Volume 13, Number 4, July-August 2006

HOT
TOPICEDITORIALHypertension guidelines in the UK: a time for change
Bryan Williams

Br J Cardiol 2006;13:233-237.

HOT
TOPICPRIMARY CAREGraduating to a higher level: national cardiology training for practitioners with a special interest
Catherine Burwell

This article describes the evaluation of a new postgraduate diploma in cardiology course run by the Bradford City Teaching Primary Care Trust.

Br J Cardiol 2006;13:293-296.

HOT
TOPICPRIMARY CAREHow well informed are general practitioners about management strategies to improve the prognosis of heart failure?
Archana Rao, John Walsh, David Gray

Heart failure is a common condition, characterised by poor prognosis. Despite evidence that effective treatment improves symptoms and prognosis, management remains sub-optimal. General practitioners (GPs) have a key role in the assessment and treatment of patients with heart failure. This study was designed to ascertain the knowledge and attitude of GPs towards the management of heart failure.
Anonymised questionnaires were sent to 355 GPs in the Nottingham area in May 2003 and 227 (64%) responded. The mean (standard deviation) age of respondents was 45 (7) years and they had been in general practice for 15 (7.6) years. The questionnaires found that 223/227 (98%) of GPs were aware that angiotensin- converting enzyme (ACE) inhibitors have been shown in clinical trials to reduce mortality in heart failure; 155/224 (69%) were aware that beta blockers reduced mortality in heart failure; 53/225 (23.3%) believed diuretics improved prognosis. Almost 60% routinely initiated ACE inhibitors but 26% expressed concerns about their side effects and so were less likely to initiate this treatment.
Most GPs seemed able to manage heart failure effectively and ACE inhibitor prescription for patients with chronic heart failure (CHF) is now well established within primary care. Knowledge and prescription rates for the remaining effective therapies remain low.

Br J Cardiol 2006;13:297-300.

REVIEWThe oblique view
Michael Norell

We continue our series in which Consultant Interventionist Dr Michael Norell takes a sideways look at life in the cath lab… and beyond. In this column, he dissects the 21st century obsession with corporate rationale.

Br J Cardiol 2006;13:254-256.

HOT
TOPICREVIEWHeart failure in older patients
Robin AP Weir, John JV Mcmurray, Jacqueline Taylor, Adrian JB Brady

As the population ages, so the prevalence of chronic heart failure (CHF) will rise. The majority of CHF patients in the future will be elderly, yet most of our current evidence for the management of this serious condition arises from trials that have largely excluded older patients. As a consequence, older patients who may derive the greatest benefit from treatments known to reduce morbidity and mortality in CHF, are often denied such treatments. The effects on quality of life of both the syndrome of CHF and its treatment in older CHF patients must be borne in mind, as must issues of compliance, prevalence of comorbidity, and requirement for physical and emotional support. We review the current epidemiology of CHF, and focus on the applicability and use of contemporary non-pharmacological and pharmacological therapy to older patients with CHF. The potential use of devices and surgery in older CHF patients is also discussed.

Br J Cardiol 2006;13:257-266.

REVIEWReducing fear and the risk of death in Marfan syndrome: a Chaucerian pilgrimage
Tal Golesworthy, Tom Treasure, Michael Lampérth, John Pepper

Chaucer's characters in The Canterbury Tales meet on their journey to the shrine of Thomas à Becket. They are on a pilgrimage, a special kind of journey that brings a diverse group of people together in a common purpose. As they converge on the place of pilgrimage, the tales they tell are informed by the varied experiences of their lives. The stories we tell here are of individuals brought together by a single objective: to find a solution better than total root replacement for people whose lives are threatened by aortic dilatation due to Marfan syndrome. Chaucer's pilgrims meet in the Tabard Inn in Southwark, where their journey to Canterbury is to begin. This modern journey began in St George's Hospital at the 2000 meeting of the Marfan Association, when the surgeon [TT] told his tale, an account of best current practice and its attendant risks.

Br J Cardiol 2006;13:267-272.

