British Cardiovascular Society

Reflex syncope is a common cause of transient loss of consciousness, often leading to injuries and a reduced quality of life. Despite the benign nature of isolated episodes, recurrent syncope poses significant clinical challenges. Cardiac pacing has been investigated as a treatment modality, particularly in patients with cardioinhibitory phenotypes, yet prior studies have shown heterogeneous outcomes. A systematic review and meta-analysis were conducted to evaluate the efficacy of permanent cardiac pacing in preventing recurrent reflex syncope. Comprehensive searches of PubMed and the Cochrane Library were performed up to September 2024 using the terms "reflex syncope" and "cardiac pacing." Eligible studies included randomised controlled trials (RCTs) involving adult patients with recurrent reflex syncope undergoing permanent pacemaker implantation. Systematic reviews, narrative reviews, case reports or series, editorials, and conference abstracts were excluded from the review. Two independent reviewers screened studies and extracted data using Covidence, with discrepancies resolved by consensus. A meta-analytical synthesis was performed using odds ratios (ORs) for recurrent syncope, employing a random- and fixed-effects model. Heterogeneity was assessed using Cochran's Q, I² statistic, and τ². Seven RCTs were included, comprising a total of 458 patients. The primary outcomes showed a pooled analysis indicating a significant protective effect of pacing in reducing syncope recurrence compared to controls (OR 0.37; 95% CI: 0.22-0.62; p = 0.009), supporting the efficacy of permanent cardiac pacing in this population. Heterogeneity was low (Q = 6.60, p = 0.36; I² = 38%; τ² = 0.051), supporting the use of a fixed-effects model, which showed a similar outcome (Log(OR) 0.378 (95% CI, 0.229-0.624; p < 0.001)). The included trials varied in pacing modality (dual-chamber pacing (DDD), closed-loop stimulation (CLS), rate-drop response (RDR)), patient selection criteria, and diagnostic approaches. Secondary outcomes included reductions in pre-syncopal symptoms and delayed recurrence of syncope with pacing, along with a low incidence of device-related adverse events. However, inconsistent reporting limited the comprehensive meta-analysis of these endpoints. Permanent pacing reduces the risk of recurrent syncope in selected patients with reflex syncope, particularly those with documented asystole or cardioinhibitory phenotypes. CLS and RDR pacing algorithms may provide enhanced protection compared to conventional DDD pacing; however, variability in patient selection and device programming across studies limits the generalisability of these findings. Larger, standardised RCTs are needed to refine patient selection criteria and optimise pacing strategies for reflex syncope.

ABSTRACTBackgroundAlopecia areata (AA) is a common non‐scarring alopecia. Data continue to emerge on associations with autoimmune and other conditions. Janus kinase inhibitors (JAKi) are increasingly used to treat AA.ObjectivesThe aim was to assess variation in laboratory testing in patients with AA among hair experts internationally and to compare subspecialized clinical practice to current guidelines.MethodsThirty hair experts from 14 countries and six continents contributed to develop a 24‐item survey collecting demographic information on respondents; methods of severity assessment; and laboratory testing practices in AA for mimics, contributory factors, associations, and workup for systemic therapy. The survey was distributed to a global network of expert hair specialists.ResultsOf 214 respondents, 79.9% (171/214) had special interest/expertise in hair loss disorders, and 35.5% (n = 76) were based in Europe. Most cared for both adults and children (87.9%, n = 188). For clinical assessment, almost two‐thirds (63.6%, n = 136) used the Severity of Alopecia Tool and 38% (n = 84) used the Dermatology Life Quality Index. Only 24.3% (n = 52) typically tested for alternative infectious or inflammatory diagnoses, 39.7% (n = 85) typically tested for contributory conditions such as nutritional deficiencies, and 50.9% (n = 109) typically tested for co‐existent autoimmune illnesses. Thyroid function testing was routinely performed in 73.4% (n = 157) and complete blood count (CBC) was checked in 65.9% (n = 141). Compared to conventional systemic therapy, experts were more likely to check lipid levels, creatine kinase, coagulation profiles, thrombophilia screens, tuberculosis blood testing, hepatitis B and C serology before prescribing JAKi.ConclusionsReal world practice of laboratory testing for AA by hair experts, who may see more severe or complex alopecia, is variable. Most experts routinely perform thyroid function and CBC testing. We discuss evidence for indications for testing for AA mimics, contributory factors, associated autoimmune conditions, and before systemic therapy. Further research is required to characterise the role of laboratory testing in AA.

The Autumn Meeting of the British Society for Cardiovascular Research in 2023 was organized by Carolyn Carr, Lisa Heather and Claudia Montes Aparicio at Wadham College at the University of Oxford and was the 50th Anniversary Meeting of the Society. The theme of the meeting was “The impact of dysregulated metabolism on cardiovascular function” and included an early career symposium on “Life in academia and beyond”. The Annual Bernard and Joan Marshall Distinguished Investigator Lecture was given by Professor Doug Lewandowski on “Metabolic flux in the driver’s seat during cardiac health and disease”. This paper presents the abstracts selected for oral and poster presentation.

