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Designed to give healthcare professionals a clear understanding on clinical aspects of anticoagulation. It is one of several modules in our anticoagulation programme. Module first published: 10 April 2013 Revised module released: 01 April 2016 1 CPD/CME credit
Designed to give healthcare professionals a clear understanding of the role of the pharmacist in anticoagulation. It is one of several modules in our anticoagulation programme. Module first published: 10 April 2013 Revised module released: 01 April 2016 0.5 CPD/CME credits
A wide array of investigations is available to the heart failure specialist. Their proper utilisation requires knowledge of their indications, and proficiency in interpretation. This was the focus of the second morning session, entitled “Different tests”, of the 8th British Society for Heart Failure (BSH) Training and Revalidation Day. Held on 3rd March 2016, at the Golden Jubilee National Hospital, Clydebank, this session included excellent presentations on cardiopulmonary exercise testing (CPET), cardiac catheterisation in heart failure, assessment of haemodynamics using echocardiography, and the use of cardiac CT in heart failure. Dr Simon Beggs reports on some of the highlights from a lively and thought-provoking day.
A 79-year-old lady was taken to the emergency department by her carer, who had noticed an acute deterioration of her general condition. Unfortunately, it was difficult to obtain an accurate history from the patient due to cognitive impairment, and her carer was not aware of her past medical history. However, she had been observed clenching her hands to her chest. She was not previously known to the admitting hospital.
This was a pilot study, in which 55 breast cancer patients were enrolled, to evaluate the alterations of strain and strain-rate parameters in breast cancer patients receiving doxorubicin and compare them with serial conventional echocardiography changes. A week prior to, and a week after, chemotherapy with doxorubicin, left ventricular ejection fraction (LVEF) and strain and strain-rate parameters were measured by conventional 2D echocardiography and tissue Doppler-based imaging, respectively. Comparison of the results of pre- and post-chemotherapy evaluation demonstrated that strain and strain-rate parameters were significantly reduced. Mean difference (standard deviation) for the strain measurement of basal-septal, basal-lateral, basal-inferior, and basal-anterior values were 2.58% (2.15), 3.20% (1.94), 4.13% (3.48), and 2.86% (2.65), respectively; and for the strain-rate values were 0.18 s–1 (0.17), 0.17 s–1 (0.17), 0.24 s–1 (0.19), and 0.19 s–1 (0.14), respectively; all p values <0.001. There was no significant change in patients’ LVEF after chemotherapy (pre-intervention 61.10 (4.86), post-intervention 61.06 (4.82), p=0.857). In conclusion, strain/strain-rate significant reduction, in the setting of normal range LVEF, suggests subclinical heart failure. Whether the strain and strain-rate imaging should replace the conventional echocardiography for early monitoring of cardiotoxicity of doxorubicin requires further investigations.
Despite the significant improvements in both diagnostic and therapeutic procedures in recent years, infective endocarditis (IE) remains a medical challenge due to poor prognosis and high mortality. Echocardiographically, the majority of the patients demonstrate vegetations on a single valve, while demonstration of involvement of two valves occurs much less frequently; triple-valve involvement is extremely rare. Reported operative mortality after triple-valve surgery is high and ranges between 20% and 25%. Surgical treatment is used in approximately half of patients with IE because of severe complications. Reasons to consider early surgery in the active phase, i.e. while the patient is still receiving antibiotic treatment, are to avoid progressive heart failure and irreversible structural damage caused by severe infection, and to prevent systemic embolism. Prognosis in IE is influenced by four main factors: characteristics of the patient, the presence or absence of cardiac and non-cardiac complications, the infecting organism, and echocardiographic findings. Prognosis of right-sided native valve endocarditis is relatively good, with an in-hospital mortality rate of about 10%. We present a case of a young man with triple-valve endocarditis followed by a brief review of the literature.
Deaths from congenital heart disease in childhood have fallen 83% in the last 25 years.1 This dramatic change has led to a significant increase in the numbers of adults with congenital heart disease (ACHD) requiring care, and prevalence is not expected to plateau until 2050.2 Even patients with extremely complex pathophysiology are now expected to survive well into adult life, and will have significantly higher rates of utilisation of all hospital services than the general population.3,4
Author: M Joy
NICE recommendations for PCSK9 inhibitors
The National Institute for Health and Care Excellence (NICE) has issued Technical Appraisal Guidance for sacubitril/valsartan (Entresto™, Novartis Pharmaceuticals). The drug has been approved for use within the NHS for the treatment of adults with symptomatic chronic heart failure with New York Heart Association class II to IV symptoms, a left ventricular ejection fraction of 35% or less, and who are also taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers.
Updated European Society of Cardiology (ESC) Guidelines for the diagnosis and treatment of acute and chronic heart failure have been published.1
Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital condition that proves to be fatal in most individuals during childhood due to significant left ventricular ischaemia. However, there are case reports of individuals surviving into adulthood that have varying presenting symptoms. We report a case of a young male, who presented to our cardiology clinic with typical ischaemic cardiac pain, with no established risk factors, and was found to have anomalous origin of the left coronary artery from the pulmonary artery that was subsequently surgically corrected.
Reflex syncope is the most common cause of transient loss of consciousness. Practical manoeuvres may help, but additional measures are often required. In our experience, midodrine gives consistently good results in patients with reflex syncope. This study also provides reassurance that the effect on blood pressure is measureable, but small, and side effects are infrequent. UK prescribing may have been limited when midodrine was unlicensed, but midodrine is now licensed. We treated 195 patients, age 40 ± 18 years, 72 (37%) aged under 30 years, 151 female (78%), who attended a Rapid Access Blackouts Triage Clinic and gave a clear history of reflex syncope. The median duration of symptoms was 28 months. A misdiagnosis of epilepsy had occurred in 39 patients and 42 had significantly low blood pressure. Follow-up was 50 ± 42 months in 184 patients (93%), with 11 patients lost to follow-up. Twenty-eight patients had minor electrocardiogram (ECG) changes but had a normal echocardiogram. Overall, 143 (73%) patients improved on a mean dose of 10 mg a day of midodrine. Syncopal events fell from 16 ± 16 to 2.6 ± 5 per six months (p<0.05), and in 69 (35%) patients, syncope was eradicated. Nineteen (10%) patients were able to […]
Chronic refractory angina results in significant NHS costs due to chronic high use of resources. This audit evaluated the clinical effectiveness of a cognitive-behavioural (CBT) programme in reducing angina symptoms after maximal medical and surgical intervention. The primary outcome was self-reported angina. Additional questionnaire data comprised perceived quality of life/disability, angina misconceptions, self-efficacy and mood. Data from the electronic patient administration system was used to compare use of cardiology hospital resources in the two years before and two years after attendance. Patients completing questionnaires reported significant improvements in all areas post-group and at two months. Resource use was lower in the two years post-programme than the two years prior. A CBT-based approach to symptom management could offer additional clinical benefits in the cardiac rehabilitation menu.
