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Syncope, as a symptom, remains poorly understood and handled in the UK. Personal involvement stemmed from successful abolition of syncope by cardiac pacing, initially in atrioventricular block then other bradycardias; UK facilities were sparse in the late 1970s. The aim was to broaden distribution and encourage understanding. To achieve this required abandoning the typical cardiology mindset and re-engaging with internal medicine. Syncope is poorly taught in medical schools, which implies that few physicians understand it and, therefore, cannot practise it to benefit patients. Syncope patients presenting in emergency departments (>1% of all) are frequently admitted to hospital to undergo numerous non-diagnostic tests, then discharged without diagnosis. Syncope has life-threatening causes in >1% of patients; given its prevalence, this represents a large number. Treatment is now possible.

Syncope science has notably advanced, offering valuable diagnostic and therapeutic strategies. Ubiquitous delivery in the UK requires a new approach, which has been applied in the Netherlands. Now, more than ever, is the time to take syncope seriously, with action now to address this critical situation.

Every week, patients present to emergency departments (EDs) following an episode of transient loss of consciousness (TLoC) due to syncope. It is common, affecting 40% of the population, and it constitutes 1–3% of ED visits and up to 6% of all hospital admissions.^1,2 The US Society for Academic Emergency Medicine – Guidelines for Reasonable and Appropriate Care in the Emergency Department (SAEM GRACE) review found that among ED patients, up to 50% remain undiagnosed after initial evaluation, that hospitalisation rates were highly variable, and approximately one-third of admitted patients are discharged without a definite diagnosis.³ Along with this, patients are subjected to unnecessary investigations, which contribute to escalating healthcare costs.⁴

Syncope is common, disabling, and, if mismanaged, potentially dangerous, both in terms of missed diagnoses or needless and harmful stays in hospital. Yet across health systems, it continues to fall between the cracks. It is time to build bridges: connecting emergency care, cardiology, neurology, geriatrics and acute medicine, through cohesive pathways that are early, equitable, efficient, and delivered by experts.

As Sutton and de Lange remind us, syncope is a symptom, not a diagnosis, and must be taken seriously.⁵ It should no longer be the orphan condition with no home. Despite not belonging in one specialty, a coordinated approach and collaboration should be forged between specialties.

This article won first prize in the recent British Junior Cardiologists’ Association (BJCA) essay competition.

Ischaemic heart disease remains the number one cause of mortality worldwide, with chest pain being one of the most common presentations to both primary care and cardiology services. Suspected angina referral pathways have become well established within NHS practice through rapid access chest pain clinics (RACPC), allowing prompt specialist assessment. While the expansion of access to noninvasive imaging has significantly enhanced risk stratification and management of patients with obstructive coronary artery disease (CAD), questions remain about the suitability of this rule-in/rule-out approach for all individuals referred to RACPC.

There is a high prevalence of frailty in people with heart failure, chronic kidney disease, type 2 diabetes, and multiple long-term conditions. These groups are eligible for treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i), with numerous large-scale trials demonstrating favourable clinical outcomes spanning disease states. There are now increasing data that the benefits of these agents are consistent across all frailty severities and are well tolerated. However, real-world data suggest a hesitancy in SGLT2i use in those with frailty. As a result, SGLT2i are either not initiated or discontinued inappropriately in people with frailty who are likely to derive benefit from these agents. This review critically evaluates current evidence and clinical guidelines for SGLT2i use in people with frailty, addressing safety concerns and offering practical recommendations for clinical practice.

Pulmonary hypertension (PH) is common in patients with severe aortic stenosis (AS). Severe PH has been associated with mortality up to two years following transcatheter aortic valve implantation (TAVI). Data on longer-term outcomes in TAVI patients with severe PH are limited. We aimed to compare all-cause mortality at five years post-TAVI in patients with and without severe PH and to identify any patient factors associated with reduced long-term survival.

