Abstract
Peebles Hydro Hotel, Peebles on Friday, 28 September & Saturday, 29 September 2018.
The 27th Annual Scottish Cardiac Society Autumn Meeting was held in Peebles this year on 28 and 29 September. Topics covered in the training meeting included coronary intervention in the elderly, management of cardiac surgical complications, how to perform a right heart catheterisation, and the assessment of ventricular ectopy. There were over 20 poster and oral presentations from cardiology trainees, specialist nurses, cardiac physiologists and medical students. As always, the quality of the abstracts and presentations was high. Our keynote lecture was from Professor Keith Oldroyd, who entertained and informed us about the lessons he has learned from a career in the cath lab.
High-sensitivity cardiac troponin I and clinical risk scores in patients with suspected acute coronary syndrome
University of Edinburgh, Edinburgh, UK
Abstract
Background
High-sensitivity cardiac troponin assays identify patients presenting to hospital with chest pain who at low risk of myocardial infarction or cardiac death. Clinical risk scores such as history, ECG, age, risk factors and troponin (HEART), Global Registry of Acute Coronary Events (GRACE) and thrombolysis in myocardial infarction (TIMI) are widely used in conjunction with troponin testing, but whether they offer improvements in safety over established rule out pathways is unclear.
Methods
Patients with suspected acute coronary syndrome were recruited from the Emergency Department of a tertiary cardiac centre (n = 1935). High-sensitivity cardiac troponin I concentrations were measured at presentation, 3 and 6 h. We evaluated the safety and efficacy of two pathways alone and with the addition of risk scores (HEART ≤ 3, GRACE < 108, or TIMI 0 or 1) for a primary outcome of type 1 myocardial infarction or cardiac death at 30 days. The European Society of Cardiology 0/3 h pathway rules out myocardial infarction at presentation if symptom onset is ≥6 h from arrival and troponin concentrations are ≤99th centile, or at 3 h if concentrations are unchanged. The highSTEACS pathway rules out myocardial infarction at presentation if symptom onset is ≥2 h from arrival and troponin concentrations are <5 ng/L, or at 3 h if the change is <3 ng/L.
Results
Myocardial infarction or cardiac death at 30-days occurred in 14.3% (276/1935). The embryonic stem cell (ESC) pathway ruled out 70% with 27 missed events giving a negative predictive value (NPV) of 97.9% (95% confidence interval (CI), 97.1–98.6%). Addition of a HEART score ≤3 reduced the proportion ruled out to 25%, but improved the NPV to 99.7% (95% CI 99.0–100%, p < 0.001). The highSTEACS pathway ruled out 65% with three missed events for a NPV of 99.7% (95% CI 99.4–99.9%). Neither the HEART, GRACE or TIMI risk score improved the NPV, but all reduced the proportion ruled out (24–47%, p < 0.001 for all, Figure).
Performance of each pathway in combination with GRACE, TIMI or HEART score.
Cumulative proportion of patients identified as low risk using each pathway in combination with the GRACE, TIMI or HEART clinical risk score.
Conclusions
Risk scores reduce the efficacy of early rule out pathways, however, this is justified by a clear improvement in safety for pathways that rely on the 99th centile for risk stratification. There is no improvement in safety when risk scores are applied in pathways using low concentrations of cardiac troponin for risk stratification.
