Search

Background/Aims Most transcatheter aortic valve implantation procedures are now performed under conscious sedation, rather than general anaesthetic. This study evaluated nurse-led conscious sedation, compared with anaesthetist-led sedation, to determine the feasibility of the former. Methods Consecutive patients undergoing transcatheter aortic valve implantation under either nurse-led or anaesthetist-led sedation between July 2018 and September 2021 were reviewed. Assessed outcomes were analysed and compared, including 30-day mortality rate, major vascular access site bleeding, moderate or severe aortic regurgitation, stroke, new pacemaker implantation, duration of procedure and length of stay. Results A total of 212 patients who underwent nurse-led sedation and 412 who underwent anaesthetist-led sedation were identified. There were no significant differences in risk scores between the two groups. In both groups, incidence of conversion to general anaesthetic was low, with nurse sedatitionists seeking anaesthetist support in 13 (6.2%) cases. Cases with nurse-led sedation had a significantly lower average duration of the procedure (90 minutes vs 111 minutes; P=0.001) and length of stay (2 days vs 3 days, P=0.0002). Conclusions Nurse-led sedation can be safely incorporated into transcatheter aortic valve implantation practice. Nurse-led sedation delivered similar outcomes to anaesthetist-led sedation, but with shorter procedural times and legnth of stay. This could allow more flexible scheduling, increased capacity and improved access for patients.

Raised lipid levels are a significant risk factor for cardiovascular disease. Alison Pottle provides an overview of how these are measured and the lifestyle measures and medications that can be used to reduce risk in these patients Cardiovascular disease (CVD) is the leading cause of death in England and Wales. Raised lipid levels are a significant risk factor for CVD. Lipids are a heterogeneous group of substances which include cholesterol, triglycerides, lipoproteins and apolipoproteins. The link between increased lipid levels and atherosclerosis was first established in the early 1900s. Numerous clinical studies have demonstrated the critical role of low density lipoproteins and other cholesterol-rich apolipoprotein-B containing lipoproteins in atherosclerotic plaque formation and the subsequent risk of CVD events. There is now clear indication that the lower the achieved LDL levels, the lower the risk of CVD. Multiple interventions including changes in lifestyle together with the use of lipid-lowering therapies may be required to achieve desired lipid levels, and practice nurses can play a key role in this. This article will discuss how cholesterol levels are measured and the treatment strategies now available.

This article explores a new advanced nursing role within interventional cardiology. The role was jointly developed by the lead consultant and clinical nurse specialist, and has received the first official centre of excellence award in the world. As a result, the service will now deliver expert training programmes taught by the consultant team and specialist nurse. This service was created for patients with mitral valve disease. It has a dedicated and structured pathway, with the patient always at the centre of care. This article introduces the role of nurse second operator in complex valvular intervention, which allows the clinical nurse specialist to be fully involved in the entire patient journey from referral to discharge. The author describes how the role was established and the developments that have been made in the first 3 years of the post. The role encompasses both inpatient and outpatient care in a bespoke, nurse-led service, as well as responsibility for maintaining accurate data collection and adherence to the patient pathway throughout the service. This has facilitated a streamlined and tailored service that strives to deliver high-quality, equitable care to patients across the UK. It is hoped that this will encourage other centres to develop such roles for specialist nurses.

Despite widespread evidence of the effectiveness of lipid modification for the reduction of cardiovascular disease (CVD) risk, lipid modification goals are commonly underachieved in the United Kingdom (UK). In order to understand current UK lipid management guidance and the corresponding attainment of recommended lipid lowering goals relating to treatment with statins and ezetimibe, a literature review was conducted using PubMed focusing on publications between January 2017 and February 2020 in order to capture the most up-to-date literature. Identified publications were reviewed against key clinical guidelines for lipid management in relation to CVD risk from the National Institute for Health and Care Excellence (NICE, CG181), the Scottish Intercollegiate Guidelines Network (SIGN, 149) and European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS). Cholesterol lowering goals are central to current lipid lowering therapy guidance, although specific goals vary depending on the guideline and patients’ individual risk profile. Current guidance by NICE and SIGN specifies that treatment should achieve a greater than 40% reduction in non-high-density lipoprotein cholesterol (non-HDL-C) at 3 months of treatment, while the ESC/EAS place emphasis on the lowering of low-density lipoprotein (LDL-C) and total cholesterol. Yet, despite widespread availability of guidance and consistent messaging that lipid lowering goals should be ambitious, current evidence suggests a significant proportion of UK patients have sub-optimal reductions in cholesterol/non-HDL-C/LDL-C. The reasons for this are reported to be multifactorial, including a lack of compliance with guidelines, particularly regarding high-intensity statin prescribing, patient adherence, statin intolerance and statin reluctance as well as wider genetic factors. A number of possible strategies to improve current lipid management and attainment of lipid-lowering goals were identified, including improving the patient-healthcare professional partnership, conducting audits of local prescribing versus guidance, implementing plans for the refinement of current services and considering alternative options such as cost-effective single pill combinations for improving adherence.

