HEART UK consensus statement on Lipoprotein(a): A call to action (2019)

Type of publication:
Journal article

Author(s):
Cegla J.; Neely R.D.G.; France M.; Ferns G.; Byrne C.D.; Halcox J.; Datta D.; *Capps N.; Shoulders C.; Qureshi N.; Rees A.; Main L.; Payne J.; Cramb R.; Viljoen A.; Soran H.

Citation:
Atherosclerosis; Dec 2019; vol. 291 ; p. 62-70

Abstract:
Lipoprotein(a), Lp(a), is a modified atherogenic low-density lipoprotein particle that contains apolipoprotein(a). Its levels are highly heritable and variable in the population. This consensus statement by HEART UK is based on the evidence that Lp(a) is an independent cardiovascular disease (CVD) risk factor, provides recommendations for its measurement in clinical practice and reviews current and emerging therapeutic strategies to reduce CVD risk. Ten statements summarise the most salient points for practitioners and patients with high Lp(a). HEART UK recommends that Lp(a) is measured in adults as follows: 1) those with a personal or family history of premature atherosclerotic CVD; 2) those with first-degree relatives who have Lp(a) levels >200 nmol/l; 3) patients with familial hypercholesterolemia; 4) patients with calcific aortic valve stenosis and 5) those with borderline (but <15%) 10-year risk of a cardiovascular event. The management of patients with raised Lp(a) levels should include: 1) reducing overall atherosclerotic risk; 2) controlling dyslipidemia with a desirable non-HDL-cholesterol level of <100 mg/dl (2.5 mmol/l) and 3) consideration of lipoprotein apheresis.

Link to full-text [open access – no password required]

Altmetrics:

Targeting dyslipidaemia to prevent cardiovascular disease (2019)

Type of publication:
Journal article

Author(s):
Viljoen A.; Fuat A.; Takhar A.; Williams S.; *Capps N.

Citation:
Prescriber; Jul 2019; vol. 30 (no. 7); p. 23-26

Abstract:
Dyslipidaemia is a key risk factor for cardiovascular disease, and its identification and treatment is important for both primary and secondary prevention. This article discusses how to screen for dyslipidaemia and optimise lipid-lowering therapy to improve cardiovascular outcomes.

Link to full-text [NHS OpenAthens account required]

Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis (2019)

Type of publication:
Systematic Review

Author(s):
*Padmanabhan, Hari; Siau, Keith; *Curtis, Jason; Ng, Alex; Menon, Shyam; Luckraz, Heyman; Brookes, Matthew J

Citation:
The Annals of Thoracic Surgery. Dec 2019; vol. 108 (no. 6); p. 1840-1848

Abstract:
BACKGROUND Pre-operative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes following cardiac surgery.METHODS A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and non-anemic patients. RESULTS Out of 1103 studies screened, 22 met the inclusion criteria. A total of 23624 (20.6%) out of 114277 patients were anemic. Anemia was associated with increased mortality (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.32-3.24; I2=69.6%; p<0?001), AKI (OR 3.13, 95% CI 2.37-4.12; I2=71.1%; p<0?001), stroke (OR 1.46, 95% CI 1.24-1.72; I2=21.6%; p<0?001), and infection (OR 2.65, 95% CI 1.98-3.55; I2=46.7%; p<0?001). More anemic patients were transfused than non-anemic (33.3 versus 11.9%). No statistically significant association was found between mortality and blood transfusion (OR 1.35, 95% CI 0.92-1.98; I2=83.7%; p=0.12) but we were not able to compare mortality with or without transfusion in those who were or were not anemic. CONCLUSIONS Preoperative anemia is associated with adverse outcomes following cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models, and as a target for risk modification.

Altmetrics

A patient-centred model to quality assure outputs from an echocardiography department: consensus guidance from the British Society of Echocardiography (2018)

Type of publication:
Journal article

Author(s):
*Ingram TE, Baker S, Allen J, Ritzmann S, Bual N, Duffy L, Ellis C, Bunting K, Black N, Peck M, Hothi S, Sharma V, Pearce K, Steeds RP, Masani N.

