Care and referral patterns in a large, dedicated nurse-led atrial fibrillation outpatient clinic

Introduction Atrial fibrillation (AF) is the most common arrhythmia and imposes a high burden on the healthcare system. A nurse-led AF outpatient clinic may alleviate the burden on the cardiology outpatient clinic by triaging patients who need care by a cardiologist or general practitioner (GP). However, care and referral patterns after initial assessment in a nurse-led AF outpatient clinic are unknown. We examined the proportion of AF patients assessed in a nurse-led clinic without outpatient follow-up by a cardiologist. Methods All patients with AF referred to our tertiary medical centre underwent cardiac work-up in the nurse-led AF outpatient clinic and were prospectively followed. Data on patient characteristics, rhythm monitoring and echocardiography were collected and described. Odds ratio (OR) for continuing care in the nurse-led AF outpatient clinic was calculated. Results From 2014 to 2018, 478 consecutive individual patients were referred to the nurse-led AF outpatient clinic. After the initial cardiac work-up, 139 patients (29.1%) remained under nurse-led care and 121 (25.3%) were referred to a cardiologist and 218 (45.6%) to a GP. Patients who remained under nurse-led care were significantly younger, were more symptomatic, more often had paroxysmal AF and had less comorbidities than the other two groups. After multivariable testing, CHA2DS2-VASc score ≥ 2 was associated with discontinued nurse-led care (OR 0.57, 95% confidence interval 0.34–0.95). Conclusion After initial cardiac assessment in the nurse-led outpatient clinic, about half of the newly referred AF patients were referred back to their GP. This strategy may reduce the burden of AF patients on secondary or tertiary cardiology outpatient clinics.

Recurrent Strokes as the First Presentation of Occult Pancreatic Cancer; Trousseau Syndrome: A Case Report

Cerebrovascular disorders (CVDs) are widespread in cancer patients, exacerbating their condition and lowering their prognosis. Approximately 15% of cancer patients have a coexisting CVD. Stroke may occur after the initial cancer diagnosis or before the diagnosis of malignant disease. The underlying causes of stroke in cancer patients are distinct from those in noncancer patients and are related to both cancer itself and the type of treatment. Cardio-embolism, large vessel atherosclerosis, and small vessel occlusion have all been identified as important causes of ischemic stroke, but nonbacterial thrombotic endocarditis has been documented only infrequently. We present a case of a 64-year-old female with recurrent ischemic stroke of unknown cause and involving different arterial territories, who was discovered to have metastatic pancreatic cancer. The initial workup with brain imaging revealed multiple acute/subacute ischemic strokes and a negative cardiac assessment. Accordingly, she underwent a whole-body positron emission tomography-computed tomography which revealed a hypermetabolic mass lesion in the pancreaticoduodenal area. Our case indicates that cancer-associated stroke should be seriously evaluated. It demonstrates the critical nature of contemplating hidden cancer in survivors of ischemic stroke and identifies factors that may necessitate further investigation as part of a comprehensive approach to ischemic stroke, especially embolic stroke of unknown sources.

Clinical Management of DMD-Associated Cardiomyopathy

Over the past decade, cardiomyopathy has become the leading cause of mortality among patients with Duchenne muscular dystrophy (DMD). The majority of DMD patients over the age of 18 experience some degree of cardiac involvement. The primary cardiac manifestations of DMD include progressive left ventricular (LV) wall stress leading to LV dilatation and wall thinning, and the development of cardiac fibrosis, all of which culminate in decreased LV contractility and reduced cardiac output. Mortality in these patients is predominantly related to pump failure and fatal arrhythmias leading to sudden cardiac death. While basic guidelines for the management of cardiomyopathy in DMD patients exist, these recommendations are by no means comprehensive, and this chapter aims to provide further insight into appropriate clinical diagnosis and management of DMD-associated cardiomyopathy. Notably, earlier and more frequent cardiac assessment and care can allow for better outcomes for these patients. Pharmacological treatments typically include an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, beta-adrenergic receptor blockers, mineralocorticoid receptor antagonists, and corticosteroids. Non-pharmacological therapies include automated implantable cardioverter defibrillators and left ventricular assist devices, as well as in rare cases cardiac transplantation. Additionally, many emerging therapies show great promise for improving standards of care. These novel therapies, based primarily on applied gene therapy and genome editing, have great potential to significantly alter the DMD care landscape in the near future.

Long-Term Cardiac Assessment in a Sample of Adolescent-Onset Anorexia Nervosa

Background: High mortality rates have been reported in patients with anorexia nervosa, mainly due to cardiovascular alterations. The purpose of the present study was to assess cardiac structural and functional abnormalities some 20 years after initial treatment in a sample of adolescent-onset anorexia nervosa (A-AN) and to compare them with matched healthy controls (HC). Methods: A sample of 29 women diagnosed and treated for AN during adolescence (A-AN) were assessed more than 20 years later. A complete cardiac evaluation was carried out including an electrocardiogram (ECG) and a standard 2D echocardiography. Thirty matched HC were also assessed. Results: In the A-AN group, four subjects had a body mass index lower than 18.5 and met full DSM 5 criteria for AN at follow-up (Low-Weight group). They were compared with the rest of the sample (n=25) who had normalized their weight (Normal-Weight group), though some still showed some eating disorder symptoms. Both groups were compared with the HC group. Subjects in the Low-Weight group presented statistically significant decreases in the left ventricular end-diastolic and left atrium dimensions and left ventricular mass in comparison with the Normal-Weight group and the HC. No other differences in cardiac parameters were found between groups. Conclusions Echocardiographic and ECG parameters of adults who had presented A-AN twenty years earlier and currently maintained normal weight were similar to those of HC who had never been treated or diagnosed with AN. Adult subjects with A-AN who still had low weight in the long term present certain cardiac abnormalities similar to those seen in short-lasting disease. More studies are needed to confirm these results in a larger sample.

