Geographical Variation in Underlying Social Deprivation, Cardiovascular and Other Comorbidities in Patients with Potentially Curable Cancers in England: Results from a National Registry Dataset Analysis.

AIMS: To describe the prevalence of cardiovascular disease (CVD), multiple comorbidities and social deprivation in patients with a potentially curable cancer in 20 English Cancer Alliances. MATERIALS AND METHODS: This National Registry Dataset Analysis used national cancer registry data and CVD databases to describe rates of CVD, comorbidities and social deprivation in patients diagnosed with a potentially curable malignancy (stage I-III breast cancer, stage I-III colon cancer, stage I-III rectal cancer, stage I-III prostate cancer, stage I-IIIA non-small cell lung cancer, stage I-IV diffuse large B-cell lymphoma, stage I-IV Hodgkin lymphoma) between 2013 and 2018. Outcome measures included observation of CVD prevalence, other comorbidities (evaluated by the Charlson Comorbidity Index) and deprivation (using the Index of Multiple Deprivation) according to tumour site and allocation to Cancer Alliance. Patients were allocated to CVD prevalence tertiles (minimum: <33.3rd percentile; middle: 33.3rd to 66.6th percentile; maximum: >66.6th percentile). RESULTS: In total, 634 240 patients with a potentially curable malignancy were eligible. The total CVD prevalence for all cancer sites varied between 13.4% (CVD n = 2058; 95% confidence interval 12.8, 13.9) and 19.6% (CVD n = 7818; 95% confidence interval 19.2, 20.0) between Cancer Alliances. CVD prevalence showed regional variation both for male (16-26%) and female patients (8-16%) towards higher CVD prevalence in northern Cancer Alliances. Similar variation was observed for social deprivation, with the proportion of cancer patients being identified as most deprived varying between 3.3% and 32.2%, depending on Cancer Alliance. The variation between Cancer Alliance for total comorbidities was much smaller. CONCLUSION: Social deprivation, CVD and other comorbidities in patients with a potentially curable malignancy in England show significant regional variations, which may partly contribute to differences observed in treatments and outcomes.

Strain rate imaging pre- and post-percutaneous coronary intervention: a potential role in the objective detection of ischaemia in exercise stress echocardiography.

AIMS: To determine the feasibility of strain rate imaging (SRI) in the objective detection of exercise-induced ischaemia. METHODS AND RESULTS: Sixteen patients undergoing elective percutaneous coronary intervention (PCI) underwent treadmill exercise stress echocardiography (ESE) pre- and post-PCI. Measurement of systolic SRI parameters was attempted in all myocardial segments at baseline, peak stress, and in recovery. Segments were divided into those supplied by target (Group 1) and non-target vessels (Group 2). Percutaneous coronary intervention was successful in all patients. In Group 1, there was no significant difference in post-systolic strain rate (SRps) at baseline or at peak stress but there was significantly greater SRps pre-PCI compared with post-PCI at 30 min into recovery (-0.37 +/- 0.53 vs. -0.07 +/- 0.44 s(-1), P = 0.004). There were similar findings with the SRps index [ratio of SRps:peak systolic strain rate (SRsys)]. Group 2 segments did not demonstrate any significant differences in SRI parameters pre- and post-PCI. At peak exercise pre-PCI, Group 1 segments had significantly delayed time to SRsys compared with Group 2 (0.12 +/- 0.05 vs. 0.09 +/- 0.05 s, P = 0.013), a difference that was abolished post-PCI. CONCLUSION: This suggests a potential role for SRI in the objective detection of exercise-induced ischaemia by echocardiography at peak stress and during recovery at the time of improved image quality.

Acute rheumatic fever mimicking an acute coronary syndrome.

An elevated troponin measurement does not always reflect myocardial ischaemia secondary to obstructive coronary artery disease. Troponin levels can also be elevated in other disease states including pulmonary emboli, myo-pericarditis, acute rheumatic fever, and in the critically ill. Thus, patients presenting with chest pain and electrocardiological and biochemical evidence of myocardial necrosis are not always suffering from an acute coronary syndrome.

Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention.

