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MacLachlan H, Antonakaki A, Bhatia R, Fyazz S, Chatrath N, Androulakis E, Marawaha S, Basu J, Miles C, Dhutia H, Zaidi A, Chandra N, Sheikh N, Gati S, Malhotra A, Finocchiaro G, Sharma S, Papadakis M. Prevalence and Clinical Significance of Electrocardiographic Complete Right Bundle Branch Block in Young Individuals. Eur J Prev Cardiol 2024:zwae082. [PMID: 38412448 DOI: 10.1093/eurjpc/zwae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/17/2024] [Accepted: 02/23/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND AND AIMS There is limited information on the clinical significance of complete right bundle branch block (CRBBB) in young individuals. The aim of this study was to determine the prevalence and significance of CRBBB in a large cohort of young individuals aged 14-35 years old. METHODS From 2008 to 2018, 104,369 consecutive individuals underwent a cardiovascular assessment with a health questionnaire, electrocardiogram, clinical consultation, and selective echocardiography. Follow-up was obtained via direct telephone consultations. Mean follow-up was 7.3 ± 2.7 years. RESULTS CRBBB was identified in 154 (0.1%) individuals and was more prevalent in males compared with females (0.20% vs. 0.06%; p<0.05) and in athletes compared with non-athletes (0.25% vs. 0.14%; p<0.05). CRBBB-related cardiac conditions were identified in 7 (5%) individuals (4 with atrial septal defect, 1 with Brugada syndrome, 1 with progressive cardiac conduction disease and 1 with atrial fibrillation). Pathology was more frequently identified in individuals with non-isolated CRBBB compared with individuals with isolated CRBBB (14% vs 1%; p < 0.05) and in individuals with a QRS duration of ≥130 milliseconds (ms) compared with individuals with a QRS of <130ms (10% vs 1%; p<0.05). CONCLUSION The prevalence of CRBBB in young individuals was 0.1% and was more prevalent in males and athletes. CRBBB-related conditions were identified in 5% of individuals and were more common in individuals with non-isolated CRBBB and more pronounced intraventricular conduction delay (QRS duration of ≥130ms). Secondary evaluation should be considered for young individuals with CRBBB with symptoms, concerning family history, additional electrocardiographic anomalies or significant QRS prolongation (≥130ms).
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Affiliation(s)
- H MacLachlan
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - A Antonakaki
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - R Bhatia
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - S Fyazz
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - N Chatrath
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - E Androulakis
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - S Marawaha
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - J Basu
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - C Miles
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - H Dhutia
- Department of Cardiology, Glenfield Hospital, Leicester, UK
| | - A Zaidi
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - N Chandra
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
- Department of Cardiology, Frimley Park Hospital, London, UK
| | - N Sheikh
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
- Department of Cardiology, Guy's and St Thomas's Hospital, London, UK
| | - S Gati
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - A Malhotra
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
- Institute of Sport, Manchester Metropolitan University and University of Manchester, Manchester, UK
| | - G Finocchiaro
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - S Sharma
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
| | - M Papadakis
- Cardiovascular Clinical Academic Group, St George's, University of London, London, UK
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Bhatia RT, Forster J, Ackrill M, Chatrath N, Finocchiaro G, Fyyaz S, MacLachlan H, Malhotra A, Marwaha S, Papadakis M, Ring L, Sharma S, Oxborough D, Rakhit D. Coronary artery anomalies and the role of echocardiography in pre-participation screening of athletes: a practical guide. Echo Res Pract 2024; 11:5. [PMID: 38383464 PMCID: PMC10882860 DOI: 10.1186/s44156-024-00041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/26/2024] [Indexed: 02/23/2024] Open
Abstract
Transthoracic echocardiography is an essential and widely available diagnostic tool for assessing individuals reporting cardiovascular symptoms, monitoring those with established cardiac conditions and for preparticipation screening of athletes. While its use is well-defined in hospital and clinic settings, echocardiography is increasingly being utilised in the community, including in the rapidly expanding sub-speciality of sports cardiology. There is, however, a knowledge and practical gap in the challenging area of the assessment of coronary artery anomalies, which is an important cause of sudden cardiac death, often in asymptomatic athletic individuals. To address this, we present a step-by-step guide to facilitate the recognition and assessment of anomalous coronary arteries using transthoracic echocardiography at the bedside; whilst recognising the importance of performing dedicated cross-sectional imaging, specifically coronary computed tomography (CTCA) where clinically indicated on a case-by-case basis. This guide is intended to be useful for echocardiographers and physicians in their routine clinical practice whilst recognising that echocardiography remains a highly skill-dependent technique that relies on expertise at the bedside.
