Volume 9, Number 2, February 2002

EDITORIALAdult congenital heart disease: time for a national framework
Michael A Gatzoulis

Br J Cardiol 2002;9:65-67.

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TOPICEDITORIALWhatever happened to silent ischaemia?
Prithwish Banerjee

Br J Cardiol 2002;9:68-71.

PRIMARY CARECaffeine-containing drinks – a cause of arrhythmias?
Saul G Myerson, Yohan Samarasinghe, Chris Taylor, Michael D Feher

Caffeine-containing drinks are increasingly available but excessive consumption can give rise to health hazards. A case is described here of a 31 year old man with no history of cardiovascular disease but a very high caffeine intake; he developed atrial fibrillation, which required treatment with flecainide. He has reduced his caffeine intake and remains well to date.

Br J Cardiol 2002;9:122-124.

REVIEWGrown-up congenital heart disease - experience in a district general hospital
Leisa J Freeman, Sheila Wood, Toni Hardiman, Antony JF Page

Some 340 adult patients (186 male, 154 female; average age 36 years) with congenital heart disease are now seen in a dedicated clinic at a district general hospital. Septal defects and aortic pathology account for 48% of cases seen and 21% have complex congenital heart disease. A first operation has been performed in 55%, a second operation in 13.3% and a third operation in 3.2%. Pulmonary hypertension is present in 7%. Eighty two of the 154 women have had 123 pregnancies. Care issues relating to the pregnant grown-up congenital heart disease (GUCH) patient are discussed. The growth of this population is highlighted, as is the requirement for more structured care. Issues relating to the establishment of a dedicated GUCH clinic are discussed, including training of cardiologists in this sub-speciality.

Br J Cardiol 2002;9:92-98.

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TOPICREVIEWAtrial septal defects – a differential diagnosis for breathlessness in adults and the elderly
Mark S Turner, Anthony P Salmon, Andrew J Marshall

Atrial septal defects are a common form of congenital heart disease that can present at any age, even in the elderly. As symptoms may be non-specific (breathlessness, palpitations), a high index of suspicion should be maintained. The ECG may be normal in the absence of significant pulmonary hypertension although a chest radiograph should be helpful. The diagnosis is usually confirmed by transthoracic echocardiography, although some types of atrial septal defects may be missed in adults who are poor echo subjects. Transoesophageal echo provides definitive diagnostic information and should be undertaken in any patient with right heart dilatation of unknown cause. Whilst closure of atrial septal defects may not prevent atrial arrhythmia, it can reduce the haemodynamic consequences if episodes occur. Many atrial septal defects can now be closed with percutaneous devices, avoiding the need for sternotomy.

Br J Cardiol 2002;9:99-102.

REVIEWPrognosis, outcome and recurrence of stroke
Graham Venables

Defining prognosis may be helpful in planning acute treatment of stroke, setting rehabilitation goals and setting resource priorities. Case fatality is 12% within the first seven days of a first-ever stroke. Late deaths are usually due to the consequences of immobilisation and stroke recurrence. Long-term outcome is difficult to predict but older age, significant pre-stroke co-morbidity and severe stroke are generally associated with poor physical recovery. Stroke patients have a risk of recurrence 15 times that of an age- and sex-matched population. Stroke type may influence recurrence. Early stroke recurrence may be prevented by antiplatelet drugs. Patients in atrial fibrillation and with recently symptomatic high-grade carotid stenosis are at particular risk of stroke.

Br J Cardiol 2002;9:103-105.

REVIEWDoes the routine use of lead V₄R increase prognostic yield in exercise electrocardiography?
Khalid Mahmood, Daniel Higham

We studied the potential benefits of using lead V₄R during routine exercise treadmill testing for patients undergoing district general hospital investigation for suspected coronary artery disease. Some 298 patients with known or suspected coronary artery disease, referred for exercise testing, had an electrocardiogram recorded with standard leads and had lead V₄ placed in the V₄R position. The exercise tests were interpreted using standard criteria and were reported as being negative, inconclusive, positive or adversely positive. The mean age of the patients was 57 years. Some 86 (29%) of the tests were positive: 12 of the 86 positive tests showed significant changes in lead V₄R (14%). Of the 86 positive tests, 25 were adversely positive (29%) and, of these, nine had a positive V₄R test (36%). Patients with V₄R positive tests compared to those with V₄R negative tests had significantly decreased exercise duration leads with ST changes and reduced workload. The finding of a positive V₄R test indicated a significantly greater chance of an adversely positive exercise test result (p<0.001), with nine of the 12 positive V₄R results (75%) being associated with adversely positive tests. There were no isolated positive V₄R tests.

Br J Cardiol 2002;9:106-108.

REVIEWThe cost-effectiveness of amlodipine treatment in patients with coronary artery disease
Roman Casciano, John J Doyle, Alistair McGuire, Raúl Arocho, Steve Arikian, JuliaN Casciano, Heather Kugel, Nick Marchant, Renee Kim

The objective of this paper was to quantify the impact on overall cardiovascular disease treatment costs resulting from the use of amlodipine in the coronary artery disease (CAD) population in the UK. A Markov cohort simulation model was developed to estimate the overall average healthcare costs of patients with CAD in the UK and to determine the cost-effectiveness of the use of amlodipine as part of their treatment regimen. Outcome probabilities used in the model were based on patient-level data from the Prospective Evaluation of the Vascular Effects of Norvasc Trial (PREVENT). Cost estimates for in-patient and out-patient care associated with each outcome were applied to quantify the overall average healthcare cost for each arm of the study.
The hospitalisation rate per patient in the placebo cohort was 61.8% while that in the amlodipine cohort was 44.3%. This corresponds to an average cost per patient for cardiovascular disease (CVD) treatment of £1,858.64 for amlodipine patients and £1,800.49 for placebo patients over three years of follow-up. Calculations yield a cost per hospitalisation avoided of £331.67.
In conclusion, the inclusion of amlodipine in the treatment regimen for patients with CAD is expected to result in improved clinical outcomes through a marginal investment in cost.

Br J Cardiol 2002;9:109-114.

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TOPICREVIEWUnited Kingdom Prospective Diabetes Study: implications for metformin
Clifford J Bailey, Ian W Campbell

One of the purposes of the United Kingdom Prospective Diabetes Study (UKPDS) was to compare the efficacy of different antidiabetic drugs in the long-term treatment of type 2 diabetes. In overweight type 2 patients, use of metformin as the initial antidiabetic drug therapy reduced overall mortality and reduced various long-term complications to a greater extent than other first-line treatments tested (sulphonylureas and insulin) whilst controlling hyperglycaemia to a similar extent. The benefit of early intervention with metformin may be due, at least in part, to its actions against insulin resistance and associated cardiovascular risk factors. Thus the UKPDS has provided evidence that early intensive glucose control with metformin in overweight type 2 diabetic patients is a particularly effective approach to reduce vascular complications and improve survival.

Br J Cardiol 2002;9:115-119.

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TOPICCASE REPORTMyocardial infarction in a patient with hypertrophic cardiomyopathy
Suneel Talwar, Khalid Khan

Br J Cardiol 2002;9:120-121.