OBJECTIVE: For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality. METHODS: A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI-CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated. RESULTS: Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI-CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI-CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90). CONCLUSIONS: Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI-CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths.

Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003-2013.

OBJECTIVE: Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation. METHODS: Whole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003-2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors. RESULTS: Overall, standardised rates of PPCI increased from 0.01% to 86.3% (2003-2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1-5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences. CONCLUSIONS: Following an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.

The SSTARS (STeroids and Stents Against Re-Stenosis) Trial: Different stent alloys and the use of peri-procedural oral corticosteroids to prevent in-segment restenosis after percutaneous coronary intervention.

BACKGROUND: Stent design and technological modifications to allow for anti-proliferative drug elution influence restenosis rates following percutaneous coronary intervention (PCI). We aimed to investigate whether peri-procedural administration of corticosteroids or the use of thinner strut cobalt alloy stents would reduce rates of binary angiographic restenosis (BAR) after PCI. METHODS: This was a two centre, mixed single and double blinded, randomised controlled trial using a factorial design. We compared (a) the use of prednisolone to placebo, starting at least six hours pre-PCI and continued for 28days post-PCI, and (b) cobalt chromium (CoCr) to stainless steel (SS) alloy stents, in patients admitted for PCI. The primary end-point was BAR at six months. RESULTS: 315 patients (359 lesions) were randomly assigned to either placebo (n=145) or prednisolone (n=170) and SS (n=160) or CoCr (n=160). The majority (58%) presented with an ACS, 11% had diabetes and 287 (91%) completed angiographic follow up. BAR occurred in 26 cases in the placebo group (19.7%) versus 31 cases in the prednisolone group (20.0%) respectively, p=1.00. For the comparison between SS and CoCr stents, BAR occurred in 32 patients (21.6%) versus 25 patients (18.0%) respectively, p=0.46. CONCLUSION: Our study showed that treating patients with a moderately high dose of prednisolone for 28days following PCI with BMS did not reduce the incidence of BAR. In addition, we showed no significant reduction in 6month restenosis rates with stents composed of CoCr alloy compared to SS (http://www.isrctn.com/ISRCTN05886349).

The Coronary Artery Revascularisation in Diabetes (CARDia) trial: background, aims, and design.

BACKGROUND: Patients with diabetes have an increased incidence and severity of ischemic heart disease, which leads to an increased requirement for coronary revascularization. Comparative information regarding mode of revascularization--coronary artery bypass graft surgery surgery (CABG) or percutaneous coronary intervention (PCI)--is limited, mainly confined to a subanalysis of the Bypass Angioplasty Revascularization (BARI) trial, suggesting a mortality benefit of CABG over PCI. No prospective trial has specifically compared these modes of revascularization in patients with diabetes. OBJECTIVE: The Coronary Artery Revascularisation in Diabetes (CARDia) trial is designed to address the hypothesis that optimal PCI is not inferior to modern CABG as a revascularization strategy for diabetics with multivessel or complex single-vessel coronary disease. The primary end point is a composite of death, nonfatal myocardial infarction, and cerebrovascular accident at 1 year. METHOD: A total of 600 patients with diabetes are to be randomized to either PCI or CABG, with few protocol restrictions on operative techniques or use of new technology. This gives a power of 80% to detect non-inferiority of PCI assuming that the PCI 1-year event rate is 9%. A cardiac surgeon and a cardiologist must agree that a patient is suitable for revascularization by either technique prior to recruitment into the study. Twenty-one centers in the United Kingdom and Ireland are recruiting patients. Data on cost effectiveness, quality of life, and neurocognitive function are being collected. Long-term (3-5 year) follow-up data will also be collected.

Devices for tachycardia termination.

Remarkable advances have been made over the last 2 decades in the management of tachyarrhythmias. Simultaneous developments have provided new drugs, new surgical and catheter ablation techniques and new implantable devices. Initial enthusiasm with antitachycardia pacemakers was tempered by the realization of dangers and difficulties associated with their use, particularly in the treatment of ventricular tachycardia. However, progress has been made along several lines: (1) improvements in the automatic detection of target tachyarrhythmias; (2) the development of termination algorithms that are more adaptable to spontaneous changes in the tachycardia termination zone; (3) improvements in the safety of termination algorithms; (4) development of automatic cardioversion or defibrillation for the management of malignant ventricular arrhythmias; and (5) incorporation of multiple pacing facilities in single implantable units.