Refractory angina (RA) describes those patients with persistence of symptoms despite optimal conventional strategies. It is often associated with a maladaptive psychological response, resulting in significant burden on hospital services. This observational study sought to assess the short- and long-term impact of psychotherapy on quality of life, mood and symptoms. Between 2011 and 2012, consecutive attendees to a specialised RA service were recruited. Intervention consisted of a course of cognitive-behavioural therapy allied with an education programme. Outcome measures were collated pre-intervention, one month and two years post-intervention. Validated questionnaires were utilised for scoring assessments: SF-36 (Short-Form 36) for quality of life, HADS (Hospital Anxiety and Depression Scale) for anxiety/depression, and SAQ (Seattle Angina Questionnaire) for functional assessment. There were 33 patients included. Median SF-36 scores increased and this effect remained in the long term. Levels of depression reduced, and improved further at subsequent review. Frequency of angina was comparable, both short and long term. Usage of glyceryl trinitrate (GTN) spray was similar at one-month follow-up and at two years. In conclusion, a short course of psychotherapy appears to improve quality of life and mood in patients with RA, and is achieved independent of symptom control. Further research is warranted so […]
Refractory angina (RA) is an increasingly common, chronic, debilitating condition, which severely reduces quality of life. It can severely impact on physical, social and psychological wellbeing. RA should be considered in patients with known coronary artery disease, who continue to experience frequent angina-like symptoms, despite surgical or percutaneous revascularisation and optimal medical therapy. Objective evidence of reversible ischaemia should also be demonstrated. Treatment is challenging and often not delivered adequately. Management should ideally be provided by a specialist multi-disciplinary team, but national provision of such services is extremely limited. As a result, patients with RA commonly enter a downward spiral of long-term local review, cycling between the outpatient department and Accident and Emergency (A&E). Consequently, a disproportionately high proportion of healthcare resource is consumed in the management of these patients due to high attendance rates in primary and secondary care, unscheduled hospitalisation, prolonged hospital stays, investigations and polypharmacy. This may be improved by the implementation of more appropriate models of care delivery.
Clinical introductionA 21-year-old male with a medical history of scoliosis was referred for an abnormal chest radiograph performed on screening (figure 1). He was asymptomatic with good exercise tolerance. Blood pressure and heart rate were normal. The heart sounds were normal. The pulmonary examination was unremarkable. A treadmill test performed 3 years prior for atypical chest pain was normal. An ECG performed was also normal. QuestionWhat abnormality is present in the chest radiograph? Dextrocardia Enlarged right heart border Mediastinal mass Prominent pulmonary vasculature Situs inversus
ObjectivesTo determine predictors of failure of transradial approach (TRA) in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and develop a novel score specific for this population. MethodsConsecutive patients with STEMI undergoing primary PCI in a tertiary care high-volume radial centre were included. TRA-PCI failure was categorised as primary (primary transfemoral approach (TFA)) or crossover (from TRA to TFA). Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. Clinical outcomes up to 1 year were assessed. ResultsFrom January 2006 to January 2011, 2020 patients were studied. Primary TRA-PCI failure occurred in 111 (5%) patients and crossover to TFA in 44 (2.2%) patients. Independent predictors of TRA-PCI failure were: weight ≤65 kg (OR: 3.0; 95% CI 1.9 to 4.8, p<0.0001), physician with ≤5% TFA conversion (OR: 0.45; 95% CI 0.2 to 0.9, p=0.033), and physician with ≥10% conversion to TFA (OR: 2.2; 95% CI 1.2 to 3.7, p=0.005), intra-aortic balloon pump (OR: 2.0; 95% CI 0.9 to 4.3, p=0.066), cardiogenic shock (OR: 2.8; 95% CI 1.4 to 5.6, p=0.0035), endotracheal intubation (OR: 107; 95% CI 42 to 339, p<0.0001), creatinine >133 μmol/L (OR: 3.6; 95% CI 1.9 to 6.8, p<0.0001), […]
Aortic valve stenosis (AS), at the simplest level, is mechanical obstruction to left ventricular (LV) outflow with severity best described by the high velocity or pressure gradient across the valve or the small valve opening area. More recently, the importance of adverse left ventricular (LV) changes in patients with aortic valve disease has led to a new classification of AS to include measures of LV function and volume flow rate as follows: (1) high gradient severe AS with a transvalvular velocity ≥4 m/s or mean gradient ≥40 mm Hg, (2) low-flow low-gradient severe AS with reduced ejection fraction (<50%), and (3) low-flow low-gradient severe AS with normal ejection fraction and a stroke volume index ≤35 ml/m2. In this issue of Heart, Capoulade and colleagues (see page 934) examined the differential value of measures of AS severity versus LV function for prediction of valve-related events and for all cause…
Modern transradial access (TRA) has evolved from a niche procedure undertaken by a few enthusiastic proponents to the default access site adopted across most of Europe and Asia, with data from the British Cardiovascular Interventional Society suggesting that over 75% of all primary percutaneous coronary intervention (PCI) procedures in the UK in 2014 were undertaken through the radial artery.1 TRA has been shown to be associated with a reduction in mortality, major adverse cardiac events (MACE) and major access site related bleeding complications in both randomised controlled trials and national registries in patients undergoing PCI at high risk from bleeding complications, particularly those in the setting of acute coronary syndromes (ACS), which has led to a Class IA recommendation for its use in the setting of ACS in the latest European Society of Cardiology Guidelines for ACS.2 Throughout this evolution, concerns about the generalisability of…
<sec> <p>Echocardiography has become essential for the diagnosis and management of cardiovascular disease. Over my medical career, cardiac ultrasound has evolved from the blurry wavy lines of M-mode tracings understandable only to a few dedicated practitioners, to real-time intuitive anatomic images accessible to all healthcare providers. In addition, the development and validation of quantitative imaging and Doppler techniques has transformed clinical cardiology with the ability to measure left ventricular ejection fraction and cardiac output, estimate pulmonary pressures, evaluate diastolic function, and quantitate valve and congenital heart disease severity. More advanced imaging modalities including transoesophageal imaging, real-time three-dimensional (3D) and biplane imaging, contrast echocardiography, tissue Doppler, and other modalities have further extended our diagnostic capabilities. There is no question that echocardiography is an accurate and powerful diagnostic tool when performed and interpreted by highly skilled professionals at centres with a high volume of complex cardiac disease. However, the real challenge…
Aortic stenosis (AS) is predominantly a degenerative valvular disease of the elderly, with a prevalence of 10–12.4% in those ≥75 years of age, severe in 3.4%.1 Population demographics clearly show Western populations to be are ageing, thereby further increasing the impact of AS. Among elderly patients with severe AS, 75% are symptomatic, 40% of whom are not treated surgically. No effective medical therapy is available for patients with AS, and if not treated by intervention, the estimated 5-year survival of severe AS is only 40% to 60%.2 Although symptoms remain the main indication for aortic valve replacement (AVR) in patients with AS, the interpretation of symptoms, particularly shortness of breath in the elderly, can be challenging.3 Therefore, accurate grading of AS severity and left ventricular (LV) function is crucial for a correct AVR indication. Severe AS has been traditionally defined as an aortic valve…
Cardiovascular disease (CVD) continues to be a leading cause of death worldwide. Because regular physical activity (PA) independently decreases the risk of coronary heart disease (CHD) while also having a positive, dose-related impact on other cardiovascular (CV) risk factors, it has increasingly become a focus of CHD prevention. Current guidelines recommend 30 min of moderate-intensity PA 5 days a week, but exercise regimens remain underused. PA adherence can be fostered with a multilevel approach that involves active individual participation, physician counselling and health coaching, community involvement, and policy change, with incorporation of cardiac rehabilitation for patients requiring secondary prevention. Viewing exercise quantity as a vital sign, prescribing PA like a medication, and using technology, such as smartphone applications, encourage a global shift in focus from CVD treatment to prevention. Community-wide, home-based and internet-based prevention initiatives may also offer a developing pool of resources that can be tapped into to promote education and PA compliance. This review summarises the underlying rationale, current guidelines for and recommendations to cultivate a comprehensive focus in the endorsement of PA in the primary and secondary prevention of CHD.
