Volume 9, Number 5, May 2002

EDITORIALUnstable angina: the case for selective aggression
Elliot J Smith, Nicholas P Curzen

Br J Cardiol 2002;9:251-254.

EDITORIALGarlic in cardiovascular disease – the last word?
James M Lawrence, John PD Reckless

Br J Cardiol 2002;9:255-257.

PRIMARY CAREOptimising management of patients with hypertension and diabetes
George Kassianos

Optimal management of hypertension and diabetes is essential if the cardiovascular and renal mortality and morbidity associated with this condition is to be reduced. Recent guidelines from the National Service Framework for Diabetes and the Scottish Intercollegiate Guidelines Network are discussed. Recent studies (UKPDS, RENAAL and PRIME) looking at the contribution tight blood pressure control and angiotensin II receptor antagonists can make to the management of this hypertension in diabetics are also covered.
Finally, the author advises how primary care can implement guidelines in practice to give the best possible care to patients with diabetes.

Br J Cardiol 2002;9:297-302.

HOT
TOPICPRIMARY CARENICE announce audit of secondary prevention guidance
Tom Quinn

Br J Cardiol 2002;9:303-304.

HOT
TOPICREVIEWThe pathophysiology of primary pulmonary hypertension
Ghada W Mikhail, J Simon R Gibbs, Magdi H Yacoub

Primary pulmonary hypertension (PPH) is a progressive disease with a poor prognosis. It is characterised by an elevated pulmonary artery pressure and pulmonary vascular resistance that ultimately lead to right ventricular failure and death. PPH is a relatively rare and neglected disease which, until recently, had been poorly understood and had no effective form of therapy. This, however, is changing with the rapid accumulation of knowledge relating to the disease and its management. In this article, we review the possible mechanisms that may have a pivotal role in the development of the disease.

Br J Cardiol 2002;9:265-272.

REVIEWTherapeutic potential of the natriuretic peptide system
Paul R Kalra, Andrew JS Coats

Neurohormonal activation has a central role in the pathophysiology of various cardiovascular disorders. Despite recent therapeutic advances, potential exists to further manipulate these activated systems. The natriuretic peptide family consists of at least four structurally related peptides, with varying degrees of biological similarity. In the context of cardiovascular disease, the vast majority of data relates to atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).

Br J Cardiol 2002;9:273-279.

HOT
TOPICREVIEWAngiotensin II receptor antagonists in the treatment of heart failure: background to and design of the CHARM study
Simon W Dubrey

While angiotensin-converting enzyme (ACE) inhibitors are established agents for the treatment of hypertension and heart failure, in contrast the angiotensin II receptor antagonists (AIIRAs) have failed to demonstrate more than equivalence in randomised clinical trials. Trials such as ELITE II are criticised on the grounds that the dose used of losartan (50 mg) may have been sub-optimal. In ValHeFT, valsartan was shown to be superior to placebo only in patients who did not also receive a beta blocker. The ambiguity of response of AIIRAs in such trials will hopefully be clarified in CHARM, a large, placebo-controlled study which will assess the effects of candesartan in heart failure patients with either reduced ejection fractions in addition to an ACE inhibitor, and in those intolerant to an ACE inhibitor, as well as in patients with preserved ventricular function (diastolic heart failure) not on an ACE inhibitor. The design of the study is discussed.

Br J Cardiol 2002;9:280-286.

HOT
TOPICREVIEWThe use of echocardiography for stroke and peripheral embolus: is it time for British/European guidelines?
Oliver R Segal, J Rex Dawson, Sandeep Gupta

The American College of Cardiology and the American Heart Association recommend echocardiography in patients with stroke or peripheral embolus who are less than 45 years of age or in those without evidence of cerebrovascular disease or other obvious cause.¹ There are no equivalent guidelines from British or European Cardiac Societies. The prevalence of stroke and peripheral embolus has made it a common indication for the use of echocardiography. Despite this, to our knowledge there has been no previously published evaluation of the use of echocardiography in such patients in the UK. We undertook a retrospective review of transthoracic (TTE) and transoesophageal echocardiogram (TOE) reports (n=7,870) over 37 months at St. Bartholomew’s Hospital department of cardiology. This identified 153 (1.9%) patients investigated for stroke/transient ischaemic attack (TIA) or peripheral embolus. Of these, six patients had two or more examinations producing a total of 160 reports; five reports were unrecorded and, therefore, 155 reports were analysed. A total of 12 reports (7.7%) identified possible cardiac sources of emboli with a further n=3 reporting spontaneous contrast in the left atrium. The potential embolic sources included patent foramen ovale (PFO)(n=3), aortic atheroma (n=3), aneurysmal atrial septum (n=2), mobile lesions on the mitral valve (n=3) and thrombus in the left atrial appendage (LAA)(n=1).
These results have led to the development of standardised criteria with the design of a template on the performing and reporting of echocardiograms in this type of patient.

Br J Cardiol 2002;9:287-290.

REVIEWCoarctation of the aorta: a life-long disease of the entire vascular system
Mark Turner, Dirk Wilson, Andrew J Marshall

Coarctation of the aorta is an important differential diagnosis in adults with hypertension. Unfortunately, simply removing the obstruction does not restore cardiovascular normality. Patients may continue to be hypertensive, demonstrate abnormalities of endothelial function and remain at risk of premature coronary artery disease and other vascular disease. Therapy therefore requires both relief of the mechanical obstruction and long-term follow-up to deliver optimal antihypertensive therapy, vascular risk factor modification and detection and management of complications (such as bicuspid aortic valve and cerebral aneurysms). This paper discusses the management of three cases of this condition.

Br J Cardiol 2002;9:291-293.

CASE REPORTExtensive multiple coronary artery to left ventricular fistulas – a 10-year case history
Matthew J Banks, Jane Flint, Peter R Forsey, George D Kitas

Br J Cardiol 2002;9:294-296.