Risk of patent foramen ovale for thromboembolic events in all age groups.

The association between a patent foramen ovale (PFO) and thromboembolic events in young patients has been reported. Autopsy data suggest that a PFO may be present in 20 to 35% of the population. To further assess the role of a PFO in patients with possible thromboembolic events, precordial and transesophageal contrast echocardiography was performed in 104 consecutive patients (age range 16 to 84 years) presenting with a stroke, transient ischemic attack or peripheral artery embolus (group I). These patients were compared with 94 consecutive patients (age range 23 to 82 years) undergoing transesophageal echocardiography for other reasons (group II). A PFO was found in 22 patients; 9 of 35 (26%) with an event but no risk factor (group Ia), 10 of 69 (14%) with an event but a recognized risk factor (group Ib), and 3 of 94 control patients (3.2%) (group II) (group Ia vs II: relative odds 10:1, p less than 0.001; group Ib vs II: relative odds 5:1, p less than 0.01; and group Ia vs Ib: p = not significant). The detection of a PFO was not related to age. The relatively low prevalence of a PFO in this study may reflect patient selection, but other explanations include: (1) Transesophageal contrast echocardiography may be relatively insensitive for its detection; (2) the prevalence in the general population may have been overestimated; and (3) most PFOs are very small, clinically insignificant and undetectable with this technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the efficacy and duration of action of isosorbide mononitrate in angina pectoris.

The magnitude and duration of the antianginal and anti-ischemic effects of isosorbide mononitrate (IS-5-MN), 20 mg, were determined in 10 patients with chronic stable angina pectoris. An exercise test (treadmill, Bruce protocol) was performed before and at 1, 6, 8 and 10 hours after oral administration of the drug. The patients were randomly assigned to receive IS-5-MN or placebo, and after 1 week of therapy were crossed over to the other formulations. The drug increased the exercise duration from 321 to 455 seconds at 1 hour (p less than 0.001). Time to moderate angina increased from 237 to 324 seconds (p less than 0.05) and time to ST depression greater than or equal to 1 mm increased from 150 to 307 seconds (p less than 0.01) at 1 hour. Placebo had no effect on any of the exercise parameters. Although partially attenuated at 6 hours, the effect of IS-5-MN remained statistically significant even at 8 hours, but not at 10 hours. It is concluded that the duration of action of a single tablet of IS-5-MN, given orally, is 8 hours.

Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction.

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA +/- stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk-a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention.

Infective endocarditis in a heart transplant recipient.

A 38-year-old man underwent orthotopic heart transplantation because of heart failure caused by ischemic heart disease. Three months after the operation cholestatic jaundice related to azathioprine hepatotoxicity developed, necessitating supplementation of cyclosporine immunosuppression with prednisolone. Seven months after heart transplantation he had a septic right femoral embolus and, by transesophageal echocardiography, was found to have a vegetation on the anterior leaflet of the mitral valve. Treatment with appropriate antibiotics resulted in complete resolution of symptoms and healing of the vegetation. Six months after the episode he remains free of symptoms and has normal heart function.

Rupture of a sinus of Valsalva aneurysm through the tricuspid septal leaflet.

We report a case of rupture of an aneurysm of the noncoronary sinus of Valsalva with the tract of the fistula emerging through the tricuspid septal leaflet. This rare pathology created a diagnostic dilemma, as the direction of the jet of blood was alternating between the right atrium and the right ventricle.

Papillary endothelial hyperplasia in a TEC coronary atherectomy specimen.

