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Ambulatory electrocardiogram (AECG) monitoring is a common cardiovascular investigation. Traditionally, this requires a face-to-face appointment. In order to reduce contact during the COVID-19 pandemic, we investigated whether drive-by collection and self-fitting of the device by the patient represents an acceptable alternative. A prospective, observational study of consecutive patients requiring AECG monitoring over a period of one month at three hospitals was performed. Half underwent standard (face-to-face) fitting, and half attended a drive-by service to collect their monitor, fitting their device at home. Outcome measures were quality of the recordings (determined as good, acceptable or poor), and patient satisfaction. A total of 375 patients were included (192 face-to-face, 183 drive-by). Mean patient age was similar between the two groups. The quality of the AECG recordings was similar in both groups (52.6% good in face-to-face vs. 53.0% in drive-by; 34.9% acceptable in face-to-face vs. 32.2% in drive-by; 12.5% poor in face-to-face vs. 14.8% in drive-by; Chi-square statistic 0.55, p=0.76). Patient satisfaction rates were high, with all patients in both groups satisfied with the care they received. In conclusion, drive-by collection and self-fitting of AECG monitoring yields similar AECG quality to conventional face-to-face fitting, with high levels of patient satisfaction.

Infective endocarditis is a rare but deadly disease, with a highly variable presentation. The clinical manifestations of the condition are often multisystemic, ranging from dermatological to ophthalmic, and cardiovascular to renal. Thus, patients with infective endocarditis may first present to the acute or general physician, who may have a variable knowledge of the condition. The diagnosis of infective endocarditis can be challenging, relying on clinical, imaging and microbiological features. Recent decades have seen a transformation in the epidemiology and microbiology of infective endocarditis and yet, despite advances in diagnostics and therapeutics, mortality rates remain high. This review outlines the emerging studies and guidelines on the assessment and management of infective endocarditis, focusing on the evolving epidemiology of the condition, the role of new imaging modalities, updated diagnostic criteria, the latest on antimicrobial and surgical management, and the role of a multidisciplinary approach in the management of patients with infective endocarditis.

In 2021 the National Institute for Health and Care Excellence updated its guidance for diagnosing and managing atrial fibrillation. This editorial summarises the key changes made in these guidelines and discusses their implementation in UK clinical practice.

The current management of acute coronary syndromes (ACS) is with an invasive strategy to guide treatment. However, identifying the lesions which are physiologically significant can be challenging. Non-invasive imaging is generally not appropriate or timely in the acute setting, so the decision is generally based upon visual assessment of the angiogram, supplemented in a small minority by invasive pressure wire studies using fractional flow reserve (FFR) or related indices. Whilst pressure wire usage is slowly increasing, it is not feasible in many vessels, patients and situations. Limited evidence for the use of FFR in non-ST elevation (NSTE) ACS suggests a 25% change in management, compared with traditional assessment, with a shift from more to less extensive revascularisation. Virtual (computed) FFR (vFFR), which uses a 3D model of the coronary arteries constructed from the invasive angiogram, and application of the physical laws of fluid flow, has the potential to be used more widely in this situation. It is less invasive, fast and can be integrated into catheter laboratory software. For severe lesions, or mild disease, it is probably not required, but it could improve the management of moderate disease in 'real time' for patients with non-ST elevation acute coronary syndromes (NSTE-ACS), and in bystander disease in ST elevation myocardial infarction. Its practicability and impact in the acute setting need to be tested, but the underpinning science and potential benefits for rapid and streamlined decision-making are enticing.

•In view of his advanced age and risk factors, Santa Claus is at high risk of developing atrial fibrillation. Despite this, no guidelines exist on the subject. •Following a review of the literature, we present our position on the management of atrial fibrillation in Santa Claus, and propose the use of the SANTA CLAUS mnemonic to aid clinicians: Screen for atrial fibrillation; Anticoagulate; Normalise heart rate; Treat comorbidities; Anti-arrhythmic drugs; Cardioversion; Lifestyle measures; Ablation treatment; Understand emotional and psychological impact; Save Santa Claus.