Effect of pre-hospital administration of unfractionated heparin in acute ST-elevation myocardial infarction
1University of Dundee, Nethergate, Dundee, UK
2Scottish Ambulance Service, Edinburgh, UK
3NHS Tayside, Dundee, UK
Abstract
We studied the effects of pre-hospital heparin in primary percutaneous coronary intervention (PCI) patients, on infarct artery patency and long-term mortality. Consecutive patients (n = 1000) admitted to Ninewells Hospital, Dundee, from 2010 to 2014 for PPCI were allocated to two groups: 437 (44%) pre-hospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin (IHH). A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and five years. Cox proportional hazards regression models were generated. The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 min vs. 251 min, p < 0.001) and less cardiogenic shock (3.9% vs. 8.0%, p = 0.008). Initial coronary flow was not different between the groups. Thirty-day mortality in PHH was 2.5% vs. 8.3%, p < 0.001. Independent predictors of 30-day mortality were age (odds ratio 1.07, 95% CI 1.04–1.09), cardiogenic shock (5.97, 3.33–10.69), radial access (0.53, 0.28–0.98) and pre-hospital heparin (0.33, 0.17–0.66). Five-year mortality in PHH was 13.0% vs. 21.6%, p < 0.001. Significant predictors of long-term mortality were age (1.07, 1.06–1.09), cardiogenic shock (3.40, 2.23–5.17) and pre-hospital heparin (0.68, 0.49–0.96).
Pre-hospital heparin was associated with reduced short- and long-term mortality after adjusting for important potential confounders.
Convalescent cardiac troponin I and cardiovascular death following acute coronary syndrome
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
Abstract
Background
Serial high-sensitivity cardiac troponin testing is used in the diagnosis of patients with acute coronary syndromes (ACS). Whether subsequent testing in convalescence can improve long-term risk prediction is unknown.
Methods
In a prospective multi-centre observational cohort study of 2140 patients with ACS, cardiac troponin I concentrations were measured in 1776 patients at 1, 4 and 12 months following the index event. Patients were stratified by troponin concentration at four months using the 99th centile (women > 16 ng/L, men > 34 ng/L) and median concentration of those within the reference range. The primary outcome was cardiovascular death.
Results
Troponin concentrations were measurable in 99.0% (1759/1776) of patients (67 ± 12 years, 72% male), and was ≤ 5 ng/L (median) and >99th centile in 44.8% (795) and 9.3% (166), respectively. There were 202 (11.4%) cardiovascular deaths after a median of 4.8 years. Patients with troponin concentrations >99th centile were at increased risk of cardiovascular death compared to those ≤5 ng/L (29.5% (49/166) vs. 4.3% (34/795); adjusted hazard ratio (HR) 4.9, 95% confidence interval (CI) 3.8–23.7). After adjusting for the GRACE score, troponin concentration at four months was an independent predictor of cardiovascular death (HR 1.4, 95% CI 1.3–1.5 per troponin doubling) with the highest risk observed in those with increasing or persistently elevated troponin concentrations at 12 months.
Conclusions
Convalescent cardiac troponin I concentrations predict long-term cardiovascular death in patients following acute coronary syndrome. Recognition of this increased risk and monitoring of convalescent troponin may improve targeting of preventative therapies and interventions.
Presenting symptoms of myocardial infarction in men and women diagnosed using high-sensitivity troponin sex-specific criteria
Royal Infirmary of Edinburgh, SU305 Chancellor's building, Edinburgh, UK
Abstract
Background
Women with suspected acute coronary syndrome are thought to present with atypical symptoms and are less likely to be diagnosed with myocardial infarction. The universal definition now recommends the use of sex-specific diagnostic criteria, but the impact of these on the presentation and clinical features of men and women is unknown.
Methods
In a prospective cohort study, we evaluated patient reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the Emergency Department at the Royal Infirmary of Edinburgh, Scotland. The diagnosis of myocardial infarction was adjudicated by two independent cardiologists using high-sensitivity cardiac troponin I with sex-specific thresholds (>16 ng/L women, > 34 ng/L men) and presenting symptoms were compared between all men and women, and those diagnosed with myocardial infarction using standardised definitions of typical and atypical pain.
Findings
Myocardial infarction was diagnosed during the index presentation in 15.5% (184/1185) of men and 11.9% (90/756) of women (p = 0.03), with 13 men and 26 women identified due to sex-specific criteria. Chest pain was the most common symptom in men and women with myocardial infarction (both 93%), with typical symptoms appearing more commonly in women (81% vs. 64% p = 0.005), a symptom presentation pattern also true for women reclassified using sex-specific criteria. Three or four typical symptoms appearing in combination (pain nature, pain location, pain radiation, additional symptoms) increased the predictive value of these symptoms for myocardial infarction in women but not in men when compared to two or fewer features being present (LR 0.64, CI 0.4–0.96 compared to LR 1.18, CI 1.03–1.31, and LR 0.87, CI 0.7–1.04 compared to 1.09, CI 0.96–1.24).
