2018 Practice Guidelines for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension.

These practice guidelines on the management of arterial hypertension are a concise summary of the more extensive ones prepared by the Task Force jointly appointed by the European Society of Hypertension and the European Society of Cardiology. These guidelines have been prepared on the basis of the best available evidence on all issues deserving recommendations; their role must be educational and not prescriptive or coercive for the management of individual subjects who may differ widely in their personal, medical and cultural characteristics. The members of the Task Force have participated independently in the preparation of these guidelines, drawing on their academic and clinical experience and by objective examination and interpretation of all available literature. A disclosure of their potential conflict of interest is reported on the websites of the ESH and the ESC.

Factors that influence obesity, functional capacity, anxiety and depression outcomes following a Phase III cardiac rehabilitation programme.

AIMS AND OBJECTIVES: To examine changes in functional capacity, anxiety, depression and BMI in patients who completed a cardiac rehabilitation programme and to determine the influencing factors. BACKGROUND: While the effectiveness of cardiac rehabilitation is long established, more studies are needed to examine the combined effectiveness of this multicomponent intervention and the factors that influence this in the changed profile of patients currently attending cardiac rehabilitation. DESIGN: The study was a longitudinal retrospective study of patients following a six- or eight-week Phase III cardiac rehabilitation programme. METHODS: The study recruited 154 patients. Functional capacity, anxiety, depression, weight, waist circumference and BMI were assessed at the beginning and end of cardiac rehabilitation. t-tests were used to assess changes over time, and multivariate regression analysis was used to determine the influence of factors on these changes. RESULTS: Significant improvements were seen in functional capacity, waist circumference, weight and BMI, but not in depression and anxiety. Multivariate analysis revealed that being younger and less fit was associated with greater improvements in functional capacity while reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Models testing the influence of the factors on BMI, anxiety and depression were not significant. CONCLUSION: Cardiac rehabilitation is still an effective method to instigate changes in cardiac risk factors despite the changes in patients profile attending programmes. RELEVANCE TO CLINICAL PRACTICE: Continued encouragement of the historically less typical patients to participate in cardiac rehabilitation is needed as reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Despite psychosocial components within the programme, no significant improvements were observed over cardiac rehabilitation in depression or anxiety. While effectiveness was observed, there is room for further optimisation of practice and research by employing and documenting clearly the use of behavioural techniques.

Dyslipidaemia management in the cardiac rehabilitation clinic of a tertiary referral centre: analysis of the impact of new ESC guidance on LDL-C target achievement.

BACKGROUND: Optimisation of low-density lipoprotein cholesterol (LDL-C) targets is one component of cardiac rehabilitation (CR). The 2019 European Society of Cardiology (ESC) guidelines recommend lower LDL-C targets than those released in 2016. AIMS: To determine the proportion of patients who met 2019 LDL-C targets and compare these to international standards; examine the effect of the introduction of the recent ESC guidelines on target achievement. Examine the choice of lipid lowering therapy (LLT) used in our cohort. METHODS: Retrospective chart review of 163 patients who attended CR in 2019. Baseline LDL-C levels were calculated where applicable. Targets achieved were compared with the contemporary ESC guidance. Required LLT was estimated for those who were unable to meet their LDL-C target. RESULTS: Overall, 96/163 (59%) patients met their absolute LDL-C targets, which was favourable when compared to international standards. Fewer patients treated using the 2019 ESC guidelines met their absolute, (63% (70/112) vs. 51% (26/51)), or relative LDL-C 43% (22/51) targets. A high intensity statin was prescribed in 63% (89/163) of patients and only 9% (5/163) patients were prescribed ezetimibe therapy; increased use of these agents may have led to a further 20% (33/162) of patients meeting their LDL-C targets. 13% (22/163) of patients likely require PCSK9i therapy. CONCLUSIONS: Patients may be more likely to meet LDL-C targets while enrolled in CR compared to standard care. Following the introduction of lower absolute LDL-C targets and additional > 50% LDL-C reduction from baseline requirement, fewer patients are meeting the LDL-C targets set out in the 2019 ESC dyslipidaemia guidelines. Additionally, many patients are not on maximum statin therapy, ezetimibe is under-prescribed, and a guideline-reimbursement gap exists for those who require PCSK9i therapy.

