James D. Newton

Prognosis for South Asian and white patients newly admitted to hospital with heart failure in the United Kingdom: historical cohort study

Abstract Objectives To compare patterns of admission to hospital and prognosis in white and South Asian patients newly admitted with heart failure, and to evaluate the effect of personal characteristics and comorbidity on outcome. Design Historical cohort study. Setting UK district health authority (population 960 000). Participants 5789 consecutive patients newly admitted with heart failure. Main outcome measures Population admission rates, incidence rates for first admission with heart failure, survival, and readmission rates. Results When compared with the white population, South Asian patients had significantly higher age adjusted admission rates (rate ratio 3.8 for men and 5.2 for women) and hospital incidence rates (2.2 and 2.9). Among 5789 incident cases of heart failure, South Asian patients were younger and more often male than white patients (70 (SD 0.6) v 78 (SD 0.1) years and 56.5% (190/336) v 49.3% (2494/5057)). South Asian patients were also more likely to have previous myocardial infarction (10.1% (n = 34) v 5.5% (n = 278)) or concomitant myocardial infarction (18.8% (n = 63) v 10.7% (n = 539)) or diabetes (45.8% (n = 154) v 16.2% (n = 817), all P < 0.001). A trend was shown to longer unadjusted survival for both sexes among South Asian patients. After adjustment for covariables, South Asian patients had a significantly lower risk of death (hazard ratio 0.82, 95% confidence interval 0.68 to 0.99) and a similar probability of death or readmission (0.96, 0.81 to 1.09) compared with white patients. Conclusions Population admission rates for heart failure are higher among South Asian patients than white patients in Leicestershire. At first admission South Asian patients were younger and more often had concomitant diabetes or acute ischaemic heart disease than white patients. Despite major differences in personal characteristics and risk factors between white and South Asian patients, outcome was similar, if not better, in South Asian patients.

Standalone balloon aortic valvuloplasty: Indications and outcomes from the UK in the transcatheter valve era

We sought to characterize UK‐wide balloon aortic valvuloplasty (BAV) experience in the TAVI era.

Interaction between statins and clopidogrel: is there anything clinically relevant?

Since their introduction several years ago, the 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors-the statins-have been widely used for hyperlipidemia and for the primary/secondary prevention of cardiovascular diseases. They have been shown to be safe as well as efficacious in a number of different clinical trials; however, studies have suggested that they can interact with other co-administered therapies. More recently, the thienopyridines have been successfully integrated with the conventional medical treatment of coronary disease as they showed effectiveness in reducing platelet activity both in stable and unstable settings. They also improve the outcome of patients treated with percutaneous coronary intervention. The potential interaction of statins and thienopyridines is a matter of concern. Despite some preclinical data suggesting an interaction between statins metabolized by the liver cytochrome P3A4-such as atorvastatin, lovastatin and simvastatin-and clopidogrel, there is no compelling clinical evidence to stop their co-administration.

Prioritizing echocardiography in Staphylococcus aureus bacteraemia

OBJECTIVES Infective endocarditis (IE) is a severe complication in Staphylococcus aureus bacteraemia (SAB) and recent guidelines from the BSAC recommend all patients undergo echocardiography. We assessed the use of echocardiography at a major tertiary referral centre and sought to identify those patients most likely to have positive findings. METHODS We retrospectively evaluated all cases of SAB at Oxford University Hospitals NHS Trust between September 2006 and August 2011. RESULTS Three-hundred-and-six out of 668 patients with SAB underwent cardiac imaging on average 9.8 ± 1.3 days from the first culture. Thirty-one patients (10.1%) had echocardiographic evidence of IE. Risk factors for observing evidence of IE on scanning included the presence of prosthetic heart valves (32% versus 4%, P < 0.001) or cardiac rhythm management (CRM) devices (16% versus 3%, P < 0.004). On excluding patients with prosthetic valves or CRM devices from the analysis, no patient with a line-related bacteraemia and only one patient (an intravenous drug user) with no/mild regurgitation on transthoracic echocardiography had echo evidence of IE. CONCLUSIONS We propose that the use of scarce echocardiography resources could be prioritized. Patients with prosthetic heart valves or a CRM device should receive early cardiological input and transoesophageal echocardiography. In patients with a clearly defined line-related bacteraemia who do not have a prosthetic valve or CRM device or clinical features of IE, response to treatment could be closely monitored and imaging deferred. Patients without a line-related infection or prosthetic valve/device could receive a transthoracic echocardiogram as a screening tool.

Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia

Left atrial appendage (LAA) occlusion is increasingly accepted to reduce the risk of stroke in patients with atrial arrhythmia who are unsuitable for routine anticoagulation. It is generally performed under general anesthesia, guided by transoesophageal echocardiography with accurate imaging being essential for correct deployment of the device. We present a case where LAA occlusion was done under local anesthesia in a high‐anesthetic risk patient, using novel placement of an intracardiac echo probe via a Mullins sheath in the right ventricular outflow tract and pulmonary artery. This allowed accurate visualization of device deployment in the LAA. This technique may increase the spectrum of patients who may benefit from the procedure and decrease procedure time, fluoroscopy, and procedure‐related morbidity.