Interpretation
Women with type 1 myocardial infarction present with typical features more commonly than men. The cumulative presence of three or more typical features is as predictive of myocardial infarction in women as men, therefore women presenting with a typical symptom cluster merit high clinical suspicion of type 1 myocardial infarction.
The involvement of microRNA-214 in the development of hypertensive heart disease
British Heart Foundation Centre of Research Excellence, Glasgow, UK
Abstract
Background
Hypertension and its sequelae of organ fibrosis and dysfunction underpin an array of cardiovascular disorders. The immune system is recognised as key to this process. MicroRNA(miR)-214 is associated with fibrosis of the cardiovascular system, as such we hypothesised that miR-214 would modulate cardiac fibrosis via an immune mechanism.
Methods
Three-month-old C57BL/6 mice and miR-214 knock out (KO) and wild type (WT) littermates were treated with 490 ng/kg/min angiotensin II for 14 or 28 days. Blood pressure was monitored by carotid artery radio-telemetry. Cardiac function was assessed by echocardiography. Histology, in situ hybridisation (ISH), immunohistochemistry, gene expression and immune cell cytometric analyses were conducted. Statistical analysis was performed using ANOVA. Data are expressed as mean ± SEM.
Results
Fourteen days of angiotensin II infusion led to four-fold induction of miR-214 in the left ventricle of C57bl/6 mice (n = 5–6, p < 0.001) and is also seen in ISH. Angiotensin II infusion to KO mice was associated with increased cardiac fibrosis compared to WT littermates using picro sirius red histological stain (4.8 ± 0.7% vs. 2.8 ± 0.52%, n = 6–9; p < 0.005), without effect on blood pressure. This was associated in a significant up-regulation of Col1a1 mRNA compared with WT (2.2 fold vs. 8.7 fold n = 3; p < 0.01). Echocardiography revealed enhanced development of ventricular wall thickening and diastolic dysfunction in mir-214 KO when compared to WT mice (E/A ratio: 1.79 ± 0.39 vs. 0.68 ± 0.04; p < 0.05, n = 4–6). In contrast to in vivo observations, in vitro fibroblast studies show that KO fibroblasts had significantly reduced expression of Col1a1 (n = 4–5; p < 0.05) and Col3a1 (n = 4–5; p < 0.05) compared with WT fibroblasts upon Ang II stimulation suggesting fibroblast activation is not the mechanism through which the KO mice develop greater cardiac fibrosis. Hypertensive KO animals had a greater proportion of neutrophils in spleen and blood compared to their WT counterparts (29.16 ± 10.07% vs. 15.82 ± 8.13%; n = 5). Furthermore, recruitment of neutrophils into the heart of KO mice was higher than in WT mice (8.61% of all CD45 cells vs. 1.82).
Conclusions
We demonstrate the novel finding that cardiac fibrosis, hypertrophy and diastolic dysfunction are enhanced in miR-214 KO animals. Mechanistically, this may be associated with alterations in neutrophil infiltration.
Reasons for non-prescription of oral anticoagulation in patients discharged with ischaemic stroke and atrial fibrillation: a case-series review
1Cardiac Unit, Raigmore Hospital, Inverness, UK
2Department of Diabetes & Cardiovascular Science, University of the Highlands and Islands, Centre for Health Science, Inverness, UK
3Highland Pharmacy Education & Research Centre, Centre for Health Science, Inverness, UK
Abstract
Background
Atrial fibrillation (AF) increases stroke risk fivefold. Oral anticoagulation (OAC) with warfarin reduces the risk of stroke by 64%. Direct oral anticoagulants are non-inferior to warfarin in preventing stroke in non-valvular AF, but have a lower risk of fatal intracranial haemorrhage. The Scottish Stroke Care Audit showed that 68% of patients with a diagnosis of ischaemic stroke and AF are discharged with OAC, or start OAC after their first outpatient clinic visit.
