Volume 12, Number 1, January-February 2005

EDITORIALTowards sensible eating, how far do we have to go?
Anne Nugent

Br J Cardiol 2005;12:5-7.

EDITORIALARBITER-2: judging the next step in lipid management
Anthony S Wierzbicki

Br J Cardiol 2005;12:9-10.

HOT
TOPICPRIMARY CAREEvidence-based treatment of hypertension: what’s the role of angiotensin II receptor blockers?
FD Richard Hobbs, Peter Irwin, Janet Rubner

Many large studies have confirmed the importance of controlling hypertension in reducing cardiovascular morbidity and mortality. Prescribers are now faced with a wide choice of antihypertensives and a growing body of evidence about their effects.
This article reviews recent evidence about angiotensin II receptor blockers (ARBs). It concludes that they are effective in reducing blood pressure and cardiovascular disease. ARBs also have a renoprotective effect in diabetes. They are generally better tolerated than ACE inhibitors or beta blockers. Newer members of the class may be more effective than older ones at controlling hypertension, and combinations of ARBs with ACE inhibitors may be more effective than either drug alone. Many patients will require combinations of different classes of antihypertensive agents, and ARBs have an important place in providing therapy tailored to the needs of the individual patient.

Br J Cardiol 2005;12:65-70.

PRIMARY CAREDeveloping an evaluated patient-mediated intervention for monitoring amiodarone therapy
Jill Murie

Br J Cardiol 2005;12:71-73.

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TOPICREVIEWThe role of candesartan in the treatment of chronic heart failure
Hugh F McIntyre

The renin-angiotensin system (RAS) plays a fundamental role in cardiovascular pathophysiology. In particular, angiotensin II (AII) has been identified as a culprit in endothelial and vascular damage, elevated blood pressure, and cardiac failure. Pharmacological inhibition of this system is available through two mechanisms; the reduction of AII formation by inhibition of angiotensin-converting enzyme (ACE), and by direct blockade of the type 1 angiotensin II receptor by angiotensin II receptor blockers (ARBs).
Angiotensin-converting enzyme (ACE) inhibitors have a proven role in the management of elevated blood pressure and diabetes and may confer specific vascular benefit. In patients with chronic heart failure (CHF) secondary to left ventricular systolic dysfunction (LVSD), there is extensive evidence that, when compared to placebo, ACE inhibitors reduce morbidity and mortality. Randomised placebo controlled trials have also shown ACE inhibitors reduce all-cause mortality and major cardiovascular events after myocardial infarction.
Given the unequivocal benefit of ACE inhibitors, initial studies with ARBs in patients with LV dysfunction (in CHF and following myocardial infarction) have focused on two areas: the role of ARBs when compared with ACE inhibitors, and when combined with ACE inhibitors.
Only recently, with the results of the CHARM study, have the role of ARBs when compared to placebo in a population with CHF been clarified. This study also addressed the benefit of ARBs in patients with heart failure and preserved LV systolic function.

Br J Cardiol 2005;12:31-36.

HOT
TOPICREVIEWCurrent insights and new opportunities for smoking cessation
Hayden McRobbie

Assisting smokers to stop smoking is often seen as a difficult task but is crucial for health improvement, especially for those with established cardiovascular disease. Healthcare professionals are now, more than ever, in a position to help smokers who want to stop. For the greatest chance of success smokers should be referred to stop smoking services that provide multi-session treatment combining intensive behavioural support with nicotine replacement therapy or bupropion. Promising new medications are being developed that will add to the current treatment strategies and may give smokers a greater chance of stopping for good.

Br J Cardiol 2005;12:37-44.

REVIEWUsing the Framingham coronary risk appraisal functions to derive the expected annual number of UK coronary artery disease events
Arran Shearer, Paul Scuffham, David E Newby

The Framingham Heart Study investigators have recently developed new coronary risk appraisal functions which relate risk factors to the short-term probability of experiencing cardiovascular disease events. We populated the risk appraisal functions with UK data and estimated that approximately 256,000 new coronary artery disease (CAD) events occur annually in the UK. Approximately half of the estimated CAD events were acute myocardial infarctions (AMI) and almost three quarters occurred in men. Our estimates fit well with hospital in-patient data but less well with British Heart Foundation estimates of AMI and angina. Differences between US and UK relative risks, clinical practice and populations may account for these discrepancies. Our estimates may be considered as a lower limit of the annual number of UK CAD events.

Br J Cardiol 2005;12:47-49.

HOT
TOPICREVIEWAudit of cardiac rehabilitation in light of the National Service Framework for coronary heart disease
Fiona Taylor, Andrew Beswick, Jackie Victory, Karen Rees, Ingolf Griebsch, Robert West, Rod Taylor, Jackie Brown, Margaret Burke, Shah Ebrahim

In England, the National Service Framework (NSF) defines a role for clinical audit in cardiac rehabilitation. Areas that audit should consider include: eligibility, recruitment, and patient age, sex and ethnicity. We surveyed cardiac rehabilitation centres to assess these parameters. We contacted 51 centres in 2002. Thirty-three (65%) reported that audit had been undertaken and 24 (47%) were prepared to share information obtained. Reasons for not collecting audit data were lack of time, resources, computing facilities, personnel, training or support. Fifty per cent of audits supplied relied on a ‘paper system’ with retrospective data extraction, and the others used regularly updated computerised databases. Ninety-one per cent of centres with audit reported information on recruitment but only 43% reported numbers eligible. Information on sex, age and ethnicity was collected by 70–87% of centres but more complete information (adequate for analysis of equity of service use by sex, age and minority ethnic group) was collected by only 30%, 26% and 22% of centres, respectively.
In England, cardiac rehabilitation audit data collection is uncoordinated despite the standards set out in the NSF. A national and policy-driven standardised audit tool and appropriate facilities, staff and funding could facilitate the identification of eligible patients and the following of patients through rehabilitation. Audit may help to make certain that local provision of cardiac rehabilitation is inclusive and ensure that patients are attending.

Br J Cardiol 2005;12:50-52.

CASE REPORTEarly amiodarone pulmonary toxicity simulating heart failure
Manoj Bhandari, Trevor W Maskell, Ian D Pavord, Peter J Hubner

Br J Cardiol 2005;12:62-63.

HEART BRAINHoles and strokes
Mushtaq Wani, Ranjini Navaratnasingam

Five case histories are described to illustrate the importance of patent foramen ovale and atrial septal aneurysm as risk factors in stroke aetiology. Diagnostic methods, and the current and future management of these atrial septal defects, are briefly discussed.

Br J Cardiol 2005;12:53-56.

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TOPICHEART BRAINAntiplatelet therapy for stroke prevention
Lian Zhao, Stan Heptinstall, Philip Mw Bath

Antiplatelet therapy plays a major role in the secondary prevention of ischaemic stroke. The antiplatelet agents that are most used in the clinic include aspirin, dipyridamole and clopidogrel. These agents inhibit platelet activation through different mechanisms of action. Aspirin is the first-line drug in the secondary prevention of stroke; a combination of aspirin with dipyridamole produces a synergistic antithrombotic effect. Clopidogrel is slightly more effective than aspirin at reducing the risk of ischaemic events. Trials comparing the combination of aspirin and clopidogrel versus aspirin are underway. Intravenous antiplatelet therapy with glycoprotein IIb/IIIa receptor inhibitors for acute stroke and as an adjunct to carotid artery stenting appears promising. However, oral GPIIb/IIIa receptor inhibitors appear hazardous.

Br J Cardiol 2005;12:57-60.