Volume 12, Number 6, November-December 2005

EDITORIALCombating vascular disease in Scotland
Alan G Begg

Br J Cardiol 2005;12:409-410.

EDITORIALThe new GMS contract QOF update – hot tips and political hot potatoes
Sarah Jarvis

Br J Cardiol 2005;12:413-415.

HOT
TOPICPRIMARY CAREHow well do primary care teams identify patients with CHD and diabetes?
Debbie A Lawlor, Rita Patel, Shah Ebrahim

Br J Cardiol 2005;12:468-470.

HOT
TOPICPRIMARY CAREHypertension – its detection, prevalence, control and treatment in a quality driven British general practice
Peter Standing, Helen Deakin, Paul Norman, Ruth Standing

This study evaluated primary care hypertension management against UK quality targets and prescribing guidelines through a survey of 738 hypertensives in an urban three-partner personal list practice in April 2005. It looked at screening rates, prevalence, blood pressures of under 150/90 mmHg, measurement bias, ABCD prescribing and cost. The survey found that 94% of adults aged 25–79 years had been screened. With 738 confirmed cases, prevalence was 11.7% for all ages; 14.4% for those aged more than 16 years; and 46% in those over 65 years of age. Some 442 patients had ‘potential’ hypertension with their last blood pressure measurement being greater than 140/90 mmHg but inadequate follow-up. Blood pressure control of less than 150/90 mmHg was achieved in 83% of hypertensives with a six-fold terminal zero measurement bias. Looking at ABCD agents, 1,186 had been prescribed (1.84 per patient) costing £129,100 per annum. We believe that QOF hypertension prevalence in the practice (11.7%) and England (11.3%) is less than half the rate reported from community surveys. The practice demonstrated that QOF outcome targets are achievable by improving blood pressure targets to under 150/90 mmHg from 52% of patients in 2002 to 83% of patients by April 2005. Practice organisation, personal patient lists and quality targets were important factors in delivering successful care. Automated blood pressure measurement could eliminate observer bias. Restructuring therapy repeat instructions to include ABCD data encourages logical prescribing.

Br J Cardiol 2005;12:471-476.

REVIEWThe oblique view
Michael Norell

Br J Cardiol 2005;12:439-440.

HOT
TOPICREVIEWAldosterone blockade in heart failure
Iain Squire

In spite of treatment with inhibitors of the renin-angiotensin system, plasma levels of aldosterone increase progressively in heart failure. This phenomenon of aldosterone escape is associated with adverse outcome. The aldosterone receptor antagonists spironolactone and eplerenone can improve prognosis for patients with heart failure. The commonest, and often problematic unwanted effect of these agents, hyperkalaemia, may limit their usefulness and brings with it the need for careful clinical and biochemical monitoring. Recent trials, however, have shown clear benefits for large groups of patients for spironolactone (in severe chronic heart failure) and eplerenone (heart failure soon after acute myocardial infarction). Due consideration should be given to the addition of the appropriate aldosterone antagonist in suitable patients.

Br J Cardiol 2005;12:443-446.

HOT
TOPICREVIEWPossible clinical implications of the Cardiac Insufficiency Bisoprolol (CIBIS) III trial
Ronnie Willenheimer, Bernard Silke

The mainstay of heart failure management is angiotensin-converting enzyme inhibitor therapy initially as a vasodilator, followed by beta blockade at a varying time interval, based on clinical judgement. Early beta blockade has theoretical advantages in terms of possible protection against dysrhythmia or disease progression, although there may be short-term concerns regarding a possible deterioration in cardiac function and aggravation of heart failure.
The Cardiac Insufficiency Bisoprolol (CIBIS) III trial examined the optimum paradigm of initiating treatment for chronic heart failure (CHF). A large cohort of 1,010 systolic CHF patients, at least 65 years of age, with stable, mild-to-moderate symptomatic disease, were followed-up for a mean of 1.25 years. Patients were randomly allocated to initial monotherapy with bisoprolol for six months, followed by the addition of enalapril, or the opposite sequence. Efficacy and safety of the bisoprolol-first strategy versus the enalapril-first strategy was similar in terms of the combined primary end point of mortality or all-cause hospitalisation (hazard ratio 0.94, 95% confidence interval 0.77–1.16, non-inferiority p=0.02). The two approaches also showed similar safety. The bisoprolol-first strategy showed a 28% mortality reduction after the monotherapy phase (p=0.24) and a 31% borderline-significant mortality reduction during the first year (p=0.06), but was associated with a 25% increase in worsening of CHF events (p=0.23). This paper highlights important features of the study design and patient population. Both the clinical perspective and possible clinical implications of CIBIS III are discussed.

