Pacemaker lead thrombosis - a rare cause of breathlessness.

As the number of pacemaker insertions increases to manage numerous cardiac arrhythmias, the number of complications is also increasing as a result. More common complications such as infection and lead displacement are routinely discussed with patients before they undergo the procedure. However rare complications such as superior vena cava syndrome are not discussed during the consenting period. But they do occur, as seen in this case of a 69-year-old male. This fit and active man had a right-sided dual-chamber pacemaker inserted due to sinus node disease and presented 5 years later with symptoms suggestive of superior vena cava obstruction (SVCO). Despite anticoagulation and before surgical intervention could be performed, the patient developed a right-sided chylothorax which was drained. An autologous pericardial patch repair of the SVC and a thrombectomy of SVC clots was subsequently performed. This was only partially successful and the SVCO recurred. A low fatty chain diet was initiated to manage the chylothorax, which remains stable. This rare complication has left the patient with a small pleural effusion and chronic pleural thickening. They can still exercise with mild breathlessness. The management of such a complication, which requires the input of many specialists, is challenging and often does not completely resolve all symptoms. For this reason, superior vena cava obstruction should be considered as a risk during the consenting procedure for a pacemaker insertion.

Systematic Review of Clinical Decision Support Systems for Prehospital Acute Coronary Syndrome Identification.

OBJECTIVES: Timely prehospital diagnosis and treatment of acute coronary syndrome (ACS) are required to achieve optimal outcomes. Clinical decision support systems (CDSS) are platforms designed to integrate multiple data and can aid with management decisions in the prehospital environment. The review aim was to describe the accuracy of CDSS and individual components in the prehospital ACS management. METHODS: This systematic review examined the current literature regarding the accuracy of CDSS for ACS in the prehospital setting, the influence of computer-aided decision-making and of 4 components: electrocardiogram, biomarkers, patient history, and examination findings. The impact of these components on sensitivity, specificity, and positive and negative predictive values was assessed. RESULTS: A total of 11,439 articles were identified from a search of databases, of which 199 were screened against the eligibility criteria. Eight studies were found to meet the eligibility and quality criteria. There was marked heterogeneity between studies which precluded formal meta-analysis. However, individual components analysis found that patient history led to significant improvement in the sensitivity and negative predictive values. CDSS which incorporated all 4 components tended to show higher sensitivities and negative predictive values. CDSS incorporating computer-aided electrocardiogram diagnosis showed higher specificities and positive predictive values. CONCLUSIONS: Although heterogeneity precluded meta-analysis, this review emphasizes the potential of ACS CDSS in prehospital environments that incorporate patient history in addition to integration of multiple components. The higher sensitivity of certain components, along with higher specificity of computer-aided decision-making, highlights the opportunity for developing an integrated algorithm with computer-aided decision support.

Bystander CPR training: is non-classroom based CPR training as effective as a classroom based approach? A systematic review of randomised controlled trials.

INTRODUCTION: In Scotland, approximately 5% of out-of-hospital cardiac arrest patients survive to hospital discharge. Improving bystander cardiopulmonary resuscitation (CPR), especially in rural areas, could have a significant effect on the numbers of lives saved. The objective of this study was to systematically review whether non-classroom-based bystander CPR training is as effective as classroom-based training.. METHODS: A database search for randomised controlled trials that compared classroom-based to non-classroom-based training in bystanders (non-medical professionals) was performed in Medline and Embase with no date restrictions. Relevant studies were critically appraised. Differences in the efficacy of CPR training between the two study arms of non-classroom and classroom-based training were measured by outcomes of compression depth, compression rate and correct hand positioning. RESULTS: Eight studies in total met the inclusion criteria. Thirteen out of a total of 15 outcomes showed non-classroom-based CPR training to be as effective as or more effective than classroom-based training. A high risk of bias was identified in every study. CONCLUSION: From the available evidence, non-classroom-based training appears at least as effective as classroom-based training for CPR. This could have significant implications for delivery of CPR training nationally, especially in remote and rural areas. However, due to the variation in how outcomes were measured, and the high risk of the presence of bias in each of the studies, further research into CPR training strategies is strongly recommended.

Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series.

INTRODUCTION: People who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RTs) and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality. In remote areas, a number of geographical and organisational barriers may influence access to ORT. These are not well understood and the exact proportion of patients who receive ORT and the relationship to time of day and remoteness from the cardiac cath lab is unknown. The aim of this retrospective study was to compare the characteristics of ORT delivery in central and remote locations in the north of Scotland and to identify potential barriers to optimal care with a view to service redesign. METHOD: The study was set in the north of Scotland. All patients who attended hospital with a STEMI between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters. Data included treatment location, date of admission, distance of patient from the cath lab, route of access to health care, left ventricular function and RT received. Distance of patients from the cath lab was described as remote if they were more than 90 minutes of driving time from the cardiac cath lab and central if they were 90 minutes or less of driving time from the regional centre. For patients who made contact in a pre-hospital setting, ORT was defined as pre-hospital TL (PHT) or pPCI. For patients who self-presented to the hospital first, ORT was defined as in-hospital TL or pPCI. Data were described as mean (standard deviation) as appropriate. Chi-squared and student's t-test were used as appropriate. Each case was reviewed to determine if ORT was received; if ORT was not received, the reasons for this were recorded to identify potentially modifiable barriers. RESULTS: Of 627 acute myocardial infarction patients initially identified, 131 had a STEMI, and the others were non-STEMI. From this STEMI cohort, 82 (62%) patients were classed as central and 49 (38%) were remote. In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received PHTs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; χ²=7.05, degrees of freedom =130, p<0.01).Several recurring barriers were identified. CONCLUSION: This study has demonstrated a significant health inequality between the treatment of STEMI in remote compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the north of Scotland.

Unexpected deaths in cardiology outpatients - what can we learn from case review?

OBJECTIVES: A proportion of cardiac patients managed at a cardiology outpatient clinic will die between clinic visits. This study aimed to identify the cause of death, to determine if case review occurred and if a formal review of such cases might be useful. DESIGN: Single-centre retrospective cohort study. SETTING: A remote regional centre in the North of Scotland. PARTICIPANTS: All patients who had been removed from the cardiology outpatient clinic due to death in the community. MAIN OUTCOME MEASURES: Cause of death, comorbidities and treatments were collected from hospital records and the national register of deaths. Chi-squared test and Student's t-test were used with significance taken at the 5% level. RESULTS: Of 10,606 patients who attended the cardiology outpatient clinic, 75 (0.7%) patients died in the community. The majority (57.0%) died from a non-cardiac cause. Eleven patients (14.9%) died due to an unexpected cardiac death. A detailed case note review was undertaken. In only two (18.2%) cases was any note made as to the cause of death in the hospital records and in only one was there details of post mortem discussion between primary and secondary care. CONCLUSIONS: A small proportion of patients attending a cardiology outpatient clinic died in the community. Documentation of the death in the hospital notes was very poor and evidence of post mortem communication between primary and secondary care was absent in all but one case. Better documentation and communication between primary and secondary care would seem desirable.