Guy Lloyd

The relationship between right ventricular pacing and atrial fibrillation burden and disease progression in patients with paroxysmal atrial fibrillation: the long-MinVPACE study.

AIMS In patients requiring permanent pacemaker implantation for sinus node disease (SND) or atrioventricular (AV) block, right ventricular (RV) pacing has been demonstrated to increase the risk of developing atrial fibrillation (AF). The effects of RV pacing in patients with paroxysmal AF are less well defined. Short- and medium-term studies have suggested no significant correlation between RV pacing and atrial fibrillation burden (AFB) measurement; we sought to assess for an effect in the long-term. METHODS AND RESULTS Sixty-six patients were randomized to receive either conventional dual chamber pacing (DDDR, n = 33), or dual chamber minimal ventricular pacing (MinVP, n = 33), for a period of at least 1 year. Patients were reviewed every 6 months and all pacemaker data were downloaded. The primary outcome measures were device-derived AFB and progression to persistent AF. The mean duration of study follow-up was 1.4 ± 0.6 years. Mean ventricular pacing was less in the MinVP cohort compared with the DDDR cohort (5.8 vs. 74.0%, P < 0.001). At follow-up, the device-derived AFB was significantly lower in the MinVP cohort when compared with the DDDR cohort (12.8 ± 15.3% vs. DDDR 47.6 ± 42.2%, P < 0.001). Kaplan-Meier estimates of time to onset of persistent AF showed significant reductions in the rates of persistent AF for MinVP pacing (9%) when compared with conventional DDDR pacing (42%), P = 0.004. CONCLUSION Right ventricular pacing induces increased AFB in patients with paroxysmal AF in the long term. Dual chamber MinVP algorithms result in reduced AFB and reduced disease progression from paroxysmal to persistent AF in the long term.

A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography

There have been significant advances in the field of echocardiography with the introduction of a number of new techniques into standard clinical practice. Consequently, a ‘standard’ echocardiographic examination has evolved to become a more detailed and time-consuming examination that requires a high level of expertise. This Guideline produced by the British Society of Echocardiography (BSE) Education Committee aims to provide a minimum dataset that should be obtained in a comprehensive standard echocardiogram. In addition, the layout proposes a recommended sequence in which to acquire the images. If abnormal pathology is detected, additional views and measurements should be obtained with reference to other BSE protocols when appropriate. Adherence to these recommendations will promote an increased quality of echocardiography and facilitate accurate comparison of studies performed either by different operators or at different departments.

No test is too routine to do properly.

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A cardiac sonographer led follow up clinic for heart valve disease

INTRODUCTION This study describes the effect of introducing a cardiac sonographer led follow up clinic for patients with stable heart valve disease. The 2 years before and after the instigation of the valve clinic were audited. MATERIALS AND METHODS The clinic was conducted in a single centre and undertaken in the cardiology department of a district general hospital. 382 patients, with 397 clinically significant valve lesions, but for whom surgery was not yet indicated but follow up required, were seen in a cardiac sonographer run clinics. These patients no longer attended a medical follow up clinic unless there was clinical or echocardiographic deterioration. Effectiveness was judged by the percentage treated according to current best practice guidelines, the number of echocardiograms performed and the number of hospital out patient visits attended. In addition mortality data for the subjects in the clinic was collected. RESULTS The proportion followed up according to best practice guidelines rose from 157 (41%) to 354 (92%) (p<0.01). The total number of echocardiograms performed fell from 807 to 550. Total number of out patient visits fell from 998 to 31. 11 patients died in the two year study period, none from progressive valve disease. DISCUSSION This study demonstrates that a protocol driven sonographer led heart valve disease follow up clinic, significantly improved the quality of follow up while bringing about a major reduction in out patients visits, without compromising patient safety.

Radiation-induced valvular heart disease

Radiation to the mediastinum is a key component of treatment with curative intent for a range of cancers including Hodgkins lymphoma and breast cancer. Exposure to radiation is associated with a risk of radiation-induced heart valve damage characterised by valve fibrosis and calcification. There is a latent interval of 10–20 years between radiation exposure and development of clinically significant heart valve disease. Risk is related to radiation dose received, interval from exposure and use of concomitant chemotherapy. Long-term outlook and the risk of valve surgery are related to the effects of radiation on mediastinal structures including pulmonary fibrosis and pericardial constriction. Dose prediction models to predict the risk of heart valve disease in the future and newer radiation techniques to reduce the radiation dose to the heart are being developed. Surveillance strategies for this cohort of cancer survivors at risk of developing significant heart valve complications are required.

Tissue Doppler–Derived Contractile Reserve Is a Simple and Strong Predictor of Cardiopulmonary Exercise Performance across a Range of Cardiac Diseases

Resting echocardiographic measures of cardiac function such as left ventricular ejection fraction correlate poorly with exercise capacity. Assessment during exercise using measures less dependent on hemodynamic loading conditions, such as tissue Doppler imaging (TDI), may more accurately characterize the relationship between cardiac function and exercise capacity.