Citation:
Echo Research and Practice. 2018 Dec 1;5(4):G25-G33

Abstract:
Background Quality assurance (QA) of echocardiographic studies is vital to ensure that clinicians can act on findings of high quality to deliver excellent patient care. To date, there is a paucity of published guidance on how to perform this QA. The British Society of Echocardiography (BSE) has previously produced an Echocardiography Quality Framework (EQF) to assist departments with their QA processes. This article expands on the EQF with a structured yet versatile approach on how to analyse echocardiographic departments to ensure high-quality standards are met. In addition, a process is detailed for departments that are seeking to demonstrate to external bodies adherence to a robust QA process. Methods The EQF consists of four domains. These include assessment of Echo Quality (including study acquisition and report generation); Reproducibility & Consistency (including analysis of individual variability when compared to the group and focused clinical audit), Education & Training (for all providers and service users) and Customer & Staff Satisfaction (of both service users and patients/their carers). Examples of what could be done in each of these areas are presented. Furthermore, evidence of participation in each domain is categorised against a red, amber or green rating: with an amber or green rating signifying that a quantifiable level of engagement in that aspect of QA has been achieved. Conclusion The proposed EQF is a powerful tool that focuses the limited time available for departmental QA on areas of practice where a change in patient experience or outcome is most likely to occur.

Link to full-text (no password required)

Altmetrics

Trial of atorvastatin for the primary prevention of cardiovascular events in patients with rheumatoid arthritis (TRACE RA): A multicenter, randomized, placebo controlled trial (2019)

Type of publication:
Journal article

Author(s):
Kitas GD, Nightingale P, Armitage J, Sattar N, Belch JJF, Symmons DPM; TRACE RA consortium.

Collaborators (137) Kitas G, Belch J, Symmons D, Williams H, Vasishta S, Storey R, Nightingale P, Bruce I, Durrington P, McInnes I, Nightingale P, Sattar N, Situnayake D, Struthers A, Lowe G, Armitage J, Fox K, Haskard D, Dore C, Bosworth A, Kitas G, Belch J, Symmons D, Williams H, Frenneaux M, Edwards C, Emberson J, Bax D, Cobbe S, Stott D, Sturrock R, Macfarlane P, Klocke R, Pullar T, Knight S, Rowe I, Kumar P, Goodson N, Mulherin D, Brzeski M, Gardiner P, Situnayake D, Walker D, Callaghan R, Allen M, McCarey D, George E, Deighton C, Kirkham B, Teh LS, Luqmani R, Chakravarty K, Nixon J, Richards S, Scott D, Woolf T, Prouse P, Packham J, Davies M, DeLord D, O’Neill T, Pande I, Harvie J, Watts R, Rankin E, Papasavvas G, Emery P, Sinha A, Dasgupta B, Bruce I, Creamer P, Zoma A, Walsh D, Van-Laar J, *Capps N, Cairns A, Marguerie C, Kumar N, Abernethy R, Lillicrap M, Ralston S, Makadsi R, Hopkinson N, Tan S, Akil M, Ahmad Y, Adler M, Bukhari M, Sanders P, Roussou E, Binymin K, Hassan A, Hughes R, O’Reilly D, Sainsbury P, Richmond R, Malgorzata M, Nisar M, McEntergart A, Roy D, Marks J, Batley M, McKenna F, Irani M, Harris H, Smyth A, Tunn E, Young A, Thomas J, Hall F, Marshall T, Rao C, Baburaj K, Dixey J, Gendi N, Birrell F, Chelliah G, Teh LS, Morgan A, Fishman D, Knights S, Coady D, Makadsi R, Smith B, Harrison B, Walker D, Siebert S, Chan A, Putchakayala K, Al-Ansari A, Gough A, Naz S, Kumar N, Pyne D, Mahmud T, Patel Y, Isdale A.

