Volume 12, Number 5, September-October 2005

HOT
TOPICEDITORIALSetting a pace in cardiac rehabilitation
Mandy Fitzgerald-Barron

Br J Cardiol 2005;12:329-330.

EDITORIALCurrent and future status of left ventricular assist devices in the UK
Emma J Birks

Br J Cardiol 2005;12:333-335.

EDITORIALASCOT – hold on to your horses!

Br J Cardiol 2005;12:336-338.

PRIMARY CARECOX-2 inhibitors: managing comorbidities in primary care
Rubin Minhas

Br J Cardiol 2005;12:392-393.

HOT
TOPICPRIMARY CAREStatin prescribing: is the reality meeting the expectations of primary care?
Adrian JB Brady, John Norrie, Ian Ford

Two surveys were carried out to look at statin prescribing in UK general practice. The first was a study of the Mediplus prescribing database in relation to coronary heart disease (CHD) patients prescribed a statin. The second was a postal survey of the attitudes and beliefs about statin prescribing among general practitioners (GPs) who had contributed to this database. Results showed that despite 80% of GPs believing they had achieved target cholesterol levels (< 5 mmol/L) in 80% of their CHD patients, this was initially only achieved in 65% of patients, rising to 78% after titrations and switching. Only 46% of patients achieved a chol-esterol reduction of 25%, which increased to 56% after titrations and switching.

Br J Cardiol 2005;12:397-400.

PRIMARY CAREPeripheral arterial disease – CVD by any other name?
Sarah Jarvis

The National Service Framework for Coronary Heart Disease (CHD) stated that individuals at greatest risk of CHD should be identified. This category included those with diagnosed peripheral vascular disease. Despite this, the condition was not included in the Quality and Outcomes Framework of the new General Medical Services contract. This article looks at the strong evidence to include peripheral arterial disease in the next update of the GMS contract, which is expected in April 2006. It also looks at what is being done to identify such patients, and their relative risk compared to other subpopulations at risk of atherothrombosis. The setting up of an international register – the REACH registry is also discussed.

Br J Cardiol 2005;12:401-404.

HOT
TOPICREVIEWCardiac rehabilitation: results of a national survey
Allison Thorpe, Sian Griffiths, Charles F George

The provision of cardiac rehabilitation (CR) services in the UK was surveyed in March 2003. Three hundred questionnaires were sent to Directors of Public Health based in Primary Care Trusts. One hundred and eighty-five replies were received, a 61.7% response rate. In 72.8% of cases CR services were provided in both the acute and community sectors, but in 22.8% services were only available in the acute sector. CR services were patchy, lacked integration and in only 31.3% of Primary Care Trusts (PCTs) were they described as adequately funded.
Many patients are not receiving this important treatment modality after either myocardial infarction or cardiac surgery.

Br J Cardiol 2005;12:361-366.

HOT
TOPICREVIEWProblems of cardiac rehabilitation coordinators in the UK: are perceptions justified by facts?
Hugh JN Bethell, Julia Evans, Sheila Malone, Sally C Turner

The National Service Framework for Coronary Heart Disease recommended in 2000 that cardiac rehabilitation (CR) should be offered to 85% of patients recovering from myocardial infarction or revascularisation. This target is a long way from being met.
Provision of CR might be improved by addressing the problems met by CR coordinators. This study, through a questionnaire and more detailed surveys of CR coordinator experiences, set out to identify these problems. CR coordinators' problems were canvassed in the 2001/2 Annual Survey of CR programmes in the UK and their responses were compared with figures from the same survey and from surveys from the North West and the South East Regions of England. We found their main problems included lack of money (87%), lack of staff (90%), lack of space (74%), lack of sessions (74%), failure of referral of heart failure patients (66%), attendance problems (71%) and waiting lists (55%). All of these perceived problems were confirmed by the figures from at least one of the surveys – and, in most cases, by two or three of the surveys.
These findings point to measures for improving CR provision. These include proper funding on a cost per patient basis, the provision of adequate space and the better use of information technology.

Br J Cardiol 2005;12:372-378.

HOT
TOPICREVIEWNew approaches to the management of dyslipidaemia
Lena M Izzat, Philip Avery

Multiple randomised controlled trials have unequivocally shown that lowering low-density lipoprotein cholesterol (LDL-C) results in a predictable reduction of coronary events and it appears that there is no threshold beyond which lowering LDL-C does not result in further benefit.
Although statins are the mainstay of treating hyperlipidaemia, they cannot always succeed in achieving more stringent lipid targets in some patients as they inhibit only one element of cholesterol homeostasis: the endogenous pathway. Ezetimibe is a novel agent which inhibits the exogenous cholesterol pathway, with resultant complementary benefits with statins.
Ezetimibe co-administered with a statin may provide an additional 16–18% reduction in LDL-C, compared to only a 6% further reduction in LDL-C with each doubling of a statin dose. This concept of combination therapy, tackling different homeostatic pathways, may be akin to strategies used in management of hypertension, where a combination of antihypertensive agents from different pharmacological classes is the norm.

Br J Cardiol 2005;12:379-386.

REVIEWCOX-2 inhibitors and the cardiovascular system: is there a class effect?
Mohamed Bakr, Derek G Waller

Selective inhibition of COX-2 preferentially inhibits the production of prostaglandins responsible for vasodilation and inhibition of platelet aggregation. This potentially creates a pro-thrombotic state. This review examines the evidence that selective COX-2 inhibitors have adverse effects on the heart and circulation. The risk of myocardial infarction and other vascular ischaemic events, the effects on blood pressure and decompensation of treated heart failure are discussed. Conclusions are drawn about the relative risk with the different members of the drug class, and recommendations for clinical practice presented.

Br J Cardiol 2005;12:387-391.

CASE REPORTMeig’s syndrome with massive pericardial effusion, bilateral pleural effusion and ascites
Mohammed N Al-Khafaji, Salim Ahmed

Meig’s syndrome is a condition in which an ovarian tumour (usually a fibroma) is associated with ascites and pleural effusion. It resolves after resection of the tumour. We report here what we believe to be the first case of a patient with pericardial effusion complicating Meig’s syndrome.

Br J Cardiol 2005;12:394-395.

REPORTThe effects of cardiac rehabilitation on heart rate variability in patients with coronary heart disease
Joseph PA Delaney, John Kelly, Gavin Sandercock, David A Brodie

Structured exercise, as a therapeutic intervention, is central to cardiac rehabilitation (CR). Following myocardial infarction (MI), cardiac autonomic activity becomes disordered, often resulting in loss of vagal reflexes and increased sympathetic activity. Sympathetic hyperactivity predisposes towards ventricular fibrillation, while vagal reflexes are considered to have a cardio-protective effect.
The activity of the autonomic nervous system (ANS) can be measured non-invasively by analysis of heart rate variability (HRV), which is a characteristic that can potentially be increased by physical activity. Coarse-graining spectral analysis (CGSA) of HRV is a sensitive, non-invasive technique commonly used to evaluate cardiac autonomic activity. HRV allows the examination of parasympathetic and sympathetic function via the analysis of the various components of the frequency domain. High frequency spectral power (HF, 0.15–0.40 Hz) is generally considered to be a measure of cardiac parasympathetic modulation, whereas low frequency power (LF, 0.04–0.15 Hz) reflects both parasympathetic and sympathetic control.
The purpose of this study was to determine the effects of a predominantly exercise-based cardiac rehabilitation programme over a six-month period on cardiac autonomic modulation, using power spectral analysis of HRV.

Br J Cardiol 2005;12:368-370.