Valvular heart disease: a call for global collaborative research initiatives

The burden of valvular heart disease (VHD) is rising rapidly as life expectancy increases. The prevalence in the USA alone is 13% in those aged over 75 years,1 while the global prevalence of rheumatic heart disease is estimated at 15.6–19.6 million.2 Despite this, the treatment of VHD still lacks an adequate research base. None of the 64 recommendations in the 2012 European Society of Cardiology (ESC) VHD guidelines3 had Level A evidence and only 14% had Level B evidence. This compares with 28% at Level A and 42% at Level B among the 270 recommendations in the 2010 ESC myocardial revascularisation guidelines.4 Therefore, there is an urgent need to stimulate the investigation. In this article, we identify deficits in our knowledge which may be amenable to research and make a call for national and international collaborative efforts to address this evidence gap. The prevalence of VHD in industrialised countries has been extrapolated from studies predominantly conducted in the USA,1 while the prevalence of rheumatic disease in sub-Saharan Africa is extrapolated from studies in North Africa. True figures need to be established nationally, while for rare causes of VHD (eg, carcinoid or antiphospholipid syndrome), this might be better done using international registries with standardised protocols. Serial echocardiography within these projects will improve our understanding of the contemporary natural history of VHD, which was previously determined in small cohorts of patients and generally with fewer comorbidities compared with the present. The genetics and developmental biology of VHD are poorly understood. Collation of genetic analyses from established bio-banks and twin studies may identify new determinants of disease or its progression. Such techniques may also provide clues towards the development of treatments for challenging conditions such as endomyocardial fibrosis. Lipid-lowering therapy has not been successful in modifying the progression …

Treating cardiovascular disease in women

Cardiovascular disease (CVD) is the most common cause of death in women but some of the challenges of management differ from those in men. This article addresses the gender-specific issues of cardiovascular management, with emphasis on ischaemic heart disease and modification of coronary risk factors. Women with ischaemic heart disease present later than men, and are therefore older and more likely to suffer from co-morbidities such as diabetes and hypertension. Proven CVD risk factors in women can be divided into those that are modifiable and those that are non-modifiable. The former include diabetes, dyslipidaemia, hypertension, smoking, obesity, sedentary lifestyle and poor nutrition; the latter include family history of heart disease and older age at presentation. It is this difference in age and general health that explains much of the variability in response to treatment. Pharmacotherapy, percutaneous intervention, surgical revascularization, and cardiac rehabilitation and disease prevention are discussed.

Stress echocardiography in clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography

AIMS Stress echocardiography (SE) is one of the leading modalities for the assessment of coronary artery disease and dynamic valvular heart disease. A wide range of different techniques have been established. There are no data which identify how current techniques have been integrated into clinical practice. METHODS AND RESULTS An electronic questionnaire was devised to identify SE practice in five core areas: service demographics, indications, methods, reporting, and adverse events. The questionnaire was sent to 198 National Health Service hospitals. Eighty-five (71%) out of the 120 departments who perform SE responded. Each unit performed a median of 400 SE (inter-quartile range 175-600). Thirty-two (37.6%) operators performed <100 SE per year. Exercise, dobutamine, dipyridamole, adenosine, and pacing SE were available in 57 (67.1%), 85 (100%), 6 (7.1%), 11 (12.9%), and 34 (40%) units, respectively. Eighty-one (95.3%) units performed SE for the evaluation of low-flow, low-gradient aortic stenosis. Thirty-four (40%) and 32 (37.6%) performed SE for the evaluation of asymptomatic severe aortic stenosis and symptomatic moderate mitral regurgitation, respectively. Eighty-three (97.6%) administered contrast agents during SE. Additional analysis of perfusion and strain was performed in 9 (10.5%) and 13 (15.3%) units, respectively. CONCLUSION SE has been incorporated into the majority of UK hospitals. A substantial proportion of operators perform less than the recommended number of procedures per year. The use of exercise SE, vasodilator SE, and SE for the evaluation of VHD are under-utilized. Penetration of new techniques is variable, contrast for left ventricular opacification has been almost universally adopted, while myocardial perfusion and mechanics are used much less.

Improving Appropriateness and Quality in Cardiovascular Imaging: A Review of the Evidence

High-quality cardiovascular imaging requires a structured process to ensure appropriate patient selection, accurate and reproducible data acquisition, and timely reporting which answers clinical questions and improves patient outcomes. Several guidelines provide frameworks to assess quality. This article reviews interventions to improve quality in cardiovascular imaging, including methods to reduce inappropriate testing, improve accuracy, reduce interobserver variability, and reduce diagnostic and reporting errors.