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Despite significant progress in cardiovascular pharmacotherapy and interventional strategies, cardiovascular disease (CVD), in particular ischaemic heart disease, remains the leading cause of morbidity and mortality among women in the UK and worldwide. Women are underdiagnosed, undertreated and under-represented in clinical trials directed at management strategies for CVD, making their results less applicable to this subset. Women have additional sex-specific risk factors that put them at higher risk of future cardiovascular events. Psychosocial risk factors, socioeconomic deprivation and environmental factors have an augmented impact on women's cardiovascular health, highlighting the need for a holistic approach to care that considers risk factors specifically related to female biology alongside the traditional risk factors. Importantly, in the UK, even in the context of a National Health Service, there exist significant regional variations in age-standardised mortality rates among patients with CVD. Given most CVDs are preventable, concerted efforts are necessary to address the unmet needs and ensure parity of care for women with CVD. The present consensus document, put together by the British Cardiovascular Society (BCS)'s affiliated societies, specifically portrays the current status on the sex-related differences in the diagnosis and treatment of each of the major CVD areas and proposes strategies to overcome the barriers in accessing diagnoses and treatments among women. This document aims at raising awareness of the scale of the current problem and hopes to stimulate a multifaceted approach to address sex disparities and enable future comprehensive sex- and gender-based research through collaboration across different affiliated societies within the BCS., Competing Interests: Competing interests: VK is an associate editor for Heart BMJ and is NIHR National Cardiovascular Research Lead, Research Delivery Network., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Echocardiography is recommended as a first-line tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. The aims of this work were to evaluate the utilisation of echocardiography in patients presenting to critical care with shock, its impact on decision making, and adherence to governance guidelines., Methods: We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom (UK) and Crown Dependencies, led by the UK's Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 h to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making., Results: 1015 patients with shock were included. An echocardiogram was performed on 545 (54%) patients within 72 h and 436 (43%) within 24 h of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive or cardiogenic shock had their management altered numerically more often by echocardiography (n = 15 [75%] and n = 100 [58%] respectively). Twenty-five percent of echocardiograms performed adhered to current national governance and image storage guidance., Conclusion: Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Ultra-endurance sports and exercise events are becoming increasingly popular for older age groups. We aimed to evaluate changes in cardiac function and physical fitness in males aged 50-60 years who completed a 50-day transoceanic rowing challenge. This case account of four self-selected males included electro- and echo-cardiography (ECG, echo), cardiorespiratory and muscular fitness measures recorded nine months prior to and three weeks after a transatlantic team-rowing challenge. No clinically significant changes to myocardial function were found over the course of the study. The training and race created expected functional changes to left ventricular and atrial function; the former associated with training, the latter likely due to dehydration, both resolving towards baseline within three weeks post-event. From race-start to finish all rowers lost 8.4-15.6 kg of body mass. Absolute cardiorespiratory power and muscular strength were lower three weeks post-race compared to pre-race, but cardiorespiratory exercise economy improved in this same period. A structured program of moderate-vigorous aerobic endurance and muscular training for>6 months, followed by 50-days of transoceanic rowing in older males proved not to cause any observable acute or potential long-term risks to cardiovascular health. Pre-event screening, fitness testing, and appropriate training is recommended, especially in older participants where age itself is an increasingly significant risk factor., Competing Interests: The authors declare that they have no conflict of interest, (Thieme. All rights reserved.)

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice., (© 2022. The Author(s).)

The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately., (© 2020. The British Society of Echocardiography.)

This article sets out a summary of standards for departmental accreditation set by the British Society of Echocardiography (BSE) Departmental Accreditation Committee. Full accreditation standards are available at www.bsecho.org. The BSE were the first national organisation to establish a quality standards framework for departments that support the practice of individual echocardiographers. This is an updated version which recognises that, not only should all echocardiographers be individually accredited as competent to practice, but that departments also need to be well organised and have the facilities, equipment and processes to ensure the services they deliver are of an appropriate clinical standard. In combination with individual accreditation, departmental accreditation lays down standards to help ensure safe and effective patient care. These standards supersede the 2012 BSE Departmental Accreditation Standards. Standards are set to cover all potential areas of practice, including transthoracic (level 2) echocardiography, transoesophageal echocardiography, stress echocardiography, training, and emergency (level 1) echocardiography. The emergency echocardiography standard is a new addition to departmental accreditation and has been developed with input from the Intensive Care Society., (© 2020 The British Society of Echocardiography.)