ObjectiveThe study evaluated the feasibility of mindfulness-based cognitive therapy (MBCT) in patients with non-cardiac chest pain by assessing their willingness to participate and adhere to the programme, and for these data to help further refine the content of MBCT for chest pain.Patients and methodsThis prospective 2:1 randomised controlled trial compared the intervention of adapted MBCT as an addition to usual care with just usual care in controls. Among 573 patients who attended the rapid access chest pain clinic over the previous 12 months and were not diagnosed with a cardiac cause but had persistent chest pain were invited. The intervention was a 2-hour, weekly, online guided 8-week MBCT course. Compliance with attendance and the home practice was recorded. Enrolled patients completed the Seattle angina questionnaire (SAQ), Hospital Anxiety and Depression Scale, Cardiac Anxiety Questionnaire, Five-Facet Mindfulness Questionnaire, and Euro Quality of Life–5 Dimensions–5 Level at baseline assessment and after 8-week period.ResultsPersistent chest pain was reported by 114 patients. Of these, 33 (29%) patients with a mean age of 54.2 (±12.2) years and 68% women, consented to the study. Baseline questionnaires revealed mild physical limitation (mean SAQ, 76.8±25), high levels of anxiety (76%) and depression (53%), modest cardiac anxiety (CAQ,1.78±0.61) and mindfulness score (FFMQ, 45.5±7.3). Six patients subsequently withdrew due to bereavement, caring responsibilities and ill health. Of the remaining 27 participants, 18 in the intervention arm attended an average of 5 sessions with 61% attending ≥6 sessions. Although not statistically powered, the study revealed a significant reduction in general anxiety, improved mindfulness and a trend towards improvement in SAQ scores in the intervention arm.ConclusionOne-third of patients with persistent non-cardiac chest pain were willing to participate in mindfulness-based therapy. An improvement in anxiety and mindfulness was detected in this feasibility study. A larger trial is required to demonstrate improvement in chest pain symptoms.

Funding Acknowledgements None Background Patients undergoing angiography and percutaneous coronary intervention (PCI) were historically reviewed post procedure by a member of the medical team who assesses the patient’s suitability for discharge and completes the discharge letter. Over the past 10 years, the number of patients admitted for these procedures as day cases has increased significantly. In addition, there has been an expansion in nursing roles in the UK with the development of a variety of clinical nurse specialist (CNS) posts which have taken over many of the traditional medical roles. The majority of patients undergoing elective angiography and PCI are admitted to a day case unit at this tertiary cardiac centre. There is no designated medical cover for the unit and medical staff from the acute cardiac unit are called to review patients and complete their discharge paperwork in addition to their other duties. This frequently results in delayed discharge and patients going home without a discharge summary. It was therefore proposed that suitably qualified CNSs could be trained to discharge these patients and others undergoing day case cardiology procedures. From June 2017, the CNS team took over the role of reviewing patients post procedure and completing the discharge letter. Purpose The aim of the study was to evaluate if CNSs were able to discharge patients and provide a timely and effective service following elective cardiology procedures and to obtain patient feedback. Method Data on the number of patients reviewed by the CNSs from June 2017 to the end of December 2019, were prospectively collected in a dedicated database. A pilot study of patient experience was carried out in January 2020. Patients were given a questionnaire which asked about the explanation they received from the CNS regarding the procedure they had undergone, if their medication was reviewed and discussed with them, and if they received a discharge summary to take home. Results 1287 patients were reviewed by the CNS team during the above period. 811 (63.0%) patients had undergone angiography and 423 (32.9%) PCI. Informal feedback from the staff working on the day case unit included that patients were discharged earlier, had improved knowledge about their procedure and that the discharge letter was more detailed when completed by the CNS team. Eight patients completed the pilot questionnaire. Six were discharged by one of the CNS team, one by a doctor and one patient was not sure who did their discharge. All patients were very satisfied with the process and the information they were given. Conclusion Experienced CNSs can deliver high-quality, timely discharge of patients following cardiology procedures. This process is being used as a template to expand nurse-led discharge to other areas in cardiology. Patient experience will continue to be audited with a larger sample size in 2020.

