Volume 9, Number 6, June 2002

HOT
TOPICEDITORIALLeft ventricular hypertrophy: a target for treatment
Jamil Mayet, Rebecca Lane

Br J Cardiol 2002;9:313-316.

PRIMARY CAREThe NHS Plan: general practitioners with special interests
David Colin-Thome

Many general practitioners (GPs) already have a special clinical interest. This role is now being developed and formalised by the Department of Health and by 2004, 1,000 posts of general practitioners with special interests (GPwSI) will have been created. Alongside their normal general practice work, these GPs will also offer a particular specialist service under contract to a Primary Care or Acute Trust taking referrals from fellow GPs. A National Develop-ment Group is currently consulting relevant bodies to publish advice on the commissioning and appointment of such GPs. It is hoped these appointments will help integrate primary care and hospital services under the new NHS Plan, leading to enhanced patient care and the delivery of the National Service Frameworks. It will also give continuing job satisfaction to GPs wanting to extend their role.

Br J Cardiol 2002;9:359-360.

HOT
TOPICPRIMARY CAREA case study from a Sussex Primary Care Group: improving secondary prevention in coronary heart disease using an educational intervention prevention guidance
Simon de Lusignan, N Hague, Claire Yates, M Harvey

An educational intervention was developed to try to raise both data quality standards and those of clinical care in the secondary prevention of coronary heart disease. The intervention was used within primary care organisations utilising their own clinical data and with primary care professionals learning from each other.
A special tool (MIQUEST) was used to extract the clinical data. Anony-mised data were then shared with the whole primary care organisation at six-monthly data quality workshops. Patients needing interventions were identified in individual practices and these practice visits were also used as learning opportunities.
At the end of the study there was an increase in the recording of the diagnosis of ischaemc heart disease (IHD). The recording of blood pressure and its control also improved. The number of IHD patients not on aspirin was reduced. Measurement of cholesterol, prescription of statins and the giving of advice to smokers all increased. The increase was largest in the practices with the lowest baseline data.
The study concluded that this primary care data quality programme could provide an educational environment within which primary care organisations could improve secondary prevention in coronary heart disease.

Br J Cardiol 2002;9:362-368.

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

The onset of symptoms in primary pulmonary hypertension (PPH) is usually insidious with several years elapsing before the diagnosis is actually made. It is important that general physicians should be made aware of this fact and that they should have a high rate of suspicion of the subtle nature of the clinical presentation in this group of patients. Patients with a suspected diagnosis of PPH should be referred to specialised centres where early diagnosis and treatment can be initiated. We review the salient features of PPH and provide an insight into the various therapeutic options that are now available for this disease.

Br J Cardiol 2002;9:330-336.

REVIEWPrimary pulmonary hypertension: a GP comment
Ross Price

Br J Cardiol 2002;9:337-338.

REVIEWComplications associated with 64 temporary pacing wires implanted at a district general hospital – should this procedure be reserved for specialist centres?
Adam Brown, Barnaby Thwaites

This study assessed complication rates in 64 emergency temporary pacing procedures, of which atrioventricular block formed the largest group (72%). Of the in-hospital deaths, most (76%) were due to myocardial infarction, and none due to the procedure. Immediate complications occurred in 22%: arrhythmia or arterial puncture, and one hemiparesis. Late complications occurred in 34%: loss of capture, infection including one instance of staphylococcal septicaemia. No complications occurred in 59%. Involvement of a consultant in the procedure did not reduce complication rates. In such potentially unstable patients, the risks of not pacing or delaying pacing probably far outweigh those of immediate intervention.

Br J Cardiol 2002;9:339-342.

REVIEWEfficacy of micronised fenofibrate in patients with primary hyperlipidaemia: a comparison with pravastatin
Jean Ducobu, Luc Van Haelst, Herva Salomon

This randomised, double-blind, six-month trial assessed the efficacy and tolerability of micronised fenofibrate and pravastatin in 265 patients (18–75 years of age) with primary hyperlipidaemia (pure hypercholesterolaemia, type IIa; and mixed dyslipidaemia, type IIb) recruited from 28 European centres. After a first three-month phase in which patients received once daily either micronised fenofibrate 200 mg or pravastatin 20 mg, type IIa patients attaining low density lipoprotein cholesterol (LDL) < 4.14 mmol/L and type IIb patients attaining LDL < 4.14 mmol/L and triglycerides < 2.26 mmol/L continued with the same dose in a three-month extension phase. Patients not meeting these criteria received a double dose of drug in this extension phase. Micronised fenofibrate and pravastatin were similarly effective in reducing levels of LDL and total cholesterol in patients with pure hypercholesterolaemia and mixed dyslipidaemia in the initial three-month phase, although high density lipoprotein cholesterol (HDL) levels were increased, and triglycerides were reduced, by a significantly greater degree by micronised fenofibrate (p=0.0001 and p=0.0011, respectively).
In the extension phase, in the constant-dosage groups, both treatments maintained their effect in reducing LDL, while micronised fenofibrate maintained the triglyceride reduction more effectively than pravastatin. In the increased dosage group, continued LDL reductions were attained with both treatments, while the patients receiving micronised fenofibrate showed a significantly greater triglyceride reduction than the pravastatin patients.
Treating patients with a new generation fibrate for primary hyperlipidaemia produces LDL and cholesterol-lowering benefits comparable to statin therapy, and has the added advantages of significant triglyceride reduction and a possibly more effective HDL-raising ability.

Br J Cardiol 2002;9:343-350.

REVIEWPatients of Southern Asian descent treated with valsartan (POSATIV) study
Jatin KV Patel and Richard Leaback, on behalf of the POSATIV investigators

Southern Asians in the UK have a substantially increased (50%) risk of coronary heart disease compared with the general population, in part due to a high prevalence of hypertension and diabetes. This patient group has not been specifically studied in a clinical trial using modern antihypertensive therapy such as the angiotensin II receptor antagonists (AIIRAs). A multi-centre, double-blind, randomised, parallel-group study compared the effects of treatment with valsartan 80 mg once daily (o.d.) with control therapy (bendrofluazide 2.5 mg o.d.) in 116 patients with mild hypertension (diastolic blood pressure [DBP] ≥ 90 mmHg and ≤ 105 mmHg) after a four-week run-in period. Sitting blood pressure was measured at baseline (end of run-in) and after four and eight weeks of treatment using the OMRON automatic oscillometric blood pressure monitor. The study medication dosage was doubled if patients had < 4 mmHg decrease in DBP after four weeks. Compared with the control group (n=62), the addition of valsartan 80/160 mg o.d. (n=51) resulted in a significantly greater reduction in blood pressure at eight weeks (mean change in blood pressure -15.6 mmHg [95% CI -19.9 to -11.2 mmHg] for systolic blood pressure [SBP] and -9.3 mmHg [95% CI -11.8 to -6.8 mmHg] for DBP; p<0.001). Both treatments were well tolerated. Valsartan is effective and well tolerated, and would be an appropriate treatment option in Southern Asian hypertensive patients.

Br J Cardiol 2002;9:351-354.

REVIEWOn-call seen as a pathophysiologic state
Johan EP Waktare, Alex Stewart, John P Lyons

Br J Cardiol 2002;9:355.

HOT
TOPICCASE REPORTSerious interaction between digoxin and warfarin
Arpandev Bhattacharyya, Manju Bhavnani, David James Tymms

Br J Cardiol 2002;9:356-357.