Background Quality assurance (QA) of echocardiographic studies is vital to ensure that clinicians can act on findings of high quality to deliver excellent patient care. To date, there is a paucity of published guidance on how to perform this QA. The British Society of Echocardiography (BSE) has previously produced an Echocardiography Quality Framework (EQF) to assist departments with their QA processes. This article expands on the EQF with a structured yet versatile approach on how to analyse echocardiographic departments to ensure high-quality standards are met. In addition, a process is detailed for departments that are seeking to demonstrate to external bodies adherence to a robust QA process. Methods The EQF consists of four domains. These include assessment of Echo Quality (including study acquisition and report generation); Reproducibility & Consistency (including analysis of individual variability when compared to the group and focused clinical audit), Education & Training (for all providers and service users) and Customer & Staff Satisfaction (of both service users and patients/their carers). Examples of what could be done in each of these areas are presented. Furthermore, evidence of participation in each domain is categorised against a red, amber or green rating: with an amber or green rating signifying that a quantifiable level of engagement in that aspect of QA has been achieved. Conclusion The proposed EQF is a powerful tool that focuses the limited time available for departmental QA on areas of practice where a change in patient experience or outcome is most likely to occur.

Objectives: The aim of this study was to assess the potential benefits of inorganic nitrite in 2 clinical models: stress-induced myocardial ischemia and whole-arm ischemia-reperfusion., Background: Inorganic nitrite, traditionally considered a relatively inert metabolite of nitric oxide, may exert vasomodulatory and vasoprotective effects. Despite promising results from animal models, few have shown effectiveness in human model systems, and none have fully translated to the clinical setting., Methods: In 10 patients with inducible myocardial ischemia, saline and low-dose sodium nitrite (NaNO₂) (1.5 μmol/min for 20 min) were administered in a double-blind fashion during dobutamine stress echocardiography, at separate visits and in a random order; long-axis myocardial function was quantified by peak systolic velocity (Vs) and strain rate (SR) responses. In 19 healthy subjects, flow-mediated dilation was assessed before and after whole-arm ischemia-reperfusion; nitrite was given before ischemia or during reperfusion., Results: Comparing saline and nitrite infusions, Vs and SR at peak dobutamine increased in regions exhibiting ischemia (Vs from 9.5 ± 0.5 cm/s to 12.4 ± 0.6 cm/s, SR from -2.0 ± 0.2 s(-1) to -2.8 ± 0.3 s(-1)), whereas they did not change in normally functioning regions (Vs from 12.6 ± 0.4 cm/s to 12.6 ± 0.6 cm/s, SR from -2.6 ± 0.3 s(-1) to -2.3 ± 0.1 s(-1)) (p < 0.001, analysis of variance). With NaNO2, the increment of Vs (normalized for increase in heart rate) increased only in poorly functioning myocardial regions (+122%, p < 0.001). Peak flow-mediated dilation decreased by 43% after ischemia-reperfusion when subjects received only saline (6.8 ± 0.7% vs. 3.9 ± 0.7%, p < 0.01); administration of NaNO2 before ischemia prevented this decrease in flow-mediated dilation (5.9 ± 0.7% vs. 5.2 ± 0.5%, p = NS), whereas administration during reperfusion did not., Conclusions: Low-dose NaNO₂ improves functional responses in ischemic myocardium but has no effect on normal regions. Low-dose NaNO₂ protects against vascular ischemia-reperfusion injury only when it is given before the onset of ischemia., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Myocardial acceleration during isovolumic contraction (IVA) has been validated as a relatively load-insensitive noninvasive index of contractility. Its feasibility, reproducibility, and variation between segments have not been studied in detail, and thus its utility in clinical practice has not been established., Methods: We analyzed myocardial velocity loops (median frame rate 182 s(-1)) from 20 young volunteers (10 men, aged 25.7 +/- 2.9 years), 20 patients with type 2 diabetes (14 men, aged 64.1 +/- 8.5 years), and 20 patients with heart failure (17 men, aged 64.6 +/- 7.7 years). Long-axis IVA was measured in all walls at the annulus and in basal and mid-ventricular segments. Intraobserver reproducibility for 1 observer in all subjects and interobserver reproducibility among 3 observers in 10 subjects from each group were assessed., Results: In control subjects, subjects with diabetes, and subjects with heart failure, the feasibility of measuring IVA was 97%, 89%, and 82%, respectively; intraobserver reproducibility was 12%, 18%, and 30%, respectively (pooled coefficients of variation); and mean interobserver reproducibility was 23%, 21%, and 28%, respectively. IVA was lower in the mid-ventricular segments by 24% to 43% compared with the annulus, and IVA was higher in the right than the left ventricle (P < .001). IVA of the medial mitral annulus discriminated those with heart failure from those with diabetes and controls, and had acceptable intraobserver reproducibility across groups (mean coefficient of variation 13%)., Conclusion: IVA may be used as a research tool if it is measured at the medial mitral annulus, but its clinical applicability is hampered by low reproducibility, especially in patients with impaired left ventricular function in whom it would otherwise be most useful., (Copyright 2010 American Society of Echocardiography. All rights reserved.)