Funding Acknowledgements None Background Rapid Access Chest Pain clinics (RACPCs) were established in the UK in 2000 following the publication of the National Service Framework for Coronary Heart Disease. Patients underwent an exercise test (ETT) in the clinic as part of a ‘one-stop’ protocol with follow-up only if further investigation was required. In 2010, the National Institute for Health and Care Excellence (NICE) produced guidelines for the assessment and diagnosis of chest pain of recent onset (CG95), replacing the recommendation for ETT with non-invasive functional testing for patients with an intermediate pre-test probability of coronary artery disease (CAD), necessitating multiple appointments to evaluate the patient’s symptoms. The guidelines were updated in 2016, with a new recommendation that patients with atypical or typical chest pain should undergo CT coronary angiography (CTCA) as the first diagnostic test. Purpose The aim of this study was to investigate the feasibility and potential benefit of performing same -day CTCA in the RACPC. Method From November 2016 all patients with atypical or typical chest pain attending the RACPC at this tertiary cardiac centre were referred for CTCA unless alternative investigation was clinically indicated. From February 2018, same day CTCA was offered to some patients. Up to two scans could be performed in each clinic, which was increased to up to three in June 2018. Results A total of 985 patients were seen in the nurse-led clinic between 12/02/2018 and 30/11/2019. 473 patients were referred for CTCA (48.0%) and 314 scans were carried out in the clinic (66.4%). Of those scans carried out in clinic, 128 patients had a CTCA which showed no evidence of CAD (40.8%) and 34.4% of scans showed non-obstructive CAD. In 18.2% of patients, the CTCA showed significant CAD and in 21 patients (6.7%) the scan was inconclusive. Patient with inconclusive scans underwent further testing which was negative in all cases. The outcome for patients with significant CAD (57 patients) is shown in the table. Conclusion CTCA on the same day as the RACPC appointment is feasible and facilitates rapid further investigation and treatment of patients with potentially significant CAD. It also enables patients with non-significant or no CAD to be reassured that their symptoms are unlikely to be cardiac which will reduce anxiety and allow timely investigation of other causes of the chest pain. Nurses need training in the risks of radiation in order to be able to request the scans and enable the clinic to be nurse-led.

BACKGROUND: Raised lipoprotein(a) [Lp(a)] is a cardiovascular risk factor common in patients with refractory angina. The apolipoprotein(a) component of Lp(a) exhibits structural homology with plasminogen and can enhance thrombosis and impair fibrinolysis. OBJECTIVES: The objective of the study was to assess the effect of lipoprotein apheresis on markers of thrombosis and fibrinolysis in patients with high Lp(a). METHODS: In a prospective, single-blind, crossover trial, 20 patients with refractory angina and raised Lp(a) > 50 mg/dL were randomized to three months of weekly lipoprotein apheresis or sham. Blood taken before and after apheresis/sham was assessed using the Global Thrombosis Test, to assess time taken for in vitro thrombus formation (occlusion time) and endogenous fibrinolysis (lysis time), as well as von Willebrand Factor, fibrinogen, D-dimer, thrombin/anti-thrombin III complex, prothrombin fragments 1 + 2, and thrombin generation assays. RESULTS: Lp(a) was significantly reduced by apheresis (100.2 [interquartile range {IQR}, 69.6143.0] vs 24.8 [17.2,34.0] mg/dL, P = .0001) but not by sham (P = .0001 between treatment arms). Apheresis prolonged occlusion time (576 ± 116 s vs 723 ± 142 s, P

Background An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has already been used at point of care with efficacy for evaluating subjects with stable chest pain (SCP) and it has been proved to correctly identify absence of significant coronary artery disease (CAD) versus standard care approach (SD) without known prognostic implication yet. Purpose The aim is to determine the prognostic value of “no testing/Follow up” AI DSS response in a referral population evaluated for SCP. Methods From 2016 to 2019, an AI DSS ESC guidelines based applicative was used on 1.291 subjects with SCP to determine testing appropriateness compared with human specialist standard evaluation. 590 of them, 332 males, mean age 62±11 years deemed to be completely negative – by “no testing/follow up” response - were evaluated. The negative response was defined and confirmed by a normal Coronary Tomography Angiography scan executed in all these subjects. Mean follow-up was 3.46±1.76 years. Two groups based on pre-test likelihood of having CAD were analyzed – low and intermediate. No subjects with high pre-test likelihood were present. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations. Results The primary endpoints classification is displayed in the Table. The unadjusted hazard ratio for primary endpoint was 3.84 (95% CI 0.32–8.68, p=0.009) in patients with intermediate compared to those with low pre-test likelihood of CAD. Moreover, the “no testing and Follow up” response showed an incremental prognostic value over conventional risk factors (χ2=7, P=0.022) and over a combination of conventional factors and ST-T changes (χ2=9, P=0.014). Conclusions In an outpatient population without known CAD evaluated for chest pain, after the administration of AI DSS, a “No tests/Follow up” confers an excellent prognosis regardless of the ESC SCORE Charts and rest ECG abnormalities. These preliminary data confirms the safety of ARTICA AI DSS use in subjects with stable chest pain. Funding Acknowledgement Type of funding source: None

