Volume 12, Number 2, March-April 2005

EDITORIALLiving with chest pain
Richard A Best

Br J Cardiol 2005;12:85-89.

PRIMARY CAREOrganising primary prevention: an approach by multifactorial risk score profile
John M Waddell, Caron Neal

Interventions on individual risk factors are most effective when directed at those with highest absolute risk. Joint British Society Guidelines and National Service Frameworks (NSF) indicate that these individuals should be identified. There is a need to continuously categorise the population by risk to identify those for primary prevention. This article describes a project that was set up to use clinical information technology in an innovative way. It was introduced as an administrative routine for the whole population of a large district (Blyth Valley, Northumberland) through the general practices to which the patients belong.

Br J Cardiol 2005;12:149-154.

HOT
TOPICPRIMARY CAREThe definition of maximally tolerated blood pressure treatment
Terry McCormack, Mark Davis

The new General Medical Services contract has introduced the term ‘maximally tolerated blood pressure treatment’, which it defines as a cut-off point at which a doctor might advise the patient to accept the current blood pressure level. Whilst this is a sensible idea, the contract does not give any guidance as to how the doctor should decide when that point has been reached. In this article the Primary Care Cardiovascular Society considers the issue, looking at available evidence, and publishes a consensus statement on the definition for maximally tolerated blood pressure treatment.

Br J Cardiol 2005;12:156-160.

HOT
TOPICREVIEWThe management of hypertension in patients with benign prostatic hyperplasia and erectile dysfunction
Michael Kirby, Roger Kirby

Lowering elevated blood pressure reduces mortality and the risk of stroke, coronary heart disease and heart failure.
The presence of benign prostatic hyperplasia (BPH) is a compelling indication for the use of an alpha blocker in the treatment of hypertension. Alpha blockers are first-line therapy for men with lower urinary tract symptoms (LUTS) and prostatic hyperplasia. In men with prostates larger than 30 cm3 or prostate-specific antigen > 1.4 ng/ml, 5-alpha reductase inhibitors may also be added. Typically, alpha blockers improve LUTS by 30–40% and maximum urinary flow rates by 16–25%, with clinical improvement within two weeks. The 5-alpha antagonists are only effective in men with a large prostate and may take up to six months to achieve their full effect.
The Medical Treatment of Prostatic Symptoms (MTOPS) study assessed the long-term effects of doxazosin, finasteride and combination treatment on symptom scores, the clinical progression of BPH and the long-term risk of complications. Combination treatment reduced the risk of clinical progression by 66%, a significantly greater reduction than that induced by either agent alone. The improvement in the symptom score was also significantly greater in the combination treatment group.
Erectile dysfunction (ED) may be a marker for other diseases, such as hypertension. ED is both more prevalent and more severe among patients with hypertension than among the general population. The link may be related to nitric oxide/cyclic GMP pathways and endothelial function. Many prescription drugs are associated with ED, including antihypertensive agents. The alpha blockers and angiotensin receptor blockers are the drugs least likely to cause ED, and may even improve the situation. All currently licensed ED treatments are suitable for managing ED in the cardiovascular patient, when used according to the manufacturer’s instructions. PDE5 inhibitors and alpha blockers should be temporally separated, or selective alpha blockers may be preferable, in order to avoid postural hypotension.

Br J Cardiol 2005;12:107-116.

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TOPICREVIEWDyslipidaemia in ethnic populations: special considerations
Anthony H Barnett

There is extensive evidence of an increased risk of coronary heart disease (CHD) amongst South Asians (Indo-Asians) compared with Caucasians. This increased risk is not explained by conventional risk factors for CHD, such as smoking, hypertension and elevated total cholesterol levels. Studies have consistently demonstrated an increased prevalence of metabolic abnormalities including insulin resistance, diabetes, impaired glucose tolerance and dyslipidaemia, characterised by low plasma levels of high-density lipoprotein cholesterol (HDL-C) and high levels of triglycerides and lipoprotein a (Lp[a]), amongst South Asians. Together these factors predispose to accelerated atherosclerosis, and this is accentuated by adoption of a Western lifestyle. Nicotinic acid is the most potent lipid-modifying therapy for increasing HDL-C (by up to 30%), and is also effective in reducing triglycerides and Lp(a). Clinical studies in Caucasian patients have shown that nicotinic acid can also be safely used in patients with controlled type 2 diabetes. Long-term intervention studies have demonstrated the clinical benefits of nicotinic acid treatment, reducing cardiovascular morbidity and mortality in Caucasian patients with CHD. Nicotinic acid could potentially offer important therapeutic benefits in South Asians. Further clinical studies in this patient group are needed to substantiate this potentially useful treatment strategy and identify specific groups that would derive most benefit.

Br J Cardiol 2005;12:118-122.