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Affiliation(s)
- Raghav T Bhatia
- Hull University Teaching Hospitals NHS Trust, Kingston-Upon-Hull, UK
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Jan Forster
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Nikhil Chatrath
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Saad Fyyaz
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Aneil Malhotra
- Institute of Sport, Manchester Metropolitan University and University of Manchester, Manchester, UK
| | - Sarandeep Marwaha
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Liam Ring
- West Suffolk Hospital NHS Trust, Bury Saint Edmunds, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - David Oxborough
- Research Institute for Sports and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Dhrubo Rakhit
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Basu J, Finocchiaro G, Miles C, Parry-Williams G, MacLachlan H, Tome Esteban MT, Sharma S, Papadakis M. The effect of ethnicity on left ventricular adaptation to exercise. Eur J Prev Cardiol 2023; 30:e69-e71. [PMID: 37086472 DOI: 10.1093/eurjpc/zwad126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Joyee Basu
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Christopher Miles
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Gemma Parry-Williams
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Maria Teresa Tome Esteban
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Orsborne C, Bhatia RT, Li ZC, MacLachlan H, Spartera M, Stoll VM. British Cardiovascular Society Young Investigator Award 2022. Heart 2023; 109:884-885. [PMID: 37028927 DOI: 10.1136/heartjnl-2023-322582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
Affiliation(s)
- Chris Orsborne
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Raghav T Bhatia
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ziwen C Li
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marco Spartera
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Victoria M Stoll
- Adult Congenital Heart Disease, Royal Papworth Hospital Foundation Trust, Cambridge, UK
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5
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Bhatia RT, Malhotra A, MacLachlan H, Gati S, Marwaha S, Chatrath N, Fyyaz S, Aleixo H, Al-Turaihi S, Babu A, Basu J, Catterson P, Cooper R, Daems JJN, Dhutia H, Ferrari F, van Hattum JC, Iqbal Z, Kasiakogias A, Kenny A, Khanbhai T, Khoury S, Miles C, Oxborough D, Quazi K, Rakhit D, Sharma A, Varnava A, Tome Esteban MT, Finocchiaro G, Stein R, Jorstad HT, Papadakis M, Sharma S. Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players. Heart 2023; 109:936-943. [PMID: 37039240 DOI: 10.1136/heartjnl-2022-322211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/21/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND AND AIM The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection. METHODS In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. RESULTS 511 soccer players (median age 21 years, IQR 18-26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3-10) compared with athletes without de-novo ECG changes (2 days, IQR 1-3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%. CONCLUSIONS 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.
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Affiliation(s)
- Raghav T Bhatia
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Aneil Malhotra
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
- Manchester Academic Health Science Centre, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Hamish MacLachlan
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sabiha Gati
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Sarandeep Marwaha
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Nikhil Chatrath
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Saad Fyyaz
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Samar Al-Turaihi
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Aswin Babu
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Joyee Basu
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Paul Catterson
- Department of Medicine, Newcastle United Football Club, Newcastle, UK
| | | | - Joelle J N Daems
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Harshil Dhutia
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Rio, Brazil
| | - Juliette C van Hattum
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Zafar Iqbal
- Department of Sports Medicine, Crystal Palace Football Club, London, UK
| | - Alexandros Kasiakogias
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Shafik Khoury
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Chris Miles
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - David Oxborough
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Kashif Quazi
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Dhrubo Rakhit
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Anushka Sharma
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Amanda Varnava
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Teresa Tome Esteban
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Ricardo Stein
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Rio, Brazil
| | - Harald T Jorstad
- Department of Cardiology, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
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Bhatia R, Malhotra A, MacLachlan H, Gati S, Kasiakogias A, Marwaha S, Chatrath N, Fyyaz S, Cooper R, Rakhit D, Varnava A, Esteban M, Finocchiaro G, Papadakis M, Sharma S. Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players.
