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Backgrounds Interventional cardiology training has a long learning curve, with potential procedural risks to patients and clinicians. We aimed to assess whether mentored simulation-based training with 3D-printed models can improve the skills of beginners in coronary diagnostic procedures in a pilot randomized trial. Methods Twenty-nine final-year medical students recruited from a single University were lectured on the fundamentals of invasive coronary angiography (ICA) for one-hour, and then randomized to conventional or simulation training. Conventional training ( n  = 15) consisted of watching a 20-minute video demonstrating ICA steps performed in a 3D-printed coronary simulator. The simulation training group ( n  = 14) were offered, in pairs, the same content in a 20-minute hands-on session using a 3D-printed simulator. The co-primary endpoint was efficacy and safety of performing a simulated ICA in the angiography suite. Efficacy and safety were graded using a 13-point procedural checklist (0-100%) and the identification of five procedural “red flags” items, respectively. The secondary endpoint was theoretical knowledge (multiple-choice test). Results All participants completed the protocol. In both components of the co-primary endpoint, the simulation group scored higher: efficacy score of 91.5 ± 3.8% vs. 64.6 ± 8.3% (mean difference 95% CI [20.8, 30.8]) and safety score 100.0% (100.0-100.0%) vs. 62.5 (20.8–79.2%) (median difference 95% CI [20.8, 79.2]), p < 0.001. The median number of “red flags” were 2 (1–4) in conventional and 0 (0–0) in simulation training ( p < 0.001). Also, simulation group obtained a higher score in the theoretical knowledge test: 85.7 ± 9.0% vs. 76.8 ± 12.7%, p = 0.039. Conclusion Mentored simulation-based training using 3D-printed simulators significantly improved theoretical knowledge and basic procedural skills of ICA. These results suggest that simulation-based training should be pursued for improving patient safety and technical proficiency. Trial registration NCT06224101. Graphical abstract Final-year medical students randomised to oficient in performing simulated invasive coronary angiography (efficacy and safety) and exhibited superior theoretical knowledge, compared to traditional teaching.

Percutaneous coronary intervention (PCI) with a drug coated balloon (DCB) is a novel treatment which seeks to acutely dilate a coronary stenosis and deliver an anti-proliferative drug to the vessel wall (reducing the risk of re-stenosis), without implanting a drug eluting stent (DES). In this study, we performed a systematic review of stentless DCB-only angioplasty in de novo coronary artery disease. We identified 41 studies examining the effects of DCB-only PCI in a variety of clinical scenarios including small vessels, bifurcations, calcified lesions, and primary PCI. DCB-only PCI appears to be associated with comparable clinical outcomes to DESs and superior angiographic outcomes to plain-old balloon angioplasty. Although current data are promising, there is still a need for further long-term randomized control trial data comparing a DCB-only approach specifically against a second- or third-generation DES. A 4-week period of dual antiplatelet therapy provides a real advantage for the DCB-only PCI approach, which is not possible with most DESs. Since rates of adverse clinical outcomes are very low for all PCI procedures attention should be turned to the development of robust endpoints with which to compare DCB-only PCI approaches to the standard treatment with a DES.

Background: Lower socioeconomic status (SES) has been associated with increased mortality from coronary heart disease. This excess risk, relative to affluent patients, may be due to a combination of more adverse cardiovascular-risk factors, inequalities in access to cardiac investigations, longer waiting times for cardiac revascularisation and lower use of secondary prevention drugs. We sought to investigate whether socio-economic status influenced long-term all-cause mortality after PCI in a large metropolitan city (London), which serves a population of 11 million people with a mixed social background over a 10-year period. Methods: We conducted an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry. This data set is collected prospectively and includes all patients treated between January 2005 and December 2015. The database includes PCI performed for stable angina and ACS (ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina). Patient socio-economic status was defined by the English Index of Multiple Deprivation (IMD) score, according to residential postcode. Patients were analysed by quintile of IMD score (Q1, least deprived; Q5, most deprived). Median follow-up was 3.7 (IQR: 2.0–5.1) years and the primary outcome was all-cause mortality. Results: The mean age of the patients was 64.3 ± 12.1 years and 25.2% were female. A total of 22.4% of patients were diabetic and 27.3% had a history of previous myocardial infarction. The rates of long-term all-cause mortality increased progressively across quintiles of IMD score, with patients in Q5 showing significantly higher long-term mortality rates compared with patients in Q1 (p = 0.0044). This persisted following the inclusion of a propensity score in the proportional hazard model as a covariate (HR for Q5 compared to Q1: 1.15 [95% CI: 1.10–1.42]). Conclusions: This study has demonstrated that low SES is an independent predictor of adverse clinical outcomes following PCI in the large, diverse metropolitan city of London. There clearly are inequalities in cardio-vascular risk factors, time to access to medical treatment/PCI, access to complex imaging and devices during PCI, access to secondary prevention after PCI, and even race differences. Hence, attention to reducing the burden of cardiovascular risk factors and improving primary prevention, particularly in patients with lower SES, is required.