HOT
TOPICREVIEWA review of olmesartan medoxomil – a new angiotensin II receptor blocker
Andrew Whittaker

Blockade of the renin-angiotensin system by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) has been shown to be effective in treating hypertension and heart failure. There are currently seven ARBs in clinical practice, of which olmesartan medoxomil (Olmetec®) is the newest agent in the class. This article reviews the pharmacokinetics, pharmacodynamics, safety, efficacy, clinical use, dosing and cost of olmesartan medoxomil. This information is based on published data from human efficacy, safety and drug comparison studies. Olmesartan medoxomil (10–40 mg) has been shown consistently to achieve significant reductions in both systolic and diastolic blood pressures in human studies, which persist over the course of one year. There are limited, mainly experimental, data on its use in heart failure and atherosclerosis.
It is an effective and well-tolerated agent with a long duration of action, allowing once-daily dosage in the treatment of hypertension.

Br J Cardiol 2005;12:125-129.

HOT
TOPICREVIEWShould all diabetic patients receive an ACE inhibitor? Results from recent trials
Claire McDougall, Gillian Marshall, Adrian JB Brady, Miles Fisher

Diabetes is associated with both premature cardiovascular disease and renal disease. The presence of microalbuminuria is itself an independent risk factor for the development of cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors were initially shown to slow the progression of established renal disease in patients with type 1 diabetes. Subsequent trials have demonstrated a similar benefit in patients with type 2 diabetes and with the use of angiotensin II receptor blockers (ARBs). The use of ACE inhibitors to prevent cardiovascular events in patients with established cardiovascular disease but not left ventricular dysfunction was established in two large randomised trials – HOPE and EUROPA. These benefits were maintained within the diabetic subgroups of these trials and appear to be independent of blood pressure lowering. The LIFE trial also provides evidence of the benefits of ARBs in reducing cardiovascular events in a high-risk population of diabetic patients with hypertension and left ventricular hypertrophy. Ideally, therefore, all diabetic patients with renal or cardiovascular disease should be treated with ACE inhibitors or ARBs.

Br J Cardiol 2005;12:130-134.

REVIEWA randomised controlled study of ramipril dose-escalation packs in clinical practice
Stephen J Leslie, Sharon A Faulds, Andrea Rankin, Allister D Hargreaves

The benefits of angiotensin-converting enzyme (ACE) inhibitors occur early in the treatment period and may be dose-dependent. The utilisation of ACE inhibitors in cardiovascular patients is often suboptimal. This current study evaluates the clinical use of a specific ACE inhibitor dose-escalation pack.
Fifty hospital in-patients with a definite indication for ACE inhibitor therapy were randomised to receive either a dose-escalation pack or 'usual' initiation and escalation of ramipril. Patients and general practitioners received an information sheet outlining the benefits and risks of ACE inhibitors and the need for monitoring of serum urea and electrolytes. The groups were matched for age, gender, deprivation score and blood pressure. One patient died in each group and one patient withdrew from the control group. More patients in the dose-escalation group reached target dose by six weeks (72% vs. 33%; p< 0.01) and three months (67% vs. 35%; p<0.05). At three months, there were no differences in serum creatinine, urea or potassium (all p>0.05). Cough was the most commonly reported side effect although there was no difference in its incidence between the dose-escalation and control groups (8% vs. 6%, p>0.05). This study demonstrates that the use of a specific dose-escalation pack for the ACE inhibitor ramipril is a simple, reliable and safe mechanism for reaching a target dose. This approach could find utility with other drug therapies.

Br J Cardiol 2005;12:136-138.

REVIEWA brief report on the data available on rapid access cardiology clinics
Joanna N Tenkorang, Kevin F Fox, David A Wood

Rapid Access Cardiology Clinics were introduced many years ago for the assessment of chest pain. Following the publication of the National Service Framework (NSF) for Coronary Heart Disease (CHD)1 the number of rapid access chest pain clinics (RACPCs) has expanded dramatically. Standard 8 of the NSF for CHD describes the use of chest pain clinics to provide specialist advice to people with symptoms of angina or suspected angina. One of the goals of the NSF was that there should be at least 100 RACPCs in the UK by April 2002. This goal has been superseded.
More recently, rapid access clinics have also been introduced for the assessment of suspected cases of heart failure and cardiac arrhythmias.
While the concept is that a prompt ‘one-stop’ assessment provides care that is clinically superior to traditional services in a cost-effective manner, there are few data describing outcomes of the patients seen in these services. In this report, we review the available evidence on rapid cardiology services.

Br J Cardiol 2005;12:139-141.