TAVI patients meeting our inclusion criteria between January 2013 and October 2017 at a specialist cardiac centre in the UK were retrospectively analysed. Severe PH was defined as a systolic pulmonary arterial pressure >40 mmHg, estimated on transthoracic echocardiography. Data on patient demographics, comorbidities and mortality were obtained from routinely collected registry data. Kaplan-Meier and Cox-proportional hazards analyses were performed.

The median ages of the patients were 84 and 83 years in the group without severe PH and the group with severe PH, respectively. Severe PH was present in 95 out of 219 patients (43%). Patients with severe PH had higher levels of disability, left ventricular impairment and serum creatinine. On multi-variate analysis, the presence of severe PH was not associated with an increased mortality (adjusted hazard ratio [HR]=1.23, p=0.29). Peripheral vascular disease (PVD) was associated with a significantly increased risk of death at five years’ follow-up (adjusted HR=2.24, p=0.002). A lower body mass index (BMI) was also independently associated with reduced survival (adjusted HR=0.96, for an increase of 1 kg/m², p=0.038).

In conclusion, our data show that severe PH in patients with AS did not affect five-year survival post-TAVI. Reduced BMI and PVD were significantly associated with long-term all-cause mortality in patients undergoing TAVI.

Anticoagulation with vitamin K antagonists is recommended for prevention of thromboembolism in patients with mechanical heart valves. However, this treatment carries a notable risk of bleeding. We performed a retrospective analysis of patients with mechanical heart valves who were anticoagulated with warfarin, extracting the number and type of mechanical heart valves and their time in therapeutic range (TTR) for various recommended international normalised ratio (INR) ranges. Following this, we carried out a prospective study, over two separate six-month periods, identifying those with mechanical heart valves who sustained a bleeding or thromboembolic event.

We identified 409 patients with mechanical heart valves with an overall TTR of 68%. Over 12 months, we recorded 32 possible bleeding incidents in 22 patients. There was one thromboembolic event during this period, specifically a cerebrovascular event.

In conclusion, while our data indicate an elevated risk of bleeding, additional larger studies are needed to better understand bleeding risks across different demographic groups.

A 78-year-old man presented to the cancer assessment bay with a history of progressive fatigue, generalised muscle pain, and bilateral ptosis after completing two cycles of nivolumab/ipilimumab for metastatic renal cancer. Physical examination revealed mild bilateral ptosis (right > left), worsening with upward gaze, binocular diplopia, and fatigable weakness in the right shoulder. Electrocardiogram (ECG) showed a new right-bundle branch block (RBBB), with left-axis deviation, and left ventricular hypertrophy. Blood analyses showed elevated troponin I, brain natriuretic peptide, and creatine kinase with values of 221 ng/L, 114 ng/L, and 1,109 U/L, respectively. He was managed as immune checkpoint inhibitor-related severe myocarditis, myositis, and myasthenia gravis overlap (triple M) syndrome with high-dose steroids and pyridostigmine, resulting in clinical and biochemical improvement. However, immunotherapy was permanently discontinued, and follow-up imaging after three months showed evidence of disease progression. This case explores the importance of a multi-disciplinary approach in the effective management of a rare and severe immune-related toxicity and the impact of toxicities on treatment options and cancer progression.

Ejection fraction (EF) offers a remarkable approach to assess ventricular and atrial pumping capacity. Its value can easily be calculated, and it seems to reflect performance. However, EF is a non-preferred candidate from a conceptual point of view. To fully understand the weakness of the EF metric, it is necessary to appreciate that its numerical value (by its definition) solely depends on end-systolic volume (ESV) and end-diastolic volume (EDV). This tight mathematical connection can best be graphically represented in the ventricular volume domain while relating ESV to EDV, leading to straight conclusions about EF.

No previous paper has addressed the curious tradition of applying EF in cardiology in terms of the indirect reasons for its popularity, as well as the intrinsic shortcomings, alongside the statistical irregularities involved. This review highlights the misleading attractiveness of EF, while also offering logical alternatives without invoking the need for relying on additional data beyond standard measurements.