Methods
We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves; (b) reduction in T-wave amplitude by 50% in contiguous leads; (c) ST-segment depression; (d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads; (e) tall T-waves ≥1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes.
Results
Athletes were aged 22±5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3±4 days. The post COVID ECG was performed 14±16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID-19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae; pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8±8 days v 2±4 days; p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3).
Conclusions
3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R Bhatia
- St George's University of London , London , United Kingdom
| | - A Malhotra
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - H MacLachlan
- St George's University of London , London , United Kingdom
| | - S Gati
- Royal Brompton and Harefield NHS Foundation Trust , London , United Kingdom
| | - A Kasiakogias
- Royal Brompton and Harefield NHS Foundation Trust , London , United Kingdom
| | - S Marwaha
- St George's University of London , London , United Kingdom
| | - N Chatrath
- St George's University of London , London , United Kingdom
| | - S Fyyaz
- St George's University of London , London , United Kingdom
| | - R Cooper
- Liverpool Heart and Chest Hospital , Liverpool , United Kingdom
| | - D Rakhit
- University Hospital Southampton NHS Foundation Trust , Southampton , United Kingdom
| | - A Varnava
- Imperial College Healthcare NHS Trust , London , United Kingdom
| | - M Esteban
- St George's University of London , London , United Kingdom
| | - G Finocchiaro
- St George's University of London , London , United Kingdom
| | - M Papadakis
- St George's University of London , London , United Kingdom
| | - S Sharma
- St George's University of London , London , United Kingdom
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7
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MacLachlan H, Dhutia H, Bhatia R, Boden K, Forenc K, Basu J, Miles C, Osborne R, Chandra N, Malhotra A, Stuart G, Peirce N, Sharma S, Papadakis M. Results of a nationally implemented cardiac screening programme in elite cricket players in England and Wales. J Sci Med Sport 2021; 25:287-292. [PMID: 35016820 DOI: 10.1016/j.jsams.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We assessed the diagnostic yield and costs of an electrocardiogram-based national screening programme in elite cricket players and the incremental value of transthoracic echocardiography and periodic evaluation. DESIGN Cross-sectional study. METHODS Between 2008 and 2019, 1208 cricketers underwent screening with a health questionnaire, 12-lead electrocardiogram and cardiology consultation. Athletes with concerning findings underwent on-site transthoracic echocardiography and further investigations as necessary. In addition, despite a normal health questionnaire and electrocardiogram, 342 (28.3%) athletes had a transthoracic echocardiogram and 493 (40.8%) underwent repeat evaluations. RESULTS After initial evaluation, 47 (3.9%) athletes underwent on-site transthoracic echocardiography of whom 35 (2.8%) were referred for further evaluation. Four athletes (0.3%) were diagnosed with major cardiac conditions; hypertrophic cardiomyopathy (n = 1), arrhythmogenic cardiomyopathy (n = 1) and Wolff-Parkinson-White pattern (n = 2). Two athletes were identified with minor valvular abnormalities. Repeat evaluation of 493 athletes identified hypertrophic cardiomyopathy in a 22-year-old athlete, two years after his initial normal screening. During a follow-up of 5.8 ± 2.9 years no additional diagnoses or adverse cardiac events were reported. The cost of the electrocardiogram-based programme was £127,844, translating to £106 per athlete and £25,569 per major cardiac condition identified.Routine transthoracic echocardiography in 342 athletes identified two athletes with major cardiac conditions (bicuspid aortic valve with severe aortopathy and aortic regurgitation and an atrial septal defect associated with right ventricular volume overload) and 10 athletes with minor abnormalities. CONCLUSIONS An electrocardiogram-based national screening programme identified a major cardiac condition in 0.3% of athletes. Routine transthoracic echocardiography and periodic evaluation increased the diagnostic yield to 0.6%, at an incremental cost.