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TOPICREVIEWCurrent ECG telemetry practice in the UK: a national audit
Analie Grimshaw, Eugénie Di Stefano, Stephen Saltissi

Electrocardiographic monitoring by telemetry has become commonplace throughout the UK. This survey was designed to assess its availability, to determine current practice and so to inform future recommendations for optimal telemetry working practice.
Data were collected via postal questionnaire followed by telephone contact. Questionnaires were completed by 280 (99.3%) of the 282 coronary care units (CCUs) contacted. Telemetry is now widely available, with 77.3% of CCUs offering a service, though practice varies widely from unit to unit. Only 15% of telemetry services were supported by written protocols, telemetry duration was routinely set in only 17.4% and interrogation was haphazard, with fewer than 27.2% of units investigating each symptomatic event.
Overall responsibility for the service was unclear, and routine medical input occurred in only 48.6% of services. The task of telemetry monitoring was delegated to relatively junior CCU nursing staff (94% D/E grade). Verbal information was commonly given to patients, but written information was very rare (2.75%). Some 70% obtained no formal patient consent (written or verbal) prior to commencing telemetry. Nonetheless, CCU staff felt strongly that the service was valuable and affected patient care positively.
UK telemetry practice is haphazard, variable and poorly supported by adequate protocols. The potential for missing arrhythmias and/or for mismanaging them is evident, making a strong case for practice guidelines defining the responsibilities of staff involved, identifying best practice and outlining supportive educational requirements.

Br J Cardiol 2005;12:142-144.

REVIEWAngiotensin-converting enzyme polymorphism in Turkish male athletes: relationship to left ventricular mass and function
Dursun Dursunoglu, Halil Tanriverdi, Harun Evrengul, Günfer Turgut, Sebahat Turgut, Osman Genç, H Asuman Kaftan, Mustafa KIlIç

Angiotensin-converting enzyme (ACE) is a key enzyme in the production of angiotensin II. The cloning of the ACE gene has made it possible to identify a deletion (D)-insertion (I) polymorphism that appears to affect the level of serum ACE activity. The aim of our study was to analyse the ACE gene I/D polymorphism in Turkish male athletes and to evaluate its relationship to left ventricular mass and function.
Forty male athletes (mean age 23.4+1.8 years) were included in this study, and they underwent both complete echocardiographic assessment and analysis of ACE I and D allele frequencies in peripheral blood by polymerase chain reaction. They were separated into three subgroups according to their ACE DD (n=13), DI (n=16) and II (n=11) genotypes. Thickness of the interventricular septum (IVS), the left ventricular posterior wall (LVPW) and left ventricular mass (LVM) and LVM index (LVMI) were measured by the M-mode. Left ventricular ejection fraction was calculated using Simpson’s method, and so was the myocardial performance index.
There was no statistically significant differences between the ACE DD, DI and II genotypes at the p>0.05 level by age, body mass index, heart rate, systolic and diastolic blood pressures. The thickness of the IVS (12 mm) and LVPW (10.7 mm), and LVM (302.8 g) and LVMI (157.3 g/m2) in ACE DD genotypes were higher than for both ACE DI (10.8 mm; 9.7 mm; 231.9 g; 125.3 g/m2) and II genotypes (9.0 mm; 8.6 mm; 185.0 g; 107.5 g/m2) in athletes. Left ventricular systolic and global functions among the three ACE genotypes were not different statistically.
Our findings suggest that left ventricular hypertrophy is partially determined by genetic disposition and DD genotype of ACE is a potential genetic marker associated with an elevated risk of left ventricular hypertrophy.

Br J Cardiol 2005;12:145.

CASE REPORTAneurysms of the sinus of Valsalva following infective endocarditis
Analie Grimshaw, Eu Krishna Adluri, Chris J Smallpeicegénie Di Stefano, Stephen Saltissi

Br J Cardiol 2005;12:146-148.

AICInterventional cardiology training in the UK: time for a change?
Nick Curzen

Br J Cardiol 2005;12:AIC5-AIC7.

HOT
TOPICAICElevation of troponin I in acutely ill medical patients: a pilot study and literature review
Jonathan Watt, Andrew P Davie, Anne Cruickshank

Previous studies have identified a significant incidence of clinically unrecognised myocardial ischaemia in intensive care unit (ICU) patients, as determined by elevation of serum troponin. This pilot study demonstrates a similar high frequency of such a phenomenon in patients who are acutely ill, but without clinical evidence of myocardial ischaemia, on the general medical wards of a large city hospital. Elevation of serum troponin in these patients is associated with higher hospital mortality and increased lengths of hospital stay. Recognition that slight elevation of troponin levels may occur in the context of significant medical illness in acute general medical ward patients is important as it may avoid erroneous diagnosis of myocardial infarction and subsequent unnecessary investigations. A literature review of the various causes of an elevated troponin result is then presented.

Br J Cardiol 2005;12:AIC9-14.