HOT
TOPICREVIEWSafety and tolerability of prolonged-release nicotinic acid combined with a statin in NAUTILUS
Anja Vogt, Ursula Kassner, Ulrike Hostalek, Elisabeth Steinhagen-Thiessen, on behalf of the NAUTILUS Study Group

NAUTILUS (The multiceNtre, open, uncontrolled sAfety and tolerability stUdy of a modified-release nicoTinic acId formuLation in sUbjects with dySlipidaemia and low HDL cholesterol) was an open label, uncontrolled, phase IIIb study. The study population included a total of 566 patients with dyslipidaemia and low high-density lipoprotein (HDL) cholesterol (< 1.0 mmol/L [< 40 mg/dL] in men and < 1.2 mmol/L [< 46 mg/dL] in women) who were inadequately controlled by diet alone. Patients received once-daily treatment with prolonged release nicotinic acid (Niaspan^®; target dose 2,000 mg/day), added to existing regimens for 15 weeks. At baseline, 40.5% of patients were receiving an HMG-CoA reductase inhibitor (statin), mostly simvastatin or atorvastatin.
Patients taking and not taking concomitant statin therapy reported a similar incidence of all-cause adverse events (AE) of 64.6% vs. 57.9%, respectively, treatment- related AE (54.6% vs. 47.2%), all-cause serious AE (3.9% vs. 3.6%), treatment-related serious AE (0.9% vs. 0.3%), and withdrawals for AE (17.5% in each group). The incidence of flushing was similar in patients with and without statin treatment (45.0% vs. 40.1%), as was the proportion of patients withdrawing because of flushing (8.7% vs. 10.4%). Only about one quarter of patients flushed more than five times. There was no sign of serious hepatic or muscle toxicity. The addition of prolonged-release nicotinic acid markedly raised HDL cholesterol levels irrespective of statin treatment; it was well tolerated and effective when combined with a statin in patients with dyslipidaemia.

Br J Cardiol 2006;13:273-277.

REVIEWSafety and tolerability of prolonged-release nicotinic acid in patients aged > 65 years enrolled in NAUTILUS
Anja Vogt, Ursula Kassner, Ulrike Hostalek, Elisabeth Steinhagen-Thiessen, on behalf of the NAUTILUS Study Group

Older patients are often at high risk for cardiovascular disease. Low high-density lipoprotein (HDL) cholesterol is an independent risk factor for cardiovascular disease. Prolonged-release nicotinic acid (Niaspan^®) is a once-daily formulation of nicotinic acid with improved tolerability compared with the immediate-release formulation. It may be used to correct low levels of HDL cholesterol. NAUTILUS (the multiceNtre, open, uncontrolled sAfety and tolerability stUdy of a modified release nicoTinic acId formuLation in sUbjects with dySlipidaemia and low HDL cholesterol) evaluated prolonged-release nicotinic acid at doses of up to 2,000 mg/day once daily in 566 patients, of whom 33.6% were aged > 65 years.
A similar incidence of adverse events (AE) was observed following 15 weeks of prolonged-release nicotinic acid treatment in older vs. younger patients for all-cause AE (55.3% vs. 63.3%) and for treatment-related AE (46.3% vs. 52.1%). Most AE were related to flushing, which also occurred at similar frequency in older and younger patients (39.5% vs. 43.4%).
Gastrointestinal AE were the most common AE apart from flushing, and occurred in 12.1% of older patients and 14.4% of younger patients. Serious AE were uncommon. There was no hepatotoxicity or serious muscle toxicity. Marked improvements in indices of atherogenic dyslipidaemia were observed (increases from baseline in HDL cholesterol of 26% in older and 21% in younger patients and decreases in triglycerides of 16% and 9%, respectively).
Prolonged-release nicotinic acid is well tolerated and effective in older patients, and is suitable for correction of low HDL cholesterol in this population.

Br J Cardiol 2006;13:278-282.

HOT
TOPICREVIEWShould acute MI patients receive dual antiplatelet therapy: a review of new data
Anthony Gershlick

Thrombolytic therapy in the management of acute myocardial infarction (MI) shows true evidence of benefit. Administration of a thrombolytic saves about 30 lives per 1,000 in those presenting within six hours of symptom onset but only 20 lives per 1,000 when patients receive treatment between six and 12 hours after symptom onset. After 12 hours there appears to be only a small and statistically uncertain benefit.
The aim in thrombolysis should be to increase the number of patients who achieve TIMI grade 3 flow as soon as possible after the occlusive event. Additional benefit in improving thrombolysis, particularly in reducing 30-day mortality, has been shown by adding the antiplatelet agent, aspirin, to thrombolytic therapy. The addition of a second antiplatelet agent, such as clopidogrel, has been shown to be of benefit in other, less immediately severe atherothrombotic manifestations (unstable angina and non-ST-elevation MI) and looks to be a promising development in the management of acute ST-elevation MI. The potential advantages of dual antiplatelet therapy in this setting, investigated in the recently published CLARITY study, are discussed.