BackgroundOutpatient care for patients with heart valve disease (HVD) is best provided by valve clinics delivered by specialists. Modern day practice in the United Kingdom (UK) is currently poorly understood and has not been evaluated for nearly a decade. Furthermore, the COVID 19 pandemic changed the management of many chronic diseases, and how this has impacted patients with heart valve disease is unclear.MethodsA British Heart Valve Society survey was sent to 161 hospitals throughout the UK.ResultsThere was a general valve clinic in 46 of the 68 hospitals (68%), in 19 of 23 Heart Centres (83%) and 29 of 45 DGHs (64%). Across all settings, 3824 new patients and 17,980 follow up patients were seen in valve clinics per annum. The mean number of patients per hospital were 197 (median 150, range 48–550) for new patients and 532 (median 400, range 150–2000) for follow up. On the day echocardiography was available in 55% of valve clinics. In patients with severe HVD, serum brain natriuretic peptide (BNP) was measured routinely in 39% of clinics and exercise testing routinely performed in 49% of clinics. A patient helpline was available in 27% of clinics. 78% of centres with a valve clinic had a valve multidisciplinary team meeting (MDT). 45% centres had an MDT co-ordinator and MDT outcomes were recorded on a database in 64%. COVID-19 had a major impact on valve services in 54 (95%) hospitals.ConclusionsThere has been an increase in the number of valve clinics since 2015 from 21 to 68% but the penetration is still well short of the expected 100%, meaning that valve clinics only serve a small proportion of patients requiring surveillance for HVD. COVID-19 had a major impact on the care of patients with HVD in the majority of UK centres surveyed.

Magnetic Resonance Imaging (MRI) is increasingly a fundamental component of the diagnostic pathway across a range of conditions. Historically, the presence of a cardiac implantable electronic device (CIED) has been a contraindication for MRI, however, development of MR Conditional devices that can be scanned under strict protocols has facilitated the provision of MRI for patients. Additionally, there is growing safety data to support MR scanning in patients with CIEDs that do not have MR safety labelling or with MR Conditional CIEDs where certain conditions are not met, where the clinical justification is robust. This means that almost all patients with cardiac devices should now have the same access to MRI scanning in the National Health Service as the general population. Provision of MRI to patients with CIED, however, remains limited in the UK, with only half of units accepting scan requests even for patients with MR Conditional CIEDs. Service delivery requires specialist equipment and robust protocols to ensure patient safety and facilitate workflows, meanwhile demanding collaboration between healthcare professionals across many disciplines. This document provides consensus recommendations from across the relevant stakeholder professional bodies and patient groups to encourage provision of safe MRI for patients with CIEDs.

In 1961, the publication of the findings of the Framingham study provided the National Institutes of Health (NIH), the USA, and the world at large with a huge return on the initial investment. Identification of the common risk factors fuelling the epidemic of cardiovascular disease (CVD) stimulated a ‘call to arms’ and the initiation of programmes to attack these targets on a national scale. This has led to stunning declines in CVD mortality over the last 40–50 years in North America, Western Europe and other high income countries. Nonetheless, this is not the time for complacency. CVD is by far and away the leading cause of deaths worldwide; the epidemic of CVD in the low and middle income countries is rampant and the alarming increases in obesity and diabetes threaten to reverse or blunt the steady decline in CVD mortality, particularly in younger people. The focus on prevention is as imperative now as it ever has been. This is the 3rd iteration of the Joint British Societies ( JBS) recommendations for the prevention of cardiovascular disease. Current prevention strategies tend to focus upon patients at relatively short term (10-year) risks and upon specific thresholds for pharmacologic therapies, although there is considerable variability among the different guidelines. This approach is logical and has been successful in directing therapy to those at highest risk who stand to gain the greatest benefit. A unique aspect of JBS3 is the emphasis upon the lifetime risk of CVD events, so as to encompass a large pool of people in the population who have a lower 10-year risk of a CVD event but who nevertheless have a high lifetime event risk. Such predominantly younger patients and women might be excluded from therapy based upon the ‘high risk strategy’, even though they have a high rate of …

The population prevalence of moderate or severe valve disease in industrialised countries is as high as 13% in those aged 75 years or older.1 Undetected valve disease leads to premature death1 but valve surgery, when indicated, can prolong life.2 Access to medical care in industrialised countries is usually good, but limitations exist3 and better ways of organising care are needed.4 A working group was therefore convened by the British Heart Valve Society with representatives of all interested national bodies and a panel of invited international commentators. The aim was to produce recommendations to improve the detection, conservative management and interventional treatment of valve disease. This paper focusses on conservative management and proposes recommendations for overcoming limitations in care by means of a specialist valve clinic. The initial management of patients with valve disease is usually conservative and meticulous follow-up is then vital. However, accepted management guidelines are not followed adequately.5–7 Furthermore, the application of accepted guidelines requires specialist experience especially in determining whether a patient is genuinely asymptomatic. Most patients with valve disease are still cared for by general cardiologists or general physicians who may be less skilled than a valve disease specialist in making a diagnostic formulation. Furthermore, it is likely that advances in practice are more slowly assimilated by a generalist than by a cardiologist who undertakes specialist continuing education. As a result, patients are often referred for surgery too late. In the EuroHeart Survey,6 approximately one half of patients were in New York Heart Association class III or IV at the time of valve surgery. At least one third of elderly patients with severe aortic stenosis are not referred for surgery at all even when clinically indicated.8 Developing a percutaneous valve programme leads to increased rates of conventional surgery suggesting …