Purpose
To determine how many patients discharged with a diagnosis of ischaemic stroke and AF were prescribed OAC, and secondly to establish reasons for, and associations with, non-prescription of OAC. Methods: All patients discharged with a diagnosis of ischaemic stroke and AF during the four-year period between 2013 and 2016 within NHS Highland were included in the study. Patients who were discharged with a plan to start OAC after a period of treatment with antiplatelets were considered as being treated with OAC. Electronic patient records provided demographics, CHA2DS2-VASc and HAS-BLED scores and information on why patients were not started on OAC.
Results
A total of 181 patients were discharged with a diagnosis of ischaemic stroke and AF over the study period. Totally 52.5% (n = 95) were female (p = 0.45). Totally 35.4% (n = 64) were discharged without OAC. The median CHA2DS2-VASc score for patients not treated with OAC was 5 (IQR 4–6). The median HAS-BLED score was 3 (IQR 2.5–4). There was no difference in rate of OAC prescription between men and women (67% vs. 62%, p = 0.45). Patients 80 years of age or older were significantly less likely to be prescribed OAC on discharge than those under 80 years (54% vs. 76%, p = 0.002; Table 1). The two most common reasons for withholding OAC were concern over bleeding risk and falls. Patients treated at a hospital with a stroke unit were no more likely to be discharged on OAC compared to those treated at hospitals without a stroke unit (66% vs. 62%, p = 0.64). There was a trend suggesting patient discharged in 2015 and 2016 may have been more likely to be discharged with OAC versus those discharged in 2013 and 2014 (71% vs. 58%, p = 0.07). Totally 64% (n = 41) of patients not treated with OAC were discharged on long-term antiplatelet drugs.
Conclusions
In this population, 35% of patients with ischaemic stroke and AF were not treated with OAC on discharge. The main reasons for withholding OAC are concerns over falls and bleeding risk. Older patients are less likely to be prescribed OAC on discharge. Most patients who were deemed too high risk for anticoagulation were discharged on antiplatelet drugs despite evidence of inferior efficacy. A falls risk alone seems an inappropriate reason to avoid OAC in patients at risk of stroke. Raising awareness of the relatively low risk of major bleeding, even in elderly patients and in those at risk of falls, might help increase OAC usage and reduce recurrent strokes.
Accuracy of hand-held bedside echocardiography performed by non-cardiologists with limited echocardiographic training
Cardiology Department, St John's Hospital, Livingston, UK
Abstract
Background
Bedside echocardiography using hand-held portable devices is reported to have favourable image quality and diagnostic accuracy when compared against standard transthoracic echocardiography (TTE). 1 However, most studies to date with hand-held echocardiography (HHE) have employed experienced cardiologists with formal echocardiography accreditation. We sought to explore the accuracy and potential clinical utility of HHE performed in a real-world clinical setting by non-cardiologists following a defined, limited period of echocardiography training.
Methods
In this prospective cross-sectional pilot study, inpatients at St John's hospital referred for TTE between 1 January 2017 and 30 January 2018 underwent bedside HHE with a Vscan (GE Healthcare), performed by one of two Clinical Fellows, prior to departmental TTE. Both fellows received 30 h of hands-on echocardiography training by a certified British Society of Echocardiography (BSE) trainer prior to study participation and neither had previous echocardiography experience or specialist Cardiology training. HHE studies were performed on an opportunistic basis around the constraints of clinical workload and each study focussed on four specific areas: assessment of (i) pericardial effusion, (ii) left ventricular systolic function, (iii) valve disease and (iv) right ventricular (RV) size and systolic function. Referrals were considered for HHE if the study request related to one of these areas but excluded if it mandated use of Spectral Doppler (e.g. quantification of valve gradients) since this technique is unavailable on handheld devices. Alongside each HHE report, the Fellow was asked whether they would recommend departmental TTE. All patients subsequently underwent formal TTE carried out by a BSE accredited sonographer blinded to the results of the HHE. Accuracy of HHE for detection of (i) pericardial effusion, (ii) RV dilatation, (iii) RV systolic dysfunction, (iv) left ventricular systolic dysfunction (LVSD) of at least moderate severity and (v) valve disease of at least moderate severity was determined using TTE as the gold standard.