Br J Cardiol 2006;13:284-286.

HOT
TOPICCASE REPORTSo where is the heart?
Amit Kj Mandal, Elizabeth Mc Ashley, David Ward, Constantinos G Missouris

A 75-year-old gentleman presented to his general practitioner with palpitations and dizziness. A 24-hour Holter monitor confirmed the diagnosis of paroxysmal sustained atrial flutter and episodes of less organised rhythm, that were thought to be atrial fibrillation. His symptoms failed to improve on combination treatment with digoxin and bisoprolol. He was referred for flutter ablation. Our aim was to replace the above pharmacological agents with a class 1C drug. The patient was not taking warfarin. A transoesophageal echocardiogram (TOE) was therefore arranged to exclude left atrial thrombus, prior to performing the ablation.

Br J Cardiol 2006;13:289.

CASE REPORTSpontaneous resolution of in-stent restenosis
Sayqa Arif, Jasper Trevelyan, Rajiv Gulati, Peter F Ludman

In 1993, a 61-year-old man underwent balloon angioplasty to the left anterior descending artery (LAD) after an anterior myocardial infarction. Repeat angiography in 1997 after a recurrence of symptoms revealed a severe proximal LAD stenosis, and this was again treated by balloon angioplasty. Two months later, the LAD had occluded and a 16 mm bare stainless steel stent (Nir®) was implanted with a 3 mm balloon (figure 1). Four months afterwards, angiography revealed severe in-stent restenosis (figure 2) and he was referred for coronary artery bypass grafting; the left internal mammary artery (LIMA) was grafted to the LAD.
He remained symptom-free for six years until 2004, when his angina recurred. Repeat coronary angiography demonstrated spontaneous regression of the previously stenosed LAD stent, which was now widely patent (figure 3). The LIMA graft had involuted. A new stenosis in a large obtuse marginal branch was treated with a drug-eluting stent.

Br J Cardiol 2006;13:290-291.

REPORTPalliative care in heart failure – a neglected area in specialist training?
Yasmin Ismail, Elizabeth McNeill, Mandie Townsend, Thomas MacConnell

Br J Cardiol 2006;13:283.

AICBivalirudin in acute coronary syndromes: one step forwards, one step backwards?
Nick West

Br J Cardiol 2006;13:AIC33-AIC36.

AICPercutaneous coronary intervention – what is the risk of inadequate risk assessment?
Rob Hatrick, Nick Curzen

Br J Cardiol 2006;13:AIC37-AIC38.

AICEstimating the risk of percutaneous coronary intervention
Anjan Siotia, Paul Hancock, Julian Gunn

Percutaneous coronary intervention (PCI) is expanding in terms of both the numbers of patients treated and the scope and severity of coronary artery disease tackled. These developments have occurred in parallel with increased awareness of the importance of accountability and clinical governance. Whilst cardiac surgeons have durable risk scores such as Parsonnet and EuroSCORE to assist them and their patients with estimating procedure-related risks, interventionists lack such universally accepted tools. Or do they? In this paper, we review the available PCI risk scores and point out the pressing need for the systematic use of a robust, simple and widely acceptable risk score for routine clinical use.

Br J Cardiol 2006;13:AIC39-AIC45.

AICDouble-barrel lumen during recanalisation of a chronically occluded stent in a saphenous vein graft
Jun Tanigawa, Omer Goktekin, Carlo Di Mario

Br J Cardiol 2006;13:AIC46-AIC47.

AIC'Gatling gun' stenting of left main stem trifurcation stenosis
Chris Newman, Julian Gunn

Br J Cardiol 2006;13:AIC48.

AICCurrent status of non-invasive coronary angiography for the diagnosis of coronary artery stenosis
Kaeng W Lee, Jonathan Panting

Recently, several techniques for non-invasive imaging of the coronary artery have emerged as promising alternatives to conventional coronary angiography for the diagnosis of coronary artery stenosis. Such imaging modalities include magnetic resonance imaging, electron-beam computed tomography and multi-slice computed tomography. With these technologies, images can be acquired rapidly with high temporal and spatial resolution. In their current state of development, non-invasive techniques can reliably be used to visualise significant stenosis of the proximal and mid portions of the coronary tree. However, complete assessment can be hindered by calcification in the vessel wall and by motion artefact.

Br J Cardiol 2006;13:AIC49-AIC56.

NEWS & VIEWSNews

Br J Cardiol 2006;13:239-246.