Volume 12, Number 4, July-August 2005

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TOPICEDITORIALFat and visceral fat: time for cardiologists to act against obesity
Michael EJ Lean, Thang S Han

Br J Cardiol 2005;12:249-253.

EDITORIALWhat’s in a name? From anticoagulation clinics to thrombosis management centres
David A Fitzmaurice

Br J Cardiol 2005;12:255-256.

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TOPICPRIMARY CAREAtrial fibrillation: strategies in primary care
Michael Kirby

This article describes the diagnosis, classification and management of atrial fibrillation (AF) in primary care. It looks at its increasing incidence, its risk factors, and the identification and classification of this common arrhythmia. The routine investigations for AF and its treatment, including drug therapy and cardioversion, are also discussed. Finally, with AF being a major risk factor for stroke, strategies to prevent thromboembolism are considered.

Br J Cardiol 2005;12:308-311.

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TOPICPRIMARY CAREAdditional benefits versus practicalities of beta-blocker use in CHF patients: the ‘some is better than none’ rule
Graham Archard

Treatments for heart failure include digoxin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists and beta blockers. Beta blockers have been contra-indicated until fairly recently, with recognition of the role of the sympathetic nervous system in chronic progression of heart damage.
Benefits of beta blockade, proven in clinical trials, include reduction in all-cause mortality, sudden death, hospitalisation rates for heart failure, and reversal of some degree of heart damage. Carvedilol and bisoprolol are currently licensed in the UK for chronic heart failure. National Institute for Clinical Excellence (NICE) guidelines give recommendations for initiation of treatment, dose titration and management of adverse effects. Benefits are still apparent in patients who cannot tolerate target drug doses. Several studies show, however, that beta blockers are underprescribed in general practice.

Br J Cardiol 2005;12:313-317.

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TOPICREVIEWShould all diabetic patients receive aspirin? Results from recent trials
Nick Barwell, Gillian Marshall, Claire McDougall, Adrian JB Brady, Miles Fisher

Atherosclerotic cardiovascular disease (CVD) is common in patients with diabetes, and antiplatelet therapy has been the cornerstone of preventative therapy for many years. The majority of the evidence for the use of aspirin in patients with diabetes comes from subgroup analysis of major secondary prevention trials. Secondary prevention data from the Antiplatelet Trialist’s Collaboration meta-analysis suggests that the benefit derived from aspirin is similar in diabetic and non-diabetic populations. In the general population, data from primary prevention studies have shown the benefit of aspirin in terms of cardiovascular mortality, but there is little evidence to suggest that aspirin is beneficial in terms of total or cardiovascular mortality for primary prevention in a diabetic population. Clopidogrel may have advantages over aspirin and combined therapy may be superior for certain types of coronary artery disease and stroke, although this is offset by an increased risk of haemorrhage in the latter setting. The use of aspirin in the prevention of CVD in patients with diabetes should therefore be focused on those with a history of vascular events or aggressively treated hypertension.

Br J Cardiol 2005;12:275-282.

REVIEWMilk, heart disease and obesity: an examination of the evidence
Peter Elwood, Janie Hughes, Ann Fehily

Milk drinking causes a rise in serum cholesterol level and it is therefore assumed that this will increase vascular disease risk. At the same time, a reduction in blood pressure by milk is largely ignored. An overview of large, long-term cohort studies gives no evidence of an increase, but rather, a significant reduction in vascular disease risk in subjects with a high milk intake relative to those who report drinking little or no milk.
Overweight is a positive factor in vascular disease and a common perception of milk is that it causes an increase in body weight. However, many observational studies show a negative association and while there have been only a few randomised trials, overall these support a beneficial effect of milk on weight, on body fat, and upon weight loss achieved by a calorie reduced diet. The mechanisms involved in these relationships are inadequately understood, but calcium is likely to be involved. Milk is the major source of calcium and yet milk intakes in the UK and in many other countries have been falling for many years.
In view of the evidence of benefit in vascular disease and on body weight, it is argued that every effort should be made to reverse the present decline in milk consumption.

Br J Cardiol 2005;12:283-290.

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TOPICREVIEWComparison of two- and three-drug combination therapy with candesartan in patients with severe hypertension
Heinrich Holzgreve, Reinhard Gotzen, Gerhard Kiel

The efficacy and tolerability of two candesartan treatment regimens were evaluated in 578 severely hypertensive patients already receiving a diuretic plus an angiotensin-converting enzyme (ACE) inhibitor, a calcium channel blocker (CCB) or a beta blocker. Existing treatments were standardised during a two-week run-in period. Patients with uncontrolled blood pressure (diastolic blood pressure [DBP] > 90 mmHg) were randomly switched to a regimen comprising candesartan 16 mg plus hydrochlorothiazide (HCT) 12.5 mg once daily for four weeks (switch regimen, n=291), or had candesartan 8 mg once daily added to their existing treatment (add-on regimen, n=287). After four weeks’ treatment, mean sitting DBP was reduced from baseline by 11.2 mmHg (SD 11.2) and 13.9 mmHg (SD 11.5) in the switch and add-on treatment groups, respectively. Mean sitting SBP was decreased by 15.3 mmHg (SD 18.7) and 20.7 mmHg (SD 20.3), respectively. During an additional four weeks’ treatment, ‘switch’ non-responders had their doses of study medications doubled, resulting in a further reduction of 5.4 mmHg (SD 9.8) DBP and 5.9 mmHg (SD 14.9) SBP. Both treatment regimens were well tolerated. Thus, in patients with severe hypertension, adding candesartan to a standard-dose two-drug combination, or switching from a pre-existing two-drug, standard-dose combination to high-dose candesartan plus HCT enables enhanced BP control, with superiority of the three- over the two-drug combination.