Pulmonary arterial hypertension (PAH) in adult patients with congenital heart disease (CHD) is associated with increased morbidity and mortality. The present review aims to discuss the clinical applications of invasive and non-invasive diagnostic modalities and to describe the strengths and weaknesses of each technique. Chest radiograph is an inexpensive investigation providing information on pulmonary arterial and hilar dilatation, pruning of peripheral pulmonary arteries and cardiomegaly. Transthoracic two-dimensional and Doppler echocardiography is the most widely used imaging tool. It provides information on cardiac anatomy and an estimate of haemodynamics and biventricular remodelling and function. In addition, echocardiography is valuable in assessing prognosis and monitoring the efficacy of therapy. Structural and functional changes associated with CHD-PAH, mainly affecting the right ventricle and pulmonary circulation, may represent an ideal target for evaluation with cardiac magnetic resonance. This non-invasive imaging modality has a low biological impact. CT plays an important role for patients with limited echocardiographic windows and those who are unable to undergo MRI (claustrophobia, poor compliance, presence of a pacemaker/implantable cardioverter defibrillator). It is the modality of choice for detailed assessment of pulmonary vessel obstruction or thrombosis. Finally, heart catheterisation remains the gold standard for diagnosing and confirming PAH in patients with […]
Pre-operative aspirin does not influence CABG outcomesAspirin is a common therapy for risk reduction among patients with coronary artery disease. However, among patients undergoing coronary artery bypass surgery, the benefits of aspirin on the risk of myocardial infarction and stroke may be outweighed by perioperative bleeding risk. To address this question, the ATACAS trial randomized 2100 patients to either receive 100 mg aspirin daily or matching placebo for 4 days immediately prior to the operation with all patients resuming aspirin within 24 hours of their bypass surgery. The primary outcome was a composite of death and thrombotic episodes (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days. Overall rates of post-operative myocardial infarction were 14.8%, which is higher than typical for studies of post-bypass outcomes and may reflect use of troponin surveillance for the identification of this outcome. There were no significant differences…
ObjectivesTo evaluate 90-day cardiovascular outcome in patients after myocardial infarction (MI) in relation to different subtypes of atrial fibrillation (AF) and MI. MethodsWe studied 155 071 hospital survivors of MI between 2000 and 2009 in Swedish registries. AF subtypes were defined according to history of AF and in-hospital ECG recordings. Clinical outcomes were evaluated with multivariable Cox models. ResultsAF was documented in 24 023 (15.5%) cases. The AF subtypes were new-onset AF with sinus rhythm at discharge (3.7%), new-onset AF with AF at discharge (3.9%), paroxysmal AF (4.9%) and chronic AF (3.0%). The event rate per 100 person-years for the composite cardiovascular outcome (all-cause mortality, MI or ischaemic stroke) was 90.9 in patients with any type of AF versus 45.2 in patients with sinus rhythm, adjusted hazard ratio with 95% CI (HR) 1.28 (1.19 to 1.37). There were no significant differences in the composite cardiovascular outcome between AF subtypes. AF was associated with higher risk of mortality, HR 1.59 (1.41 to 1.80), reinfarction, HR 1.14 (1.05 to 1.24), and ischaemic stroke, HR 2.29 (1.92 to 2.74), respectively. In subgroup analysis, AF was associated with a higher risk of composite cardiovascular outcome in the non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) […]
ObjectiveThe study purpose was to assess the usefulness of echocardiographic parameters of aortic stenosis (AS) severity and left ventricular (LV) systolic function to predict mortality in AS. The main hypothesis is that parameters of LV systolic function are the most important independent predictors of mortality, whereas parameters of stenosis severity are not. Methods1065 consecutive patients with AS referred to the echocardiography laboratory and meeting the inclusion/exclusion criteria were included and followed during 5.7 years. The end points were aortic valve replacement (AVR) (n=584), composite of AVR or death (n=932), all-cause mortality (n=550) and cardiovascular mortality (n=398). ResultsThe most powerful echocardiographic predictors of valve-related events were parameters of AS severity, such as peak aortic jet velocity (VPeak), mean gradient (MG) and aortic valve area (AVA) (all p<0.001). Regarding mortality, the main predictors were LV ejection fraction (LVEF) and stroke volume index (SVi) (p<0.05). After multivariable adjustment, LVEF (p<0.001) and SVi (p=0.02) remained the only echocardiographic predictors of mortality, even after adjustment for symptomatic status. AVA was also associated with mortality, whereas VPeak and MG were not. ConclusionsThe most powerful echocardiographic predictors of mortality are low LVEF and low flow, whereas AS severity parameters predict valve-related events but not overall mortality. Hence, low […]
Clinical introductionA 36-year-old African woman consulted because of crescendo dyspnoea New York Heart Association Functional Classification (NYHA) II–III and slight palpitations. There was no angina or coughing. Her medical and family history was unremarkable. Physical examination revealed a discrete systolic murmur, followed by a diastolic murmur (grade 3/6) along the left sternal border and at the apex. Blood pressure was 160/100 mm Hg. Lung auscultation and jugular venous pressure were normal. There were no signs of oedema. Blood tests demonstrated a slight anaemia (hemoglobin (Hb) 10.6 mg/dL), normal creatine kinase and troponin levels, as well as normal C reactive protein. N-terminal of the prohormone brain natriuretic peptide (NT-pro-BNP) was 107 ng/L. The ECG showed a normal sinus rhythm with non-specific T wave changes. Discrete cardiomegaly was seen on the chest radiography. A transthoracic echocardiographic examination was performed and shown in figures 1 and 2.