AICImmediate stent recoil: a forgotten phenomenon
Julian Gunn, David Beacock, Allison Morton, John Bowles, David Crossman

We sought to measure immediate stent recoil (before vs. after deflation of the deployment balloon) in diseased coronary artery segments. Immediate recoil has not been assessed since the early days of stenting.
We performed a prospective study in 120 consecutive, high pressure-stented coronary artery lesions. Angiographic images of the stent on the balloon during final balloon inflation, and of the reated segment of artery immediately afterwards, were recorded in two projections. The unconstrained balloon was measured at nominal pressure in the aorta for validation. Measurements were made blind, off-line. Comparison was made with the diameters quoted by the manufacturer for the balloon pressures used.
The stent deployment pressure was 12.82(SEM 0.30) atm. Measurement of the balloon at nominal pressure in the aorta disclosed an accuracy of 99% (the manufacturer's stated balloon/stent diameter at nominal pressure was 3.16[0.07] mm and the measured value was 3.20[0.07] mm). The manufacturer's stated balloon/stent diameter at deployment pressure was 3.37(0.05) mm ('100%'), whereas the balloon/stent in the diseased segment measured 3.23(0.05) mm (96[1.5]%) and the final stented segment measured 3.02(0.05) mm (90[1.5]%) (p<0.0001 for all).
Even using contemporary stents at high pressure, undersizing of the stent occurs by 4% compared to the manufacturer's stated size at deployment pressure. There is immediate recoil of a further 6% when the balloon is deflated, presumably due to constraint by the surrounding atherosclerotic vessel. Stents may prevent late, but not immediate, recoil. The stented segment diameter is 10% smaller than intended.

Br J Cardiol 2005;12:AIC15-19.

AICRisk of death, MI and patterns of care delivered in non-ST elevation ACS patients with intermediate elevations in cardiac troponin T: a UK DGH experience
Kausik Ray, James Bolton, Alice Veitch, Paul Sheridan, Michael Gillett, Ahmed Al Rifai, Ramasamy ManivArmane, Alan Brennan, Gillian Payne, Wazir Baig

Prior studies have suggested a gradation in clinical risk with increasing elevations of cardiac troponins in patients with non-ST elevation acute coronary syndromes (ACS). We hypothesised that patients with cardiac troponin-T (cTnT) between 0.01-0.1 µg/L might be perceived as a low-risk group and consequently receive less active medical treatment.
Data were drawn from a UK district general hospital ACS registry between 2001 and 2002, and from the Office of National Statistics. A total of 255 patients were found to have had a non-ST elevation ACS with a cTnT rise between 0.01-0.10 µg/L.
Minor elevations in cTnT below 0.1 µg/L were found to be associated with a 20.1% risk of cardiovascular death or myocardial infarction (MI) at six months, with no ascending grade of risk from the lowest to the highest quintile. The use of statins (48.6%), angiotensin- converting enzyme (ACE) inhibitors (46.7%) and combined antiplatelet treatment (7.5%) was low, as was the use of angiography (8.2%) and stress testing (8.2%). In patients not undergoing early angiography, non-use of statins and ACE inhibitors was associated with twice the risk of death or MI (p=0.02). In a multivariate analysis, ST segment depression and non-use of ACE inhibitors were significant markers of risk.
Patients with non-ST elevation ACS and a cTnT between 0.01–0.1 µg/L are a universally high-risk group with no gradation of risk throughout this range. In a representative UK district general hospital (DGH), use of cardioprotective medication and cardiovascular assessment is low. An increased use of statins, ACE inhibitors and antiplatelet drugs, together with early angiography, might improve prognosis in this group.

Br J Cardiol 2005;12:AIC22-26.

AICDelivering a modern PCI service: can we change with the times?
Michael S Norell, Saib S Khogali, James M Cotton, Michael R Cusack

The volume and complexity of patients undergoing percutaneous coronary intervention (PCI) is growing steadily. This, and the increasing tendency for these procedures to be unplanned, requires us to rethink the way we deliver care in this setting. This article addresses the processes involved, which include pooling of PCI lists, multidisciplinary team meetings and integrated care pathways for both elective and unplanned cases. The value of pre-assessment clinics, specific cardiac triage teams and “generic” catheter lab workers is also discussed. More traditional elements of the service such as on-call rotas are reappraised. Newer concepts, like dedicated PCI meetings to plan strategy and review previous problem cases for educational purposes, are also introduced.

Br J Cardiol 2005;12:AIC27-30.

AICComplex cardiac myxoma
David J Fox, Geir J Grötte, Lawrence Cotter

Cardiac myxomas are the most common benign intracardiac tumour, and are more common in women. Since many patients suffer from cerebral or systemic embolism, early diagnosis is vital to plan for surgical intervention. Surgical excision is advocated as soon as possible, particularly in left atrial myxoma, because of the high risk of valvular obstruction and systemic embolisation. Patients with a family history of the disorder are at greater risk of tumour recurrence.

Br J Cardiol 2005;12:AIC31-32.