Br J Cardiol 2005;12:448-454.

REVIEWGender difference in health-related needs and quality of life in patients with acute chest pain
Mohsen Asadi-Lari, Chris Packham, David Gray

Inequalities in health care between men and women have been described extensively with regard to access to diagnostic and therapeutic procedures. These inequalities affect coronary heart disease care. Although survival rates differ for men and women following a myocardial infarction, this alone does not fully explain inequity in access to health services, especially diagnostic and treatment procedures, for infarct survivors.
A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients (41% female) admitted to the Acute Cardiac Unit, Nottingham.
Women expressed more dissatisfaction than men overall (p<0.05) and appeared to have more physical needs. Women were more likely to complain about transport, which influenced their access to healthcare facilities (p<0.001), to be concerned about getting help with cleaning (p<0.01), and to request information about rehabilitation services, potential limitations on their daily activities, and nutrition and diet (p<0.05).
Women had lower health-related quality of life scores in all the HRQL variables, which was significant in EQ-5D (usual activities, and pain/discomfort), Seattle angina questionnaire (angina stability), and both components of the Short Form-12.
This survey was the first attempt to apply a needs assessment tool combined with quality of life assessment for cardiac patients to identify potential gender disparities. Women reported greater health needs and greater dissatisfaction with current health services and had worse HRQL. Recognition of gender disparities in health needs and HRQL would clarify areas for improvement in healthcare services, and these might allow a better quality of life for infarct survivors.

Br J Cardiol 2005;12:459-464.

REVIEWMyocardial calcification following post-operative septicaemia
Jeban Ganesalingam, Sanjay Prasad, Paul J Oldershaw

Br J Cardiol 2005;12:465-467.

HOT
TOPICREPORTProgress in cardiology in northern England?
Klaus KA Witte, Andrew L Clark

Patients attending cardiology clinics, particularly those with chronic heart failure (CHF), frequently have co-morbidities and attend other hospital medical clinics. We examined the case notes of 162 patients attending two cardiology clinics. Many patients’ notes extended to more than one volume (20%). Patients with CHF were more likely to require rubber bands to maintain control of their notes than other cardiac patients. Despite efforts to move to a paperless record keeping system, rubber bands still play a major role in the NHS.

Br J Cardiol 2005;12:441.

AICThe coronary pressure wire for decision- making in the real world
Williams Omorogiuwa, Michael Fisher

Coronary angiography is an imperfect tool for assessing the functional significance of lesions: while this may be determined non-invasively using myocardial perfusion scintigraphy or stress echocardiography, it is often not done. In these circumstances the coronary pressure-derived fractional flow reserve (FFR) serves as an alternative, lesion-specific means of assessing physiological importance.
FFR is an invaluable tool not only in determining whether a lesion is functionally significant and should be tackled, but it also ensures that the appropriate physiological outcome is obtained from coronary intervention.

Br J Cardiol 2005;12:AIC74-AIC79.

AICPercutaneous coronary interventions in West Yorkshire for the year 2002: an audit
Khaled Alfakih, Elizabeth Rennie, Stacey Hunter, James Mclenachan

Early invasive management in patients with unstable angina and non-ST elevation myocardial infarct (NSTEMI) is now well established. However, patients can wait for weeks at district general hospitals (DGHs) for in-patient transfer to the cardiac centre for percutaneous coronary intervention (PCI), which results in inefficient bed utilisation.
At the Yorkshire Heart Centre (YHC), the referral process for unstable angina/NSTEMI was streamlined to minimise the delay between time of referral and PCI. We audited the waiting time from referral to the PCI procedure as well as the six- and 12-month outcomes for both acute and elective PCI and compared our outcome data to the published trials.
A total of 1,757 patients underwent PCI at YHC in 2002; of these 47% were acute cases. 72% of patients were treated within two days of referral and 97% within three days. The mean waiting time for patients referred from within the YHC was 1.9 days and for those referred from the DGHs was 2.2 days. The six-month mortality rate for the acute PCI group was 2.5%.

