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October 2021 Br J Cardiol 2021;28(4) doi: 10.5837/bjc.2021.043 Online First

Pain during cardiac implantable electronic device implantation

David G Wilson, Nicki Brewster, Robin J Taylor, Amelia Trevelyan, Michail Apostolakis, Deepak Goyal, Will Foster, Elaine Walklet, Eleanor Bradley

Abstract

In order to evaluate the extent and causes of pain during cardiac implantable electronic device (CIED) implantation in our hospital, a prospective audit over a 23-month period using a patient self-reporting questionnaire was undertaken.

In total, 599 procedures were reported, 52.9% for de novo pacemaker implantation and 23.4% for high-energy devices (cardiac resynchronisation therapy defibrillator [CRT-D], implantable cardiac defibrillator [ICD], subcutaneous ICD). Overall, the median pain score was 2/10 (interquartile range 2–4). In total, 61.6% (367/599) reported no pain or mild pain (pain scores 0–3/10), 27.7% (165/599) reported moderate pain (pain score of 4–6/10) and 10.7% (64/599) reported severe pain (pain score of 7–10/10) during the procedure. Significant pre-implant worry (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.22 to 3.73) and higher lidocaine doses (OR 1.06, 95%CI 1.00 to 1.11) were associated with severe patient-reported pain.

In conclusion, most patients underwent CIED implantation with minimum stress and maximum comfort. An important minority reported severe pain during the procedure. Optimising surgical technique and interventions targeted at reducing pre- and peri-implant worry, particularly in women, and especially in those receiving ICDs, warrants further investigation to reduce patient-reported pain during CIED implantation.

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October 2021 Br J Cardiol 2021;28(4) doi: 10.5837/bjc.2021.044 Online First

Analysis of the trend in community prescribing of RAAS inhibitors during the COVID-19 pandemic

Layla Guscoth, Sam Hodgson

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has sparked novel research and insights, but also concerns and anxiety regarding established practices. Early into the pandemic, public and scientific concern was raised regarding the role of renin–angiotensin–aldosterone system (RAAS) inhibitors on the susceptibility to COVID-19 given their effect on angiotensin-converting enzyme 2 (ACE-2), the host receptor for the virus. This gathered media attention globally, despite several health boards encouraging the ongoing use of these medications. We aimed to investigate whether, despite advice supporting continued use of these medications, there was a change in prescribing practices for RAAS inhibitors in general practice. Data were collated from the NHS digital platform, which provides monthly practice-level prescribing information for all primary care practices in England. We performed an interrupted time-series analysis on national-level prescribing data comparing time-series coefficients pre- and post-March 2020 with metformin used as a control. We find that from March to December 2020, prescribing rates of RAAS inhibitors were reduced relative to the previous time-series trend. This finding persisted after adjustment for rates of metformin prescription. This suggests that there was a change in prescribing behaviour during the COVID-19 pandemic, which may be linked to the public and scientific concerns during this time.

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October 2021 Br J Cardiol 2021;28(4) doi: 10.5837/bjc.2021.046 Online First

Funny Auckland Skyline New Zealand Tee Cartoon Sketch Long Sleev

Mohamed Daoub, Philippa Cawley, Jonathan Sahu

Abstract

Loperamide is an over-the-counter, peripherally-acting, µ-opioid receptor agonist commonly used in the treatment of diarrhoea. It has increasingly been recognised as a potential drug of misuse, having previously been thought to have low potential for abuse owing to its low bioavailability and poor penetration of the central nervous system. High doses can result in life-threatening cardiac-toxicity.

We present a case of a young woman who had been self-treating her depression with high doses of loperamide for one year, who then presented to hospital with syncope secondary to ventricular tachycardia (VT). While in the emergency department (ED) the patient had monomorphic pulseless VT requiring electrical cardioversion multiple times. Transfer to a tertiary cardiac centre was immediately arranged after she was stabilised and intubated. This complicated the diagnostic process as a thorough history could not be obtained on arrival to the tertiary centre, which meant the loperamide misuse only came to light multiple days into admission, after the patient was extubated. The final diagnosis of loperamide-induced secondary long-QT syndrome was made and the patient made a full recovery.

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September 2021 Br J Cardiol 2021;28:89–94 doi: 10.5837/bjc.2021.037

Real-life outcomes and readmissions after a TAVI procedure in a Glasgow population

Joanna Osmanska, David Murdoch

Abstract

Transcatheter aortic valve implantation (TAVI) is a routine procedure for patients with symptomatic severe aortic stenosis who are deemed inoperable or high-risk surgical candidates. The aim of this study was to examine real-world data on death and readmission rates in patients following the procedure.

Electronic health records for patients who underwent TAVI between April 2015 and November 2018 were reviewed. Details of the procedure, complications, length of initial hospital stay and outcomes of interest (subsequent admissions and mortality) were recorded.

In our cohort of 124 patients, the mean age was 80.8 years and 43% were male. Cardiac comorbidities were common, more than 30% had myocardial infarction (MI) and 15% had a previous coronary artery bypass graft (CABG). One in five suffered from chronic obstructive pulmonary disease (COPD), with similar prevalence of diabetes mellitus and cerebrovascular accident (CVA). In-hospital mortality was low at 3.3%, however, 30-day readmission rates were high at 14.6%; 44.4% were readmitted to hospital within one year.

TAVI is a successful procedure in Scotland with good outcome data. The potential benefit of the procedure in many patients is limited by comorbidities, which shorten life-expectancy and lead to hospital readmission. These data highlight the importance of effective multi-disciplinary discussion in a time of realistic medicine.

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September 2021 Br J Cardiol 2021;28:98–101 doi: 10.5837/bjc.2021.038

Outpatient parenteral antimicrobial therapy (OPAT) service is associated with inpatient-bed cost savings

Chun Shing Kwok, Joanna J Whittaker, Caroline Malbon, Barbara White, Jonathan Snape, Vikki Lloyd, Farah Yazdani, Timothy Kemp, Simon Duckett

Abstract

In a cardiology department, there are some patients that require long-term antibiotics, such as those with infective endocarditis or infected prosthetic devices. We describe our experience with intravenous antibiotic therapy for patients with cardiology diagnoses who require a period of antibiotics in our outpatient service during the period of the COVID-19 pandemic. A total of 15 patients were selected to have outpatient antibiotic therapy (age range 36 to 97 years, 60% male). A total of nine patients had infective endocarditis, four patients had infected valve prosthesis or transcatheter aortic valve implantation (TAVI) endocarditis, one patient had infected pericardial effusion while another had infected pericarditis. For these 15 patients there was a total of 333 hospital bed-days, on average 22 days per patient. These patients also had a total of 312 days of outpatient antibiotic therapy, which was an average of 21 days per patient. The total cost, if patients were admitted for those days, assuming a night cost £400, was £124,800, which was on average £8,320 per patient. Three patients were readmitted within 30 days. One had ongoing endocarditis that was managed medically and another had pulmonary embolism. The last patient had a side effect related to daptomycin use. In conclusion, outpatient antibiotic therapy in selected patients with native or prosthetic infective endocarditis appears to be safe for a selected group of patients with associated cost savings.

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