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Affiliation(s)
- H MacLachlan
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - H Dhutia
- Department of Cardiology, Glenfield Hospital, United Kingdom
| | - R Bhatia
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - K Boden
- England and Wales Cricket Board and National Centre for Sports and Exercise Medicine and National Cricket Performance Centre, Loughborough University, United Kingdom
| | - K Forenc
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - J Basu
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - C Miles
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - R Osborne
- Cardiac Risk in the Young, United Kingdom
| | - N Chandra
- Department of Cardiology, Frimley Park Hospital, United Kingdom
| | - A Malhotra
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom
| | - G Stuart
- National Institute of Health Research Cardiovascular Biomedical Research Centre, Bristol Heart Institute, United Kingdom
| | - N Peirce
- England and Wales Cricket Board and National Centre for Sports and Exercise Medicine and National Cricket Performance Centre, Loughborough University, United Kingdom
| | - S Sharma
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom
| | - M Papadakis
- Cardiovascular Clinical Academic Group, St Georges, University of London, United Kingdom.
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8
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Parry-Williams G, Obaid D, Miles C, Basu J, MacLachlan H, Moser J, Vlahos I, O'Driscoll J, Chis Ster I, Papadakis M, Tome Esteban MT, Sharma S. Determinants of high-risk coronary artery disease in ostensibly healthy male master endurance athletes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Healthy male master endurance athletes have a greater prevalence of high coronary calcium (CAC) scores compared to healthy sedentary counterparts, and some demonstrate high-risk plaque features. A number of theories have been postulated but reasons remain unclear. Concurrently atherosclerotic coronary artery disease (CAD) is the most common cause of sudden cardiac death in male master athletes drawing much public and scientific interest and making this an important public health issue.
Purpose
To examine the relationship of age, resting systolic blood pressure (SBP), exercise dose and sporting discipline with high-risk CAD markers in male master endurance athletes.
Methods
A prospective study undertaken over 19 months evaluated 214 male master (40–65 years) endurance athletes, free from known cardiovascular risk factors, symptoms or relevant health conditions. Clinical evaluation included cardiopulmonary exercise test, resting blood pressure (BP) and coronary computed tomogram angiography (CCTA). CCTA assessed CAC score, significant stenosis, (>50%) and plaque vulnerability markers. Exercise dose was defined by years of endurance exercise and average MET-hours/week (lifetime exercise volume multiplied by the metabolic equivalent scores). Resting BP was the average of 3 consecutive supine measures after at least 5 minutes rest.
Results
Athletes (mean age 51, SD 70.1) exercised for minimum 6 hours/week (median 8.5) for a median of 15 years (2–26). Almost half (60.2%) were multi-endurance athletes i.e. any combination swimming, cycling and running. The remainder were runners (22.4%) and cyclists (15.4%). Median Framingham risk score 3.2% (1.8–5.8). The mean resting BP was 129/80 mmHg and a quarter (26%) of athletes were hypertensive (≥140/90 mmHg) at rest. A CAC score >100 Agatston units (AU) was present in 16% of athletes. There was a total of 15 stenotic lesions in 11 (5%) athletes. 13% had plaque vulnerability markers.
Logistic regression evaluated whether age, resting SBP, exercise dose measures and sporting discipline were predictive for a CAC score >100 AU, significant stenosis and plaque vulnerability markers (table 1). CAC score was associated with age, years of endurance exercise and resting SBP. A Stenosis >50% and plaque vulnerability markers were associated with resting SBP and cycling compared with all other sporting disciplines.
