Volume 11, Number 5, September-October 2004

HOT
TOPICEDITORIALNICE try but a long way to go in heart failure
Andrew Owen

Br J Cardiol 2004;11:339-341.

HOT
TOPICEDITORIALLow haemoglobin in patients with chronic heart failure: common but commonly ignored
Paul R Kalra

Br J Cardiol 2004;11:343-345.

EDITORIALFashioning a new approach to heart disease in women
Vahini V Naidoo

Br J Cardiol 2004;11:347-349.

HOT
TOPICPRIMARY CARECommunity echocardiography for heart failure
A consensus statement from representatives of the British Society of Echocardiography, the British Heart Failure Society, the Coronary Heart Disease Collaborative and the Primary Care Cardiovascular Society.

Br J Cardiol 2004;11:399-402.

PRIMARY CAREEchocardiography in the community: mind the gap
Gerald Partridge

In the first of two commentaries on echocardiography in the community, general practitioner Gerald Partridge writes about his personal experiences with providing such a service in Keighley, West Yorkshire.

Br J Cardiol 2004;11:403-404.

PRIMARY CAREEchocardiography in the community
Ed Southall

In the second commentary on echocardiography in the community, general practitioner Ed Southall writes about the new British Society of Echocardiography accreditation process and his own experiences in running a community echocardiography service in South Devon.

Br J Cardiol 2004;11:405-407.

PRIMARY CAREBeta blocker therapy for patients with heart failure in primary care
David Wald, Sarah Milne, Richard Chinn, Margaret Martin, Ranjit More

Beta blockers are under-used in heart failure, despite their evident benefits. Here an educational and clinical support link between secondary and primary care was set up to mentor a nurse practitioner in heart failure management. A nurse-led heart failure clinic was established in a Hampshire general practice that enabled beta blocker therapy to be started safely and up-titrated successfully, without hospital referral.

Br J Cardiol 2004;11:408-412.

REVIEWThe prevalence and natural history of anaemia in an optimally treated heart failure population
Enda Ryan, Maeve Devlin, TerEnce Prendiville, Mark Ledwidge, Kenneth McDonald

The prevalence of anaemia in heart failure (HF) is becoming better recognised, yet little is known about its natural history in a HF population.
We examined the records of 200 consecutive patients who were admitted to our service with New York Heart Association (NYHA) class IV HF, survived and were followed for six months following discharge. Complete records were available on 120 patients. Anaemia was defined as a haemoglobin concentration of < 13 g/dL in males and < 12 g/dL in females. Forty-one patients (34%) were found to have anaemia of unknown cause on admission. At follow-up (mean time 6.1+0.3 months), 28 patients were persistently anaemic. The haemoglobin concentration in the remaining 13 had returned to normal. A further group of 11 patients had become anaemic during the six-month follow-up period. All patients had been treated with maximally tolerated medical therapy. Anaemia was found to be equally prevalent in patients with preserved systolic function HF. Factors found to be independently associated with lower haemoglobin at follow-up were female sex, a history of gastrointestinal disease, inflammatory disease and a low glomerular filtration rate (GFR). Haemoglobin concentration at follow-up was found, on univariate analysis, to be associated with an increased risk of a HF-related admission during the follow-up period and increased severity of HF symptoms. On multivariate analysis, haemoglobin concentration at follow-up was found to be an independent predictor of NYHA class III–IV symptoms. In conclusion, anaemia is prevalent in a population admitted with class IV failure. While the haemoglobin concentration had normalised in a significant number of patients during follow-up, the presence of anaemia six months after discharge was associated with having a HF-related readmission and independently associated with moderate-to-severe HF symptoms.

Br J Cardiol 2004;11:369-375.

HOT
TOPICREVIEWCocoa, flavanols and cardiovascular risk
Norman K Hollenberg, Harold Schmitz, Ian MacDonald, Neil Poulter

There has been a long-standing interest in the relation between what we eat and cardiovascular risk. Over the years, attention has been given to calories, total fat, saturated fat, cholesterol, omega-3 polyunsaturated fatty acids, trans fatty acids, folic acid, antioxidants and, most recently, flavanols. Flavanol concentrations can be moderately high in a number of foods that have been associated with a reduction in cardiovascular risk including red wine, and black and green tea. Some cocoa and chocolate products are extraordinarily rich in flavanols but, as with other flavanol-containing foods, certain post-harvesting and processing procedures can have a striking influence on the flavanol content of chocolate and cocoa.
Endothelial dysfunction with a consequent reduction in nitric oxide production has achieved a central conceptual role in the pathogenesis of atherosclerosis and coronary artery disease, diabetes mellitus and hypertension. Recent evidence that flavanol-rich cocoa activates vascular nitric oxide synthesis in the intact human raises an interesting possibility of a therapeutic potential.

Br J Cardiol 2004;11:379-386.

REVIEWLowering blood pressure for the secondary prevention of stroke
Joanna K Lovett

Hypertension is the most important modifiable risk factor for stroke. The risk of stroke increases directly in proportion to systolic and diastolic blood pressure, and lowering blood pressure can reduce the risk of a first stroke by up to 40%. Current evidence suggests that it is safe and effective to lower blood pressure with an ACE inhibitor and a thiazide diuretic in patients with established cerebrovascular disease. The reduction in subsequent stroke is present both in hypertensive and non-hypertensive patients and is most likely to be related directly to the blood pressure- lowering effect. Ongoing studies will help to determine whether other classes of drugs, such as the angiotensin receptor blockers, are also safe and effective in the secondary prevention of stroke, and whether blood pressure should be lowered in the first few days after a major stroke.

Br J Cardiol 2004;11:388-392.

HOT
TOPICREVIEWThe treatment of peripartum cardiomyopathy
Stephen J Leslie, Yaso Emmanuel, C Mark Francis, Andrew D Flapan

Peripartum cardiomyopathy (PPCM) is characterised by the development of left ventricular (LV) dilatation and dysfunction during the last month of pregnancy, or the first five months of the post-partum period, in the absence of any pre-existing cardiac disease. PPCM is a rare but serious complication of pregnancy, with a variable outcome. Symptoms such as breathlessness and peripheral oedema are common in normal pregnancy and it is easy to misdiagnose PPCM in its early stages. The aetiology of the condition is uncertain.
Treatment options are similar to those for other forms of dilated cardiomyopathy. However, there are important considerations when treating women with PPCM as they may be pregnant or breast feeding. Close communication is required between cardiologists, obstetricians and neonatologists, not only for the treatment of the PPCM patient but also for protection of the baby. Women who decide to continue with further pregnancies should be carefully monitored.

Br J Cardiol 2004;11:393-396.