Manish Gandhi

Tachycardia due to atrial flutter with rapid 1:1 conduction following treatment of atrial fibrillation with flecainide

Flecainide can “organise” atrial fibrillation into atrial flutter with 1:1 conduction, leading to cardiovascular compromise.

Fortnightly review: Intracoronary stents.

During the past five years there has been a sharp increase in the use of intracoronary stents as an adjunct to percutaneous transluminal coronary angioplasty (PTCA) for the revascularisation of patients with angina. In 1996 stents were used in half (mean 46%, range 15-99%) of the 20 500 PTCA procedures undertaken in the United Kingdom, representing a fivefold increase since 1994 (HH Gray, personal communication). Stents were developed to improve clinical outcome after PTCA. In selected patients, PTCA is as effective as bypass surgery,1 and more effective than medical treatment,2 in relieving angina. The early benefit of PTCA over medical treatment particularly applies to patients with severe angina and single vessel coronary artery disease at baseline. This benefit, however, diminishes during long term follow up and in patients with multivessel coronary artery disease, partly because repeat revascularisation is required for restenosis.3,4 In the early days after the first PTCA was performed in 1977, abrupt periprocedural closure of vessels and late angiographic restenosis were apparent.5 In an attempt to overcome these limitations, the first report of 24 coronary stents deployed in 19 patients was published 10 years later.6 Summary points Intracoronary stents increase luminal diameter, seal intimal flaps, limit vessel recoil, and reduce vascular remodelling to provide a wider and smoother coronary lumen than balloon angioplasty alone 50-90% of coronary angioplasty procedures are followed by elective intracoronary stenting; this improves angiographic and clinical outcomes in patients undergoing percutaneous revascularisation for stable and unstable angina, reducing the need for repeat intervention The role of intracoronary stenting in acute myocardial infarction remains unproved; it may be considered in selected patients when reperfusion with thrombolysis is contraindicated or fails Randomised trials are under way to compare intracoronary stenting with bypass surgery in patients with stable and unstable angina who have multivessel coronary artery disease Stents are flexible endovascular prostheses made from stainless steel alloys. They are designed as either metallic coils or slotted tubes.7 Most stents are expandable by balloon, and some are self expanding. The stent is mounted on a balloon catheter and, with the aid of fluoroscopic screening and radiopaque markers, is positioned across the stenotic lesion, which has usually been predilated with a balloon. Inflation of the balloon results in expansion and deployment of the stent circumferentially in apposition to the endothelial surface of the coronary artery (figs ​(figs11 to ​to3).3). Available stents range from 2.5 mm to 6 mm in diameter and from 8 mm to 50 mm in length. Figure 1 Balloon catheter (a), and close up of tip with balloon mounted coronary stent (b) Figure 3 Severe stenosis in a coronary artery (top), and angiographic appearance (bottom) after stent deployment

Development and refinement of a complex intervention within cardiac rehabilitation services: experiences from the CADENCE feasibility study

BackgroundPatients who experience a cardiac event are at higher risk of developing depression than the general population. Despite this, cardiac rehabilitation (CR) programmes do not provide a systematic approach to psychological care for depression. The CADENCE study aimed to develop and pilot an enhanced psychological care (EPC) intervention consisting of behavioural activation (BA) and mental health care coordination. Following original research commissioning guidance, the intervention was planned to be embedded in routine care and delivered by CR nurses to patients with depression attending CR. This paper describes how qualitative methods were used to develop, embed and refine the intervention.MethodsThis feasibility study involved three CR teams. Observations were made of CR nurses delivering usual care, of EPC training given to nurses, and of supervision sessions provided to the CR nurses. Four nurses were interviewed shortly after their EPC training, and three were interviewed again 6–7 months later having delivered EPC to patients. All nine patients recruited to receive EPC were interviewed. Analyses of the observation notes and interview transcripts focused on how the intervention could be improved in terms of its acceptability and implementation.ResultsVariations were found between the CR teams regarding patient waiting list times, how CR was delivered, what facilities were available and how many CR sessions were offered to patients. EPC was acceptable to both nurses and patients. However, nurses struggled to provide this additional care within their existing workload and resources, and patients’ disrupted progression through the CR programme affected EPC delivery. Limited time and availability of private space meant nurses also delivered EPC by telephone, which was viewed as a pragmatic solution but less preferable than face-to-face. Nurses indicated that patients struggled with some of the written materials. Findings were used to revise the intervention to become a protocol of care coordination which included guided self-help BA.ConclusionsInsights gained through conducting interviews and observations enabled us to identify barriers to the implementation of EPC, and to modify the intervention to facilitate its delivery within existing services whilst remaining acceptable to both nurses and patients. The multiple method, iterative approach used was key to the success of this qualitative study.Trial registrationISRCTN34701576 Registered 29/05/2014.

Patients’ and nurses’ views on providing psychological support within cardiac rehabilitation programmes: a qualitative study

Objective To explore patients’ and nurses’ views on the feasibility and acceptability of providing psychological care within cardiac rehabilitation services. Design In-depth interviews analysed thematically. Participants 18 patients and 7 cardiac nurses taking part in a pilot trial (CADENCE) of an enhanced psychological care intervention delivered within cardiac rehabilitation programmes by nurses to patients with symptoms of depression. Setting Cardiac services based in the South West of England and the East Midlands, UK. Results Patients and nurses viewed psychological support as central to good cardiac rehabilitation. Patients’ accounts highlighted the significant and immediate adverse effect a cardiac event can have on an individual’s mental well-being. They also showed that patients valued nurses attending to both their mental and physical health, and felt this was essential to their overall recovery. Nurses were committed to providing psychological support, believed it benefited patients, and advocated for this support to be delivered within cardiac rehabilitation programmes rather than within a parallel healthcare service. However, nurses were time-constrained and found it challenging to provide psychological care within their existing workloads. Conclusions Both patients and nurses highly value psychological support being delivered within cardiac rehabilitation programmes but resource constraints raise barriers to implementation. Consideration, therefore, should be given to alternative forms of delivery which do not rely solely on nurses to enable patients to receive psychological support during cardiac rehabilitation. Trial registration number ISCTRN34701576.

Authors’ reply to Sharvill and Beales

We thank Sharvill and Beales for drawing attention to gastroprotection for dyspepsia associated with dual antiplatelet therapy and a higher bleeding risk in elderly people, which we referred to in our article.123 We agree that a proton pump inhibitor or H2 receptor antagonist should be used to reduce the risk of bleeding in patients with a history of bleeding in the upper gastrointestinal tract and should …

Additional file 1: of Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial

Guide for session planning for nurses delivering enhanced psychological care as part of a comprehensive cardiac rehabilitation programme. (DOCX 44 kb)