ObjectiveVariable coronary anatomy has been described in patients with bicuspid aortic valves (BAVs). This was never specified to BAV morphology, and prognostic relevance of coronary vessel dominance in this patient group is unclear. The purpose of this study was to evaluate valve morphology in relation to coronary artery anatomy and outcome in patients with isolated BAV and with associated aortic coarctation (CoA). MethodsCoronary anatomy was evaluated in 186 patients with BAV (141 men (79%), 51±14 years) by CT and invasive coronary angiography. Correlation of coronary anatomy was made with BAV morphology and coronary events. ResultsStrictly bicuspid valves (without raphe) with left-right cusp fusion (type 1B) had more left dominant coronary systems compared with BAVs with left-right cusp fusion with a raphe (type 1A) (48% vs. 26%, p=0.047) and showed more separate ostia (28% vs. 9%, p=0.016). Type 1B BAVs had more coronary artery disease than patients with type 1A BAV (36% vs. 19%, p=0.047). More left dominance was seen in BAV patients with CoA than in patients without (65% vs. 24%, p<0.05). ConclusionsThe incidence of a left dominant coronary artery system and separate ostia was significantly related to BAVs with left-right fusion without a raphe (type 1B). These patients more often […]
ObjectiveInfective endocarditis is associated with high morbidity and mortality and optimal timing for surgical intervention is unclear. We performed a systematic review and meta-analysis to compare early surgical intervention with conservative therapy in patients with infective endocarditis. MethodsPubMed, Cochrane, EMBASE, CINAHL and Google-scholar databases were searched from January 1960 to April 2015. Randomised controlled trials, retrospective cohorts and prospective observational studies comparing outcomes between early surgery at 20 days or less and conservative management for infective endocarditis were analysed. ResultsA total of 21 studies were included. OR of all-cause mortality for early surgery was 0.61 (95% CI 0.50 to 0.74, p<0.001) in unmatched groups and 0.41 (95% CI 0.31 to 0.54, p<0.001) in the propensity-matched groups (matched for baseline variables). For patients who had surgical intervention at 7 days or less, OR of all-cause mortality was 0.61 (95% CI 0.39 to 0.96, p=0.034) and in those who had surgical intervention within 8–20 days, the OR of mortality was 0.64 (95% CI 0.48 to 0.86, p=0.003) compared with conservative management. In propensity-matched groups, the OR of mortality in patients with surgical intervention at 7 days or less was 0.30 (95% CI 0.16 to 0.54, p<0.001) and in the subgroup of patients who underwent surgery between […]
ObjectiveTo estimate the burden of social inequalities in coronary heart disease (CHD) and to identify their major determinants in 15 European populations. MethodsThe MORGAM (MOnica Risk, Genetics, Archiving and Monograph) study comprised 49 cohorts of middle-aged European adults free of CHD (110 928 individuals) recruited mostly in the mid-1980s and 1990s, with comparable assessment of baseline risk and follow-up procedures. We derived three educational classes accounting for birth cohorts and used regression-based inequality measures of absolute differences in CHD rates and HRs (ie, Relative Index of Inequality, RII) for the least versus the most educated individuals. ResultsN=6522 first CHD events occurred during a median follow-up of 12 years. Educational class inequalities accounted for 343 and 170 additional CHD events per 100 000 person-years in the least educated men and women compared with the most educated, respectively. These figures corresponded to 48% and 71% of the average event rates in each gender group. Inequalities in CHD mortality were mainly driven by incidence in the Nordic countries, Scotland and Lithuania, and by 28-day case-fatality in the remaining central/South European populations. The pooled RIIs were 1.6 (95% CI 1.4 to 1.8) in men and 2.0 (1.7 to 2.4) in women, consistently across population. Risk factors accounted […]
ObjectiveThe hybrid approach for hypoplastic left heart syndrome (HLHS) could theoretically result in better preservation of right ventricular (RV) function then the Norwood procedure. The aim of this study was to compare echocardiographic indices of RV size and function in patients after Norwood and hybrid throughout all stages of palliation. Methods76 HLHS patients (42 Norwood, 34 hybrid) were retrospectively studied. Echocardiography was obtained before stage I, before and after stage II, and before and after Fontan. Median follow-up was 4.9 years (range 1.1–8.5). ResultsBaseline characteristics before stage I were similar. Hybrid patients demonstrated a significant decrease in RV fractional area change (FAC) between baseline and pre-stage II (36±9% vs 27±6%; p<0.01); Norwood patients remained stable (32±10% vs 32±7%; p=0.21). At pre-stage II, moderate/severe tricuspid valve (TV) regurgitation was found in nine Norwood (33%) and four hybrid (18%) patients (p=0.19). After stage II, the difference in FAC became insignificant (29±7% vs 25±8%, p=0.08) and moderate/severe TV regurgitation (TR) was found in 13 Norwood (48%) and four hybrid patients (19%) (p=0.18). At pre-Fontan, RV FAC was similar after Norwood and hybrid (34±5% vs 33±6%, p=0.69), which remained unchanged after Fontan. After Fontan, one Norwood and one hybrid patient had moderate TR. RV and […]
Learning objectives Understand the importance of venous thrombosis in cardiovascular medicine. Appreciate the mode of action of different oral anticoagulants. Recall the uses, risks and benefits of each non-vitamin K antagonist oral anticoagulants. IntroductionThrombosis is the common pathophysiology responsible for ischaemic heart disease, ischaemic stroke and venous thromboembolism (VTE), and a major contributor to the global disease burden.1 This effect is markedly more pronounced by considering the view that cancer is also a thrombotic disease.23 Cardiovascular disease (CVD, manifesting as acute coronary syndromes, myocardial infarction and stroke) is almost entirely related to thrombosis within arteries. However, many of the risk factors for arterial thrombosis are also risk factors for VTE, and in addition VTEs have additional risk factors such as obesity and cancer.45 Indeed, VTE is a risk factor for…
KN Assress, M Marciniak, A Marciniak. Development of the atrial septum. Heart 2016;102:481–482. Published Online First: 2 February 2016 doi:10.1136/heartjnl-2016-309289. In this letter the author KN Assress should have been listed as KN Asrress.
