Cardiovascular care

Non-contrast MRI for assessment of thoracic aorta dimension (2021)

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Type of publication:
Conference abstract

Author(s):
*Gupta M.; *Ingram T.; *Clarke H.; *Pakala V.; *Lee E.; Hargreaves O.; *Otun J.

Citation:
Heart; Jun 2021; vol. 107

Abstract:
Introduction Multi-modality imaging plays a significant role in evaluating and interval monitoring of patients with aortopathies. Echocardiogram is the first screening test followed by Computerised Tomography (CT) and/ or Magnetic Resonance Imaging (MRI). Most patients require repeated scans at interval. Both CT and MRI require contrast administration and furthermore, radiation exposure in CT. Locally, we have c adopted surveillance scanning with non-contrast MR to overcome the above limitations. This is not widely practised. Aim The aim of the study is to compare inter-modality agreement between CT (gold standard) and non-contrast MRI measurements of ascending aortic dimensions. Methods 126 consecutive patients underwent non-contrast
MRI thoracic aorta our hospitals between 2017 and 2021. Thirty-eight patients (61% males, age 61+/-14 years) have had both CT and MRI. A retrospective analysis was conducted to assess the inter-modality agreement of ascending aorta measurements. Statistical analysis was done using R programme (R studio). A Bland-Altman graph was used to assess inter-modality agreement of ascending aorta measurements. Differences in measurements of the two modalities were reported as mean and 95% confidence interval. Results There is good linear correlation (Pearson's R=0.86, p<0.05) between CT and MRI measurements. Mean difference between CT and MRI measurements was 2.39mm, 95% confidence interval 6.5mm to 8.4mm, see figure 1. Conclusion
There is good inter-modality agreement of ascending aorta measurements between CT non contrast MRI in our experience. Non contrast MRI has the advantage of requiring no radiation and no need for contrast. This is desirable particularly in young patients requiring long term surveillance.

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Suitability for low-dose rivaroxaban based on compass trial: A district general hospital perspective (2021)

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Type of publication:
Conference abstract

Author(s):
*Asad M.; *Irfan Kazi S.; *Makan J.; *Gupta M.; Alaguraja P.; McCaughey D

Citation:
Heart; Jun 2021; vol. 107

Abstract:
Introduction COMPASS trial has recommended that low-dose rivaroxaban reduces major adverse cardiac and limb events among patients with stable atherosclerotic vascular disease. In the real-world practice, the recommendations from COMPASS trial can be used as a standard to recognise potentially suitable patients. The objective of our study was to establish the cohort of patients identified as COMPASS-eligible for low dose rivaroxaban. Methods A health service evaluation of Cardiology Outpatients from Shrewsbury and Telford Hospital NHS Trust (SaTH) was carried out. The specific characteristics of the selected cohort included known stable atherosclerotic vascular disease while the inclusion and exclusion criteria incorporated in the COMPASS
trial was used as a standard. The SaTH clinical databases from January 2021 were utilized to conduct a retrospective analysis to identify patients who could prospectively benefit from low-dose rivaroxaban. Results Among the 99 patients who were found to have stable atherosclerotic vascular disease, 34 patients were deemed eligible for low dose rivaroxaban. Patients in our COMPASS-eligible group included 26 patients who were >=65years of age while 8 patients were noted to be <65 years of age. Further analysis revealed that 94% of the patients had coronary artery disease as compared with only 6% found to have peripheral artery disease. In this cohort of patients, 79 % of the non-eligible patients were excluded due to underlying atrial fibrillation. Conclusion About one-third of our cohort of patients met the COMPASS criteria and could potentially benefit from low dose rivaroxaban therapy. There is certainly a strong mandate for introduction of rivaroxaban
following the COMPASS trial recommendations. Local protocols should be established to ensure that this window of opportunity to prevent major adverse cardiovascular and limb events is not missed in the clinical practice.

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Myocardial bridges: A meta-analysis (2021)

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Type of publication:
Systematic Review

Author(s):
*Roberts W.; Ang C.; Charles S.M.; Tubbs R.S.; Loukas M.; Holda M.K.; Walocha J.; Lachman N.