The International Liaison Committee on Resuscitation has called for a randomised trial of delivery to a cardiac arrest centre. We aimed to assess whether expedited delivery to a cardiac arrest centre compared with current standard of care following resuscitated cardiac arrest reduces deaths. ARREST is a prospective, parallel, multicentre, open-label, randomised superiority trial. Patients (aged ≥18 years) with return of spontaneous circulation following out-of-hospital cardiac arrest without ST elevation were randomly assigned (1:1) at the scene of their cardiac arrest by London Ambulance Service staff using a secure online randomisation system to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centres or standard of care with delivery to the geographically closest emergency department at one of 32 hospitals in London, UK. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible. The primary outcome was all-cause mortality at 30 days, analysed in the intention-to-treat (ITT) population excluding those with unknown mortality status. Safety outcomes were analysed in the ITT population. The trial was prospectively registered with the International Standard Randomised Controlled Trials Registry, 96585404. Between Jan 15, 2018, and Dec 1, 2022, 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest centre and 431 (50%) to standard care. 20 participants withdrew from the cardiac arrest centre group and 19 from the standard care group, due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest centre group and 412 in the standard care group for the primary analysis. Of 822 participants for whom data were available, 560 (68%) were male and 262 (32%) were female. The primary endpoint of 30-day mortality occurred in 258 (63%) of 411 participants in the cardiac arrest centre group and in 258 (63%) of 412 in the standard care group (unadjusted risk ratio for survival 1·00, 95% CI 0·90–1·11; p=0·96). Eight (2%) of 414 patients in the cardiac arrest centre group and three (1%) of 413 in the standard care group had serious adverse events, none of which were deemed related to the trial intervention. In adult patients without ST elevation, transfer to a cardiac arrest centre following resuscitated cardiac arrest in the community did not reduce deaths. British Heart Foundation.

Schemes promoted in the UK for switching statins focus on discontinuation of high-cost branded statins at low to intermediate doses (mainly atorvastatin 10 mg or 20 mg) and substitution with the therapeutically equivalent simvastatin 40 mg.2 At the time of Butler and Wainwright's audit, among the ten primary-care trusts (PCTs) within the Staffordshire and Shropshire cardiac network, the annual spend on atorvastatin 10 mg or 20 mg was £8.9 million per annum, £7 million of which would be saved by switching patients to simvastatin 40 mg.

BackgroundPatients with prior coronary artery bypass grafting (CABG) account for around 10% of non-ST-elevation acute coronary syndromes (NSTE-ACS), but the optimal diagnostic and management strategy remains uncertain. Invasive coronary angiography (ICA) in this group is technically challenging, carries increased risk and often does not lead to percutaneous coronary intervention (PCI). CT coronary angiography (CTCA) may help identify which patients benefit from ICA and reduce unnecessary invasive procedures.MethodsIn the BYPASS-CTCA (Randomised Controlled Trial to Assess Whether Computed Tomography Cardiac Angiography Can Improve Invasive Coronary Angiography in Bypass Surgery Patients) study, patients with prior CABG undergoing ICA were randomised to CTCA plus ICA or ICA alone. For this analysis, anonymised case vignettes and CTCA reports from 150 patients with NSTE-ACS were independently reviewed by 50 experienced interventional cardiologists (median 17 years post-qualification; 5103 total case reviews). Agreement on management strategy before and after CTCA was assessed using Fleiss’ κ statistic.ResultsBased on clinical information alone, respondents chose medical therapy in 13.2% of cases, with poor agreement on management strategy (κ=0.14, 95% CI 0.11 to 0.17). After reviewing CTCA, agreement improved to moderate (κ=0.53, 95% CI 0.48 to 0.58; p<0.001), and medical management was selected in 39.3% (p<0.001). When invasive management was selected post-CTCA, PCI was required in 85% of cases, and a selective angiographic approach was planned in 79%.ConclusionsManagement decisions for post-CABG NSTE-ACS vary widely among experienced cardiologists. Incorporating CTCA into the diagnostic pathway substantially improves consensus, reduces unnecessary invasive angiography and enables targeted, lower-risk procedures. These findings support evaluation of a CTCA-guided strategy in a prospective randomised trial.

