Volume 9, Number 10, November-December 2002

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TOPICEDITORIALImproving care for patients with heart disease: implications of the Fifth report on the provision of services for patients with heart disease
Paul Kalra, Roger Hall, John Camm

Br J Cardiol 2002;9:567-569.

EDITORIALHEART UK – a new charity to help tackle blood fats and vascular disease
John Reckless

Br J Cardiol 2002;9:570-571.

EDITORIALThe genetics of cardiovascular disorders
John Payne, Hugh Montgomery

Br J Cardiol 2002;9:572-575.

PRIMARY CAREGerman bears, Greek philosophers and Mediterranean diets – this year’s PCCS Annual Scientific Meeting goes European
This year’s Primary Care Cardiovascular Society annual meeting was the occasion for a number of firsts. Not only was it the first Annual Scientific Meeting to be held outside England, it was also the first time members had the opportunity to take part in a Socratic Dialogue. The Greek philosopher’s technique did stimulate lively interaction and subsequent proceedings proved to be highly participative. With the highest attendance so far recorded, Chairman, Professor Richard Hobbs, felt that the 2002 meeting easily qualified as the best to date. Ola Soyinka reports from Cardiff.

Br J Cardiol 2002;9:617-623.

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TOPICPRIMARY CAREEarly thrombolysis for the treatment of acute myocardial infarction. Who will provide this treatment in the UK? Part II.
Terry McCormack

This article describes the successful provision of a thrombolysis service by general practitioners in the isolated rural area of Whitby, North Yorkshire, and also in rural areas of Sweden. It discusses the difficulties in providing such a service, particularly the rural/urban paradox whereby specialist pre-hospital thrombolysis services can be much more easily provided in urban areas than rural areas where the need is normally much greater.
The results of a small straw poll on thrombolysis amongst Primary Care Cardiovascular Society members show that rural general practitioners are much more interested in providing a pre-hospital thrombolysis service than their urban colleagues; paying a fee for such a service should be considered in future planning. The article also reviews the various thrombolytic agents favouring the use of fibrin-specific thrombolytic agents by bolus for pre-hospital thrombolysis.

Br J Cardiol 2002;9:624-627.

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TOPICPRIMARY CAREThe electronic health record and the management of cardiovascular disease
Alan G Begg, John M Griffith

A dvanced web-based clinical care applications as part of an electronic health record can assist clinicians to meet Government targets for the management of cardiovascular disease. A clinical module of the Tayside electronic health record collects electronic data automatically from a variety of sources and holds this data in a central regional repository. It identifies those patients with existing cardiovascular disease and also those high priority patients at risk of developing clinical atherosclerosis. It allows the clinician to effectively manage these patients in line with national evidence-based guidelines. Real time audit of patient management is instantly available at the point of direct patient contact, as well as benchmarking to agreed performance criteria. Demonstrating improvement in clinical outcomes remains the eventual goal.

Br J Cardiol 2002;9:630-633.

PRIMARY CAREThe HEARTS collaboration – delivering improved secondary prevention of CHD for patients with heart disease
Frank Sullivan, Stuart D Pringle, Hamish Dougall, Neill McEwan, Gavin Murphy, Douglas Boyle, Andrew D Morris

Full implementation of the available evidence on secondary prevention should ensure that all patients after myocardial infarction should be offered both effective treatment and be maintained on treatment. This article describes the Heart disease Evidence-based Audit and Research in Tayside Scotland (HEARTS) collaboration which has been set up to try and achieve this. HEARTS can collect electronic data from many sources; prioritise data from multiple sources, such as hospital and general practice; process and link patient records; and, allow manual validation of electronic data. It can also facilitate clinical governance issues in general practice and hospital plus disseminate information to patients. It is hoped that, in addition to secondary prevention, it will be able to extend its focus to other aspects of cardiovascular disease in the future as well as being used for epidemiological and qualitative projects. The system maintains the security and rights of patients at all times.

Br J Cardiol 2002;9:634-638.

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TOPICPRIMARY CAREHypertension trials – the current evidence base and forthcoming trials
Peter Sever, Neil Poulter

Recently reported and ongoing morbidity and mortality trials in hypertensive patients are addressing important unanswered questions in hypertension management. What is the optimal first-line treatment for hypertension, what is the ideal combination of antihypertensive drugs, how are these influenced in particular patient subgroups, and what are the treatment thresholds and blood pressure goals of treatment for optimal prevention of cardiovascular disease? Limitations of some recent trials are highlighted and emphasise the need for further prospective meta-analyses of studies to provide adequate power to address some of these important questions. Current ongoing large scale studies, including ALLHAT and ASCOT, will shortly be reporting results to the scientific community and are likely to influence management decisions across a wide range of patient subgroups.

