Volume 10, Number 1, January-February 2003

HOT
TOPICEDITORIALCardiac rehabilitation taking a centre stage in British cardiology
Lip-Bun Tan, J Malcolm Walker

Br J Cardiol 2003;10:7-10.

EDITORIALThe expert patient: good thinking or a cross
Jane Flint

Br J Cardiol 2003;10:11-13.

HOT
TOPICPRIMARY CARECurrent progress in lipid therapy
Rubin Minhas

There is strong evidence to support a causal relationship between the level of circulating plasma cholesterol and the risk of clinically overt coronary heart disease (CHD) events. Current UK guidelines recommend reductions of total cholesterol levels to below 5.0 mmol/L. Statins remain the drugs of first choice for reducing low-density lipoproteins (LDL). Rosuvastatin has already been approved in the Netherlands and is likely to become more widely available in the next year. It has a potent effect in lowering LDL and it also appears to raise high-density lipoproteins (HDL). It has a similar safety profile compared with other statins.
Cholesterol absorption inhibitors are a new treatment option for the management of hypercholesterolaemia. Ezetimibe, the first drug in this class, has recently been approved for use in the US and Germany. It selectively inhibits the uptake of dietary and biliary cholesterol at the level of the enterocyte. The site of action of ezetimibe may be the ‘sterol permease’ transport protein. As monotherapy, the role of ezetimibe appears limited at present. However, in combination with a low-dose statin, significant reductions in plasma LDL levels are seen. It may also be a useful agent for patients with homozygous familial hypercholesterolaemia.

Br J Cardiol 2003;10:59-68.

HOT
TOPICPRIMARY CAREAmiodarone monitoring: involving patients in risk management
Jill Murie

Amiodarone is a potentially hazardous drug indicated for atrial and ventricular arrhythmias. The purpose of the audit was to assess the risk associated with amiodarone therapy and identify measures to improve patient safety. The setting was a rural practice with 13,000 patients in Lanark, Scotland. A computer search identified 16 patients (11 male, five female) receiving amiodarone. The mean age was 74 years (range 61–89 years).
Action taken was raising doctor awareness and systematic biochemical and clinical review. Results showed that, in spite of substantial mortality and morbidity prior to the audit, there was no effective practice monitoring system for amiodarone therapy. The prevalence of clinical hypothyroidism and hyperthyroidism (29%) and ‘silent’ biochemical thyroid dysfunction (14%) exceeded published estimates (14–18% and 10% respectively). Although standards improved for biochemical monitoring, increasing awareness of the need for close surveillance did not appear to change the practice of some of the general practitioners (GPs), notably the clinical examination of pulse and blood pressure.
The audit demonstrates a need for a more systematic approach to amiodarone monitoring. Recommenda-tions include enhancements to the patient information leaflet, the development of local protocols and patient involvement in quality improvements including improved communication, patient-held record cards, better quality follow-up information, and more effective reporting systems.

Br J Cardiol 2003;10:70-72.

PRIMARY CAREAnalgesia alert
John K Inman

The mode of action of non-steroidal anti-inflammatory drugs and the role of the cyclo-oxygenase enzymes COX1 and COX2 and their inhibitors is described. These can have potentially serious effects on the cardiovascular and renal system which are discussed.
The alternative, widely-prescribed analgesic, paracetamol, is also discussed, as are two theories ‘confounded by indication’ and ‘protopathic bias’ to help explain why paracetamol is sometimes described as being linked to asthma and upper gastro-intestinal damage, both effects not expected from a knowledge of its mode of action.

Br J Cardiol 2003;10:74-76.

HOT
TOPICREVIEWThe SIGN guideline on cardiac rehabilitation
Chris Isles

The SIGN guideline on cardiac rehabilitation was published in January 2002 and endorsed by the British Association of Cardiac Rehabilitation. This paper summarises the recommendations, which cover all four phases of recovery and the three main cardiac rehabilitation interventions.

Br J Cardiol 2003;10:29-34.