Citation:
Clinical Anatomy; Jul 2021; vol. 34 (no. 5); p. 685-709

Abstract:
Myocardial bridges are anatomical entities characterized by myocardium covering segments of coronary arteries. In some patients, the presence of a myocardial bridge is benign and is only incidentally found on autopsy. In other patients, however, myocardial bridges can lead to compression of the coronary artery during systolic contraction and delayed diastolic relaxation, resulting in myocardial ischemia. This ischemia in turn can lead to myocardial infarction, ventricular arrhythmias and sudden cardiac death. Myocardial bridges have also been linked to an increased incidence of atherosclerosis, which has been attributed to increased shear stress and the presence of vasoactive factors. Other studies however, demonstrated the protective roles of
myocardial bridges. In this study, using systematic review and a meta-analytical approach we investigate the prevalence and morphology of myocardial bridges in both clinical imaging and cadaveric dissections. We also discuss the pathophysiology, clinical significance, and management of these anatomical entities.

British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab (2021)

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Type of publication:
Journal article

Author(s):
Dobson R.; Ghosh A.K.; Stanway S.; Manisty C.; Ky B.; Marwick T.; Stout M.; Pearce K.; Harkness A.; Steeds R.; Robinson S.; Oxborough D.; Adlam D.; Rana B.; *Ingram T.; Ring L.; Rosen S.; Plummer C.; Harbinson M.; Sharma V.; Lyon A.R.; Augustine D.X.

Citation:
Echo Research and Practice; Mar 2021; vol. 8 (no. 1)

Abstract:
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

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BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab (2021)

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Type of publication:
Journal article

Author(s):
Dobson R.; Ghosh A.K.; Manisty C.; Ky B.; Marwick T.; Stout M.; Pearce K.; Harkness A.; Steeds R.; Robinson S.; Oxborough D.; Adlam D.; Stanway S.; Rana B.; *Ingram T.; Ring L.; Rosen S.; Lyon A.R.; Plummer C.; Harbinson M.; Sharma V.; Augustine D.X.

Citation:
JACC: CardioOncology; Mar 2021; vol. 3 (no. 1); p. 1-16

Abstract:
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor receptor (HER) 2-positive targeted treatment (e.g., trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

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Can existing routine clinical data be used to predict hypoxaemia for mnd patients undertaking commercial flight? (2021)

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Type of publication:
Conference abstract

Author(s):
Cliff I.J.; Mustfa N.; Stone H.; Hurst C.; *Crawford E.

Citation:
Thorax; Feb 2021; vol. 76

Abstract:
Introduction: Pre-COVID-19, the total number of passengers traveling by commercial airlines rose to 4.3 billion, with Europe amounting to a 7.2% increase. The risks of respiratory compromised patients developing hypoxaemia during flight is well documented. Assessment of these patients is time consuming and often requires specialised equipment. Furthermore, the majority of evidence is based on research into patients with Chronic Obstructive Pulmonary Disease (COPD). The aim of this study is to investigate potential predictive biomarkers relating to the development of hypoxaemia during flight in patients with Motor Neurone Disease (MND). Method(s): 118 MND patients referred into a fitness to fly service (n=118) completed baseline lung function and a Hypoxic Challenge Test (HCT) as part of a risk stratification for (Table presented) planned air travel (77 male). Data from patients requiring inflight oxygen was compared to patients who did not, in accordance with the British Thoracic Society recommendations 2011: Managing passengers with stable respiratory disease planning air travel. Statistical analysis was performed using one-way ANOVA, Kruskal-Wallis, and Chi-Squared tests, as appropriate. Result(s): There was no significant difference between the pass (n=94) and fail (n=24) groups for age, gender, smoking history or BMI. There was a significant difference for all spirometry data (FEV1, FVC and FEV1/FVC ratio – absolute, percent predicted and standardised residuals). Moreover, the resting blood gases (FiO221%) data showed significant difference for all parameters with the exception of pH (<0.001). The Regression analysis showed limited predictive value of spirometry and/or resting blood gas data with the exception of PaCO2 and base excess (BE). Conclusion(s): The predictive value of spirometic paraments and resting blood gases are limited in assessing hypoxaemia during commercial flight in MND patients, with the exception of parameters relating to respiratory failure. Despite the significant difference between the two groups, routine physiological data was limited in the predictive regression equations. We recommend that the safest approach in managing this group of patients is to perform an HCT in all patients intending to use air travel until more evidence-based data is available.