Background & aims The emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes Coronavirus Disease 2019 (COVID-19) has resulted in a worldwide pandemic. SARS-CoV-2 is highly contagious and its severity highly variable. The fatality rate is unpredictable but is amplified by several factors including advancing age, atherosclerotic cardiovascular disease, diabetes mellitus, hypertension and obesity. A large proportion of patients with these conditions are treated with lipid lowering medication and questions regarding the safety of continuing lipid-lowering medication in patients infected with COVID-19 have arisen. Some have suggested they may exacerbate their condition. It is important to consider known interactions with lipid-lowering agents and with specific therapies for COVID-19. This statement aims to collate current evidence surrounding the safety of lipid-lowering medications in patients, who have COVID-19. We offer a consensus view based on current knowledge and we rated the strength and level of evidence for these recommendations. Methods Pubmed, Google scholar and Web of Science were searched extensively for articles using search terms: SARS-CoV-2, COVID-19, coronavirus, Lipids, Statin, Fibrates, Ezetimibe, PCSK9 monoclonal antibodies, nicotinic acid, bile acid sequestrate, nutraceuticals, red yeast rice, Omega-3-Fatty acids, Lomitapide, hypercholesterolaemia, dyslipidaemia and Volanesorsen. Results & Conclusions: There is no evidence currently that lipid lowering therapy is unsafe in patients with COVID-19 infection. Lipid-lowering therapy should not be interrupted because of the pandemic or in patients at increased risk of COVID-19 infection. In patients with confirmed COVID-19, care should be taken to avoid drug interactions, between lipid-lowering medications and drugs that may be used to treat COVID-19, especially in patients with abnormalities in liver function tests., Graphical abstract Image 1, Highlights • Patients with known atherosclerotic cardiovascular disease and related comorbidities are at increased risk of severe illness and mortality if infected with COVID-19. • There is no convincing evidence to suggest harm from lipid lowering therapy or on-treatment low LDL cholesterol if patients develop acute illnesses or SARS-CoV-2. In fact, available evidence suggests that statin therapy is associated with benefits. • Patients treated for hyperlipidaemia should not interrupt their treatment because of COVID-19 pandemic. • Continue lipid lowering therapy in patients with confirmed diagnosis of COVID-19 unless possible risks outweigh benefits. • In patient treated for COVID-19 with pharmacologic agents, drug interactions with lipid lowering therapies should be investigated and assessed.

The role of nurse consultant was introduced in the late 1990s to strengthen leadership in nursing, improve patient outcomes and enhance the quality of healthcare services. Nurse consultants have a wide-ranging remit that includes expert practice, professional leadership and consultancy, education, and service development. In this article, the author reflects on her experience of being one of the first nurse consultants, which included setting up nurse-led clinics, maintaining professional relationships with medical colleagues and assuming increasing responsibility for services. The article also examines the changes that the nurse consultant role has undergone since its inception in the 1990s.

Inherited cardiac conditions are a variety of genetic conditions affecting the heart and vasculature, which can result in sudden cardiac death. Identification of patients with these conditions and subsequent cascade testing of family members is vital if the impact from these conditions is to be reduced. This article focuses on two such conditions which are among the most common: hypertrophic cardiomyopathy and familial hypercholesterolaemia. The case studies illustrated detail the identification of the conditions, as well as the individual management of the two patients. The importance of cascade testing of relatives will be discussed in both cases together, with the need for dedicated clinics for managing patients with inherited cardiac conditions.

The European Society of Cardiology (ESC) (2012) recommends that patients with ST-Segment elevation myocardial infarction (STEMI) should be monitored in a coronary care unit (CCU) for a minimum of 24 hours post primary percutaneous coronary intervention (PPCI). However, in practice, stable patients with complication-free PPCI are often stepped down earlier than the recommended 24 hours as a result of the increased demand on CCU beds. The aim of this audit was to establish optimum CCU monitoring time and the complication rate in this patient group within the 48 hours of PPCI. The audit shows that 37% of patients were stepped down from CCU earlier than the recommended period. All complications observed were minor and more than 50% of these occurred within the first 6 hours. The results demonstrated that a minimum of 24 hours of CCU monitoring is not mandatory and the length of CCU monitoring can be decided upon on an individual patient basis.

Aims CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). Methods and results Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). Conclusion In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a ‘gatekeeper’ in this patient cohort, obviating the need for further more expensive tests.