Br J Cardiol 2005;12:291-297.

REVIEWCardiac patients’ concerns and desire for information: a case for unmet needs
Mohsen Asadi-Lari, Chris Packham, David Gray

Tailoring healthcare provision to fulfil patients' needs is a principal objective of health services. Data on needs are sparse, especially in patients with coronary heart disease, who tend to have a high mortality rate, who often require admission to hospital and have an impaired health-related quality of life. A novel questionnaire was administered concomitantly with generic and specific quality of life tools in a cross-sectional study of a random sample of patients (n=242) aged 31–93 years (median 71 years) admitted with suspected acute coronary syndromes.
Patients with confirmed infarction had fewer healthcare needs and reported less need for information on heart disease compared to those with other manifestations of coronary disease (p<0.01). Those recently seen by a general practitioner were better informed about their current treatment (p<0.01). Coronary disease patients with low quality of life scores were more likely to be anxious about cardiac problems (p<0.001). They were more likely to spend more time thinking about these concerns (p<0.001) and to seek help from, and to have increased expectations of, the family doctor or cardiologist (p<0.001), particularly in seeking greater commitment to their care. Reported deficiencies in service included difficulty accessing healthcare services, especially for men < 65 years (p=0.01) and availability of repeat prescriptions for the over 75-year-olds (p<0.05).
Patients with coronary disease had unmet healthcare needs and worse health-related quality of life. Further investigation of healthcare needs among patients with coronary disease could lead to simply improved services and major health improvement. Assessment of quality of life appeared to be a surrogate for formal healthcare needs assessment.

Br J Cardiol 2005;12:298-301.

REVIEWProfile of documented medical history of chest pain: a multicentre audit of 1,226 consecutive patients with validated acute MI
Niamh Kilcullen, Rajiv Das, Peter Mackley, Christiana A Hall, Christine Morrell, Beryl M Jackson, Micha F Dorsch, Robert J Sapsford, Mike B Robinson, Alistair S Hall for the EMMACE-1 Study Group

This study set out to evaluate the completeness of medical records of chest pain. A planned, multicentre, structured abstraction of data from case-notes was made at 20 adjacent acute hospitals in Yorkshire on 1,226 consecutive patients presenting with chest pain and validated myocardial infarction (MI). The hospital records included those collected by ambulance crews, accident and emergency staff, and admitting medical teams. The main outcome measure was completeness of medical records with regard to 10 commonly advocated descriptors of chest pain.
A mean number of 5.62 chest pain descriptors was recorded. This value differed with hospital (range 4.81 to 6.73 factors recorded; p<0.0001); place of admission (medical admissions unit = 6.10; coronary care unit 5.94; accident & emergency department = 5.62; general ward = 5.08; p<0.0001); gender (male = 5.74; female = 5.39; p=0.004) and age (< 68.4 years = 5.83; > 68.4 years = 5.43; p<0.0001). Mean chest pain scores were also significantly different for District General Hospitals (DGHs) without angiography facilities as compared to DGHs with angiogram facilities and tertiary centres (respectively 5.46 vs. 5.81 vs. 5.81 p<0.007).
Contrary to standard medical texts and teaching, we observed that documentation of chest pain histories was abbreviated in many cases.

Br J Cardiol 2005;12:302-305.

REVIEWNew analysis of LIFE trial shows reduction of new-onset atrial fibrillation with losartan
Brian Crichton

A new analysis of the LIFE study has shown that losartan can reduce new-onset atrial fibrillation in hypertensive patients with left ventricular hypertrophy. General practitioner Brian Crichton summarises this new analysis and explains how losartan might achieve these effects.

Br J Cardiol 2005;12:268-269.

CASE REPORTTranexamic acid and acute myocardial infarction
Amit KJ Mandal, Constatinos G Missouris

The plasminogen activator inhibitors have an important therapeutic role in controlling bleeding in patients with congenital and acquired coagulation disorders. They are being increasingly used in patients with blood loss and to prevent bleeding. However, these antifibrinolytic agents can also facilitate the development of thrombosis. We report a patient with severe gastrointestinal bleeding who developed acute myocardial infarction following the administration of the antifibrinolytic agent, tranexamic acid.

Br J Cardiol 2005;12:306-307.

AICAre drug-eluting stents living up to the hype?
Adrian P Banning

Br J Cardiol 2005;12:AIC42-AIC44.