REVIEWPrescribing of ACE inhibitors and statins after bypass surgery: a missed opportunity for secondary prevention?
R Andrew Archbold, Azfar G Zaman, Nicholas P Curzen, Peter G Mills

Angiotensin-converting enzyme (ACE) inhibitors and statins improve prognosis in patients with coronary artery disease. Effective secondary prevention strategies, however, are frequently under-utilised. We sought to determine prescribing habits for ACE inhibitors and statins in 324 patients undergoing coronary artery bypass graft surgery (CABG) at two regional cardiac centres in the United Kingdom. We prospectively recorded ACE inhibitor and statin use on admission and discharge, ACE inhibitor and statin initiation and withdrawal during the hospital stay, and sought associations with treatment withdrawal. 82 (25.3%) patients were taking an ACE inhibitor on admission compared with 37 (11.4%) at discharge (p<0.0005). An ACE inhibitor was initiated during the hospital stay in five (1.5%) patients and was withdrawn in 50 (15.4%). On admission, 157 (48.5%) patients were receiving statin therapy compared with 154 (47.5%) at discharge (p=ns). Statin treatment was initiated in 23 (7.1%) patients, but was withdrawn in 20 (6.2%) others. Thus, only a minority of patients were receiving ACE inhibitors and statins on admission for isolated elective CABG. ACE inhibitor treatment was discontinued during the hospital stay in over 60% of these patients. Furthermore, statin therapy was no more common at discharge than on admission. This study highlights a missed opportunity for effective secondary prevention in a high risk population.

Br J Cardiol 2003;10:36-43.

HOT
TOPICREVIEWThe future of cardiology – heart disease in older patients
Andrew Docherty, Jacqueline Taylor, Adrian JB Brady

Cardiovascular death is steadily decreasing but still accounts for 40% of deaths (235,000) in this country per year. More than 85% occur in older patients over the age of 65 years. The future of cardiology lies in the delivery of care to this rapidly expanding population of older people, whose growing numbers will account for an increasing trend upwards in the prevalence of cardiovascular morbidity in the UK. There will be increasing numbers of heart failure, hypertension, myocardial infarction, angina, atrial fibrillation, pacemaker implants and heart valve implantation in older patients. Randomised clinical trials often exclude the treatment of these conditions in patients over 75 years and results cannot always be easily extrapolated. Older patients often seem to be disadvantaged when compared with younger patients with cardiovascular disease. This article is the first in a series examining the treatment of older patients with cardiovascular disease.

Br J Cardiol 2003;10:45-48.

HOT
TOPICREVIEWNational survey of emergency department management of patients with acute undifferentiated chest pain
Steve Goodacre, Jon Nicholl, Jo Beahan, Deborah Quinney, Simon Capewell

Acute, undifferentiated chest pain (chest pain ?cause) presents a frequent and difficult challenge to clinicians working in the emergency setting. We aimed to survey current management of this problem in UK accident and emergency departments by sending a postal questionnaire to the lead clinician or first named consultant in every major A&E department in the UK.
Responses were received from 177/238 departments (74%). Although 74 departments (42%) had formal guidelines, many referred only to diagnosed coronary syndromes. Guidelines for undifferentiated chest pain usually recommended observation for six to 12 hours followed by troponin testing. Short-stay facilities were available in 38 departments (21%) and were planned for 55 departments (31%). Provocative cardiac testing could be accessed by 38 departments (21%). Patients were admitted by general physicians in 152 hospitals (86%) and cardiologists in 18 (10%). The estimated proportion of patients admitted was extremely variable. Although 45 departments (25%) employed specialist nurses, only in 20 did they manage patients with undifferentiated chest pain.
Reported management of acute, undifferentiated chest pain in the UK shows wide variation. Innovative technologies and diverse methods of service delivery are being adopted in a number of departments. These innovations require thorough evaluation.

Br J Cardiol 2003;10:50-54.

CASE REPORTPregnancy following heart transplantation: a case report
Thomas A Barker, Lawrence Cotter

Br J Cardiol 2003;10:56-57.

AICThe donor crisis in heart transplantation
John Pepper

Br J Cardiol 2003;10:AIC3-AIC5.

AICFuture direction for the care of the acutely ill medical patient in the UK?
Stephen Brett

Br J Cardiol 2003;10:AIC6-AIC7.

AICHeart attack patients in England are getting faster treatment but there is still more to do
Tom Quinn

Br J Cardiol 2003;10:AIC9-AIC11.