Citation:
Arthritis Rheumatol. 2019 Apr 15. doi: 10.1002/art.40892. [Epub ahead of print]

Abstract:
OBJECTIVE:

Rheumatoid arthritis (RA) is associated with increased cardiovascular event (CVE) risk. The impact of statins in RA is not established. We assessed whether atorvastatin is superior to placebo for the primary prevention of CVE in RA patients.

METHODS:

Randomized, double-blind, placebo-controlled trial designed for 80% power at p<0.05 to detect a 32% CVE risk reduction based on an estimated 1.8% per annum (pa) event rate. Patients aged >50 years or with RA duration >10 years; without clinical atherosclerosis, diabetes, or myopathy; received atorvastatin 40mg daily or matching placebo. Primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, transient ischemic attack, or any arterial revascularization. Secondary/tertiary endpoints included plasma lipids and safety.

RESULTS:

3002 patients (mean age 61 years, 74% female) were followed for a median 2.51 years (IQR 1.90-3.49) [7,827 patient-years] – early termination was due to lower than expected event rate (0.77% pa). Among patients allocated atorvastatin 24/1504 (1.6%) had a primary endpoint, compared with 36/1498 (2.4%) on placebo (hazard ratio 0.66, 95%CI 0.39-1.11, p=0.115); adjusted hazard ratio (0.60, 95%CI 0.32-1.15, p=0.127). At trial end, patients on atorvastatin had 0.77±0.04 mmol/L lower LDL-cholesterol compared to placebo (p<0.0001); CRP (mg/L) was also significantly lower on atorvastatin than placebo (2.59 (0.94-6.08) vs. 3.60 (1.47-7.49) – p<0.0001). CVE risk reduction per mmol/L LDLc reduction was 42% (95%CI -14%-70%). Adverse events in the atorvastatin (298 (19.8%)) and placebo (292 (19.5%)) groups were similar.

CONCLUSION:

Atorvastatin 40mg daily was safe and resulted in significantly greater reduction of LDLc than placebo in patients with RA. The 40% (adjusted) CVE risk reduction is consistent with the Cholesterol Treatment Trialists’ Collaboration meta-analysis of statin effects in other populations.

Altmetrics

Patient experience within the adult congenital heart disease outreach network: A questionnaire-based study (2018)

Type of publication:
Journal article

Author(s):

Georgina Ooues, Paul Clift, Sarah Bowater, Sayqa Arif, Andrew Epstein, Neeraj Prasad, Dawn Adamson, Mandy Cummings, Charles Spencer, Paul Woodmansey, Jenny Borley, *Thomas Ingram, Adrian Morley-Davies, William Roberts, Najmi Qureshi, Susan Hawkesford, Nichola Pope, James Anthony, Thomas Gaffey, Sara Thorne, Lucy Hudsmith and On behalf of The West Midlands ACHD Network, UK

Citation:
Journal of Congenital Cardiology; Sep 2018; vol. 2 (no. 1)