Consultation and clinical assessment of the heart and cardiovascular system

This article aims to increase knowledge of cardiac assessment. Anatomy and physiology of the heart are briefly reviewed and reference is made to pathology that can cause cardiac dysfunction. The main features to look for when taking a cardiac history are discussed, with suggestions for questions to elicit this information, and the signs to look for when undertaking a cardiac examination. There is also an introduction to the main investigations to aid differential diagnosis and clinical reasoning. A follow-up article will look in more detail at some common cardiac conditions presenting to emergency care, with an emphasis on critical thinking and diagnostic reasoning. These articles are written from an emergency care perspective, and therefore do not focus in great detail on invasive investigation of cardiology conditions, but more so on picking up these possibilities in undifferentiated patients presenting to emergency care.

Vertebral heart size and cardiosternal contact evaluation in thoracic roentgenographs of the Nigerian indigenous dog

The aim of this cross-sectional prospective radiologic study was to determine reproducible biometric ratios for cardiac assessment in the indigenous dog. Thirty healthy male and female dogs were used for the study. Sixty right and left lateral thoracic projections of the dogs were acquired. Parameters in each radiograph were objectively evaluated, namely: cardiac long and short axes in right and left lateral views. Indices generated were the vertebral heart size and the cardiosternal contact (also known as intercostal heart size). The mean values of vertebral heart size (VHS) and intercostal heart size (IHS) were: 9.82±0.08/9.70±0.10 and 3.40±0.05/3.37±0.05 for the right and left lateral radiographs, respectively. Vertebral heart size correlated strongly, positively and significantly with cardiac long and short axes while IHS showed a high, positive and significant relationship with short axis but a moderately, positively significant association with long axis. The indices determined in the study are easy to use and allow for objective investigation of the canine heart. The results of this research are clinically relevant in the diagnosis and management of cardiac anomalies. Keywords: Diagnosis, Nigerian dogs, radiology, thoracic measurements

Cardiology referrals before and during the COVID-19 pandemic: a health service evaluation

Background/Aims The COVID-19 pandemic has resulted in unprecedented changes to healthcare services. This study aimed to evaluate the impact of the COVID-19 pandemic on referrals to cardiology services in a tertiary hospital. Methods Royal Stoke University Hospital has a cardiac assessment nurse team that provides rapid access to specialist cardiology opinion. All referrals are recorded on a database, which was used to determine how COVID-19 affected the number and types of referrals to cardiology during March–September 2019 and March–September 2020. Results A total of 12 447 referrals were made to the cardiac assessment nurse teams over the evaluation period. Compared to the average number of referrals across all months, there was a decline of 10.5%, 31.2% and 18.5% during March, April and May 2019 respectively. Comparing 2020 to 2019, there were more 999 calls (17.7% vs 15.7%) and accident and emergency referrals (46.5% vs 45.0%), and fewer interhospital referrals (16.0% vs 19.6%). In terms of advice provided for the 999 referrals, a greater number were advised to go to the accident and emergency department (10.5% vs 0%) and direct phone advice provided to those in other settings increased (11.7% vs 0.1%) in 2020. Conclusions The COVID-19 pandemic was associated with a reduction in the number of overall referrals to cardiology, while also demonstrating a shift towards more advice to attend the accident and emergency department for assessment or direct phone advice being provided about management in the community.

Compound heterozygote KCNQ1 mutation causing Jervell Lange Neilson syndrome: a case report of genotype-phenotype correlation

Congenital sensorineural hearing loss (SNHL) is a common phenomenon with several genetic and non-genetic associations that require early diagnosis and work-up to prompt appropriate interventions. Of the genetic associations, Jervell and Lange-Nielsen syndrome (JLNS) remains a rare monogenic disease that is characterized by SNHL, prolongation of QT interval, syncopal attacks due to ventricular arrhythmias and sudden cardiac death from very early in life. We hereby report a 5 years old girl with SNHL and recurrent blackout episodes in early childhood with significant family history, admitted for cochlear implant who developed ventricular arrhythmias requiring multiple interventions with further investigations revealing a prolonged QT interval on electrocardiography (ECG) with metabolic abnormalities (hypomagnesemia and hypokalemia). Her clinical exome study showed a compound heterozygous KCNQ1 mutation, a more sporadic form of JLNS managed using oral beta-blocker. This experience illustrates the relevance of a detailed systemic evaluation with an elaborate cardiac assessment in children with SNHL, more so in the presence of frequent unexplained acute life-threatening episodes.