Br J Cardiol 2005;12:AIC81-AIC82.

HOT
TOPICAICModelling the cost-effectiveness of cardiac interventions: the case of sirolimus-eluting stents
Neil Hawkins, Mark Sculpher, Martin Rothman

This article aims to provide a primer on decision modelling to assess the cost-effectiveness of interventions in cardiology. The paper uses a cost-effectiveness model developed to compare alternative coronary stents. This decision analytic model assesses costs to the UK health service and health benefits in terms of quality-adjusted life-years (QALYs). Data were taken from a range of sources, including 12-month follow-up data from three important double-blind randomised controlled trials: RAVEL, SIRIUS and E-SIRIUS. Methods are employed to show the uncertainty in cost-effectiveness.
Sirolimus-eluting stents were compared to ‘bare metal’ stents in constructing this decision model. The patients included were those individuals with stable coronary disease randomised to the three trials.
The main outcome measures were: mean QALYs, mean health service costs, incremental cost per additional QALY, and the probability that sirolimus- eluting stents are more cost-effective than bare metal stents.
Mean QALY gains per patient from the sirolimus-eluting stent range from 0.011 to 0.017 over 12 months. Although the list price of the sirolimus- eluting stent is £617 more than the bare metal stent, its additional total mean cost per patient, including ‘cost offsets’ from a lower rate of subsequent events, ranges from £53 to £166. The incremental cost of the sirolimus-eluting stent per additional QALY ranges from £3,181 to £15,198. The probability that the sirolimus-eluting stent is less costly than the bare metal stent ranges from 0.13 to 0.34. If the health service is willing to pay up to £40,000 per additional QALY, the probability of the newer stent being the more cost-effective ranges between 0.8 and 1.0. These results are sensitive to assumptions about the price differential between the two forms of stent.
Cost-effectiveness analyses based on models are used increasingly as a basis for decision making. It is essential that these models are developed with clinical input regarding appropriate assumptions and interpretation of evidence.

Br J Cardiol 2005;12:AIC83-AIC91.

AICThe ‘no-reflow’ phenomenon
Lucy Blows, Divaka Perera, Simon Redwood

Microvascular perfusion is considered a key factor with respect to preservation of left ventricular function and prognosis. No-reflow is recognised in the context of acute coronary syndromes and percutaneous intervention: myocardial blood flow at a tissue level remains impaired following restoration of epicardial flow. Once no-reflow is established, treatment is often ineffective and this phenomenon is associated with poor short- and long-term outcomes. A number of different pharmacological agents are used to prevent and treat this condition although data to support their use are limited. This article examines the pathophysiological aspects of this condition, its clinical correlates and proposed management strategies.

Br J Cardiol 2005;12:AIC92-AIC97.

AICAn unusual pulmonary embolus
Umeer Waheed, Phang Boon Lim, Jeremy Cordingley, Mike Mullen

Due to advances in paediatric congenital heart surgery in recent years, the number of patients who survive into adulthood with complex congenital heart disease has increased remarkably. When these patients present to non-specialist hospitals with apparently specific symptoms, the diagnosis may not be as straightforward as initially thought. Here we highlight a case which demonstrates this.

Br J Cardiol 2005;12:AIC98-AIC100.

HEART BRAINHow would British stroke physicians diagnose and treat hypoxia in patients with acute stroke?
Christine Roffe, Amit Arora, Peter Crome, Richard Gray

There is no evidence from randomised controlled trials to guide oxygen treatment after stroke. This survey aims to establish a snapshot of views of clinicians on best current practice relating to the management of hypoxia early after acute stroke.
A postal questionnaire was sent to all 231 members of the British Association of Stroke Physicians (BASP). For 88% of the 130 respondents the decision to give oxygen was guided by the oxygen saturation, and for 67% it was guided by clinical criteria. The mean cut-off for oxygen supplementation suggested was ? 93% SD 2 (range 85–98%). Sixty-seven respondents would give oxygen by nasal cannulae and 74 via face mask. The oxygen concentration selected was 24% (n=17), 28% (n=31), 35% (n=15), 40% (n=3) and 100% (n=3).
This shows there is wide variation amongst stroke physicians about when to start oxygen, how much to give and by which route. There is a need for a randomised clinical trial to guide oxygen therapy after acute stroke.

Br J Cardiol 2005;12:456-458.