Abstract:
Background: Specialist multi-disciplinary care improves outcomes of Adult Congenital Heart Disease (ACHD) patients. Following the NHS England Congenital Heart Disease standards review, the aim is to deliver high quality, patient-centred, care closer to patients’ homes. Cardiac investigations performed on the same day of outpatient appointments reduce the non-attendance rates. This young cohort of patients, benefits from comprehensive multi-disciplinary management. We developed a Patient Questionnaire across our West Midlands ACHD network to measure patient experience. Methods: Patient questionnaires were distributed to patients attending outpatient clinics in all 8 Outreach Centres and the Level 1 ACHD Centre (University Hospitals Birmingham). Results: 71 males (55%) and 59 females (45%), median age range 25-34years old (range between 16 and 75years old), returned the questionnaires (n=130). Most patients travelled less than one hour to hospital (93%, n=120) and less than 20miles (86%, n=99). The mean travel distance was 14+/-12.3miles (range 1 to 160miles), with Level 1 ACHD Centre patients travelling a significantly longer distance (mean 29.6+/-44miles) compared to the local Outreach Centres (mean 11.3+/-9miles, p=0.0037). There was a wide variability in the provision of parking, although most patients found the appointment time and location convenient (91%, n=117 and 95%, n=121 respectively). There was also marked variation in the number of electrocardiograms (19-100%) and echocardiograms (0-60%) performed on the same day as their clinic appointment. Most patients felt they were given enough information regarding their condition (85%, n=98), with no significant differences between the centres (p=0.24). Conclusion: To our knowledge, this is the first questionnaire-based study assessing patient experience within the NHS ACHD Outreach network with significantly reduced travel times and maintained high patient satisfaction. There was a wide variation ininvestigations performed and patient information leaflets provided. Standardisation of services is required at allcentres to ensure equity of care, with Specialist Nurses’ input and more availability of tests on the day of clinicappointments in all centres.

Link to full-text [no password required]

Assessment of chronic obstructive airways disease in heart failure : An analysis of current practice (2018)

Type of publication:
Conference abstract

Author(s):
*Muthusami R.; *Mahmoud M.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.S.; *Moudgil H.; *Candassamy N.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) are global epidemics incurring significant morbidity and mortality with overlapping symptoms & risk factors. Whereas with other coexisting co-morbidities such as with Diabetes Mellitus and Ischaemic Heart Disease, much work has been done to concurrently improve outcomes from both pathologies, whether anything is uniformly undertaken in practice to firstly recognize and secondly improve outcomes from HF and COPD is less understood. The objective here was to establish our current pattern of assessment to identify potential areas of improvement that would enable us to better manage the modern multi-morbid patient. METHODS Electronic medical records of all patients admitted to our District General Hospital (serving fairly static population 250,000) over a 6 month period to end December 2016 and referred internally to our Heart Failure Specialist Team were assessed. Data for all admitted cases were cross-referenced to Electrocardiography (ECHO) and Pulmonary Function Lab Databases. RESULTS 116 patients (63% male) with mean (SD, range) age 74.9 (11.7, 32-100) years had been admitted and of these 37% had died over the subsequent 12 months follow up period. Of the total, 113 (97%) had prior transthoracic cardiac ECHO (updated within a two year window); Mean estimated Left Ventricular Ejection Fraction (LVEF) was 41%. Comparatively, only 31 (27%) patients had undergone Spirometry testing at our centre over the preceding 10 year period and of these approximately half (51%) had shown obstructive spirometry. Collectively, 44 (38%) were known to have any Obstructive Airways Disease with 32 (28%) being COPD but a slightly higher figure at 50 (43%) were on inhaler treatment. . Sub-analysing, the 59 (51%) specifically with Ischaemic Heart Disease as opposed to other causes for Heart Failure (Valvular Heart Disease, Cardiomyopathy etc.) had a higher 12 month mortality rate (49%) as well as higher prevalence of known COPD (32%), higher proportion of patients with obstructive spirometry (65%) and patients on inhaler therapy (45%). Only 2 of the 7 patients on Amiodarone had Spirometry. CONCLUSION The basic provision of spirometry to Heart Failure patients, and in particular those with Ischaemic Heart Disease, needs to be improved with our findings probably consistent with others providing the same models of diagnosis driven care. Our findings are in a population with established Heart Failure and potentially in their final years of life but there may be improved quality of life and care planning, if assessing those presenting earlier.

Cardiovascular risk assessment in psychiatric inpatient setting (2016)

Type of publication:
Conference abstract

Author(s):
*Dahmer E., *Lokunarangoda N.C., Romain K., Kumar M.

