A late complication of a patent foramen ovale amplatzer occluder device

A 33-year-old woman had an embolic event to her fifth leftfinger1-week post-partum. An echocardiogram demonstrated a patentforamenovale (PFO) and right-to-left shunt with coughing     

Establishment and feasibility of community-based general-practitioner-led cardiology clinics

BACKGROUND: Community-based general practitioner (GP) cardiology clinics (locality clinics) offer an alternative to hospital-based cardiology clinics. In the Greenwich area, four GPs were trained for 3 months in cardiology, followed by another 3 months in a hospital out-patient clinic. GPs then established cardiology clinics in their practices and continued to act as hospital clinical assistants on an alternate-week basis. AIM: To assess referral and investigation patterns for the locality clinics over their first 3 years. DESIGN: Pilot study, retrospective case-note audit. METHODS: We analysed 125 sets of notes selected at random from the locality and the hospital clinics, and compared them. RESULTS: There were no differences in demographics or the indication for referral between locality and hospital clinics, and despite the small sample size, no major differences in referral and investigation patterns. In both clinics, approximately 83% of patients had at least one cardiac investigation, and approximately 63% were discharged after initial consultation. Some 10% of locality patients were referred for follow-up in the hospital clinic. Beta-blockers were prescribed more by hospital doctors (14% vs. 3%), with no significant difference in other cardiac medications. Coronary risk factors were more often recorded in the notes of locality patients. DISCUSSION: Establishing community-based GP cardiology clinics seems feasible, and these clinics may be the way forward for enhancing cardiac care in the community.     

Under-use of beta-blockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease

BACKGROUND: Beta-blockers (BB) improve morbidity and mortality in ischaemic heart disease. There is a general reluctance to use BB, especially in patients with chronic obstructive pulmonary disease (COPD), which is perceived as an absolute contraindication. As large numbers of patients are labelled with COPD without objective evidence, they may miss out on the benefit from these drugs. AIM: To assess the use of BB in patients with COPD admitted with acute coronary syndrome (ACS), and to assess the supporting evidence for the diagnosis of COPD in these patients. METHOD: Case-note review and retrospective analysis of 457 consecutive patients admitted with troponin-positive ACS between October 2002 and October 2003. RESULTS: Of 457 ACS patients studied, 246 (54%) were discharged on a BB. Cardiologists prescribed BB in ACS patients more frequently than did general physicians, (70% vs. 30%, respectively). The reasons for withholding BB were: not documented 27%, COPD 33%, heart failure 24%, others 16%. Ninety-four patients (21%) had a diagnosis of COPD; only 58 (62%) of these had been reviewed by a chest physician or had previous pulmonary function tests. Of the 94 patients with COPD, only 15 (16%) were prescribed BB during the admission: 9 by cardiologists and 6 by non-cardiologists. BB were discontinued in two patients due to an increase in dyspnoea. CONCLUSION: Many patients with a diagnosis of COPD have no objective evidence to support the diagnosis and are denied the prognostic benefits of BB when presenting with ACS. Before withholding beta-blockers, COPD and reversibility should be ascertained by pulmonary function testing. The overall use of beta-blockers remains sub-optimal and could be improved in this setting.     

Cardiopulmonary exercise testing and its application

Cardiopulmonary exercise testing (CPET) has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure.     

Feasibility and safety of 7-Fr radial approach for complex PCI

Background: Although the transradial approach is well established for percutaneous coronary intervention (PCI), it is perceived as being not suitable for 7‐Fr complex PCI, which is traditionally performed from the femoral approach. Objective: To evaluate the procedural success and outcome of 7‐Fr transradial complex PCI. Method: Retrospective review and analysis of all patients undergoing 7‐Fr transradial complex PCI from August 2008 until October 2010 in a tertiary cardiac center setting. Results: Transradial 7‐Fr complex PCI was performed in 77 patients after manual assessment of the radial pulse and size. The radial access was obtained successfully in all 77 patients. The age range was 39–88 years with 16 patients (23.4%) over 80 years of age and 14 females (18.1%). There were 30 left main stem PCI (39%), 31 (40.2%) chronic total occlusion (CTO), and 13 (16.8%) rotational atherectomy. Intravascular ultrasound (IVUS) was used in 17 (22%) cases, cutting balloons in 16 (20.7%), and LASER PCI in 2 (2.6%) cases. Procedural success was achieved in 76 of 77 (98.7%) with 1 failure to canalize a CTO. There was 1 patient with type I coronary perforation managed conservatively. There was no in‐hospital mortality. All radial pulses were present 6 hours after the procedure and only 23 patients were seen for follow‐up, and all had patent radial artery 4–6 months following the procedure. Conclusion: A 7‐Fr transradial complex PCI is feasible and can be carried out safely and successfully with excellent results. In suitable patients, male or female, complex PCI need not always be performed from the femoral approach. (J Interven Cardiol 2011;24:383–388)