Introduction In patients with heart failure with reduced ejection fraction (HFrEF), a raised serum parathyroid hormone (PTH) level is associated with increased morbidity and mortality. Previous studies suggest that PTH levels correlate with peak VO2 and markers of endothelial dysfunction in HFrEF. We examined the role of PTH in the pathophysiological difference between response and non-response to cardiac resynchronisation therapy (CRT) in HFrEF. Methods All patients met National Institute for Health and Care Excellence criteria for CRT implantation and were prospectively recruited from a single centre. A positive response to CRT was defined as an improvement in all four of the following domains: 1) a greater than 1ml/kg/min increase in peak VO2; 2) a 10% reduction in left ventricular end-systolic volume (LVESV); 3) a 10% reduction in symptoms as measured by the Minnesota living with heart failure questionnaire (MLWHFQ); 4); over 10% increase in 6 minute walk distance (6MWD). PTH levels were measured at baseline and at 6 months following CRT. Percentage change in PTH level was calculated as (6 month PTH level – baseline PTH level)/(baseline PTH level). Data are presented as mean ± standard error of the mean. Analyses were performed using IBM SPSS version 24. Paired continuous data were compared with paired t test; unpaired continuous data with independent sample t test. Tests were 2-tailed. p Results A total of 19 patients were studied (9 responders, 10 non-responders; 95% male, age 70 ± 1.9 years). At baseline, there was no significant difference in estimated glomerular filtration rate (64.1 ± 3.2 ml/min/1.73m2 in responders, 58.3 ± 3.9 ml/min/1.73m2 in non-responders; p=0.27), corrected serum calcium level (2.31 ± 0.02 mg/dL in responders, 2.36 ± 0.02 mg/dL in non-responders; p=0.13), or serum 25-hydroxy vitamin D levels (56.5 ± 6.8 ng/mL in responders and 45.1 ± 12 ng/mL in non-responders; p=0.44) in between the two groups. At baseline, PTH levels in responders were 85.4 ± 9.9 pg/mL, compared to 63.4 ± 9.8 pg/mL in non-responders (p=0.06). At 6 months, PTH levels in responders were 72.3 ± 11.5 pg/mL, compared to 87.8 ± 10.7 pg/mL in non-responders (p=0.2). There was a significant difference in the percentage change in PTH levels between responders (an average reduction of 16 ± 3.6 %) and non-responders (an average increase of 38 ± 3.4 %) (p=0.002) (figure 1A). All responders had a decrease in serum PTH level at 6 months, whereas 8 out of 10 non-responders had an increase in serum PTH levels at 6 months (figure 1B). Conclusion This small, single-centre study suggests that a positive response to CRT is associated with a reduction in serum PTH levels at 6 months following the procedure. Conversely, non-response to CRT is generally characterised by an increase in PTH levels at 6 months. The pathophysiological role of PTH in CRT response warrants further investigation. Conflict of Interest Nil.

Background: Four-dimensional (4D) flow cardiovascular magnetic resonance imaging (MRI) is an emerging technique used for intra-cardiac blood flow assessment. The role of 4D flow cardiovascular MRI in the assessment of trans-valvular flow in patients with atrial fibrillation (AF) has not previously been assessed. The purpose of this study was to assess the feasibility, image quality, and internal validity of 4D flow cardiovascular MRI in the quantification of trans-valvular flow in patients with AF. Methods: Patients with AF and healthy controls in sinus rhythm underwent cardiovascular MRI, including 4D flow studies. Quality assurance checks were done on the raw data and streamlines. Consistency was investigated by trans-valvular flow assessment between the mitral valve (MV) and the aortic valve (AV). Results: Eight patients with AF (88% male, mean age 62±13 years, mean heart rate (HR) 83±16 beats per minute (bpm)) were included and compared with ten healthy controls (70% male, mean age 41±20 years, mean HR 68.5±9 bpm). All scans were of either good quality with minimal blurring artefacts, or excellent quality with no artefacts. No significant bias was observed between the AV and MV stroke volumes in either healthy controls (–4.8, 95% CI –15.64 to 6.04; P=0.34) or in patients with AF (1.64, 95% CI –4.7 to 7.94; P=0.56). A significant correlation was demonstrated between MV and AV stroke volumes in both healthy controls (r=0.87, 95% CI 0.52 to 0.97; P=0.001) and in AF patients (r=0.82, 95% CI 0.26 to 0.97; P=0.01). Conclusions: In patients with AF, 4D flow cardiovascular MRI is feasible with good image quality, allowing for quantification of trans-valvular flow.