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Can historical assumptions be used to assess fitness to fly for MND and ILD patients? An evaluation of physiological parameters to risk stratify patients planning air travel (2021)

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Type of publication:
Conference abstract

Author(s):
Cliff I.J.; Mustfa N.; Stone H.; Hurst C.; Allen M.B.; *Crawford E.

Citation:
Thorax; Feb 2021; vol. 76

Abstract:
Introduction: The risk associated with commercial flight for respiratory compromised patients is well known. Many of the assumptions are based on studies that have included patients with Chronic Obstructive Pulmonary Disease (COPD) and have often been extended to other respiratory and non-respiratory disorders. This study aimed to examine differences in physiological parameters and Hypoxic Challenge Test (HCT) outcome in patients with Motor Neurone Disease (MND), Interstitial Lung Disease (ILD) and COPD. Method(s): Respiratory patients who were referred into a fitness to fly service (n=225) with COPD (n=51), MND (n=118) and ILD (n=56) completed baseline lung function and a HCT as part of a risk stratification for planned air travel. Statistical analysis was performed using one-way ANOVA, Kruskal-Wallis, and Chi-Squared tests, as appropriate. Result(s): Demographic data relating to age, smoking history and BMI were significantly different between the patient groups. Spirometric data showed significant differences in Forced Expiratory Volume in one second (FEV1) absolute, percent predicted and standardised residuals, however there was no significant difference in Forced Vital Capacity (FVC) absolute or percent predicted. Resting capillary blood gases (CBGs) (FiO221%) showed significant differences between patient groups in all parameters with the exception of pH. Responses to the hypoxic mix during the HCT (FiO215%) showed differences in all CBG values with the exception of pH. This was also mirrored in the corrective values (FiO228%). The difference between the PaO2 at rest (21%) and during the HCT (15%) is higher in the MND and ILD groups (2.66and 2.74 kPa respectively) versus the COPD group (2.2kPa). The HCT fail rate was greatest for the COPD group (table 1). Conclusion(s): In this retrospective, exploratory examination, the physiological data supports significant differences between the disorders for the majority of data. The assumptions and algorithms based on the study of COPD patients cannot be assumed for MND or ILD, and these groups need to be (Table presented) specifically studied to better understand their response to the commercial cabin environment.

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Cardiovascular disease incidence in 21 years follow-up in severe and non-severe familial hypercholesterolaemia (FH) : Data from the UK Simon Broome FH register (2020)

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Weng S.; Roderick P.; *Capps N.; Durrington P.; Mcdowell I.; Soran H.; Neil A.; Humphries S.E.

Citation:
Atherosclerosis; December 2020; vol. 315

Abstract:
Background: The Simon Broome (SB) FH register has previously reported a 2.2-fold higher Cardiovascular Disease (CVD) mortality in those with "severe-FH" (SFH) compared to "non-severe-FH" (NSFH). Here we examine CVD morbidity over 21 years follow-up, by linking the register participants with the UK secondary care Hospital Episode Statistics (HES) database.
Method(s): SFH and NSFH were as defined by the 2016 International Atherosclerosis Society criteria. Patients aged 20-79 years (52% female) were recruited from 21 UK lipid clinics and followed between 1997-2018. Outcomes analysed were composite CVD (first HES outcome of coronary heart disease (CHD), myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG) and then CVD subtypes. The excess Standardised Morbidity Ratio (SMbR) compared to an age-matched UK general practice sample was calculated (95% Confidence intervals).
Result(s): Of the 3553 SB register subjects, linkage with HES was available for 2988 (84%) participants, of whom 1,646 (66.7%) met the SFH definition. Overall the composite CVD SMbR was 6.55(6.20-6.92). In the SFH group (27,680 pyrs follow-up and 762 events) the SMbR for any CVD event was 9.38 (8.74-10.07), while in the NSFH group (13,750 pyrs follow-up and 237 events) was 5.87(5.17-6.67). For CHD the estimates were 11.88(11.01-12.82) vs 7.38(6.45-8.47) respectively.
Conclusion(s): CVD morbidity in conventionally treated FH patients was over 6-fold higher than the general population, with rates in those with SFH 60% higher than those with NSFH. This emphasises the potential value of more intensive lipid-lowering, and management of other risk factors for those with FH.