Background and aims In 2008, the National Institute of Health and Care Excellence in the UK recommended that patients undergoing lipoprotein apheresis (LA) should be included in an anonymised registry. The UK Lipoprotein Apheresis Registry was subsequently established in 2011. Methods Between 2011 and 2017, data was entered retrospectively and prospectively by seven LA centres in the UK for 151 patients. Twenty-two patients were involved in a research study and were therefore excluded from the analysis. Observational data was analysed for the remaining 129 patients. Results Most patients had heterozygous familial hypercholesterolaemia (HeFH) (45.0%); 23.3% had homozygous FH (HoFH); 7.8% had hyper-lipoproteinaemia (a) (Lp(a)) and 24.0% had other forms of dyslipidaemia. Detailed treatment data is available for 63 patients relating to 348 years of LA treatment. The number of years of treatment per patient ranged from 1 to 15. The mean reduction in interval mean LDL-C from the pre-procedure baseline was 43.14%. The mean reduction in interval mean Lp(a) from baseline was 37.95%. The registry data also shows a 62.5% reduction in major adverse cardiovascular events (MACE) between the 2 years prior to, and the first 2 years following introduction of LA. Conclusions The data generated by the UK Lipoprotein Apheresis Registry demonstrates that LA is a very efficient method of reducing LDL-C and Lp(a) and lowers the incidence rate of MACE. LA is an important tool in the management of selected patients with HoFH and drug-resistant dyslipidaemias.

Raised lipid levels are a significant risk factor for coronary heart disease. Lipids are a heterogeneous group of substances which include cholesterol, triglycerides, lipoproteins and apolipoproteins. The link between increased lipid levels and atherosclerosis has been known since the early 1900s. Optimum levels of total cholesterol and low density lipoprotein cholesterol (LDL) are unknown but the general consensus is ‘the lower the better’ with some guidelines suggesting that the goal should be an LDL of

The burden of treating stable angina is vast, as it is estimated that almost 2 million people currently have or have had angina in the UK ( Health and Social Care Information Centre (HSCIC), 2006 ). Angina is the main symptom of myocardial ischaemia, usually caused by atherosclerotic obstructive coronary artery disease, restricting bloodflow and therefore oxygen delivery to the heart muscle ( National Institute for Health and Care Excellence (NICE), 2011 ). Characteristic features of stable angina include tightness or heaviness across the chest, which can radiate to the left arm, neck, jaw and back. However, it is important to be aware that some people present with atypical symptoms. A diagnosis of stable angina can be based on clinical assessment alone or with the addition of diagnostic testing. Diagnosic tests used in this instance can include: exercise testing, computerised tomography (CT), myocardial perfusion scanning and stress echocardiography, in addition to blood tests and electrocardiogram which all patients will undergo. Management of angina includes medical therapy, the aim of which is to help reduce symptoms and prevent cardiovascular events such as myocardial infarction and stroke ( Montalescot et al, 2013 ). Guidelines on stable angina by NICE (2011) and the European Society of Cardiology (ESC) ( Montalescot et al, 2013 ) provide us with recommendations on which medications should be prescribed. Lifestyle changes are a key aspect of angina management: namely in the areas of diet, exercise, smoking, diabetes, hypertension and psychological issues.

Introduction Following NICE approval of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in June 2016, a multi-disciplinary team (MDT) consisting of nurse specialists in Familial Hypercholesterolaemia, specialist cardiology pharmacists and the lead consultant cardiologist worked together to establish supplementary guidelines and setup a nurse-led PCSK9 clinic to facilitate the initiation and continued monitoring of patients commenced on PCSK9 inhibitors. There are two PCSK9 inhibitors currently approved for use in the UK; evolocumab and alirocumab. Both these drugs are licensed and approved for lowering LDL cholesterol (LDL-C) in selected patients with hypercholesterolaemia. Method Trust supplementary guidelines were developed in collaboration with the local Clinical Commissioning Group (CCG) which included the referral pathway, criteria for initiation, process for obtaining funding, recommendations for ongoing monitoring and definition of successful response to treatment. A nurse-led PCSK9 clinic was established to manage the initiation and continued monitoring of these patients. Following funding approval, patients attended the clinic for education, training and supervision with their first two injections and further follow-up at 3 months, 6 months (via a telephone appointment) and 12 months. Data was collected prospectively from 7/9/2016 until 30/11/2017 with a minimum of 3 months patient follow-up data. Results Adverse effects PCSK9 inhibitors have been generally well tolerated. Four patients (11.1%) have discontinued treatment within the first 6 months due to side effects. Conclusions The MDT approach to initiating and monitoring PCSK9 therapy has been successful. PCSK9 therapy has been generally well tolerated by patients and a median percentage LDL-C reduction of 49% achieved at 3 months has been maintained at 12 months. Experience to date shows some variation in the response to PCSK9 therapy based on Background lipid lowering therapy.