Secondary prevention and cardiovascular care across Europe: A survey of European Society of Cardiology members' views.

INTRODUCTION: Secondary prevention of cardiovascular disease is a significant clinical challenge and despite European Society of Cardiology (ESC) Guidelines, evidence confirms sub-optimal patient care. AIM: The aim of this study was to evaluate ESC members' opinions on the current provision of cardiovascular prevention and rehabilitation services across Europe and explore barriers to guideline implementation. METHOD: Electronic surveys using a secure web link were sent to members of the ESC in eight purposively selected ESC affiliated countries. RESULTS: A total of 479 professionals completed the survey, of whom 67% were cardiologists, 8.6% general physicians, 8.2% nurses and 16.2% other healthcare professionals. Respondents were predominantly (91%) practising clinicians, generally highly motivated regarding cardiovascular disease prevention, but most reported that secondary prevention in their country was sub-optimal. The main barriers to prevention were lack of available cardiac rehabilitation programmes and long-term follow-up, patients' disease perception and professional attitudes towards prevention. While knowledge of the prevention guidelines was generally good, practices such as motivational counselling and better educational tools were called for to promote exercise, smoking cessation and for nutritional aspects. CONCLUSIONS: The provision of services focusing on the secondary prevention of cardiovascular disease varies greatly across Europe. Furthermore, despite ESC Guidelines and a strong evidence base supporting the efficacy of secondary prevention, the infrastructure and co-ordination of such care is lacking. In addition patient motivation is considered poor and some professionals remain unconvinced about the merits of prevention. The disappointing results outlined in this survey emphasise that improved tools are urgently required to educate both patients and professionals and confirm the priority of cardiovascular prevention internationally.

2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension.

: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP).

BACKGROUND: The European Society of Cardiology (ESC) has a comprehensive clinical guideline development programme, relevant for all clinicians. However, implementation of guidelines is not always optimal. AIM: The aim of this study was to determine nurses' and allied professionals' awareness and barriers regarding clinical guideline implementation. METHODS: A cross-sectional survey was administrated online and in print at EuroHeartCare 2015. A questionnaire was developed which examined awareness and barriers to implementation of ESC guidelines on cardiovascular disease prevention in clinical practice (2012) and ESC guidelines in general. RESULTS: Of the 298 respondents, 12% reported that the prevention guidelines were used in their practice area. Respondents identified, in order of magnitude, that lack of leadership, workload, time, resources and a perception that they were unable to influence current practice were barriers to the use of the prevention guidelines. When asked to rank barriers to use of any ESC guidelines, time (22%) and leadership (23%) were ranked highest. CONCLUSIONS: Implementation of ESC guidelines by nurses, the majority responders in this survey, is a serious problem, requiring urgent improvement to ensure patients receive optimal evidence based care. Issues of leadership, workload, time and resources are significant barriers to guideline implementation. It is of concern that these professionals perceive both that they have little influence on implementation decisions and lack of leadership regarding guideline implementation. Educational and organisational strategies to improve leadership skills are imperative. These will build self-efficacy and empower nurses and allied professionals to advocate for evidence-based care in the clinical environment.

A human bite to the scrotum: a case report and review of the literature.

Human bites to the scrotum are rare and can be associated with a high morbidity rate if poorly managed. We report a case of a human bite to the scrotum that was successfully treated with a 5-day course of antibiotics, surgical debridement and healing by secondary intention.

Inner-city gunshot wounds­10 years on.