Case report: Evaluating the role of ultrasound in the diagnosis of bilateral persistent sciatic arteries (2020)

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Type of publication:
Conference abstract

Author(s):
*Bell S.

Citation:
Ultrasound; 2020; vol. 28 (no. 2)

Abstract:
Peripheral vascular disease (PVD) affects 13% of the population aged over 50 in the western world and can be divided into two main groups: organic and functional. Other less common causes to include in the differential diagnosis in younger patients are Buerger's disease and anatomical variants such as duplication of the superficial femoral artery and persistent sciatic arteries (PSAs). PVD is a major cause of morbidity and mortality globally. Symptoms vary from cold extremities, intermittent claudication, to acute and critical ischaemia. All of these have a significant financial burden on critical healthcare resources. This case report evaluates the role of ultrasound in the diagnosis of bilateral PSAs. A 16-year-old female was referred by her GP to the vascular clinic presenting with bilateral intermittent claudication. On examination, missing dorsals pedis pulses were noted bilaterally. No previous imaging was available and the patient was referred for a lower limb Doppler ultrasound. Initial ultrasound scanning demonstrated no evidence of diseased vessels causing the patient's pain, but unusual arterial anatomy. Both superficial femoral arteries tapered to the distal thigh, where collaterals were demonstrated. Following the scan a diagnosis of persistent bilateral sciatic arteries was made. Ultrasound, due to its many advantages, is usually the first line imaging investigation to assess the peripheral arteries. In this case ultrasound was able to demonstrate that there was no evidence of any organically diseased vessels, but an anatomical variant causing the patient's symptoms. However, it was unable to demonstrate the overall view of the lower limb vasculature, the origin of the PSA, or provide all information to classify the sub type in view of any potential treatment or surgery. Although ultrasound is useful in the diagnosis of PSA, it lacks the ability to assess the whole of the peripheral circulation.

Sex differences in cardiovascular morbidity associated with familial hypercholesterolaemia: A retrospective cohort study of the UK Simon Broome register linked to national hospital records (2020)

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Type of publication:
Journal article

Author(s):
Barbara Iyen, Nadeem Qureshi, Stephen Weng, Paul Roderick, Joe Kai, *Nigel Capps, Paul N. Durrington, Ian FW. McDowell, Handrean Soran, Andrew Neil, Steve E. Humphries

Citation:
Atherosclerosis, 2020 Dec;315:131-137

Abstract:
Background and aims: The UK Simon Broome (SB) familial hypercholesterolaemia (FH) register previously reported 3-fold higher standardised mortality ratio for cardiovascular disease (CVD) in women compared to men from 2009 to 2015. Here we examined sex differences in CVD morbidity in FH by national linkage of the SB register with Hospital Episode Statistics (HES).
Methods: Of 3553 FH individuals in the SB register (aged 20–79 years at registration), 2988 (52.5% women) had linked HES records. Standardised Morbidity Ratios (SMbR) compared to an age and sex-matched UK general practice population were calculated [95% confidence intervals] for first CVD hospitalisation in HES (a composite of coronary heart disease (CHD), myocardial infarction (MI), stable or unstable angina, stroke, TIA, peripheral vascular disease (PVD), heart failure, coronary revascularisation interventions).
Results: At registration, men had significantly (p < 0.001) higher prevalence of previous CHD (24.8% vs 17.6%), previous MI (13.2% vs 6.3%), and were commenced on lipid-lowering treatment at a younger age than women (37.5 years vs 42.3 years). The SMbR for composite CVD was 6.83 (6.33–7.37) in men and 7.55 (6.99–8.15) in women. In individuals aged 30–50 years, SMbR in women was 50% higher than in men (15.04 [12.98–17.42] vs 10.03 [9.01–11.17]). In individuals >50 years, SMbR was 33% higher in women than men (6.11 [5.57–6.70] vs 4.59 [4.08–5.15]).
Conclusions: Excess CVD morbidity due to FH remains markedly elevated in women at all ages, but especially those aged 30–50 years. This highlights the need for earlier diagnosis and optimisation of lipid-lowering risk factor management for all FH patients, with particular attention to young women with FH.

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