Much of the work in reducing the mortality and morbidity from heart failure will be carried out in primary care. Treatment of these patients with optimal therapy will bring significant benefits. As the armamentarium of agents to treat this condition grows, this article considers why many patients are inappropriately treated in primary care and which patients will most benefit from the new angiotensin-receptor–neprilysin inhibitor (ARNI) class of drugs.
Professor John McMurray, the principal investigator in the PARADIGM-HF study, writes about his experience with sacubitril/valsartan (known as LCZ696 at the time of the study) and how to optimally use this new agent in clinical practice, including how to switch patients to this treatment.
PARADIGM-HF was the first study to compare the long-term efficacy and safety of the angiotensin-receptor–neprilysin inhibitor (ARNI), sacubitril/valsartan (previously known as LCZ696), against standard care with the angiotensin-converting enzyme (ACE) inhibitor, enalapril, in patients with chronic symptomatic heart failure and reduced ejection fraction (HFREF). The trial was stopped early due to benefit.
The pathophysiology of heart failure is complex. This article describes the neurohumoral pathways that are active in chronic heart failure with left ventricular systolic dysfunction (also known as heart failure with reduced ejection fraction [HFREF]). It also explains the rationale behind the development of therapies to favourably modulate the neurohumoral imbalance seen in this condition.
Heart failure is a leading cause of morbidity and mortality and presents many treatment challenges. Its prognosis is poor yet many patients do not receive optimal therapy. In the UK, the increasingly ageing population means rates of heart failure hospitalisation are estimated to rise by 50% over the next 25 years.
The burgeoning evidence of patients diagnosed with sigmoidal hypertrophic cardiomyopathy (HCM) later in life has revived the quest for distinctive features that may help discriminate it from more benign forms of isolated septal hypertrophy often labelled ventricular septal bulge (VSB). HCM is diagnosed less frequently than VSB at older ages, with a reversed female predominance. Most patients diagnosed with HCM at older ages suffer from hypertension, similar to those with VSB. A positive family history of HCM and/or sudden cardiac death and the presence of exertional symptoms usually support HCM, though they are less likely in older patients with HCM, and poorly investigated in individuals with VSB. A more severe hypertrophy and the presence of left ventricular outflow obstruction are considered diagnostic of HCM, though stress echocardiography has not been consistently used in VSB. Mitral annulus calcification is very prevalent in both conditions, whereas a restrictive filling pattern is found in a minority of older patients with HCM. Genetic testing has low applicability in this differential diagnosis at the current time, given that a causative mutation is found in less than 10% of elderly patients with suspected HCM. Emerging imaging modalities that allow non-invasive detection of myocardial fibrosis and disarray […]
ObjectiveSexual activity is a central component of intimate relationships, but sexual function may be impaired by coronary heart disease (CHD). There have been few representative population-based comparisons of sexual behaviour and concerns in people with and without CHD. We therefore investigated these issues in a large nationally representative sample of older people. MethodsWe analysed cross-sectional data from 2979 men and 3711 women aged 50 and older from the English Longitudinal Study of Ageing. Sexual behaviour and concerns were assessed by validated self-completion questionnaire and analyses were weighted for non-response. Covariates included age, partnerships status and comorbidities. ResultsThere were 376 men and 279 women with CHD. Men with CHD were less likely to be sexually active (68.7% vs 80.0%, adjusted OR 0.62, 95% CI 0.47 to 0.81), thought less about sex (74.7% vs 81.9%, OR 0.72, CI 0.54 to 0.95), and reported more erectile difficulties (47.4% vs 38.1%, OR 1.46, CI 1.10 to 1.93) than men without CHD. Effects were more pronounced among those diagnosed within the past 4 years. Women diagnosed <4 years ago were also less likely to be sexually active (35.4% vs 55.6%, OR 0.44, CI 0.23 to 0.84). There were few differences in concerns about sexual activity. Cardiovascular medication […]
ObjectiveTo examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge. MethodsThis was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using 2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS). ResultsThe intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% 2=6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 […]
ObjectivesDiastolic dysfunction (DD), a key driver of long-term Fontan outcomes, may be concealed during standard haemodynamic evaluation. We sought to identify Fontan patients with occult DD using ‘ventricular stress testing’ with rapid volume expansion (RVE). MethodsCardiac catheterisation with RVE was performed routinely in Fontan patients between 11/2012 and 4/2015. Baseline and post-stress haemodynamic data were compared using t test, Mann–Whitney U test, 2 and Fisher’s exact tests. A post-stress ventricular end diastolic pressure (EDP) threshold of 15 mm Hg defined occult DD. ResultsForty-six Fontan patients (48% female, median age 14.1 (IQR 9.1 to 21.3) years) were included. The median Fontan duration was 10.8 (IQR 5.1 to 17.8) years and dominant left ventricular morphology was present in 63% of patients. Volume expansion increased mean Fontan pressure (15.2±2.5 vs 12.4±2.2 mm Hg, p<0.001), pulmonary capillary wedge pressure (11.3±2.6 vs 7.9±2 mm Hg, p<0.001) and EDP (12.7±3.3 vs 8.5±2.1 mm Hg, p<0.001). Sixteen patients (35%) had occult DD, demonstrating higher baseline EDP (10.3±1.9 vs 7.6±1.5 mm Hg, p<0.001) and greater increase in EDP (6.3±2.4 vs 3.1±1.4 mm Hg, p<0.001) compared with patients without DD. Higher baseline EDP, lower baseline cardiac index and longer duration of Fontan circulation were associated with higher post-stress EDP. There were no complications related to RVE. ConclusionsVentricular stress testing by RVE […]
ObjectiveA standardised diagnostic definition of protein-losing enteropathy (PLE) in Fontan patients serves both patient care and research. The present study determined whether a diagnostic definition of PLE was routinely used in published clinical Fontan studies, and to identify potentially relevant diagnostic criteria for composing a uniform PLE definition. MethodsA systematic review was conducted in adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. Published clinical Fontan studies that were written in English and included at least four patients with PLE were selected. PLE definitions were quantitatively analysed using a lateral thinking tool in which definitions were fractionated into constituent pieces of information (building blocks or diagnostic criteria). ResultsWe identified 364 papers. In the final analysis, data from 62 published articles were extracted. A diagnostic definition of PLE was used in only 27/62 (43.5%) of selected studies, and definitions were very heterogeneous. We identified eight major diagnostic criteria. Hypoalbuminaemia (n=23 studies, 85.2%), clinical presentation (n=18, 66.7%), documentation of enteric protein loss (n=16, 59.3%) and exclusion of other causes of hypoproteinaemia (n=17, 63.0%), were the most frequently used diagnostic criteria. Most studies used three diagnostic variables (n=13/27, 48.1%). Cut-off values for laboratory parameters (serum albumin, protein or faecal […]
