09, p = 0.01) and myocardial scar burden (OR 0.90, 95% CI 0.83-0.96, p = 0.004) were the sole independent predictors of response to CRT. Patients with marked RV dysfunction (RVEF < 30%) had a particularly low response rate (18.2%) to CRT. Conclusions Right ventricular function is an important predictor of both response to CRT and long-term clinical outcome. Routine assessment of the right ventricle should be considered in the evaluation of patients for CRT.

Over the last 30 years we have gone from famine to feast in terms ofthe epidemiological data now published for heart failure (HF). The field started with the seminal publication on the natural history ofHF from the Framingham study in 1971 showing a prevalence of HF of 0.8% in those aged between 50 and 59, rising to 9.1% inthose over 80 years with incidence rates of 0.2% at age 54 and 0.4% at age 85. This was followed by a large European study,‘The men born in 1913’, which gave similar figures of a prevalenceof 2.1% at age 50 and 13% at age 67 and incidence rates of 0.15% and 1% respectively at ages 50 and 67. These landmarkstudies relied on a clinical diagnosis of HF, basedon symptoms, signs, and scoring systems to identify cases. Moremodern epidemiological studies have used definitions of HF whichinclude objective measures of cardiac function in their definition,in keeping with current European and United States guidelines forthe diagnosis of HF. Initial studies focused on systolic dysfunctionbecause they reported at much the same time as the HF treatmenttrials which also enrolled patients with systolic HF. More recentlyattention has turned to describing the epidemiology of HF withpreserved systolic function, in addition.When describing the epidemiology of HF, it is worth bearing inmind that estimates of incidence and prevalence will vary according to the definition of HF used and the type of cohort being studied.This is especially important when assessing work which hasobjectively measured left ventricular systolic function. Variablessuch as left ventricular ejection fraction are normally distributed,so the cut point chosen is a critical determinant of the eventualresults.The present chapter aims to outline the contemporary epidemiologyof HF by describing its prevalence, incidence, aetiology andmortality as well as describing the trends which are occurring in thearea. It will discuss hospitalization rates, prognosis and economicburden in both Europe and the United States.

Background The experience of cardiac resynchronization therapy (CRT) in critically ill patients with cardiogenic shock or advanced heart failure is limited and inadequately described in literature. Methods CRT implants performed in patients on the cardiothoracic intensive care unit (ICU) at a tertiary cardiac centre during 2007–2010 were retrospectively studied. Results We identified 24 patients, 17 male, of median age 76years (IQR 11) treated with a CRT pacemaker ( n =10) or CRT defibrillator ( n =14). Prior to implantation median left ventricular ejection fraction (LVEF) was 26% (IQR 13) and median QRS duration 146ms (IQR 29). Eleven (46%) patients were post elective cardiac surgery and 8 (33%) post emergency cardiac surgery or intervention with high prevalence of co-morbidities. Nineteen patients required inotropic support pre-implantation, 8 patients were on mechanical circulatory support and 18 were on mechanical ventilation. Post CRT LVEF improved from 26% to 39% ( p =0.027) and the estimated glomerular filtration rate increased from 42ml/min/1.73m 2 (IQR 26) to 63ml/min/1.73m 2 (IQR 48, p =0.001). All but one patient were successfully weaned from inotropic support within a median of 4days (IQR 5) post CRT and 22/24 (92%) survived to hospital discharge. After a median follow up of 392days (IQR 538), 7 (33%) patients died. In-hospital and one year mortality rates were 8.3% and 29.4% respectively. Ten out of 12 patients (83%) were alive at long-term (22±9months) follow up. Conclusions CRT may assist weaning from circulatory and respiratory support in critically ill patients with left ventricular systolic dysfunction.

estimate the level of reporting at our hospital which is located in an area of the UK with a low incidence of TB (six cases/100,000 population). We undertook a survey of all prescriptions for the isoniazid and rifampicin combination drugs, rifinah-300 and rifinah-150, ethambutol and pyrazinamide during 2005. A casenote review was performed on the patients identified to ascertain which were being treated for TB, sputum positivity for acid fast bacilli if appropriate and whether culture confirmation was obtained. The names of patients with TB were correlated with those listed with the local Health Protection Agency to whom notifications are made. Forty patients were identified by this process with 25 being treated for TB. Of the others, four had atypical mycobacterial infection, six were being treated for latent TB, and five were given empirical trials of treatment but retrospectively considered not to have TB. Of the TB cases, 11 were culture positive (2 pulmonary, 7 lymph node, 1 ascites, 1 psoas abscess), three were smear positive but culture negative (all pulmonary) and the remaining had highly suggestive clinical features (3 meningeal, 5 pulmonary, 1 spinal, 1 laryngeal, 1 other) (Table 1). Only 13 (52%) of these cases were notified, but included 10 of the culture positives and all the smear positive cases. This suggests that notification levels were good when there was positive microbiology (93%) but fell dramatically (0%) when this was not available. All appropriate notifications were subsequently made. Our under-notification rate was higher than previously reported in the literature. We speculate that this may stem from the relatively low TB incidence in our area and consequently a reduced awareness to notify. Additionally, a number of cases were under the care of non-respiratory physicians, who may not have been as familiar with the notification process. Interestingly, virtually all patients with any form of positive microbiology were notified, suggesting that this led to a heightened awareness of this obligation. This mirrors previous findings. 2 The true extent of the notification rate was still an estimate as we used a single source to define which patients may have been receiving first-line treatment for TB. It did not identify patients who may have received all their treatment from a community pharmacy source; patients being treated with secondary-line agents or indeed patients who were diagnosed with TB but never received treatment (eg postmortem diagnoses). We reiterate the need to remind all healthcare workers to notify all clinically suspected TB cases, not just those with positive microbiology.

