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21st November 2008 @ 9:43am |
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Volume 15, Number 5, September-October 2008HOT When any doctor or nurse refers to a colleague they should automatically ask themselves: is this referral necessary and will it benefit the patient? Referral should never be an automatic choice and the circumstances may dictate a different option. An extreme example is the terminally ill patient with severe central chest pain. Even if they are suffering a myocardial infarction, urgent admission may not be the best option in their care. Unnecessary referral wastes the time of both clinicians and patients. It adds to waiting times for more needy patients. Equally we could be guilty of under referral and could be providing less than perfect care for our patients. Br J Cardiol 2008;15:225. EDITORIALDelivering PCI in the UK – need for strategic thinking and a quality agenda The UK has witnessed a seismic shift in the delivery of healthcare to patients with coronary heart disease, but there is still a lot to be done. Promoted by the National Service Framework (NSF), and supported by a £775 million capital programme from the Department of Health and Lottery Funding (£122 million towards new cath labs), waiting lists have been slashed and patients are able to be investigated and treated nearer to home. In its annual audit reports for 2001, the British Cardiovascular Intervention Society (BCIS) reported on activity in 64 percutaneous coronary intervention (PCI) centres and 62 centres performing diagnostic invasive procedures only. The report for 2006 included data from 91 PCI centres and another 90 diagnostic-only centres. Br J Cardiol 2008;15:227. REVIEWPercutaneous coronary angioplasty in a district general hospital: safe and effective – the Bournemouth model
Recent studies have suggested that the safety, efficacy and feasibility of percutaneous coronary intervention (PCI) in hospitals without on-site surgical cover is equivalent to those with these facilities. In addition, recent UK figures suggest that PCI growth is in the region of 15% per year with a corresponding fall in coronary artery bypass grafts (CABGs) hence the ratio of PCI to CABG is increasing. In the UK 35% of PCI centres are without on-site surgical cover, however, these centres represent only 18% of total PCI procedures. The Dorset Heart Centre opened in April 2005 the nearest surgical centre being approximately 28 miles in distance. In addition to elective PCI, our centre provides a 9-to-5 Monday-to-Friday primary and rescue PCI service for the Dorset area. Br J Cardiol 2008;15:244. HOT An exploratory study with individual interviews before seeing the cardiologist, one week after the appointment, and at three-month follow-up was conducted to explore how participants’ perception and experience of heart palpitations are affected by seeing a cardiologist. Eleven of 20 participants cited anxiety as a possible cause of palpitations. A similar number were worried about their heart. After seeing the cardiologist, 7/20 participants thought something serious may have been missed, only one out of seven of whom had a clinically significant arrhythmia. It was reported that cardiologists did not address the role of psychological factors. Seven of the 20 participants still had heart-related health concerns at three months. Br J Cardiol 2008;15:249. HOT The majority of patients with hypertension are treated in primary care and well controlled. Typically, a practice will achieve about 80% control as judged against the Quality Outcome Framework (QOF). The QOF only requires a practice to reach a target of 70%. A practice will need to control the blood pressure of about 18% of their patients and therefore about 3.5% of the practice population will not be controlled. Too many to refer to secondary care and therefore the practice needs a strategy to try and improve control in-house and to identify those in greatest need of referral. Br J Cardiol 2008;15:254. REVIEWProtecting the heart during myocardial revascularisation Much effort has been expended assessing the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CAGB) surgery. Much less energy has been directed towards understanding the potential of these two interventions for causing additional myocardial damage during the procedure and the means to avoid this injury. This review examines the impact of myocardial injury in elective PCI and CABG, principles of myocardial protection, and their efficacy in current coronary revascularisation. The objective of every coronary revascularisation should be a technically perfect result without producing myocardial damage. A patent graft that perfuses an area of myocardium with numerous pockets of myocyte necrosis serves no useful purpose. Br J Cardiol 2008;15:258. HOT Renal artery stenosis is a condition that has significant effects on the progression and outcomes of co-existent cardiac disease. The most important cause of renal artery stenosis is atherosclerotic renovascular disease (ARVD). As the drugs and techniques used to manage ARVD are similar to those used to treat coronary artery disease, cardiologists are increasingly becoming involved in its management. However, while there are similarities, there are also significant differences in the management of ARVD and coronary artery disease. There are also many differing opinions on the best management. This review maps the minefield of conflicting evidence and gives clear, pragmatic guidelines regarding the management of patients with cardiorenal disease. Br J Cardiol 2008;15:261. REVIEWRadiation dose from cardiac investigations: a survey of cardiac trainees and specialists To identify the knowledge of ionising radiation doses and radiation-related risk in common cardiac procedures among cardiology trainees, cardiologists and general practitioners with a specialist interest in cardiology, a face-to-face questionnaire survey of 47 cardiac specialists, both regular referrers and practitioners of radiation-based procedures, was conducted at the British Cardiovascular Society Annual Conference 2006. Br J Cardiol 2008;15:266. REVIEWOcclusion of left main coronary artery diagnosed by computed tomography of the chest A 55-year-old smoker with no significant past medical history was admitted following an episode of dyspnoea and intrascapular pain. Clinical examination was normal. His blood pressure (BP) was 80/40 mmHg and his electrocardiogram (ECG) showed a sinus tachycardia and right bundle branch block. A computed tomography (CT) scan of the chest excluded a pulmonary embolism and aortic dissection, and, although not a dedicated cardiac CT, suggested an occlusion of the left main coronary artery (LMCA) (figure 1). Echocardiography showed impaired left ventricular function with an akinetic anterior, inferior and lateral wall. An intra-aortic balloon pump (IABP) was inserted and coronary angiography was performed, which confirmed an occlusion of the LMCA (figure 2, panel B). This was pre-dilated, and then stented with a bare-metal stent (3.5 x 16 mm Liberté) producing an excellent final angiographic result (figure 2, panel D). Despite continued IABP support, he required ventilation for refractory pulmonary oedema, and died five days later. Br J Cardiol 2008;15:269. CASE REPORTMicroscopic polyangiitis presenting as a pericardial effusion
Microscopic polyangiitis is a systematic necrotising vasculitis that affects small vessels without granulomata. Typically the most common manifestation is renal involvement. We report an unusual presentation of microscopic polyangiitis in a young male. Br J Cardiol 2008;15:271. HOT Highlights of the European Society of Cardiology meeting held in Munich, Germany, August 30th – September 3rd 2008 showed further benefit for fish oils, this time in heart failure and the first outcome study with the new sinus node inhibitor, ivabradine. There were more equivocal findings for drug-eluting stents, however, and also for statins in heart failure and aortic stenosis. Br J Cardiol 2008;15:231. REPORTCVD risk and beyond at H•E•A•R•T UK conference 2008 There was a buzz about this year’s H·E·A·R·T UK – The Cholesterol Charity’s annual conference. An impressive array of speakers, plus the pertinent theme, Beyond Risk Assessment: Non Invasive Assessment of Atherosclerosis, meant that each lecture attracted enthusiastic audiences. Br J Cardiol 2008;15:237. NEWS & VIEWSGetting under the skin
Br J Cardiol 2008;15:241. |
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