Lightning strikes are a common and leading cause of morbidity and mortality. Multiple organ systems can be involved, though the effects of the electrical current on the cardiovascular system are one of the main modes leading to cardiorespiratory arrest in these patients. Cardiac effects of lightning strikes can be transient or persistent, and include benign or life-threatening arrhythmias, inappropriate therapies from cardiac implantable electronic devices, cardiac ischaemia, myocardial contusion, pericardial disease, aortic injury, as well as cardiomyopathy with associated ventricular failure. Prolonged resuscitation can lead to favourable outcomes especially in young and previously healthy victims.

Background: Lower socioeconomic status (SES) has been associated with increased mortality from coronary heart disease. This excess risk, relative to affluent patients, may be due to a combination of more adverse cardiovascular-risk factors, inequalities in access to cardiac investigations, longer waiting times for cardiac revascularisation and lower use of secondary prevention drugs. We sought to investigate whether socio-economic status influenced long-term all-cause mortality after PCI in a large metropolitan city (London), which serves a population of 11 million people with a mixed social background over a 10-year period. Methods: We conducted an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry. This data set is collected prospectively and includes all patients treated between January 2005 and December 2015. The database includes PCI performed for stable angina and ACS (ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina). Patient socio-economic status was defined by the English Index of Multiple Deprivation (IMD) score, according to residential postcode. Patients were analysed by quintile of IMD score (Q1, least deprived; Q5, most deprived). Median follow-up was 3.7 (IQR: 2.0–5.1) years and the primary outcome was all-cause mortality. Results: The mean age of the patients was 64.3 ± 12.1 years and 25.2% were female. A total of 22.4% of patients were diabetic and 27.3% had a history of previous myocardial infarction. The rates of long-term all-cause mortality increased progressively across quintiles of IMD score, with patients in Q5 showing significantly higher long-term mortality rates compared with patients in Q1 (p = 0.0044). This persisted following the inclusion of a propensity score in the proportional hazard model as a covariate (HR for Q5 compared to Q1: 1.15 [95% CI: 1.10–1.42]). Conclusions: This study has demonstrated that low SES is an independent predictor of adverse clinical outcomes following PCI in the large, diverse metropolitan city of London. There clearly are inequalities in cardio-vascular risk factors, time to access to medical treatment/PCI, access to complex imaging and devices during PCI, access to secondary prevention after PCI, and even race differences. Hence, attention to reducing the burden of cardiovascular risk factors and improving primary prevention, particularly in patients with lower SES, is required.

AimTo establish the prevalence of cardiac conditions in British Army recruits in whom a murmur is detected.MethodsRecruits were screened with a standardised questionnaire and physical examination by military occupational physicians. Those with cardiac symptoms, a history suspicious for cardiac disease, or with hypertension, were referred to their civilian Primary Care Doctor for further investigation. Those recruits with an isolated murmur on auscultation underwent an ECG, echocardiogram and cardiology review in a military clinic and are the subject of this study.ResultsOver a seven year period, 11420 consecutively referred recruits aged 15-32 years (89% male) were evaluated. Significant valve disease was identified in 146 (1.28%) recruits. Bicuspid aortic valve occurred in 124 (1.09%) recruits of which 67.7% demonstrated some form of valvular dysfunction, aortopathy, coarctation of the aorta or left ventricular dysfunction.Cardiac disease was strongly suspected or diagnosed in a total of 921 recruits (positive predictive value (PPV) 8.06%). Of these recruits, 298 (32.4%) had cardiac conditions associated with an increased risk of sudden cardiac death (SCD) including 98 (10.6%) with probable cardiomyopathy; 22 (2.4%) with accessory pathways; and 30 (3.3%) with possible channelopathies (see Table 1). Males accounted for 91.9% of those with cardiac abnormalities but no significant male disease preponderance was observed (p = 0.117). The remainder of the recruits had a range of ECG and echocardiographic abnormalities not typically associated with SCD.Abstract 80 Table 1Frequency of cardiac abnormalities in the potential recruitsConditionFemales with conditionMales with conditionTotal with condition % total females% total males% of total screenedCardiomyopathies5 (5.1%)93 (94.9%)980.39%0.91%0.86%Accessory pathways3 (13.6%)19 (86.4%)220.24%0.19%0.19%Long QT Syndrome4 (15.4%22 (84.6%)260.32%0.22%0.23%Brugada Syndrome1 (25%)3 (75%)40.08%0.03%0.04%Mitral valve prolapse5 (22.7%)17 (77.3%)220.40%0.17%0.18%Bicuspid aortic valve8 (6.5%)116 (93.5%)1240.64%1.14%1.09%Anomalous origin coronary artery0 (0%)3 (100%)30%0.03%0.03%Other coronary artery abnormalities0 (0%)5 (100%)50%0.05%0.05%Individuals with one or more conditions associated with SCD24 (8.1%)274 (91.9%)2981.91%2.70%2.61%DiscussionThese results show that an isolated murmur, detected by military occupational physicians as part of a cardiac screening program, has a low PPV for the detection of significant valve disease in asymptomatic individuals. The screening program incidentally detected a larger cohort of recruits with potentially serious underlying cardiac abnormalities, resulting in deferral of military service. Most of these conditions are not classically associated with a cardiac murmur and were diagnosed from ECG or echocardiography. Without these investigations, it is unlikely they would have been detected. Therefore, the addition of routine ECG, and possibly echocardiography to the British Army cardiac screening protocol should be considered. This approach would improve the detection rate of potentially serious, non-valvular cardiac disease requiring further evaluation before military service can be approved.In military populations, cardiac conditions are a potentially preventable cause of mortality and morbidity. It is believed that individuals with these conditions can be readily identified using a standardised history and physical examination. However, there is growing evidence that addition of routine 12-lead ECG increases the sensitivity for detection of underlying cardiac abnormalities. Current guidelines on pre-participation screening in athletes recommend this approach.