A 73-year-old former smoker with previous occupational exposure to asbestos presented with a pneumothorax that was initially managed by simple aspiration. Despite this, it re-accumulated and a bronchopleural fistula was suspected. A video-assisted thoracoscopic procedure was performed and revealed an abnormally thickened pleura that turned out to be a mesothelioma. All persistent pneumothoraces should be investigated.

Background Clinical audit provides a mechanism to review the quality of patient care, and highlight areas for further development. The National Institute of Clinical Excellence (NICE) updated the clinical guidelines for chronic heart failure (HF) in August 2010. Incorporated into this update were audit criteria, which were used to create an electronic tool to assess current outpatient management. Methods The audit targeted patients with HF secondary to left ventricular disease attending a tertiary cardiac centre in London. After an initial pilot period using hard copy proformas, the audit was extended in electronic format to all HF clinics within the institution. This enabled the capture of demographical data, diagnosis, treatment, monitoring including heart rhythm and rate, measures of clinical follow-up, and the compliance with rehabilitation. Results A total of 282 patients were included in the 8-month audit, of which 71% were male. The majority of patients were elderly, with a mean age of 68 years, and most lived outside of London (68%). The three commonest HF aetiologies were ischaemic heart disease (40%), idiopathic dilated cardiomyopathy (20%) and primary valvular disease (12%). Treatment demonstrated 89% correctly prescribed a β-blocker, 91% correctly prescribed an ACE-inhibitor or angiotensin receptor antagonist and 64% correctly prescribed an aldosterone antagonist. Rehabilitation questions changed after 3 months. Within the initial 155 patients, 15% were offered a rehabilitation programme. The subsequent 127 patients were audited using three questions, demonstrating that 6% were referred, and 1% were enrolled into a rehabilitation programme, and 36% were educated regarding the benefits of exercise for HF. Discussion The experience throughout this audit was positive as it was flexible and well supported by the audit department. The electronic proforma is easily adaptable to incorporate subsequent clinical or research questions as desired. Treatment and monitoring reflect national recommendations, but rehabilitation referrals are below desired levels. A minority of patients have been referred to or enrolled in HF rehabilitation programmes reflecting poor national provision. Two-thirds of patients lived outside of London, making it impractical for them to frequently visit our hospital. Hence a hospital-based rehabilitation programme would not improve this care priority. Added questions demonstrated less than optimal numbers receive exercise education within clinic. Conclusion This audit demonstrated that a tertiary HF service has high rates of documentation, follow-up and compliance with established medical therapies. Notably many patients did not receive cardiac rehabilitation. This may be influenced by geographical limitations and the configuration of local services. To improve patient management further, alternative strategies including tele-health and enhanced multi-disciplinary team education are currently being explored.

A 17-year-old girl with a previous history of deliberate self-harm self-presented to accident and emergency after intentionally ingesting a large quantity of yew tree leaves and shoots. She presented feeling nauseous with non-specific symptoms. She was drowsy but rousable with a Glasgow Coma Scale

Background Cardiac resynchronisation therapy (CRT) is an established treatment for patients with advanced heart failure (HF). However, a proportion of patients do not derive benefit post implantation of CRT. Despite an established predictive role in HF, the significance of RV dysfunction in gauging clinical benefit from CRT has not been investigated. Cardiovascular magnetic resonance (CMR) is an important tool in the assessment of HF and is considered the gold-standard in estimating RV function. We used this technique to assess the impact of RV dysfunction on clinical outcomes following CRT implantation. Methods We evaluated 48 consecutive patients attending a heart failure pacing clinic who had a CMR study within 6 months prior to CRT implantation. Clinical, biochemical, ECG and imaging data were collected. Biventricular function and myocardial scar were assessed by CMR including gadolinium enhancement. The primary end-point was a composite of all cause mortality (ACM) or unplanned cardiovascular hospitalisation. Results The mean age was 64.5±12.7 years. HF was ischaemic in 42% of patients, and 85% were in NYHA class III/IV at the time of implantation. Atrial fibrillation/flutter was found in 27% of patients. The mean LVEF estimated by CMR was 27±8%, while the median RVEF was 52% (IQR 35%–63%). The mean tricuspid annular plane systolic excursion (TAPSE) was 14.0±6.0 mm, and the mean pulmonary artery pressure (on echocardiography) was 37 ±10 mm Hg. Ten patients (21%) met the primary end-point over a mean follow-up of 28.6 months. On time-to-event analysis, only atrial fibrillation (HR 4.8, p=0.02) and RV dysfunction, ie, reduced RVEF (HR 0.96 per 1% EF, p=0.01) or TAPSE (HR 0.80 per mm, p Conclusions RV dysfunction is an independent predictor of adverse clinical outcomes following CRT. The assessment of RV function may be considered in patient selection for CRT implantation.

Cardiac resynchronization therapy (CRT) is an established treatment for patients with advanced heart failure (HF). However, a significant proportion of patients do not gain benefit from CRT, the reasons for which are unclear. Despite an established predictive role in HF, the significance of right ventricular (RV) dysfunction in gauging clinical benefit from CRT has not been elucidated. Cardiovascular magnetic resonance (CMR) is an important tool in the assessment of HF and is considered the gold-standard in estimating RV function. We used this technique to assess the impact of RV dysfunction on clinical outcomes in HF patients receiving CRT.