Background Cardiac involvement in Anderson–Fabry disease (AFD) can lead to arrhythmia, including ventricular tachycardia (VT). The literature on radiofrequency ablation (RFA) for the treatment of VT in AFD disease is limited. Case summary We discuss RFA of drug-refractory VT electrical storm in three males with AFD. The first patient (53 years old) had extensive involvement of the inferolateral left ventricle (LV) demonstrated with cardiac magnetic resonance imaging (CMRI), with a left ventricular ejection fraction (LVEF) of 35%. Two VT ablation procedures were performed. At the first procedure, the inferobasal endocardial LV was ablated. Furthermore, VT prompted a second ablation, where epicardial and endocardial sites were ablated. The acute arrhythmia burden was controlled but he died 4 months later despite appropriate implantable cardioverter-defibrillator therapies for VT. The second patient (67 years old) had full-thickness inferolateral involvement demonstrated with CMRI and LVEF of 45%. RFA of several endocardial left ventricular sites was performed. Over a 3-year follow-up, only brief non-sustained VT was identified, but he subsequently died of cardiac failure. Our third patient (69 years old), had an LVEF of 35%. He had RFA of endocardial left ventricular apical disease, but died 3 weeks later of cardiac failure. Discussion RFA of drug-refractory VT in AFD is feasible using standard electrophysiological mapping and ablation techniques, although the added clinical benefit is of questionable value. VT storm in the context of AFD may be a marker of end-stage disease.

Background Coronary microvascular dysfunction (CMD) is defined by diminished flow reserve. Functional and structural CMD endotypes have recently been described, with normal and elevated minimal microvascular resistance, respectively. Objectives This study determined the mechanism of altered resting and maximal flow in CMD endotypes. Methods A total of 86 patients with angina but no obstructive coronary disease underwent coronary pressure and flow measurement during rest, exercise, and adenosine-mediated hyperemia and were classified as the reference group or as patients with CMD by a coronary flow reserve threshold of 2.5; functional or structural endotypes were distinguished by a hyperemic microvascular resistance threshold of 2.5 mm Hg/cm/s. Endothelial function was assessed by forearm blood flow (FBF) response to acetylcholine, and nitric oxide synthase (NOS) activity was defined as the inverse of FBF reserve to NG-monomethyl-L-arginine. Results Of the 86 patients, 46 had CMD (28 functional, 18 structural), and 40 patients formed the reference group. Resting coronary blood flow (CBF) (24.6 ± 2.0 cm/s vs. 16.6 ± 3.9 cm/s vs. 15.1 ± 4.7 cm/s; p, Central Illustration

Patients with atrial fibrillation necessitating anticoagulation frequently develop concomitant stable coronary artery disease requiring antiplatelet therapy and vice versa. The optimal choice of antithrombotic therapy in this cohort has been unclear. Which therapy is most effective at reducing mortality and thrombotic events while avoiding a disproportionate increase in bleeding risk? ### EBM verdict EBM Verdict on: Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med 2019;381:1103-–1113. doi: 10.1056/NEJMoa1904143. In patients with atrial fibrillation and stable coronary artery disease, monotherapy with rivaroxaban is non-inferior to combination therapy with rivaroxaban and an antiplatelet in terms of preventing death and cardiovascular events. Rivaroxaban monotherapy is associated with less major bleeding. In patients with atrial fibrillation (AF) who have recently undergone percutaneous coronary intervention (PCI) and have a high ischaemic risk, current guidelines recommend triple therapy (with aspirin, a P2Y12 inhibitor and an oral anticoagulant (OAC)) for the shortest duration possible after PCI.1 Following this, combination therapy with an OAC and a P2Y12 inhibitor is recommended for up to a year, …