AimTo establish the prevalence of cardiac conditions in British Army recruits in whom a murmur is detected.MethodsRecruits were screened with a standardised questionnaire and physical examination by military occupational physicians. Those with cardiac symptoms, a history suspicious for cardiac disease, or with hypertension, were referred to their civilian Primary Care Doctor for further investigation. Those recruits with an isolated murmur on auscultation underwent an ECG, echocardiogram and cardiology review in a military clinic and are the subject of this study.ResultsOver a seven year period, 11420 consecutively referred recruits aged 15–32 years (89% male) were evaluated. Significant valve disease was identified in 146 (1.28%) recruits. Bicuspid aortic valve occurred in 124 (1.09%) recruits of which 67.7% demonstrated some form of valvular dysfunction, aortopathy, coarctation of the aorta or left ventricular dysfunction.Cardiac disease was strongly suspected or diagnosed in a total of 921 recruits (positive predictive value (PPV) 8.06%). Of these recruits, 298 (32.4%) had cardiac conditions associated with an increased risk of sudden cardiac death (SCD) including 98 (10.6%) with probable cardiomyopathy; 22 (2.4%) with accessory pathways; and 30 (3.3%) with possible channelopathies (see Table 1). Males accounted for 91.9% of those with cardiac abnormalities but no significant male disease preponderance was observed (p = 0.117). The remainder of the recruits had a range of ECG and echocardiographic abnormalities not typically associated with SCD.Abstract 80 Table 1Frequency of cardiac abnormalities in the potential recruitsConditionFemales with conditionMales with conditionTotal with condition % total females% total males% of total screenedCardiomyopathies5 (5.1%)93 (94.9%)980.39%0.91%0.86%Accessory pathways3 (13.6%)19 (86.4%)220.24%0.19%0.19%Long QT Syndrome4 (15.4%22 (84.6%)260.32%0.22%0.23%Brugada Syndrome1 (25%)3 (75%)40.08%0.03%0.04%Mitral valve prolapse5 (22.7%)17 (77.3%)220.40%0.17%0.18%Bicuspid aortic valve8 (6.5%)116 (93.5%)1240.64%1.14%1.09%Anomalous origin coronary artery0 (0%)3 (100%)30%0.03%0.03%Other coronary artery abnormalities0 (0%)5 (100%)50%0.05%0.05%Individuals with one or more conditions associated with SCD24 (8.1%)274 (91.9%)2981.91%2.70%2.61%DiscussionThese results show that an isolated murmur, detected by military occupational physicians as part of a cardiac screening program, has a low PPV for the detection of significant valve disease in asymptomatic individuals. The screening program incidentally detected a larger cohort of recruits with potentially serious underlying cardiac abnormalities, resulting in deferral of military service. Most of these conditions are not classically associated with a cardiac murmur and were diagnosed from ECG or echocardiography. Without these investigations, it is unlikely they would have been detected. Therefore, the addition of routine ECG, and possibly echocardiography to the British Army cardiac screening protocol should be considered. This approach would improve the detection rate of potentially serious, non-valvular cardiac disease requiring further evaluation before military service can be approved.In military populations, cardiac conditions are a potentially preventable cause of mortality and morbidity. It is believed that individuals with these conditions can be readily identified using a standardised history and physical examination. However, there is growing evidence that addition of routine 12-lead ECG increases the sensitivity for detection of underlying cardiac abnormalities. Current guidelines on pre-participation screening in athletes recommend this approach.