It is well established that Lipoprotein(a) [Lp(a)] is an independent cardiovascular risk factor and predictor of major adverse cardiovascular events. Lipoprotein apheresis is currently the most effective approved treatment available, with minimal effect conferred by conventional lipid lowering agents. A growing body of evidence suggests that aggressively lowering raised Lp(a) may improve cardiovascular and clinical outcomes, although more prospective research is required in this field. Angina which is refractory to conventional medical therapy and revascularisation is extremely challenging to manage. There is a significant unmet need to establish therapeutic options. Our goal is to determine the impact of lipoprotein apheresis on clinical parameters and symptoms of patients with refractory angina secondary to advanced coronary disease and raised Lp(a). Determining whether we should aggressively lower Lp(a) in such patients remains a very important question, which could potentially impact on the management of a large population. We will also gain insight into how this treatment works and the mechanisms via which Lp(a) increases cardiovascular risk. We are currently conducting a prospective, randomised controlled crossover study of patients with refractory angina and raised Lp(a), randomised to undergoing three months of weekly lipoprotein apheresis or sham apheresis. Patients will then crossover to the opposite study arm after a 1 month wash-out phase. We will assess myocardial perfusion, carotid atherosclerosis, endothelial vascular function, thrombogenesis, oxidised LDL and their antibodies, exercise capacity, angina and quality of life at the beginning and end of treatment, to determine the net true treatment effect on the above parameters. This is a novel area of research, as previous studies have not assessed the role of lipoprotein apheresis in patients with refractory angina and raised Lp(a) in a prospective randomised controlled manner.

Introduction:Lipoprotein apheresis (LA) has proven to be an effective, safe and life-saving therapy. Vascular access is needed to facilitate this treatment but has recognised complications. Despite consistency in treatment indication and duration there are no guidelines in place. The aim of this study is to characterise vascular access practice at the UK’s largest LA centre and forward suggestions for future approaches.Methods:A retrospective analysis of vascular access strategies was undertaken in all patients who received LA treatment in the low-density lipoprotein (LDL) Apheresis Unit at Harefield Hospital (Middlesex, UK) from November 2000 to March 2016.Results:Fifty-three former and current patients underwent 4260 LA treatments. Peripheral vein cannulation represented 79% of initial vascular access strategies with arteriovenous (AV) fistula use accounting for 15%. Last used method of vascular access was peripheral vein cannulation in 57% versus AV fistula in 32%. Total AV fistula failure rate was 37%.Conclusions:Peripheral vein cannulation remains the most common method to facilitate LA. Practice trends indicate a move towards AV fistula creation; the favoured approach receiving support from the expert body in this area. AV fistula failure rate is high and of great concern, therefore we suggest the implementation of upper limb ultrasound vascular mapping in all patients who meet treatment eligibility criteria. We encourage close ties between apheresis units and specialist surgical centres to facilitate patient counselling and monitoring. Further prospective data regarding fistula failure is needed in this expanding treatment field.

Raised levels of cholesterol are an important risk factor for coronary heart disease (CHD). There are a variety of medications that can be used to reduce cholesterol levels. In addition, it is important that patients make changes to their lifestyle. Changes to diet, stopping smoking and increasing exercise can all help in cholesterol reduction. Health professionals need to help and support patients in making these lifestyle changes.

An elevated level of low-density lipoprotein cholesterol in the bloodstream has been considered a risk factor in the development of coronary heart disease for many years. Cholesterol-lowering medication, while usually successful, may prove insufficient and lipoprotein apheresis may be the required method of treatment in order to achieve targets and reduce coronary heart disease risk. Efficacy of lipoprotein apheresis is measured by checking total cholesterol and low-density lipoprotein cholesterol levels before and after each treatment, with the aim of achieving a 50% reduction in each. This small study investigated whether apolipoprotein B is a more accurate measure of lipoprotein apheresis efficacy.

Aims To determine the clinical impact of lipoprotein apheresis in patients with refractory angina and raised lipoprotein(a) > 500 mg/L on the primary end point of quantitative myocardial perfusion, as well as secondary end points including atheroma burden, exercise capacity, symptoms, and quality of life. Methods We conducted a single-blinded randomized controlled trial in 20 patients with refractory angina and raised lipoprotein(a) > 500 mg/L, with 3 months of blinded weekly lipoprotein apheresis or sham, followed by crossover. The primary endpoint was change in quantitative myocardial perfusion reserve (MPR) assessed by cardiovascular magnetic resonance. Secondary endpoints included measures of atheroma burden, exercise capacity, symptoms and quality of life. Results The primary endpoint, namely MPR, increased following apheresis (0.47; 95% CI 0.31–0.63) compared with sham (−0.16; 95% CI − 0.33–0.02) yielding a net treatment increase of 0.63 (95% CI 0.37–0.89; P Conclusion Lipoprotein apheresis may represent an effective novel treatment for patients with refractory angina and raised lipoprotein(a) improving myocardial perfusion, atheroma burden, exercise capacity and symptoms.