ObjectivePatients with Fontan physiology may eventually require heart transplantation (HT). We determined the rates and outcomes of HT in a national, population-based multicentre study. MethodsFrom 1990 to 2015, 1369 patients underwent the Fontan procedure as recorded in the Australia and New Zealand Fontan Registry. We identified those who underwent HT and analysed their outcomes. We compared rates of HT between two catchment areas. In area 1 (n=721), patients were referred to the national paediatric HT programme or its associated adult programme. In area 2 (n=648), patients were referred to the national paediatric HT programme or one of the other adult HT programmes. ResultsMean follow-up time post-Fontan was 11±8 years. Freedom from Fontan failure was 74%±3.9% at 20 years. HT was performed in 34 patients. Patients living in area 1 were more likely to have HT (4.0%, 29/721 vs 0.8%, 5/648, p<0.001) with a cumulative proportion of 3.4% vs 0.7% at 10 years and 6.8% vs 1.2% at 20 years (p=0.002). Area 1 patients were more likely to undergo HT (hazard ratio 4.7, 95% CI 1.7 to 13.5, p=0.003) on multivariable regression. Post-HT survival at 1, 5 and 10 years was 91%, 78% and 71%, respectively. Compared with other patients with congenital heart disease (n=87), Fontan […]
Effective surgical palliation for complex congenital heart disease in infancy and childhood allows these patients to live into adulthood but may be associated with adverse outcomes over the longer term. Management of adult patients with “Fontan physiology” is especially challenging. The Fontan operation was first described in 1971 so that the oldest surviving patients with this procedure are only in their 40’s, with most being much younger.The physiology of the Fontan circulation, as elucidated in an elegant review by Gewillig and Brown (see page 1081), is characterized by an obligatory increase in systemic venous pressures because blood flow is directed to the pulmonary circuit without an intervening pumping chamber (e.g. absence of a functional right ventricle). In addition, forward cardiac output is lower than normal and is not responsive to normal physiological stressors, such as exercise (figure 1). In addition, over the long term, the Fontan…
Clinical introductionAn 80-year-old male with a medical history of hypertension, diabetes and moderate calcific aortic stenosis, presented with ischaemic chest pain at rest. Cardiovascular examination revealed soft systolic murmur only. ECG (see online supplementary figure S1) demonstrated inferolateral ST segment depression with ST elevation in lead aVR, suggesting diffuse subendocardial ischaemia possibly consistent with a threatening left main or proximal left anterior descending (LAD) coronary lesion. Emergency coronary angiography demonstrated tandem smooth stenoses in the proximal left circumflex (LCx) and LAD arteries (figure 1A), which persisted throughout the cardiac cycle, and after 200 mcg bolus of intracoronary nitrate. Aortogram is shown (figure 1B). QuestionWhat diagnosis underlies the cause of this patient’s symptoms? Congenital coronary artery anomaly. Coronary artery vasospasm. Myocardial bridging. Obstructive coronary artery disease. Unruptured left sinus of Valsalva aneurysm.
Human quality of life in contemporary societies is heavily influenced by sexuality. When coronary heart disease (CHD) occurs, both the affected individuals and their partners are concerned that sexual activity could exacerbate the cardiac condition, possibly causing myocardial infarction (MI) or sudden death.1 Although MI might be triggered by various factors, such as physical exertion, stressful events or heavy meals, when triggers are ranked from the highest to the lowest odds ratios (by calculating attributable fractions at the population level), traffic exposure poses at least a threefold higher risk than positive emotions or sexual activity.2 However, post-MI patients and their partners have limited access to information and/or counselling about sexual issues during the post-hospitalisation phase, despite an ascertained need for sexual counselling by healthcare professionals and the importance of sexual concerns in early, middle, and later recovery after MI.3 Sexual activity post-MI…
ObjectiveThe objective of this European multicenter study was to report surgical outcomes of Fontan takedown, Fontan conversion and heart transplantation (HTX) for failing Fontan patients in terms of all-cause mortality and (re-)HTX. MethodsA retrospective international study was conducted by the European Congenital Heart Surgeons Association among 22 member centres. Outcome of surgery to address failing Fontan was collected in 225 patients among which were patients with Fontan takedown (n=38; 17%), Fontan conversion (n=137; 61%) or HTX (n=50; 22%). ResultsThe most prevalent indication for failing Fontan surgery was arrhythmia (43.6%), but indications differed across the surgical groups (p<0.001). Fontan takedown was mostly performed in the early postoperative phase after Fontan completion, while Fontan conversion and HTX were mainly treatment options for late failure. Early (30 days) mortality was high for Fontan takedown (ie, 26%). Median follow-up was 5.9 years (range 0–23.7 years). The combined end point mortality/HTX was reached in 44.7% of the Fontan takedown patients, in 26.3% of the Fontan conversion patients and in 34.0% of the HTX patients, respectively (log rank p=0.08). Survival analysis showed no difference between Fontan conversion and HTX (p=0.13), but their ventricular function differed significantly. In patients who underwent Fontan conversion or HTX ventricular systolic dysfunction appeared to […]
Dr van Melle and associates from the European Congenital Heart Surgeons Association (ECHSA) are to be congratulated on their multicenter study on the treatment of failed Fontan patients.1 With the Fontan operation now being 40 years old surgeons are seeing the full spectrum of Fontan circulation failures.2 Strategies (and outcomes) for treating these patients are critically important and the review from the ECHSA is very timely and helpful. The authors have divided the failed Fontan patients into three groups: those undergoing Fontan takedown early after the Fontan operation, those undergoing the Fontan conversion procedure, and those undergoing heart transplantation. These are all critically ill patients with high mortality rates in all three groups. A summary of their results is shown in table 1 (Results of Surgical Intervention for the failing Fontan).1 The immediate conclusion looking at these numbers is that all of…
BackgroundLifetime risk for cardiovascular (CV) disease is high but predicting incident events on an individual level remains difficult. Single measurements of galectin-3, a marker of tissue fibrosis, predict mortality and new-onset heart failure (HF). Persistently elevated levels may indicate a clinically silent disease process. ObjectivesOur aim was to establish the value of serial galectin-3 measurements to predict CV outcomes in the general population. MethodsPlasma galectin-3 was measured in the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) study at baseline and after ~4 years. Changes in serial galectin-3 were expressed as categorical changes or absolute change from baseline and were related to subsequent outcome. ResultsSerial galectin-3 was measured in 5958 subjects (mean age 49±12 years; 49% female). The median duration of follow-up was 8.3 years. Persistently elevated galectin-3 (defined as highest quartile at baseline and highest quartile during visit 2, n=757 subjects) was associated with a higher risk for new-onset HF, CV mortality, all-cause mortality, new-onset atrial fibrillation and CV events, compared with subjects with non-persistently elevated galectin-3. After multivariable adjustments for baseline characteristics, serial galectin-3 remained an independent predictor of new-onset HF (HR 1.85 (1.10–3.13); p=0.02) but not for other outcomes. Serial measurements provided more accurate prognostic value to predict new-onset HF, […]