Results
Diagnostic accuracy of HHE.
(n): numbers of times abnormality detected on TTE.
Significant decrepancies between TTE and HHE findings.
TR: tricuspid regurgitation; MR: mitral regurgitation; RV: right ventricle.
Conclusions
HHE appears to have high levels of diagnostic accuracy for specified indications in real-world clinical practice, even when employed by non-cardiologists with only a limited period of echo training. If replicated in larger studies, these findings would suggest that focussed training of physicians in HHE could help to guide real-time clinical decision making and reduce demand for departmental TTEs.
Reference
Automated data capture from echocardiography reports to enhance heart failure population research
University of Dundee, Dundee, UK
Abstract
Introduction
Heart failure (HF) is a common health concern and echocardiography is widely used to aid its diagnosis. Data from echocardiogram reports may become a powerful resource for HF research. We aimed to formulate and validate a natural language processing (NLP) algorithm that extracts keywords from echocardiogram reports to identify patients with impaired left ventricular systolic function (LVSF) and left ventricular hypertrophy (LVH).
Methods
Free text descriptions of LVSF were identified and processed from 150,000 echocardiograms performed in Ninewells Hospital since 1994. Code was developed to parse the free text and generate a lexicon from which to determine the reporter's impression of LVSF. Validation was performed using a selection of 1000 reports that were manually reviewed by an independent investigator and correlation between manual and code-based assessment were examined. One hundred and five individuals with impaired LVSF were identified and their case notes reviewed to test the reliability of the above HF definition and 42 scans with varying degrees of left ventricular impairment were blindly re-reported by British Society of Echocardiography (BSE) accredited echocardiographers. The algorithm was retested following an update to the echocardiography database in 2012.
Results
The algorithm used identified 19,758 individuals with impaired LVSF. Of the 1000 reports, 98% reviewed manually showed concordance with the algorithm. Of the 105 HF cases, 91% based on impaired LVSF and loop diuretic prescription were confirmed cases of heart failure on review of their case notes. The algorithm was also found to be applicable to the new NHS Tayside database as it had an overall recall of 94.2%, overall precision of 98.39%, and an overall F1 score of 96.25%.
Conclusion
This algorithm provides a robust method of identifying those with evidence of impaired LVSF on echocardiogram. This may be linked to prescribing data to accurately identify HF, allowing its use for clinical research.
Improving the heart failure inpatient journey
Royal Infirmary of Edinburgh, Edinburgh, UK
Abstract
Background
It is known from national data that there are adverse outcomes for patients admitted to hospital with heart failure, with high mortality and readmission rates. NHS Lothian had an established community heart failure nurse service for people with left ventricular systolic dysfunction but there was no consistent pathway/review for patients admitted with heart failure. The referrals to service were ad hoc, delayed from discharge and care was inconsistent. Patients were often not on evidence-based therapy. We had audit date demonstrating higher readmission rates in general medical v's cardiology for all types of heart failure. They often had no specialist input during their admission, which is associated with higher mortality rates.
Intervention
Development of a cohesive inpatient heart failure service for both preserved and reduced ejection fraction. Consisting of a team of one whole time equivalent (WTE) inpatient heart failure nurse, consultant/registrar time/MDT/urgent review clinic. We screen all admissions for potential heart failure, reviewing and managing their cardiac care on their parent ward as a specialist outreach team. Ensuring accurate diagnosis and evidence-based treatment, referral for advanced therapy, support for palliative patients and discharge planning with patient education. For patients with LVSD, we provide an integrated model from acute to primary care and for patients with preserved LV link them to long-term condition community teams. We aim to review them within 14 days of discharge.