Prominence of the Eustachian valve in paradoxical embolism

AIMS to investigate the relationship between Eustachian valve (EV) length and degree of atrial septal movement in patients with patent foramen ovale (PFO) and presumed paradoxical cerebral embolism. PFO is a well-established risk factor for cryptogenic stroke. However, due to the high prevalence of PFO, many of these are bystanders rather than true pathological entities. Other studies have sought to define which patients with PFO are particularly at risk of cryptogenic stroke by measuring various parameters of right atrial anatomy. We investigated the relationship between EV length and atrial septal movement. METHODS AND RESULTS measurements of EV length and atrial septal movement were made prospectively from 72 consecutive patients referred to our centre for PFO closure following presumed cryptogenic stroke, by intracardiac phased array echocardiography. The most significant finding from this study was that patients with fewer than 10 mm atrial septal movement had significantly longer EVs than those in whom there was >10 mm septal movement (P = 0.003). The mean EV length with >10 mm septal movement is 6.35 mm, and 13.33 mm with fewer than 10 mm movement. The prevalence of septal movement beyond 10 mm was significantly less in our series than in previously published papers. CONCLUSION we propose that while a large degree of atrial septal movement significantly increases propensity to cerebral embolism in patients with PFO, its absence does not negate this risk. We have shown that long EV may function independently from atrial septal movement to potentiate paradoxical embolism.

Acute worsening in migraine symptoms following PFO closure: A matter of fact?

There is currently conjecture in the literature as to whether percutaneous closure of patent foramen ovales (PFO) leads to an improvement in migraine symptoms. The present study reports the migraine status at 30 days, of 57 consecutive patients who underwent closure PFO closures for cryptogenic stroke at our institution. Our findings suggest a significant change in migraine character following PFO closure with the majority of these patients reporting a worsening in migraine severity. Those patients with more severe migraine prior to the procedure were more likely to experience deterioration. Patients should be counselled about the possibility of changing or worsening migraine prior to percutaneous closure for cryptogenic stroke.

Percutaneous Plugging of an Ascending Aortic Pseudoaneurysm

A 76-year-old woman presented to hospital with a 1-month history of progressively worsening central chest pain. Her medical history was remarkable for a previous aortic valve replacement with an ascending aortic interposition graft 10 years earlier. A computed tomography (CT) scan showed a large

What a Headache Rare Neuroendocrine Indication for Cardiopulmonary Bypass for Severe Left Ventricular Dysfunction and Shock

A 45-year-old male presented with 2 days of nausea, sweating, and abdominal pain. Examination revealed tachycardia, hypertension, diaphoresis, widespread crepitations, and diffuse abdominal tenderness. Profound hypotension developed, despite intravenous fluids, and was treated with noradrenaline and dobutamine; hypoxia required endotracheal intubation, followed by chest radiograph, which demonstrated extensive pulmonary edema. Echocardiography revealed severe global left ventricular systolic impairment, with an estimated ejection fraction of only 10% (Data Supplement Movies I and II). The patient was transferred to our hospital for the consideration of intraaortic balloon counterpulsation or left ventricular assist device support or both. An intraaortic balloon pump was inserted, and inotropic support was changed to adrenaline with modest improvement. Examination revealed a large mobile nonpulsatile mass in the left paraumbilical region, confirmed as a paraganglionoma on computed tomography (Figure 1). α-Blockade with …

Transcatheter aortic valve implantation: a durable treatment option in aortic stenosis?

Thirteen years following the first human transcatheter aortic valve implantation (TAVI),1 the procedure is now established as a proven therapy for patients with symptomatic severe aortic stenosis (AS) who are at high or excessive risk for conventional surgical aortic valve replacement (AVR). Remarkable efficacy demonstrated in pivotal randomised controlled studies2 ,3 has been confirmed within large-scale, real-world international multicentre registries, and TAVI is now approved by regulatory bodies and embedded within international guidelines as a Class I recommendation. More than 100 000 TAVI procedures have now been performed worldwide. A predictable consequence of this widely publicised success story is the move to consider the wider use of TAVI in patients conventionally treated by means of open surgery, either as a result of physician preference or patient choice. While further randomised controlled trials to evaluate TAVI in intermediate or low-risk cohorts are planned or underway, valid long-term outcome data concerning the durability of percutaneously implanted valves will ultimately determine whether TAVI becomes the default treatment of choice for the majority of patients with AS. Patients with AS are frequently elderly and frail with attendant comorbidity, and selection of the optimal treatment option is frequently challenging as a consequence. The development of a robust ‘Heart Team’ to evaluate, discuss and treat these patients is a fundamental principle of a successful TAVI service, and this multidisciplinary approach is strongly endorsed by the European Society of Cardiology and American College of Cardiology/American Heart Association Guidelines on Valvular Heart Disease. Guiding a patient and their family in the choice between AVR and TAVI (or no intervention in some patients where high-risk intervention …