Volume 9, Number 3, March 2002

EDITORIALPROGRESS in the secondary prevention of stroke
Scott W Muir, Kennedy R Lees

Br J Cardiol 2002;9:131-134.

HOT
TOPICPRIMARY CAREDelivering evidence-based care to patients with heart failure: results of a structured programme
Martin R Cowie, Hugh McIntyre, Zoya Panahloo ON BEHALF OF THE OMADA INVESTIGATORS

The Omada programme, a nurse-delivered model of care, has achieved improved levels of evidence-based intervention for patients with chronic heart failure in nine secondary care centres in the UK. It may provide an appropriate model for audit and delivery of care, in line with the requirements of the National Service Framework for Coronary Heart Disease.

Br J Cardiol 2002;9:171-181.

PRIMARY CAREContinuity and quality of care in people with coronary heart disease in general practice
Kamlesh Khunti, Kate C Windridge

Continuity of care is much valued by patients and doctors. It is seen as a core feature of the discipline in general practice, although there is little supporting evidence that it leads to improvement in the care given during the management of patients with chronic disorders. This study shows that increased continuity is not associated with improved clinical care in the secondary prevention of coronary heart disease. The study also shows that it is possible to maintain high continuity for a chronic condition in a group practice with flexible working arrangements. This has implications for recruitment of future general practitioners.

Br J Cardiol 2002;9:182-184.

REVIEWIntracoronary brachytherapy
Dougal R McClean, Martyn R Thomas

Restenosis following PTCA or intracoronary stent insertion remains the greatest challenge to interventional cardiology. Intracoronary brachytherapy may use either beta- or gamma- radiation. The target cells are most likely in the adventitial layer of the vessel wall. The principle of using brachytherapy post-angioplasty to reduce restenosis has been proven in animal models. Multiple randomised trials have shown brachytherapy to be the current optimal therapy to treat in-stent restenosis. The data for the use of intracoronary radiation for treatment of de novo coronary lesions are less strong. Potential complications of brachytherapy include ‘edge effect’ and ‘late late stent thrombosis’. These problems are being minimised with the use of long sources and prolonged antiplatelet therapy. Drug delivery stents may challenge the role of brachytherapy in preventing and treating restenosis in the near future.

Br J Cardiol 2002;9:147-152.

HOT
TOPICREVIEWA survey of control of major risk factors following coronary artery bypass graft surgery
Mohd R Abdul-Rahman, Saveena S Ghaie, Justo R Sadaba, Levent T Guvendik, Alexander R Cale, Michael E Cowen, Steven C Griffin

The aim of this survey was to review the awareness and efficacy amongst patients and general practitioners (GPs) in controlling coronary risk factors following coronary artery bypass graft surgery (CABG). It was a prospective cohort study based on an inclusive registry at our department.
230 patients who underwent CABG between April 1999–July 2000 and who had a history of hypertension and hypercholesterolaemia were selected. Frequency of blood pressure (BP) and cholesterol monitoring, blood glucose control, current smoking status, weight and medications were established via telephone interview of patients. BP and cholesterol levels were confirmed by written questionnaires to GPs. BP and cholesterol were considered to be controlled if they were ≤ 140/85 mmHg and ≤ 5.0 mmol/L respectively.
Of the 230 patients, 213 were successfully contacted. After surgery, 181 (85%) patients had BP checks at least six-monthly by their GPs, 13 (6.1%) less frequently and 19 (8.9%) not at all. Cholesterol levels were checked at least six-monthly in 128 (60.1%), less frequently in 47 (22.1%) and not at all in 38 (17.8%). Thirteen of the 20 patients who were smoking at the time of surgery continued to smoke. BP and cholesterol readings were obtained for 169 of the 213 patients. Of these, BP was well controlled in 92 (54.4%), uncontrolled in 61 (36.1%) and not checked in 16 (9.5%). Cholesterol was well controlled in 106 (62.7%), uncontrolled in 35 (20.7%) and not checked in 28 (16.6%) patients. Although patients and GPs are generally aware of the importance of controlling coronary disease risk factors, more effort is required if we are to meet the Joint British recommendations on prevention of coronary heart disease.

Br J Cardiol 2002;9:153-157.

HOT
TOPICREVIEWThe clinical application of ACE inhibitors in coronary artery disease
Abba Gomma, John Henderson, Henry Purcell, Kim Fox

The renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathogenesis of cardiovascular disease. Blockade of this system results in a number of biologically important beneficial effects, including inhibition of the breakdown of bradykinin, reduction in blood pressure and inhibition of neuroendocrine activity, as well as reversal of endothelial dysfunction. Angiotensin-converting enzyme (ACE) inhibitors have an established role in the management of hypertension and heart failure. More recently, for instance in the HOPE trial, they have been investigated in patients with a history of coronary artery disease, stroke, peripheral vascular disease, or diabetes plus at least one other cardiovascular risk factor, but with preserved left ventricular function. Treatment with ramipril was shown to reduce cardiovascular events significantly, especially in patients who had diabetes. Two further ongoing trials – EUROPA (with perindopril) and PEACE (with trandolapril) – are described, which have important differences in trial design and which will further assess the protective effects of ACE inhibition in patients with stable coronary artery disease.

Br J Cardiol 2002;9:158-162.

HOT
TOPICREVIEWStroke in the patient with coronary heart disease
Diana R Holdright

Coronary heart disease (CHD) and stroke frequently coexist, partly because they share many risk factors. After myocardial infarction (MI), there is a significant risk of mural thrombus formation, left ventricular aneurysm, impaired left ventricular function and atrial fibrillation; all these increase the risk of stroke. The risk of neurological deficit after cardiac surgery is higher in those patients who have already had a stroke. Cognitive decline after cardiac surgery is common: it may follow a pattern of early improvement but later decline. Lipid-lowering therapy has been shown to reduce non-fatal stroke in patients at risk of developing or with coronary artery disease. Clopidogrel with aspirin may be of benefit in patients with unstable angina and non-ST elevation MI. Antihypertensive treatment and stopping smoking are helpful. The HOPE trial results showed a powerful and preventative role for ACE inhibitors.

Br J Cardiol 2002;9:163-167.

REVIEWRecurrent syncope in a patient with Andersen’s syndrome
Wayne R Arthur, Gerry C Kaye, Robert F Mueller

Br J Cardiol 2002;9:168-170.