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TOPICAICDrug-eluting stents: NICE guidelines and the reality
Tim Wells, Keith Dawkins

The National Institute for Clinical Excellence (NICE) stent appraisal (2003) defined criteria for the use of drug-eluting stents (DES) on the basis of lesion length, vessel diameter and the absence of recent myocardial infarction or intra-luminal thrombus. The appraisal suggested that as many as one third of all stents may need to be DES.
In order to determine the requirement for DES and adherence to these guidelines, we assessed 1,673 consecutive patients undergoing coronary intervention over a 17-month period. A total of 2,513 stents were implanted, of which 50.1% were DES. In all, 77.4% of patients fulfilled NICE criteria for at least one DES. A further 7.3% of patients were excluded because of either a recent (< 24 hours) myocardial infarct or visible intra-luminal thrombus. A total of 33.4% of patients who did fulfil NICE criteria for DES deployment inappropriately received a bare-metal stent (BMS) whilst 5.7% patients inappropriately received a DES. These results would suggest that NICE have grossly underestimated the need for DES in ‘real world’ practice. Despite our centre using a high volume of DES, significant numbers of patients were inappropriately treated with BMS, with a smaller number inappropriately treated with DES, according to NICE criteria.

Br J Cardiol 2005;12:AIC45-AIC48.

AICDiabetic revascularisation by coronary angioplasty: is one stent better than another?
Jeremy N Butts, Kenneth P Morgan, Kevin J Beatt

As confidence in the use of drug-eluting stents (DES) increases, they are being used in patients with progressively more complex disease. Diabetes is still an independent risk factor for restenosis along with lesion length and reference vessel diameter.
This article gives an overview of recent stenting trials, including those with more complex disease such as DIABETES, PORTO 1 and TAXUS V. It also looks at head-to-head randomised controlled trials of sirolimus-eluting stents against paclitaxel-eluting stents: ISAR-DESIRE, SIRTAX, ISAR-DIABETES and REALITY. These give a better indicator of comparative efficacy than meta-analyses which include differing patient populations and trial designs. Finally, studies comparing angioplasty with surgery are considered.

Br J Cardiol 2005;12:AIC49-AIC53.

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TOPICAICIntroduction of primary percutaneous coronary intervention for ST elevation myocardial infarction in a district general hospital Sohail Qaisar, Melanie Fellows, Hannah Whitlam, Rumi Jaumdally, James M Beattie,
Sohail Qaisar, Melanie Fellows, Hannah Whitlam, Rumi Jaumdally, James M Beattie, Patricia J Lowry, Nadia El-Gaylani, Robert G Murray, Jerome Ment, Michael Pitt

The objective of this study was to assess the feasibility and impact of providing a primary percutaneous coronary intervention (PCI) programme for ST elevation myocardial infarction (STEMI) in a district general hospital (DGH) in the UK.
A retrospective review of cardiac catheter laboratory PCI database records and hospital notes was carried out in a 950-bed teaching DGH in the West Midlands, serving a catchment population of 500,000. The patients consisted of 108 men and women aged 28–86 years presenting with thrombolysis-eligible STEMI, treated by primary PCI between November 2002 and August 2004. The main outcome measures used in this study were time from hospital presentation to PCI (‘door to coronary device’ time), mortality and hospital length of stay.
The median door to device time was 86 minutes (range 25 to 286). Some 78% and 52% of patients had door to device times of less than 120 and 90 minutes, respectively. Median length of hospital stay was five days (range 3–30), compared to eight days in patients treated with thrombolysis in the years 2000–2004. In-hospital mortality was seven patients (6.5%).
We conclude that, in the contemporary era of interventional cardiology, it is feasible to introduce a primary PCI service for STEMI in a DGH setting with acceptable ‘door to coronary device’ times and mortality.

Br J Cardiol 2005;12:AIC56-AIC59.

AICSub-intimal dissection guided by retrograde angiography to recanalise a chronic coronary artery occlusion
Amal Louis, Julian Gunn

Br J Cardiol 2005;12:AIC61.

AICOral treatments for pulmonary arterial hypertension
Matt J Wright, J Simon R Gibbs

The management of pulmonary arterial hypertension (PAH) has changed dramatically over the last decade. Where once the physician had only limited tools to combat this devastating condition, recent randomised controlled trials have shown that there are now treatments that both prolong the rate of progression and improve survival. The ‘gold standard’ of treatment, due to its beneficial effect on survival, is epoprostenol, a prostacyclin analogue. However, there are a number of problems with the prostacyclin analogues, mainly centred on their administration and cost, which led to their use only in severely ill patients. A better understanding of the pathophysiology of PAH has led to a number of other pharmacological targets, namely antagonism of endothelin (ET) receptors and increasing local levels of nitric oxide (NO) via inhibition of phosphodiesterase 5.
The successful treatment of PAH means that there is now a growing population of patients on disease-modifying agents, so it is essential that physicians are aware of their use, benefits and side effects.

Br J Cardiol 2005;12:AIC62-AIC67.