ObjectivesA number of randomised control trials (RCTs) investigating the effects of long-acting somatostatin analogues in autosomal dominant polycystic kidney disease (ADPKD) and polycystic liver disease (PLD) have been recently reported. We sought to evaluate all available RCTs investigating the efficacy of somatostatin analogues treatment in ADPKD and PLD.Data sourcesElectronic databases; Pubmed, Clincaltrials.gov and Cochrane Central Register of Controlled TrialsEligibility criteria for selecting studiesRCTs and randomised cross-over trials comparing the effects of somatostatin analogue treatment with controls in patients with ADPKD or PLD.Data extraction and synthesisData extraction and bias assessments were performed by two independent reviewers between January and May 2019. Outcomes assessed included estimated glomerular filtration rate (eGFR), total kidney volume (TKV), total liver volume (TLV), progression to end stage renal failure (ESRF) and adverse effects. Data were pooled using a random-effects model and reported as relative risk or mean difference with 95% CIs.ResultsMeta-analysis was performed of six RCTs or randomised cross-over trials and three secondary analyses. A total of 592 patients were included. Compared with controls, somatostatin analogue treatment significantly reduced TLV (mean difference −0.15 L, 95% CI −0.26 to −0.03, p=0.01). There was no significant effect on TKV (mean difference −0.19 L, 95% CI −0.50 to 0.12, p=0.23) or eGFR (mean difference 0.27 mL/min/1.73 m2, 95% CI −2.03 to 2.57, p=0.82). There was no effect on progression to ESRF. Somatostatin analogues were associated with known adverse effects such as gastrointestinal symptoms.ConclusionsThe available RCT data show improvement in TLV with somatostatin analogue treatment. There was no benefit to TKV or eGFR in patients with ADPKD, while being associated with various side effects. Further studies are needed to assess potential benefit in reducing cyst burden in patients with PLD.

​Patients with end-stage renal disease on dialysis are at a high risk of sudden cardiac death (SCD). The Implantable Cardioverter-Defibrillator in Dialysis Patients (ICD-2) trial studied the role of the primary prevention ICD in preventing death in dialysis patients with a left ventricular ejection fraction (LVEF) ≥35%. Compared with the general population, annual mortality rates are over 10-fold higher in patients with end-stage renal disease undergoing dialysis.1 A large proportion of deaths in dialysis patients are attributed to SCD.2 The annual incidence of SCD in haemodialysis patients is between 5% and 7%, compared with 4% in patients with heart failure, and 1.5%–2.7% in patients with chronic kidney disease not requiring dialysis.2 The increased risk of SCD is ascribed to a combination of proarrhythmogenic factors, including dialysis-induced haemodynamic stress and myocardial ischaemia, electrolyte and fluid shifts, left ventricular hypertrophy and fibrosis, and autonomic dysregulation.2 3 A number of clinical trials have previously identified groups of patients at high risk of SCD who gain a mortality benefit from the insertion of an …

Introduction Exercise-based cardiac rehabilitation is an established intervention in the management of several cardiovascular conditions, including ischaemic heart disease and heart failure. There is increasing recognition for the role of exercise-based cardiac rehabilitation in the management of patients with atrial fibrillation (AF); however, this has not yet been widely adopted within the National Health Service (NHS). We assessed the feasibility of utilising an established NHS cardiac rehabilitation programme in the management of AF, and examined the effects of this intervention on exercise capacity, weight, and psychological health. Methods Patients with AF were invited to participate in an established 6-week cardiac rehabilitation programme, composed of physical activity and education sessions, organised through Sheffield Teaching Hospitals NHS Foundation Trust, between April 2016 to July 2018. At the start of the programme, patients were weighed and measured, performed the 6-minute walk test (6MWT), completed the Generalised Anxiety Disorder Questionnaire (GAD-7; scoring 0–21, higher scores indicating higher anxiety levels), and the Patient Health Questionnaire (PHQ-9; scoring 0–27, higher scores indicating higher depression levels). Measurements were repeated on completion. Analyses were performed using IBM SPSS (24). Continuous variables expressed as mean ± SEM, and normality of distribution assessed using the Shapiro-Wilk test. Paired continuous data were compared with paired t test or Wilcoxon signed rank test, and unpaired continuous data with independent sample t test or Mann-Whitney U tests, as appropriate. Tests were 2-tailed. P Results Seventy-seven patients were invited to join the programme. Of these, 22 patients (28.5%) declined participation prior to initial assessment, whilst 22 (28.5%) accepted and attended the initial assessment, but subsequently failed to attend the programme. In total, 33 patients (43%) completed the entire programme (63.9±1.7 years, 58% female, BMI 33.9±1.3 kg/m2, mean left atrial size 5.1±0.2cm). Pertinent demographics are summarised in table 1. On completion, enrolled patients covered longer distances during the 6MWT (389.5 vs. 447.9 metres, p Conclusion Enrolling patients with AF into an established NHS cardiac rehabilitation programme is feasible, with nearly half of those invited completing the programme. This resulted in improved 6-minute walk test, and reduced anxiety and depression levels, in the short term. Severe obesity, high anxiety and depression levels, and lower initial exercise capacity may be barriers to enrolling patients with AF into exercise-based cardiac rehabilitation; a holistic approach that targets these factors may result in improved clinical outcomes. Conflict of Interest None to declare.