Conclusion
Despite correcting for age, higher exercise dose (years endurance exercise) is associated with CAC score >100 AU but does not predict significant stenosis or plaque vulnerability markers. Resting SBP and cycling strongly predict high-risk disease. Cycling enables a greater intensity of exercise compared with other endurance sports, which may be associated with prolonged rises in SBP. Resting SBP and cycling are important determinants for high-risk CAD in middle-aged male endurance athletes and should be considered when risk stratifying in pre-participation evaluation.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship
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Affiliation(s)
- G Parry-Williams
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - D Obaid
- Swansea University, Swansea, United Kingdom
| | - C Miles
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - J Basu
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - H MacLachlan
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - J Moser
- St George's Healthcare NHS Trust, London, United Kingdom
| | - I Vlahos
- University of Texas MD Anderson Cancer Centre, Houston, United States of America
| | - J O'Driscoll
- Canterbury Christ Church University, Canterbury, United Kingdom
| | - I Chis Ster
- St George's University of London, London, United Kingdom
| | - M Papadakis
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - M T Tome Esteban
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
| | - S Sharma
- St George's University of London, Molecular and Clinical Sciences Research, London, United Kingdom
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9
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MacLachlan H, Drezner JA. Cardiac evaluation of young athletes: Time for a risk-based approach? Clin Cardiol 2020; 43:906-914. [PMID: 32242971 PMCID: PMC7403680 DOI: 10.1002/clc.23364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 12/13/2022] Open
Abstract
Pre‐participation cardiovascular screening (PPCS) is recommended by several scientific and sporting organizations on the premise that early detection of cardiac disease provides a platform for individualized risk assessment and management; which has been proven to lower mortality rates for certain conditions associated with sudden cardiac arrest (SCA) and sudden cardiac death (SCD). What constitutes the most effective strategy for PPCS of young athletes remains a topic of considerable debate. The addition of the electrocardiogram (ECG) to the medical history and physical examination undoubtedly enhances early detection of disease, which meets the primary objective of PPCS. The benefit of enhanced sensitivity must be carefully balanced against the risk of potential harm through increased false‐positive findings, costly downstream investigations, and unnecessary restriction/disqualification from competitive sports. To mitigate this risk, it is essential that ECG‐based PPCS programs are implemented by institutions with a strong infrastructure and by physicians appropriately trained in modern ECG standards with adequate cardiology resources to guide downstream investigations. While PPCS is compulsory for most competitive athletes, the current debate surrounding ECG‐based programs exists in a binary form; whereby ECG screening is mandated for all competitive athletes or none at all. This polarized approach fails to consider individualized patient risk and the available sports cardiology resources. The limitations of a uniform approach are highlighted by evolving data, which suggest that athletes display a differential risk profile for SCA/SCD, which is influenced by age, sex, ethnicity, sporting discipline, and standard of play. Evaluation of the etiology of SCA/SCD within high‐risk populations reveals a disproportionately higher prevalence of ECG‐detectable conditions. Selective ECG screening using a risk‐based approach may, therefore, offer a more cost‐effective and feasible approach to PPCS in the setting of limited sports cardiology resources, although this approach is not without important ethical considerations.
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Affiliation(s)
- Hamish MacLachlan
- Cardiovascular Sciences Research Centre, St Georges University of London, London, UK
| | - Jonathan A Drezner
- Department of Family Medicine and the Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
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10
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Keteepe-Arachi T, Malhotra A, Basu J, Parry-Williams G, Ensam B, Miles C, Dassanayake S, MacLachlan H, Ibrahim B, Papdakis M, Tome M, Khong T, Sharma S, Anderson L. P3839Hypertension or hypertrophic cardiomyopathy? Using cardiovascular magnetic resonance imaging to unmask the great imitator. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Structural cardiac adaptations due to hypertension (HTN) present a diagnostic challenge when differentiating from hypertrophic cardiomyopathy (HCM), using traditional imaging techniques such as echocardiography (echo). Cardiac magnetic resonance imaging (CMR) offers reproducible anatomical, functional quantification and myocardial tissue characterisation which discriminates between hypertension and HCM.
Purpose
To identify hypertensive individuals with undiagnosed HCM using CMR imaging.
Methods
100 consecutive hypertensive patients underwent CMR at a tertiary centre dedicated blood pressure clinic (55% male, mean age 51 years). In keeping with ESC guidelines, end diastolic wall thickness (EDWT) ≥15mm identified individuals within the “grey zone” between hypertension and with a potential HCM diagnosis. 19 individuals were referred on to the dedicated inherited cardiac conditions clinic for further evaluation. Four patients expressed a definitive LV phenotype and were diagnosed with HCM. CMR parameters were compared in three groups: Hypertensive (HTN), “grey zone” Hypertensive (GZH) and HCM.