Citation:
European Psychiatry, March 2016, vol./is. 33/(S281)

Abstract:
Objectives To assess the general cardiac health of inpatients in acute psychiatric units and to evaluate the practice of ECG use in this setting. Aims Overall cardiac risk is assessed using QRISK2. Clinically significant ECG abnormality detection by psychiatric teams are compared with same by cardiologist. Methods Ten percent of patients (n = 113) admitted to five acute psychiatric wards during a period of 13 months across three hospital sites, covering a population of 1.1 million, were randomly selected. Electronic health care records were used to collect all data, in the form of typed entries and scanned notes. An experienced cardiologist, blind to the psychiatrist assessments, performed ECG analysis. The QRISK2 online calculator was used to calculate 10-year cardiovascular risk as recommended by NIHR, UK. Results A score of 10% or more indicates a need for further intervention to lower risk.13.5% of patients had a QRISK2 score of 10-20%, 5.2% had a score of 20-30%, and 1 patient had a QRISK2 score > 30%. In total, 19.7% had a QRISK2 of 10% or greater. A total of 2.9% had prolonged QTC interval (> 440 ms), with 2.9% having a borderline QTC (421-440). A total of 34.3% of ECGs were identified by the ward doctors as abnormal, with action being taken on 41.6% of these abnormal ECGs. Cardiologist analysis identified 57.1% of ECGs with abnormalities of potential clinical significance. Conclusions One in five patients admitted to psychiatry wards have poor cardiac health requiring interventions. Though QTC interval prolongation is rare, half of patients may have abnormal ECGs that require further analysis.

Chest pain with raised troponin, ECG changes but normal coronary arteries (2014)

Type of publication:
Journal article

Author(s):
*Amjad A,  *Ali A, *Bashir A,  *Ali M,  *Azam MN

Citation:
BMJ Case Reports, 2014, vol./is. 2014/, 1757-790X (2014)

Abstract:
A 65-year-old woman presented to A&E department, with acute onset central chest pain and dyspnoea. ECG showed dynamic T wave changes while 12 h troponin was elevated. A diagnosis of acute coronary syndrome was made and she underwent an inpatient coronary angiogram. Although her coronary arteries were normal, symptoms persisted and D-dimers were found to be elevated. This led to a CT pulmonary angiogram, which ruled out pulmonary embolism, but uncovered a large ascending aortic aneurysm with a contained leak. She was immediately transferred to regional cardiothoracic unit for urgent surgical intervention. This case report illustrates the importance of a good clinical history, physical examination and timely investigations. It also emphasises that not all chest pain events with elevated troponin level are due to acute coronary syndrome and that alternative diagnoses should still be considered.

Link to more details:

Link to full-text: http://casereports.bmj.com/content/2014/bcr-2013-201975.abstract

 

Asymptomatic coronary artery spasm with acute pathological ST elevation on routine ECG: is it common? (2014)

Type of publication:
Journal article

Author(s):
Mohammed I, *Zaatari MS, Tyrogalas N, Khalid MI

Citation:
BMJ Case Reports, 2014, vol./is. 2014/, 1757-790X (2014)

Abstract:
Asymptomatic spontaneous coronary artery spasm is rare and there are no case reports in literature presenting with acute ST elevation on routine ECG. We present the case of a 68-year-old Caucasian man who presented to a primary care physician for a routine ECG as part of hypertension follow-up. ECG revealed ST elevation in inferior leads II, III and aVF with reciprocal ST depression in leads I, aVL and also ST depression in anterior leads V1, V2 and V3 suggesting ongoing inferoposterior ST elevation myocardial infarction. The patient was completely well, stable and asymptomatic and he was rushed immediately to the coronary care unit via emergency ambulance. The patient was subjected to a battery of urgent investigations which were all normal. Also an urgent coronary angiogram was undertaken which showed completely normal coronary anatomy. 2014 BMJ Publishing Group Ltd.

Link to full-text: http://casereports.bmj.com/content/2014/bcr-2013-202586.abstract