Despite therapeutic advances in the management of heart failure (HF), approximately 25% of hospitalised patients with HF are readmitted within 30 days.1 These costly episodes of care have given rise to numerous policy initiatives, such as the Medicare Hospital Readmissions Reduction Programme which fiscally penalises hospitals with ‘excess’ readmissions.2 Transitional care programmes have emerged as a potential solution to avert HF readmissions by monitoring and supporting patients and caregivers for a limited period of time post-discharge. A recent meta-analysis of these interventions suggests that programmes which incorporate home visits are effective at reducing all-cause readmission and mortality, whereas less-intensive programmes of structured telephone support alone can reduce HF-related readmissions and mortality.3 In their Heart publication, Wong et al report the findings from their pilot trial of a transitional palliative care programme for patients with end-stage HF (TPC-ESHF).4 They demonstrate that patients randomised…
Learning objectives Curriculum sections: 2.8 (Acute Coronary Syndromes) and 2.9 (Chronic Ischaemic Heart disease). Learning objectives: outline the differences in the presentation patterns, clinical characteristics, behavioural characteristics and clinical outcomes relating to gender and coronary heart disease (CHD). This will incorporate the following: Knowledge: understand the benefit of cardiovascular interventions in women in comparison with men in both the acute and chronic presentations of CHD. Delineate the data reflecting the need for more research into women and heart disease, coupled with more patient and physician education. Skills: learn the presentation patterns and gender-specific issues related to patients presenting with CHD. Behaviours and attitudes: discuss the preconceived ideas around gender and heart disease, emphasising the need for enhanced assessment of women with heart disease. IntroductionThe importance of coronary heart disease (CHD) as a disease of both genders tends to be underappreciated,…
The Fontan operation was first performed in 1968. Since then, this operation has been performed on thousands of patients worldwide. Results vary from very good for many decades to very bad with a pleiad of complications and early death. A good understanding of the physiology is necessary to further improve results. The Fontan connection creates a critical bottleneck with obligatory upstream congestion and downstream decreased flow; these two features are the basic cause of the majority of the physiologic impairments of this circulation. The ventricle, while still the engine of the circuit, cannot compensate for the major flow restriction of the Fontan bottleneck: the suction required to compensate for the barrier effect cannot be generated, specifically not in a deprived heart. Except for some extreme situations, the heart therefore no longer controls cardiac output nor can it significantly alter the degree of systemic venous congestion. Adequate growth and development of the pulmonary arteries is extremely important as pulmonary vascular impedance will become the major determinant of Fontan outcome. Key features of the Fontan ventricle are early volume overload and overgrowth, but currently chronic preload deprivation with increasing filling pressures. A functional decline of the Fontan circuit is expected and observed […]
When Dennis Krikler completed his term of office as Editor of the British Heart Journal in 1992 the succeeding Editor, Professor Mike Davies, commissioned a Festscrift to acknowledge the achievements of his predecessor who had been at the helm of the journal for 11 years. The contents are a fascinating glimpse of the man, some of his cardiological achievements, certainly his wide-ranging interests and assuredly his international friendships. It is almost certainly the only time that the British Heart Journal has published an article entirely in French, a monologue by Phillipe Coumel who was one of the most original thinkers of modern arrhythmology and a scientific collaborator with Dennis. Dennis Krikler was born in 1928 in South Africa. Most of his lifetime interests—cultural, medical, scientific, historical, and photographic—were rooted in the rich world of his childhood in the seaside resort of Muizenberg outside Cape Town where he lived for his…
Stages of puberty: what happens to boys and girls
Stages of puberty: what happens to boys and girlsPuberty is when a child’s body begins to develop and change as they become an adult. Girls develop breasts and start their periods, and boys develop a deeper voice and start to look like men.The average age for girls to begin puberty is 11, while for boys the average age is 12. But there’s no set timetable, so don’t worry if your child reaches puberty before or after their friends. It’s completely normal for puberty to begin at any point from the ages of 8 to 14. The process takes about four years overall.Late or early pubertyChildren who begin puberty either very early (before the age of 8) or very late (after 14) should see a doctor to rule out an underlying medical condition.Read more about puberty problems.This page covers:Signs of puberty in girls Signs of puberty in boys Mood changes during puberty Puberty support for children Puberty support for parents and carers First signs of puberty in girlsThe first sign of puberty in girls is usually that their breasts begin to develop. It’s normal for breast buds to sometimes be very tender or for one breast to start to develop several months […]
Using e-cigarettes to stop smoking
Using e-cigarettes to stop smokingOver recent years, e-cigarettes have become a very popular stop smoking aid in the UK. Evidence is still developing on how effective they are, but many people have found them helpful for quitting. An electronic cigarette (e-cigarette) is a device that allows you to inhale nicotine without most of the harmful effects of smoking. E-cigarettes work by heating and creating a vapour from a solution that typically contains nicotine; a thick, colourless liquid called propylene glycol and/or glycerine; and flavourings. As there is no burning involved, there is no smoke. E-cigarettes do not produce tar and carbon monoxide – two of the main toxins in conventional cigarette smoke. The vapour from e-cigarettes has been found to contain some potentially harmful chemicals also found in cigarette smoke, but at much lower levels. Benefits and risks of e-cigarettes E-cigarettes are still fairly new and we won’t have a full picture on their safety until they have been in use for many years. However, on current evidence, they carry a fraction of the risk of cigarettes and they can help you stop smoking. If you want to use an e-cigarette to help you quit, you’ll give yourself the best chance if you get expert support […]
How to get more fibre into your diet
How to get more fibre into your diet Most of us need to eat more fibre and have fewer added sugars in our diet. Eating plenty of fibre is associated with a lower risk of heart disease, stroke, type 2 diabetes and bowel cancer.Government guidelines published in July 2015 say that our dietary fibre intake should increase to 30g a day, as part of a healthy balanced diet. As most adults are only eating an average of about 18g day, we need to find ways of increasing our intake.Children under the age of 16 don’t need as much fibre in their diet as older teenagers and adults, but they still need more than they get currently:2-5 year-olds: need about 15g of fibre a day 5-11 year-olds: need about 20g 11-16 year-olds: need about 25g On average, children and teenagers are only getting around 15g or less of fibre a day. Encouraging them to eat plenty of fruit and vegetables and starchy foods (choosing wholegrain versions and potatoes with the skins on where possible) can help to ensure they are eating enough fibre.Why do we need fibre in our diet?There is strong evidence that eating plenty of fibre (commonly referred to as […]