Results
CMR demonstrated end diastolic wall thickness (EDWT) >11 mm in 50% of hypertensives. 73% of the referred patients were Afro-Caribbean (AC) and all 4 HCM patients were AC. All referrals demonstrated EDWTs ≥14mm, 9 (47%) demonstrated late gadolinium enhancement of which 3 (16%) had HCM. Three had asymmetrical septal hypertrophy – 2 were in the HCM cohort and one underwent endomyocardial biopsy confirming HTN. Left ventricular mass index (LVMI) was significantly higher in GZH compared to HTN (p<0.0001) and in HCM compared to HTN (p=0.0004). EDWT was significantly greater in GZH compared to HTN (p<0.0001) and in HCM compared to HTN (p=0.0002). There was no significant difference in these parameters between GZH and HCM.
Table 1. P-values for CMR data in hypertensive (HTN), gray zone hypertensive (GZH) and hypertrophic cardiomyopathy (HCM) cohorts CMR Parameter HCM vs. HTN GZH vs. HTN GZH vs. HCM EDVI NS p=0.025 NS EDWT p=0.0002 p<0.0001 NS LVMI p=0.0004 p<0.0001 NS
Conclusion
This study reports a 4% prevalence of HCM among hypertensive patients - 20 x greater than in the general population - which would be left undiagnosed using echo alone. Screening hypertensive individuals with CMR is not routine but we advocate its use in these individuals especially in Afro Caribbeans and in those in the “grey zone”, to identify undiagnosed HCM, which has significant implications for lifestyle modification and family screening.
Acknowledgement/Funding
Cardiac Risk in the Young
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Affiliation(s)
- T Keteepe-Arachi
- St George's University of London, St Geor, London, United Kingdom
| | - A Malhotra
- St George's University of London, St Geor, London, United Kingdom
| | - J Basu
- St George's University of London, St Geor, London, United Kingdom
| | - G Parry-Williams
- St George's University of London, St Geor, London, United Kingdom
| | - B Ensam
- St George's University of London, St Geor, London, United Kingdom
| | - C Miles
- St George's University of London, St Geor, London, United Kingdom
| | - S Dassanayake
- St George's University of London, St Geor, London, United Kingdom
| | - H MacLachlan
- St George's University of London, St Geor, London, United Kingdom
| | - B Ibrahim
- St George's University of London, St Geor, London, United Kingdom
| | - M Papdakis
- St George's University of London, St Geor, London, United Kingdom
| | - M Tome
- St George's University of London, St Geor, London, United Kingdom
| | - T Khong
- St George's University of London, St Geor, London, United Kingdom
| | - S Sharma
- St George's University of London, St Geor, London, United Kingdom
| | - L Anderson
- St George's University of London, St Geor, London, United Kingdom
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11
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Abstract
PURPOSE OF REVIEW We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes. RECENT FINDINGS A large proportion of sudden cardiac death in young individuals and athletes occurs during rest with sudden arrhythmic death syndrome being recognised as the leading cause. The international recommendations for ECG interpretation have reduced the false-positive ECG rate to 3% and reduced the cost of screening by 25% without compromising the sensitivity to identify serious disease. There are some quality control issues that have been recently identified including the necessity for further training to guide physicians involved in screening young athletes. Improvements in our understanding of young sudden cardiac death and ECG interpretation guideline modification to further differentiate physiological ECG patterns from those that may represent underlying disease have significantly improved the efficacy of screening to levels that may make screening more attractive and feasible to sporting organisations as a complementary strategy to increased availability of automated external defibrillators to reduce the overall burden of young sudden cardiac death.
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Affiliation(s)
- Harshil Dhutia
- Cardiovascular Sciences Research Centre, St George's University of London, London, UK.