A 65 year-old lady with metastatic breast cancer presented with pituitary apoplexy. Following surgery, histopathology confirmed metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary. Tumours that metastasise to a normal pituitary gland are unusual. More so, such neoplasm-to-neoplasm metastasis is extremely rare. This is, as far as we are aware, the first description of a metastasis into a gonadotroph cell pituitary adenoma presenting as apoplexy.

BACKGROUND Growing evidence supports physiology-guided revascularization, with Fractional Flow Reserve (FFR) the most commonly used invasive measure of coronary blood flow impairment at the time of diagnostic angiography. Recently, there has been growing interest in stenosis severity indices measured at rest, such as Instantaneous Wave Free Ratio (iFR) and the ratio of distal coronary to aortic pressure at rest (resting Pd/Pa). Their reliability may, theoretically, be more susceptible to changes in microvascular tone and coronary flow. This study aimed to assess variability of resting coronary flow with normal catheter laboratory stimuli. METHODS Simultaneous intracoronary pressure (Pd) and Doppler Average Peak Flow Velocity (APV) recordings were made at rest and following the verbal warning preceding an intravenous adenosine infusion. RESULTS 72 patients undergoing elective angiography were recruited (mean age 62 years, 52.7% male) with a wide range of coronary artery disease severity (FFR 0.86 ± 0.09). Average peak flow velocity varied significantly between measurements at rest and just prior to commencement of adenosine, with a mean variation of 10.2% (17.82 ± 9.41 cm/s vs. 19.63 ± 10.44 cm/s, p

Background Moyamoya disease (MMD), arterial venous malformations (AVMs), and intracranial aneurysms are distinct cerebrovascular disease processes that most commonly occur in isolation. The literature on the treatment algorithm of each individual condition is well established. An association between MMD and intracranial aneurysms is also known, but MMD in association with AVM is rare. Case Descriptions The authors discuss various dilemmas in the multimodality management of these conditions when they coexist with an illustrative case of a 46-year-old woman who presented following a stroke, with 1) left-sided MMD, 2) left-sided frontal AVM, and 3) an aneurysm arising from the A1 segment of the right anterior cerebral artery. These were managed respectively by 1) the left external carotid artery to M2 segment of middle cerebral artery bypass using an autologous radial artery graft and left indirect superior temporal artery—encephaloduroarteriosynangiosis, 2) stereotactic radiosurgery, and 3) endovascular coiling of the aneurysm. Three years following intervention, cerebral angiography showed a patent bypass, complete obliteration of the AVM, and no residual filling of the coiled aneurysm. Conclusions Our strategy of surgical revascularization for MMD, radiosurgery for AVM, and endovascular coiling for aneurysm resulted in a positive long-term clinical outcome. In view of the rarity of the condition, the authors propose a management algorithm for such patients.

EBM Verdict EBM Verdict on: Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA Randomized Clinical Trial. JAMA 2019 Mar 15. doi: 10.1001/jama.2019.0693. Catheter ablation in atrial fibrillation is effective at restoring sinus rhythm. Until recently, the prognostic effects of ablation have been unknown. The recent Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation trial compared catheter ablation with medical therapy and assessed the effect on disabling stroke, death and quality of life. Atrial fibrillation (AF) is the most common cardiac rhythm disturbance, …