Passive smoking: protect your family and friends
Passive smoking: protect your family and friendsSecondhand smoke is dangerous, especially for children. The best way to protect loved ones is to quit smoking. At the very least, make sure you have a smokefree home and car. When you smoke a cigarette (or roll-up, pipe or cigar), most of the smoke doesn’t go into your lungs, it goes into the air around you where anyone nearby can breathe it in. Secondhand smoke is the smoke that you exhale plus the ‘sidestream’ smoke created by the lit end of your cigarette. When friends and family breathe in your secondhand smoke – what we call passive smoking – it isn’t just unpleasant for them, it can damage their health too. People who breathe in secondhand smoke regularly are more likely to get the same diseases as smokers, including lung cancer and heart disease. Pregnant women exposed to passive smoke are more prone to premature birth and their baby is more at risk of low birthweight and cot death. And children who live in a smoky house are at higher risk of breathing problems, asthma, and allergies. How to protect against secondhand smoke The only surefire way to protect your friends and family from […]
BBC newsreader donates kidney to save mother
BBC newsreader donates kidney to save motherA BBC news presenter who donated a kidney to save his mother’s life says her health has been ‘completely transformed’ since having the operation. Sabet Choudhury was told his mother Sakina, 70, could have only three years to live after her kidneys failed. He said he had “little choice” but to donate a kidney, as she could have been waiting 10 years for a transplant because of the lack of deceased donors among black and Asian people. “She could have waited to find a kidney from someone on the Organ Donor Register, but that would have taken a long time, which she did not necessarily have,” he said. The operation was a success, but he said the wait for other black and minority ethnic (BME) families could be “long and fatal”. Transplants are more likely to be successful if the donor is of a similar ethnic background because blood and tissue types are more likely to match, according to NHS Blood and Transplant. Sabet, a presenter for BBC Points West news in southwest England, is urging more black and Asian people to register to donate organs. ‘New lease of life’ Sakina, who is of […]
Family alerts travellers to deadly fake alcohol
Family alerts travellers to deadly fake alcoholThe family of a British backpacker who died after drinking gin which had been mixed with methanol have launched a campaign to warn travellers of the dangers of fake alcohol. Cheznye Emmons, 23, was fatally poisoned after drinking the counterfeit gin, which she bought from a shop in a sealed bottle sporting a familiar brand while travelling in Indonesia in 2013. Methanol (also known as methyl alcohol) is a colourless liquid with a mild alcohol odour. When ingested, it is extremely poisonous and is known to cause blindness, kidney failure, seizures and death. The chemical is deliberately added to strengthen or stretch illegal alcoholic drinks, especially spirits, some of which are being sold in bars, shops and hotels in popular tourist areas such as Bali, Lombok and Sumatra. Bottles ‘look genuine’ The practice is common in many parts of the world. However, Indonesia has recently been singled out following a number of deaths and cases of serious illness of locals and foreigners. Some fake alcohol on sale in Indonesia has been found to contain concentrations of methanol 44,000 times above safe levels. Figures suggest 280 people have died from illicit alcohol poisoning since 2011 […]
Breast changes in older women
Breast changes in older womenAs you get older, it’s natural for your breasts to lose their firmness, change shape, shrink in size and become more prone to certain abnormal lumps. In most cases, breast lumps are harmless but, whatever your age, it’s important that you report any new lumps to your doctor.From around the age of 40, you can expect your breasts to change in size and shape. It’s normal for breast tissue to become less glandular and more fatty as you get older, which makes them feel less firm and full.With age, there’s also an increasing risk of abnormal growths in the breast. These are often harmless breast lumps, like cysts, but they can also be a sign of serious conditions like breast cancer.As the years go by, you might also notice a wider space between your breasts and that your breasts shrink in size, sometimes by a cup size or more (unless you put on weight, in which case your breasts may get bigger). The area around the nipple (the areola) tends to become smaller and may nearly disappear, and the nipple may turn in slightly.Many of the breast changes that happen as you get older are caused […]
Stay gas safe this summer
Stay gas safe this summerGas safety is just as important in the summer as it is in the winter. Poorly maintained appliances and boilers can cause carbon monoxide poisoning, which can be fatal. Find out how you can keep safe. Gas central heating may be turned off in the summer, but your boiler is still being used for hot water and, perhaps, you use a gas cooker. Remember the barbecue, too, which is often gas. More than 40% of us own a gas barbecue and 30% of us use it weekly to produce simple meals to enjoy outdoors. How do appliances cause carbon monoxide poisoning? Carbon monoxide (CO) is a poisonous gas produced when fuel such as gas (or charcoal or petrol) burns incompletely. Inadequately installed or poorly maintained appliances and boilers increase the risk of carbon monoxide being produced. You can’t see, taste or smell carbon monoxide. The Health and Safety Executive (HSE) reported that last year 319 people were killed or injured due to carbon monoxide poisoning. It is important to look out for the warning signs of carbon monoxide poisoning and to seek urgent medical attention from your GP or accident and emergency department. It is not […]
NHS screeningScreening is a way of finding out if people are at higher risk of a health problem, so that early treatment can be offered or information given to help them make informed decisions. This page gives an overview of screening, with links to the different types of screening offered by the NHS in England. What is screening? What types of screening are offered by the NHS in England? Benefits, risks and limitations of screening What is screening? Screening is a way of identifying apparently healthy people who may have an increased risk of a particular condition. The NHS offers a range of screening tests to different sections of the population. The aim is to offer screening to the people who are most likely to benefit from it. For example, some screening tests are only offered to newborn babies, while others such as breast screening and abdominal aortic aneurysm screening are only offered to older people. Screening results If you get a normal result (a screen negative result) after a screening test, this means you are at low risk of having the condition you were screened for. This does not mean that you will never develop the condition in the future, just […]
Where’s your pain?
Where’s your pain?Pain can strike anywhere in the body. Wherever you feel pain, whether it’s in your hip, back, foot or head, use this guide to find the information you need. Head and neck Headache Ear pain Sore throat Sore lips Painful tongue Toothache Neck pain Chest, shoulders and back Back pain Shoulder pain Breast pain Chest pain Rib pain Arms and hands Arm or elbow pain Hand pain Abdomen, pelvis and genitals Stomach ache and abdominal pain Pelvic pain Ovulation pain Period pain Anal pain Vaginal pain Legs and feet Hip pain Knee pain Foot pain Heel pain