Rapid access chest pain clinics (RACPC) were introduced nationally following the publication of the National Service Framework for Coronary Heart Disease in 2000. The aim is to ensure that people with new onset chest pain, thought to be angina, receive prompt treatment and investigations following evidence based guidelines. In 2010 the National Institute for Clinical Excellence (NICE) published new guidance on the assessment and diagnosis of new onset chest pain which suggested changes in how most RACPC are run. This paper presents an audit that examined putting this NICE guidance into practice and discusses various issues that arose relating to its clinical application.

In the past couple of decades nursing has undergone significant change. This has partly been driven by changes in medical practice such as the European Working Time Directive and also the desire of nurses to extend and expand their skills and scope of practice. Nurses are now frequently carrying out roles which were previously felt to be in the domain of medical staff. The cardiac field has seen a rapid expansion in specialist nursing posts and therefore the development of a variety of exciting changes in the way nurses contribute to patient care. This article describes the establishment of a nurse-led ward round for patients following percutaneous coronary intervention and discuss the use of non-medical prescribing in this setting. It also shows how collaborative working with other members of the multidisciplinary team can be used to benefit both patients and the organization.

Raised cholesterol is a recognized risk factor for cardiovascular disease (CVD). If lifestyle changes do not result in cholesterol levels reaching the desired targets, then pharmacological agents may be required. Statins are the first-line treatment, but sometimes other classes of lipid-lowering drugs are required. Ezetimibe is a novel agent, which acts by inhibiting the intestinal absorption of cholesterol. Nurses caring for patients with CVD or at risk of developing CVD need to be aware of all the agents which may be used to control cholesterol levels. This article will outline the process of cholesterol metabolism and examine the role of ezetimibe in the reduction of cholesterol levels. It will also discuss side effects and contraindications to this therapy so that nurses are able to safely care for patients taking ezetimibe.

Summary Objective: To determine the efficacy and safety of liposorber D low-density lipoprotein (LDL) apheresis system in high-risk cardiac patients. Design: Retrospective analysis of 466 treatments undertaken in eight patients with coronary heart disease. Five patients had severe heterozygous familial hypercholesterolaemia (FH), one had severe hypertriglyceridaemia and two were cardiac transplant recipients with FH intolerant to statins. Acute reductions during single sessions and preprocedural long-term changes in lipoprotein subfractions, laboratory safety parameters, adverse events and clinical outcome were recorded. Results: In 352 treatments performed in seven patients, acute reductions averaged 52.8% (standard deviation: 8.61%) for total cholesterol (TC), 61.8% (10.13%) for LDL-cholesterol (LDL-C), 21.1% (9.66%) for high-density lipoprotein cholesterol (HDL-C), 71.1% (median) for lipoprotein (a) [Lp(a)] and 44.5% (14.42%) for triglycerides (p

Heterozygous familial hypercholesterolaemia is the most common genetic disorder in Europe and the USA, affecting about 1:500 of the population. Most patients can control their cholesterol level with a combination of diet and medication. However, for a small number, this is not adequate and they require apheresis of low density lipoprotein ( LDL-apheresis). This care study focuses on the management of a 56-year-old lady with familial hypercholesterolaemia. Her management before the treatment will be discussed, together with details of her LDL-apheresis treatment. Patients with familial hypercholesterolaemia are at an increased risk of developing coronary artery disease and the importance of identifying these patients and ensuring they receive optimum treatment will be presented

Background: Angina that is refractory to conventional medical therapy and revascularisation, remains challenging to manage and poses significant burden to patients. Elevated lipoprotein(a) [Lp(a)] has emerged as an important independent cardiovascular risk factor and predictor of adverse outcomes in atherosclerotic disease. The prevalence of raised Lp(a) amongst patients with refractory angina has not yet been defined. Objective: To establish the prevalence of raised [Lp(a)] >500 mg/L in patients with refractory angina. Methods: We conducted an epidemiological screening pilot study in 75 patients with refractory angina from a UK tertiary cardiac centre. We determined the proportion of the cohort with raised Lp(a) >500 mg/L using an isoform-insensitive method. In addition, a full fasting lipid profile (including: LDL cholesterol, HDL cholesterol, total cholesterol to HDL ratio and triglycerides) was obtained. Patients were also asked about the presence of conventional cardiovascular risk factors. Results: Our study demonstrated that 60% of the 75 patients with refractory angina had raised Lp(a) levels of >500 mg/L. The median and inter-quartile range of Lp(a) values were 771 mg/L (162 mg/L,1260 mg/L) respectively. Conclusions: This high prevalence of raised Lp(a) detected in our cohort with refractory angina may suggest a causal role. Further research is necessary to confirm this association and prospective studies are needed to explore the potential therapeutic benefit of Lp(a) reduction in patients with refractory angina.