Angiography in a 37 year old female with a three week history of typical crescendo angina found an 80% stenosis of the proximal left anterior descending (LAD) artery. The patient underwent percutaneous transluminal coronary angioplasty involving TEC artherectomy of the LAD artery. The specimen removed by atherectomy was found to have the appearance of papillary endothelial hyperplasia. This is an unusual histological diagnosis that occurs in association with thrombus. It is rarely found within arterial vessels and has not been reported in a coronary artery. Papillary endothelial hyperplasia is now thought to be a form of organising thrombus, probably dependent on the production of basic fibroblast growth factor by the endothelium.

Erosion of the left ventricle by the epicardial patch of an automatic implantable cardioverter defibrillator.

A 56 year old man with an implantable cardioverter defibrillator was admitted with chest pain and collapse. Erosion of the left ventricle by an epicardial patch was confirmed by thoracotomy, but surgical repair was impossible. This rare complication should be considered in patients with a history of cardioverter defibrillators implanted by thoracotomy.

Transesophageal echocardiography in unsedated outpatients: technique and patient tolerance.

Transesophageal echocardiography is an important new imaging technique for the evaluation of heart disease. To maximize the number of patients who can be scanned in one outpatient session and to minimize the facilities needed, we elected to perform the technique on unsedated patients. To assess the tolerance of patients to this policy, we designed a questionnaire to evaluate the patients' own assessment of the technique. Overall, the technique was well tolerated by 79% of 204 patients, although 37% found swallowing the transducer unpleasant. The procedure was not tolerated as well by younger patients. When asked whether they would prefer to be sedated or unsedated, 83% preferred to be unsedated for an outpatient scan, and 73% preferred to be sedated for an inpatient scan. We concluded that the technique is well tolerated by most unsedated patients. Because a few patients preferred sedation, some outpatient facilities for patient recovery were necessary. We now ask young patients, selected inpatients, and patients undergoing repeat studies whether they would prefer sedation, but we otherwise perform the technique on unsedated patients.

Corona stenting in a patient menorrhagia: use of a gonadotrophin releasing hormone agonist to facilitate anticoagulation.

We report a case with menorrhagia due to uterine fibroids who was admitted following an episode of unstable angina. Her coronary angiogram showed a tight proximal left anterior descending artery lesion for which stenting was deemed necessary. She was successfully anticoagulated in spite of her menorrhagia under cover of a gonadotrophin hormone releasing agonist; goserilin.

Transoesophageal echocardiography in the diagnosis of paradoxical embolism.

Two patients with systemic embolism were studied with transoesophageal contrast echocardiography which demonstrated its probable paradoxical nature. In both cases paradoxical embolism was associated with pulmonary embolism. Precordial contrast echocardiography demonstrated a right-to-left shunt in one patient but was unable to demonstrate a shunt in the second. Transoesophageal echocardiography suggested that the shunt was across a patent foramen oval in both cases and revealed large thrombi in the pulmonary arteries in one. When precordial contrast echocardiography reveals a right-to-left shunt or when it is technically inadequate in patients suspected of having one, transoesophageal contrast echocardiography can demonstrate the nature of the shunt and is an alternative to cardiac catheterisation techniques. In addition, it can reveal large thrombi in the pulmonary arteries.

The value of transoesophageal ultrasonography in the management of a mediastinal foregut cyst.

Mediastinal foregut cysts account for approximately 10% of primary mediastinal masses. The differentiation of these cysts from other mediastinal masses is important, especially if a policy of aspiration and observation of cysts is adopted. Computed tomography (CT) is generally regarded as the definitive imaging modality in these cases, but it may occasionally fail to identify the cystic nature of the mass. We report a case in which transoesophageal ultrasound contributed to the diagnosis and demonstrated features of the cyst contents that were not visible on CT.

Type A dissection of the ascending thoracic aorta during percutaneous coronary intervention.

Retrograde dissection of the aorta is extremely rare during percutaneous coronary intervention (PCI), but is a recognized and potentially life-threatening complication. We describe a case in which retrograde dissection of the aorta, necessitating urgent surgical repair, occurred during an attempt to open a chronically occluded right coronary artery. Initially localized, the dissection extended during an attempt to seal the right coronary ostium. Our experience suggests that if localized aortic retrograde dissection occurs, the management will depend on the stability of the distal coronary vessel. If stable, a conservative approach may be preferable to an attempt to seal the dissection.