INTRODUCTION: In 1997, Injury published one of the first research papers to document the incidence and characteristics of civilian gunshot wounds in a UK urban environment. Since then there has been concern that firearm deaths and injuries have increased despite little published clinical evidence. METHODS: We carried out a retrospective survey ten years on from the initial study. All patients presenting to the Emergency Department (ED) of King's College Hospital with gunshot wounds from 1st January 2003 to 31st December 2004 were identified. Information regarding incidence, patient and injury characteristics and outcome was determined. RESULTS: 46 patients presented with firearm injuries. 44 were male and the average age was 24 years. The majority were from minority ethnic groups. 38/46 presented out of hours and the police were documented to be involved in 36 cases. All injuries were due to assault by low energy projectiles. Of the 32 patients admitted the mean length of stay was 12.4 days. The majority of injuries were to the musculo-skeletal system. Six patients died from their injuries­5 from head/neck or chest injuries and 1 from intra-abdominal injury. DISCUSSION: There appears to be little increase in firearm injuries seen over this 10 year period at our hospital and predominately young, black males continue to be the victims. Most present out of hours,potentially placing considerable challenges on junior medical staff. Most wounds were to the musculoskeletal system perhaps reflecting the desire to maim rather than kill and the absence of high velocity injuries may reflect the UK's stringent gun control legislation. The importance of high quality clinical audit is necessary to effectively plan training, service provision and violence prevention efforts. CONCLUSION: Despite public, political and media concerns that deaths and injuries caused by firearm shave increased dramatically, this study finds little change in incidence or characteristics of those injured and attending an urban ED over a ten year period.

Contributing factors to patient non-attendance at and non-completion of Phase III cardiac rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) is generally underutilized. AIM: The aim of this study was to describe the rate of non-attendance after enrolment and non-completion after commencement to Phase III CR and to explore associated factors. METHOD: A review of medical records was carried out to determine the profile of all patients who enrolled on a CR programme. Patients who enrolled but did not attend or did not complete the programme were surveyed to ascertain the primary underlying reasons for this. A convenience sub-sample of these was then selected for semi-structured interviews (n=7) to explore the reasons for non-attendance/non-completion further. RESULTS: Of the patients that enrolled, 11% (n=29) did not attend and 19% (n=51) did not complete the programme. The non-attendees and non-completers were significantly more likely to be unskilled manual workers (p=0.018) or smokers (p=0.001). Illness and not interested were the most common primary reasons for non-attendance and non-completion respectively. Further qualitative exploration of the contributing factors revealed exercise, depression and organizational factors contributed to these reasons. CONCLUSIONS: The study highlights that individual patient profiles and needs, if unmet contribute to poor attendance. This suggests that if these needs were identified and addressed more comprehensively throughout CR, attendance at Phase III programmes would improve.

Changes in diet, exercise and stress behaviours using the stages of change model in cardiac rehabilitation patients.

The behavioural changes initiated during Phase III cardiac rehabilitation programmes were recorded using Prochaska and Diclemente's "stages of change" model. This study aimed to ascertain if changes were initiated, maintained or further developed during Phase III programmes and 6 months after the programmes with a view to ascertaining the usefulness of this tool in providing stage matched individualised care. The risk factors examined were: exercise, diet and stress. The stages were recorded quantitatively and were numerically designated a value of 1-5. The results were analysed using SPSS. The sample number was one hundred and eighty seven patients. Significant improvements were made by the end of the programme (6 or 8 weeks) indicating that most patients had modified their behaviour during the programme. There was no significant additional improvement in the risk factors 6 months later. These results are a further indication of the need for support post Phase III programmes. Patients entered Phase III rehabilitation at different stages in their risk behaviours and with regard to exercise this stage at commencement influences the final stage achieved. "Stages of change" is a useful simple method of recording behavioural change and this type of routine monitoring of a patient could be used effectively as part of the individual care plan during the programme.

Multiple toxicity from 3,4-methylenedioxymethamphetamine ("ecstasy").

There have been no published case series illustrating "ecstasy" (3,4-methylenedioxymethamphetamine [MDMA]) toxicity in a group of patients who have ingested ecstasy in the same environment. We report a series of 7 patients who ingested ecstasy in a nightclub and presented with varying degrees of MDMA toxicity. Three patients presented with features of severe MDMA toxicity. One died within an hour of hospital admission, another died 4 days later, after developing fulminant hepatic failure, and the third recovered after 12 days in intensive care. MDMA was identified in the serum of all 7 patients. High serum MDMA concentrations correlated with severe clinical and biochemical features including coma, hyperpyrexia, cardiovascular compromise, acidosis, and hyperkalaemia. "Poisoned ecstasy" was widely reported by the media as being responsible for the adverse effects observed. This report highlights a relationship between serum concentrations and toxic effects of MDMA, and the ongoing need to educate the public about the dangers of this substance.