AICThe role of glucose-insulin-potassium therapy in the current management of acute myocardial infarction
Narbeh Melikian, Farzin Fath-Ordoubadi

Glucose-insulin-potassium (GIK) therapy addresses the metabolic changes of ischaemia secondary to acute myocardial infarction. These changes include elevated plasma free fatty acid concentration and glucose intolerance. A meta-analysis of trials from the pre-thrombolysis era showed a significant reduction in the number of deaths in the GIK group in comparison to placebo (16.1% vs. 21% respectively, p=0.004). High-dose GIK therapy was found to be of particular benefit.
Three randomised trials in the post-thrombolysis era have been published, with variable results. The DIGAMI study (in diabetics) and the ECLA pilot trial had positive results: in the latter there was a 60% reduction in in-hospital mortality in patients who received GIK therapy plus reperfusion. By contrast, the Pol-GIK trial was negative.
Outstanding questions include the usefulness of GIK therapy and beta blockade in the presence of thrombolysis or primary angioplasty. GIK therapy and beta blockade might act in complementary fashion to antagonise the metabolic changes of ischaemia while thrombolysis or angioplasty improve early reperfusion and limit infarct size. Patients with acute coronary syndrome might benefit more from GIK therapy since they have some coronary flow.

Br J Cardiol 2003;10:AIC17-AIC20.

AICPercutaneous intervention in unprotected left main coronary disease
Kanarath P Balachandran, Keith G Oldroyd

A significant left main coronary artery (LMCA) stenosis is an important predictor of survival in patients with coronary artery disease. In the past, percutaneous coronary intervention (PCI) was generally restricted to patients with protected left main disease; and >50% stenosis of the LMCA was a contraindication to balloon angioplasty.
In the pre-stent era, results of left main balloon angioplasty were poor. For example, in one series, in-hospital mortality was 9.1% in the elective group and 50% in the acute group. The development of coronary stenting and effective antiplatelet therapy in the 1990s stimulated renewed interest in PCI for LMCA disease. A number of studies reported good outcomes for protected LMCA lesions, though results in haemodynamically unstable patients remained poor.
The figures for a number of studies of elective PCI for unprotected left main stenosis are also described. The best documented outcomes so far are one-year actuarial survival of 89% in high-risk patients and 98% in low-risk patients.
If severe calcification is obvious on angiography or ultrasound then debulking seems sensible. The data suggest that directional coronary atherectomy alone or with stenting may be associated with reduced restenosis rates.
The use of glycoprotein IIb/IIIa inhibitors and drug-eluting stents may further improve the outlook for patients with LMCA stenosis.

Br J Cardiol 2003;10:AIC22-AIC27.

AIC‘Real world’ small vessel coronary artery stenting: an analysis
Allison Morton, Thomas Papadopoulos, Clare Wales, Robert Bowes, Stephen Campbell, David Oakley, Nigel Wheeldon, Christopher Newman, David Crossman, David Cumberland, Julian Gunn

The objective of this study was to describe the context, procedural outcome and long-term results of contemporary small vessel (SV) coronary artery stenting. It was set in a tertiary cardiology centre. The study was designed as a retrospective analysis of the procedural and long-term results in a consecutive series of patients undergoing implantation of an SV stent (defined as < 2.5 mm) in 1999–2000.
Of the 1,130 percutaneous coronary interventions (PCIs) in the study period, 138 (12%) involved placement of SV stents. Of these interventions 58% consisted of SV stents as sole treatment. Some 69% of patients were male and their mean age was 58 years; 46% were hypertensive, 13% diabetic, 84% hypercholesterolaemic and 18% were smokers. Of these patients 54% were in anginal classes III and IV. Of the SV stents fitted, 94% were 2.5 mm and 6% were 2.0 mm. 75% of SV stents were implanted in main epicardial vessels. The mean follow-up for these patients was 17 months. Long-term symptomatic benefit was achieved in 76%. The major adverse cardiac events (MACE) rate was 15%, comprising 1% acute myocardial infarction (AMI) and 14% re-PCI. There were no deaths.
In conclusion, SV stenting in the modern era, in an unselected series of patients, is performed in 12% of PCI procedures. It comprises the sole treatment in 58% of these interventions. The majority of SV stents are 2.5 mm and are placed in main coronary arteries. Procedural and long-term results are excellent. These data may inform the choice of treatment for patients with SV disease and may be useful in planning studies in stenting SVs.

Br J Cardiol 2003;10:AIC28-AIC32.