Volume 9, Number 7, July-August 2002
HOT
TOPICEDITORIALAtherosclerosis imaging and coronary calcification: the UK perspective
Gareth J Morgan-Hughes, Carl A Roobottom, Andrew J Marshall Br J Cardiol 2002;9:373-376. EDITORIALJournal links with British Hypertension Society information service
Bryan Williams
Br J Cardiol 2002;9:377. PRIMARY CAREHypertension in the elderly – the primary care perspective
Sarah Jarvis The proportion of the elderly population is rapidly growing, increasing the numbers of hypertensive patients and the workload in primary care. The average GP will currently have around 100 hypertensive patients over the age of 75 years in their care; this number is likely to be much higher in popular retirement areas.
Clinical trials have shown the benefits of vigorous blood pressure control in the elderly; current recommendations are to reduce blood pressure to under 140/85 mmHg in at-risk groups and to under 130/80 mmHg in diabetics. Hypertension treatment continues to be difficult, however, due to poor compliance. This is for a number of reasons, including the fact that it is often a symptomless condition, the side effects of antihypertensive medication and the number of concomitant medical conditions making drug regimes complicated in the elderly.
Newer classes of antihypertensive agents, such as beta blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists, are proving to reduce other risks as well as reducing blood pressure. Angiotensin II receptor antagonists appear to be better tolerated than other antihypertensive drugs; clinical trial results are awaited to assess their protective effects as well as their effect on quality of life, health economics and cost-effectiveness. Br J Cardiol 2002;9:422-424. HOT
TOPICREVIEWAtherosclerosis imaging and coronary calcification
Matthew J Budoff Recently published data have greatly expanded the applicability of electron beam tomography and electron beam angiography. Guidelines and policy towards these modalities have shifted, with increased recognition of their importance among experts in cardiology, lipidology and preventive medicine. Given the high sensitivity of coronary calcification for the presence of obstructive coronary artery disease (CAD) (95–99%), exclusion of coronary calcium may be useful as a filter prior to invasive diagnostic procedures or hospital admission.
The prognostic power of coronary calcium has been recognised to be superior to risk factor assessment in summary data from nine studies. The presence of coronary calcification was associated with a 10-fold increased risk of cardiovascular events. Several trials have demonstrated slowing of the calcification process under the influence of statin therapy. Data suggest that change in calcium score can be used to assess the efficacy of lipid-lowering therapy and is currently being used as a surrogate end point for a host of pharmaceutical studies.
Electron beam angiography provides non-invasive visualisation of native coronary arteries and bypass grafts. Some current clinical uses include: following non-diagnostic stress tests; for any person with an intermediate likelihood of CAD (where the step to coronary angiography might be premature); for symptomatic persons post-angioplasty and possibly post-stent; for evaluating graft patency post-coronary artery bypass graft (CABG); and for early detection of obstructive CAD in the high-risk person.
Br J Cardiol 2002;9:394-400. HOT
TOPICREVIEWThe effect of nifedipine GITS on outcomes in patients with previous myocardial infarction: a subgroup analysis of the INSIGHT study
Giuseppe Mancia, Luis M Ruilope, Moris J Brown, Christopher R Palmer, Talma Rosenthal, Alain Castaigne, Peter W de Leuw, Gilbert Wagener Post-myocardial infarction (MI) patients have a higher risk for subsequent cardiovascular and cerebrovascular events than the average population. This study was to test the effects on outcomes of nifedipine GITS compared to the diuretic combination co-amilozide in hypertensive patients with a history of MI on outcomes (subset of the INSIGHT study).
The multinational, randomised, double-blind International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment (INSIGHT) study compared the treatment effects of nifedipine GITS 30 mg and co-amilozide (hydrochlorothiazide 25 mg plus amiloride 2.5 mg) in hypertensive patients aged 55–80 years with a blood pressure of 150/95 mmHg (or 160 mmHg systolic). This pre-specified subanalysis was performed in patients with a history of MI. The primary outcome was a composite of cardiovascular death, non-fatal stroke, MI, and heart failure.
Of 6,321 randomised patients, 383 (6.1%) had a previous MI. The percentage of primary outcomes in post-MI patients did not differ between the two treatment groups (14.9%). The number of post-MI patients with composite secondary outcomes was 53 (27.2%) in the nifedipine GITS group and 60 (31.9%) in the co-amilozide group. The incidence rates of primary and secondary outcomes were higher in patients with a previous MI than in patients without a history of MI.
For the randomised use of nifedipine GITS and co-amilozide in hypertensive patients with a previous MI, the choice seemed unimportant for outcomes and blood pressure lowering. The results of this subgroup analysis are consistent with INSIGHT's overall findings of no significant differences in efficacy, suggesting that post-MI hypertensive patients are no more likely to suffer further events when treated with long-acting nifedipine than on co-amilozide. Br J Cardiol 2002;9:401-405. HOT
TOPICREVIEWBrugada syndrome: a review
Badri Chandrasekaran, Arvinder S Kurbaan Brugada syndrome was described 10 years ago. It is a syndrome of sudden cardiac death associated with partial right bundle branch block and ST segment elevation in the right precordial leads V1-V3 on the resting ECG. Those affected have structurally normal hearts (as demonstrated by standard techniques) but they have a mortality rate of 10% a year, whether they are symptomatic or asymptomatic.
It is thought to be primarily a disease of cardiac conduction and has been linked to abnormalities in the sodium channel (SCN5A). Differential diagnoses include arrhythmogenic right ventricular dysplasia, idiopathic ventricular fibrillation and polymorphic ventricular tachycardia. Brugada et al. suggest that the Brugada shift pattern on 12-lead ECG is a specific marker for those at risk of sudden death. They recommend that symptomatic individuals be protected with an implantable cardiac defibrillator. Asymptomatic individuals remain a diagnostic dilemma. Br J Cardiol 2002;9:406-410. CASE REPORTCoronary artery ectasia identified on chest X-ray
Duncan Hogg, Stephen Yule, Kevin Jennings Br J Cardiol 2002;9:411-413.
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