Inorganic nitrite has recently been recognized to possess vascular activity that is enhanced in hypoxia. This has been demonstrated in humans in the forearm vascular bed. In animal models nitrite reduces pulmonary vascular resistance, but its effects upon the pulmonary circulation of humans have not yet been demonstrated. This paradigm is of particular interest mechanistically since the pulmonary vasculature is known to behave differently to the systemic. To investigate, 18 healthy volunteers were studied in a hypoxic chamber (inspired oxygen, 12%) or while breathing room air. Each received an infusion of sodium nitrite (1 micromol/min) or 0.9% saline. Three protocols were performed: nitrite/hypoxia (n = 12), saline/hypoxia (n = 6), and nitrite/normoxia (n = 6). Venous blood was sampled for plasma nitrite, forearm blood flow was measured by strain-gauge plethysmography, and pulmonary arterial pressure was measured by transthoracic echocardiography. Plasma nitrite doubled and clearance kinetics were similar whether nitrite was infused in hypoxia or normoxia. During hypoxia, nitrite increased forearm blood flow (+36%, P < 0.001) and reduced three separate indirect indexes of pulmonary arterial pressure by 16%, 12%, and 17% (P < 0.01). Pulmonary, but not systemic, arterial effects persisted 1 h after stopping the infusion, at a time when plasma nitrite had returned to baseline. No effects were observed during normoxia. Therefore, in hypoxic but not normoxic subjects, sodium nitrite causes arterial and pulmonary vasodilatation. In addition, hypoxia-induced pulmonary vasoconstriction was attenuated for a prolonged period and not dependent on a simultaneous elevation of plasma nitrite. This finding is consistent with the direct extravascular metabolism of nitrite to nitric oxide to effect hypoxia-associated bioactivity.

This study uses an organ chamber bioactivity assay to characterise the direct effect of sodium nitrite upon rabbit blood vessels (aorta (Ao), inferior vena cava (IVC) and pulmonary artery (PA)) in a haemoglobin independent/variable oxygen environment. In 95% oxygen constriction to 8g (Ao), 6g (PA) and 4g (IVC) was achieved using 1 microM phenylephrine. The same constriction in 1% oxygen required 3 microM. During 95% oxygen constriction was consistent and sustained for all vessels. However under 1% oxygen PA was quick to constrict but rapidly gave up this tension whereas Ao was slower to constrict but exhibited a more sustained response. Relaxation of each vessel was assessed post constriction using 10 microM sodium nitrite. Results were expressed as a percentage loss in tension compared to the maximum achieved and corrected by controls which received no nitrite. At 95% oxygen PA relaxed greater than Ao (10.04% +/- 2.28% vs. 5.25% +/- 1.51%). IVC response was varied (2.26% +/- 9.43%). At 1% oxygen all vessels relaxed more. However the pattern was reversed with both IVC (14.20% +/- 3.63%) and PA (16.55% +/- 0.93%) relaxing less than Ao (42.20% +/- 5.21%). These results suggest that relatively low concentrations of sodium nitrite can vasodilate blood vessels. This effect is independent of haemoglobin and tissue specific.

A plethora of publications on techniques and methodologies for measuring nitric oxide (NO) or reaction products of NO (NO metabolites) has served in recent years to complicate and confuse the majority of researchers interested in this field. Here, we provide a practical approach and summarize the key issues and corresponding solutions regarding quantification with the use of ozone-based chemiluminescence, which is the most accurate, sensitive, and widely used NO detection method. We have drawn on the vast experience of leaders in the field to produce this consensus, but the views and implications presented herein represent our own, and we limit our advice to those techniques with which we have direct experience. Hopefully, this guide will allow authors to make more informed decisions regarding NO metabolite measurement methodology, without the need for each subsequent group to rediscover previously observed advantages and pitfalls.

Objective: To compare ethnic Tibetan children with Han Chinese migrants for signs of right ventricular strain using electrocardiography (ECG) that would suggest chronic hypoxia at altitudes of 3500 to 4500 m above sea level., Methods: One hundred thirty-five asymptomatic school children aged 7 to 12 years were assessed for height, weight, and blood pressure and underwent a single ECG at 2 centers at 3500 and 4500 m. A questionnaire was given to parents to provide demographic data with relevant medical history., Results: There was a high prevalence of right ventricular strain on ECG for both Tibetan and Han children (33%) with no significant difference between the 2 ethnic groups or sexes., Conclusions: Other studies showing higher observed rates of symptomatic chronic altitude sickness in Han Chinese children suggest that other extracardiologic factors play a role in the pathogenesis of the disease.