- Department of Cardiology, Glenfield Hospital, Leicester, UK.
| | - Hamish MacLachlan
- Cardiovascular Sciences Research Centre, St George's University of London, London, UK
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12
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MacLachlan H, Thomas R, Langtree J, Hare C, Mitchell ARJ. Is there a role for a local inpatient CT coronary angiography service in selected patients with acute coronary syndrome? A cohort analysis of inpatient tertiary centre referrals for invasive coronary angiography. Open Heart 2016; 3:e000389. [PMID: 27042324 PMCID: PMC4800760 DOI: 10.1136/openhrt-2015-000389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a retrospective analysis of inpatients referred for invasive coronary angiography (ICA) at a tertiary centre, with suspected or confirmed acute coronary syndrome (ACS). METHODS A retrospective cohort study was conducted at Jersey General Hospital. We evaluated 198 inpatients referred for ICA with suspected or confirmed ACS over a 3-year period. Patients presenting with ST elevation myocardial infarction were excluded. The primary outcome was to identify the number of patients who did not require subsequent coronary intervention following ICA. Patient variables were measured to establish those who met European Society of Cardiology (ESC) criteria for consideration of CT coronary angiography (CTCA) as an alternative to ICA. Cost of care for those referred for ICA was calculated. RESULTS ICA demonstrated evidence of coronary heart disease requiring coronary intervention in 119 (60%) of the referred patients. 28 (35%) of the patients not requiring coronary intervention at ICA met ESC criteria for preassessment with CTCA. The cost of care for this subgroup was £9089 per patient. Inpatient CTCA was calculated at £376 per patient. CONCLUSIONS Low-intermediate risk patients presenting with suspected or confirmed ACS to hospitals without onsite coronary revascularisation should be considered for in-hospital CTCA before consideration of ICA. Using CTCA as a gatekeeper for targeted ICA appears cost-effective, particularly for hospitals without the required onsite facilities.
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Affiliation(s)
| | - Ranji Thomas
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Jessica Langtree
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Chris Hare
- Department of Cardiology , Jersey General Hospital , Jersey , UK
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13
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Mitchell ARJ, Hurry R, Le Page P, MacLachlan H. Pre-participation cardiovascular screening: is community screening using hand-held cardiac ultrasound feasible? Echo Res Pract 2015; 2:49-55. [PMID: 26693333 PMCID: PMC4676452 DOI: 10.1530/erp-15-0010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 04/03/2015] [Accepted: 04/15/2015] [Indexed: 11/16/2022] Open
Abstract
We evaluated the feasibility and costs of utilising hand-held cardiac ultrasound (HHCU) as part of a community-based pre-participation cardiovascular screening programme. Ninety-seven school children were screened using a personal history, a physical examination, a resting 12-lead electrocardiogram (ECG) and a HHCU. A consultant cardiologist independently reviewed and reported the data. Previously undiagnosed cardiovascular abnormalities were identified in nine participants (9%). An additional three participants (3%) were diagnosed with hypertension. The nine abnormalities were identified at a cost of £460 per finding, with a cost of £43 per participant screened. The marginal cost of adding a HHCU to the personal history, physical examination and ECG was £16 per participant. Pre-participation screening in the community using hand-held echocardiography is practical and inexpensive. The additional sensitivity and specificity provided by the ultrasound may enhance screening programmes, thereby reducing false positives and the need for expensive follow-up testing.
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Affiliation(s)
- A R J Mitchell
- Department of Cardiology, Jersey International Centre for Advanced Studies, Jersey General Hospital, Gloucester Street, St Helier, JE1 3QS, Channel Islands, Jersey
| | - R Hurry
- Department of Cardiology, Jersey International Centre for Advanced Studies, Jersey General Hospital, Gloucester Street, St Helier, JE1 3QS, Channel Islands, Jersey
| | - P Le Page
- Department of Cardiology, Jersey International Centre for Advanced Studies, Jersey General Hospital, Gloucester Street, St Helier, JE1 3QS, Channel Islands, Jersey
| | - H MacLachlan
- Department of Cardiology, Jersey International Centre for Advanced Studies, Jersey General Hospital, Gloucester Street, St Helier, JE1 3QS, Channel Islands, Jersey
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