Br J Cardiol 2002;9:640-644.

REVIEWRevascularisation and the diabetic patient: the potential role of drug-eluting stents
David Barrow

Br J Cardiol 2002;9:590-592.

REVIEWThe cardiological complications associated with HIV infection and acquired immune deficiency syndrome (AIDS)
Timothy C Hardman, Scott D Purdon

Our increased understanding of the human immunodeficiency virus (HIV), including elucidation of the processes of transmission and replication, has led to the development of relatively effective therapies to minimise and manage the clinical consequences of HIV infection. These therapeutic developments have undoubtedly improved rates of morbidity and mortality in infected patients. The improvements in quality of life and life expectancy have been accompanied by an increase in the number of patients demonstrating cardiac complications, occurring either as a result of the infection itself or the drugs used to control the virus.
Cardiac involvement occurs frequently in HIV/AIDS patients and it seems likely that the myocardium, pericardium and/or endocardium are involved. Myocarditis, one of the most common types of cardiac involvement observed in HIV patients, the cause of which can be difficult to identify, may be responsible for myocardial dysfunction. Opportunistic infections, including HIV itself, have been suggested as the cause of myocarditis. Dilated cardiomyopathy is usually found in the late stage of HIV infection and myocarditis may be the triggering causative factor. The mechanism behind pericardial effusion remains unclear but it too may be related to infections or neoplasms. Non-bacterial thrombotic endocarditis and infective endocarditis have been described in AIDS patients, both of which cause significant morbidity. Human immunodeficiency virus-related pulmonary hypertension is a diagnosis of exclusion, and symptoms and signs may mimic other pulmonary conditions in AIDS patients. Cardiac Kaposi’s sarcoma and cardiac lymphoma are the frequently encountered malignant neoplasms in AIDS patients – the prognosis is grave in patients with these conditions.

Br J Cardiol 2002;9:593-599.

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TOPICREVIEWWhat is the current role of omega-3 polyunsaturated fatty acids in post-myocardial infarction management?
Lena Marie Izzat, Philip Avery

The low incidence of ischaemic heart disease amongst Greenlandic Eskimos has intrigued researchers for many years. The answer was found in their marine-based diet, very rich in omega-3 polyunsaturated fatty acids (n-3 PUFAs). These have shown anti-arrhythmic, endothelial protective, anti-atherogenic, antithrombotic and antiplatelet effects in many observational studies, which have paved the way for the potential role in secondary prevention post-myocardial infarction.
Many trials have emphasised the importance of oily fish in the secondary prevention of coronary heart disease. Oily fish consumption, however, is poor in the UK. It has the disadvantages of possible toxic chemical contaminants, a large calorific content and some people simply do not like it. The GISSI-Prevenzione trial studied the effect of a highly purified n-3 PUFA supplement and found it conferred a 20% relative risk reduction in mortality and a 45% reduction in the risk of sudden cardiac death. This early protection supports the anti-arrhythmic potential of n-3 PUFAs.
A supplement containing 90% concentrate of the n-3 PUFAs, eicosapentaenoic acid and docosahexanoic acid, known as Omacor™, is now licensed in the UK as adjuvant treatment in secondary prevention post-myocardial infarction, in addition to standard medical treatment including statins.
The prescription of n-3 PUFA supplements are best initiated in secondary care. The index admission is generally the best time to initiate secondary prevention when patients tend to be most receptive.

Br J Cardiol 2002;9:600-609.

REVIEWFish oils and cardioprotection – mechanisms explored
Derek M Yellon, Derek Hausenloy

Br J Cardiol 2002;9:609-610.

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TOPICREVIEWIn-patient transfer for coronary angiography: a substitute for clinical evaluation?
Emma Helm, Elizabeth Hamlyn, John Chambers

Waiting for in-patient transfer for the investigation of chest pain is a significant cause of ‘bed-blocking’. We performed an audit of 58 consecutive in-patient transfers. The mean delay between referral and transfer was 10 days (range one to 28 days). At the time of transfer the mean number of pain-free days was five (range one to 21 days). Of the 37 patients with a working diagnosis of unstable angina, only 19 (51%) underwent some sort of non-invasive risk stratification prior to referral, nine patients (24%) were walking around the hospital or had taken weekend leave and 13 (35%) had normal anatomy or subcritical disease. Of 21 with post-infarct angina, seven (33%) underwent exercise stress testing, five (24%) were mobilising around the hospital and 18 (86%) underwent some sort of intervention.
In conclusion, waiting times for in-patient angiography were long and utilisation of non-invasive investigation was low.

Br J Cardiol 2002;9:611-613.

CASE REPORTAn unusual case of pericardial constriction
Michael Pitt, Stephen Rooney, R Gordon Murray

Br J Cardiol 2002;9:615-616.