Methods
We performed a retrospective cohort study of patients admitted to the Royal Infirmary of Edinburgh with heart failure during a three-month period before (1 June–31 August 2016) and after (1 June–31 August 2017) service implementation. The electronic patient records of patients whose ICD-1-discharge code corresponded to a diagnosis of possible heart failure were screened and patients included if heart failure was confirmed to be the primary reason for admission. The primary efficacy outcome was ‘days alive and out of hospital’ (DAOH) at 60 days post-discharge. This single measure captures several key outcomes including index length of stay, mortality and subsequent hospital admission. Other efficacy outcomes included mortality and all-cause readmission at 60 days. Key process outcomes were the proportion of eligible patients reviewed by the heart failure team during their inpatient stay and the proportion followed up by the heart failure nurse service within 14 days of discharge. Categorical and continuous variables were analysed using Fischer's exact test and the Mann–Whitney test. Statistical significance was accepted at p < 0.05.
Results
Patients from 2016 (n = 74) and 2017 (n = 75) well matched for age (79 vs. 75 years), sex (53% vs. 63%male) and proportion with LVSD (86% vs. 87%; p > 0.05 for all). Following introduction of the inpatient service 91% of patients admitted with heart failure received input from the heart failure team during their inpatient stay, and the proportion of eligible patients receiving heart failure nurse follow up within 14 days of discharge increased from 29.8% to 58.4% (p = 0.002). DAOH at 60 days increased by 5.7 days (48.0 vs. 53.7, p = 0.043) post intervention while inpatient mortality fell from 9.5% to 1.3% (p = 0.034). Median length of index stay (5.7 days vs. 5.2 days; p = 0.76) and post-discharge 60 day mortality (10.5 vs. 10.8%; p = 0.99) were unchanged before and after service implementation but there was a non-significant trend toward a reduction in 60-day all-cause readmission (34.3% vs. 24.7%; p = 0.19).
Discussion
This service model allowed us to provide specialist HF input to more than 90% of patients hospitalised with HF during inpatient stay and doubled the number of patients receiving early HF nurse follow-up. The increased specialist input was accompanied by a clear improvement in outcomes including days spent alive and out of hospital and inpatient mortality.
Atropine: blocking muscarinic receptors or blocking beds?
Queen Elizabeth University Hospital, Glasgow, UK
Abstract
Aim
To examine the efficacy and safety of atropine compared to isoprenaline in the management of patients admitted acutely with bradyarrhythmia.
Methods
This was an exploratory retrospective cohort study. The medical notes were reviewed for all patients who underwent urgent permanent pacemaker (PPM) insertion at a large tertiary teaching hospital over a two-year period. All patients who received intravenous atropine or isoprenaline prior to PPM were included in the study.
Results
Thirty-five patients received atropine prior to PPM insertion. A haemodynamic response was evident in 12 patients (34%). Seven patients (20%) developed new confusion following atropine administration – of which only two had experienced haemodynamic response. Newly confused patients received larger doses of atropine (2.3 mg) compared to those whose cognition was unaffected (1.4 mg). The median time to PPM insertion was 10 days in patients with new onset confusion compared with 3.5 days in those with no change in cognition. Median length of stay in hospital post-PPM was 15 days vs. six days, respectively. Twenty-four patients (68%) required further intervention (mostly isoprenaline) prior to undergoing PPM. Thirty-nine patients received isoprenaline but not atropine prior to PPM insertion. A haemodynamic response was noted in 36 patients (92%). Median time to PPM insertion and post-PPM hospital stay were three and five days, respectively. One patient (2.6%) was noted to be newly confused. Time to PPM and post-PPM hospital stay were five and 11 days, respectively, in this patient.
Conclusion
In this selective retrospective study of the emergency management of patients presenting with bradyarrhythmia, atropine had lower efficacy than isoprenaline, and was associated with a higher rate of complications, particularly when used at higher dosage. This delayed time to PPM and increased the length of hospitalisation.