Coronary heart disease is the leading cause of mortality and morbidity in the UK, for which hypercholesterolaemia is a risk factor. This article concentrates on the management of patients with familial hypercholesterolaemia (FH). It discusses FH, how it is diagnosed, and the treatments that are available.

A 24-year-old woman with cystic fibrosis underwent bilateral sequential lung transplantation and unintentionally received an ABO incompatible graft (blood type A(1) graft into a type O recipient). The recipient had a high titer of IgG anti-A antibody (256 by the indirect antiglobulin test). Emergency treatment included antibody removal by plasmapheresis and additional immunosuppression with mycophenolate, rabbit antithymocyte globulin and polyspecific intravenous immunoglobulin. Subsequently, immunoadsorption and the anti-CD20 antibody rituximab were used to remove anti-A antibody and inhibit its resynthesis. Early graft function was good; one episode of rejection at Day 46 responded promptly to treatment with methylprednisolone. Subsequently, graft function continued to improve and anti-A antibody titers remained low. No infectious or other complications were encountered. The treatment regimen that we adopted may prove useful in other cases of unplanned ABO-incompatible organ transplants. The successful outcome suggests that planned ABO-incompatible lung transplants may be possible.

Coronary artery disease remains a significant cause of morbidity and mortality in the Western world. High plasma Lp(a) concentrations are related to the risk of cardiovascular disease, but Lp(a) is rarely assayed and treated. We present the case of a 50-year-old gentleman with refractory angina, whose coronary disease continued to progress despite optimal medical and surgical therapy. We show that the aggressive reduction of Lp(a) successfully ameliorated the progression of coronary stenosis and provides effective and durable relief of symptoms.

Alison Pottle† & Mahmoud Barbir †Author for correspondence Royal Brompton & Harefield NHS Trust, LDL-Apheresis Unit, Cardiology Department, Harefield Hospital, Hill End Road, Harefield, Middlesex, UB9 6JH, UK Tel.: +44 1895 823 737; Fax: +44 1895 828 677; a.pottle@rbht.nhs.uk ‘The main advantages of the whole-blood systems are that they have a simplified extracorporeal circuit ... and the treatment time is reduced.’

The aim of this chapter is to provide nurses with the knowledge to be able to assess, manage, and care for people with coronary heart disease (CHD) in an evidence-based and person-centred way. The chapter will provide a comprehensive overview of the causes, risk factors, and impact of CHD. In guiding you through patient assessment, the differences between acute coronary syndromes (ACS) and angina are established before exploring best practice to deliver care, as well as to prevent or to minimize further ill-health. Nursing assessments and priorities are highlighted throughout, and the nursing management of the symptoms and common health problems associated with coronary heart disease can be found in Chapters 15, 22, 24, and 25, respectively. CHD is defined as the failure of the coronary arteries to deliver adequate oxygen for myocardial work. It is almost always caused by atherosclerosis—a gradual build-up of fatty plaques within the artery wall that reduces blood flow. This failure to meet metabolic demands results in a range of clinical conditions sharing common pathological process (Baxendale, 1992), including ACS and angina. Chest pain is the symptom that informs clinical decision-making. It is classified based on history-taking and investigations such as the electrocardiogram (ECG). Angina was first described by Heberden in 1772 as a ‘painful and disagreeable sensation in the breast, which seems as if it would take their life away if it were to increase or continue.’ (cited by Fox et al., 2006). Stable angina is described as a clinical syndrome that is characterized by discomfort in the chest, jaw, shoulder, back, and arms, typically elicited by exertional emotional stress and relieved by rest or nitroglycerine (Fox et al., 2006). ACS is an umbrella term for several clinical presentations, including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). The European Society of Cardiology defines ACS as ‘. . . a life threatening manifestation of atherosclerosis . . . caused by a ruptured atherosclerotic plaque . . . causing sudden complete or critical reduction in blood flow’ (Bassand et al., 2007).

Low density lipoprotein (LDL) apheresis is now accepted as the treatment of choice for patients with homozygous familial hypercholesterolaemia and for heterozygotes with cardiovascular disease refractory to lipid-lowering drug therapy. However, a paucity of evidence has meant that detailed guidance on the extent of cholesterol reduction required to prevent the onset or progression of cardiovascular disease in these high risk patients is lacking. This review defines criteria for expressing the efficacy of apheresis, proposes target levels of total and LDL cholesterol for homozygotes and heterozygotes based on recent follow-up studies and suggests a scheme for monitoring cardiovascular disease in these patients. Establishing a uniform approach to data collection would facilitate the setting up of national or multi-national registers and might eventually provide the information needed to formulate evidence-based guidelines for LDL apheresis.

The measurement and management of cholesterol levels are essential to reduce the risk of developing heart disease. Nursing staff play a key role in the detection and treatment of high cholesterol levels and the promotion of good nutritional health. This article focuses on the process of and rationale for cholesterol testing.