Volume 10, Number 2, March-April 2003

EDITORIALBeating heart coronary surgery and the ‘foundation stone’ evidence
Raimondo Ascione, Gianni D Angelini

Br J Cardiol 2003;10:87-89.

EDITORIALThe Coronary Heart Disease Collaborative
Mark Dancy

Br J Cardiol 2003;10:91-92.

PRIMARY CAREA four-year audit of secondary prevention in a single general practice
George Savage, Peter Ewing, Helen Kirkwood, Katrina Cowie

Scotland has one of the highest mortality rates for ischaemic heart disease (IHD) in the world, accounting for one quarter of all deaths. Much evidence demonstrates aggressive management of risk factors can make a significant difference to this high morbidity and mortality. Current evidence suggests that secondary prevention of IHD is currently not carried out well in primary care in the UK. Our practice set out to see if this could be improved by using computer records. Over the course of four years more than 80% of IHD patients are now on aspirin, almost 90% have blood pressure recorded annually (average 130/74 mmHg), 82% are non-smokers, 84% have an annual cholesterol check, 65% have a cholesterol < 5 mmol/L, 56% are on a cholesterol-lowering drug (average cholesterol is 4.76 mmol/L), 61% are on cardioprotective drugs, and there was one acute infarct. We suggest that secondary prevention can be improved at a practice level with a good recording system, and a motivated primary care team.

Br J Cardiol 2003;10:145-152.

PRIMARY CAREDrawbacks and benefits of cardiovascular risk tools
Penny Lockwood

There are now well-recognised guidelines which state that when reducing someone’s risk of cardiovascular disease the decision to start medication depends on the patient’s absolute risk of coronary heart disease, as opposed to their relative risk, which should be determined using multiple risk factors.
More than 29 cardiovascular risk tools are available to calculate a patient’s absolute risk of cardiovascular disease. Choosing which risk tool to use can be difficult. This article gives a description of the differences between cardiovascular risk tools. It also discusses some of the problems and benefits of risk tools in general and examines the differences between absolute and relative risk.

Br J Cardiol 2003;10:155-158.

PRIMARY CAREMy approach to assessing CHD risk
Rubin Minhas

Br J Cardiol 2003;10:159-160.

HOT
TOPICREVIEWHow can ambulatory blood pressure monitoring help in the management of patients with uncontrolled or variable hypertension?
Wasim Ahmed, Maurice A Jackson, Jonathan Odum, Johann CB Nicholas, Paul B Rylance

The study aim was to compare clinic and 24-hour ambulatory blood pressure monitoring, and to determine the influence of the latter on the management of a group of patients with variable or uncontrolled blood pressure. A retrospective data analysis was carried out on patients selected from out-patient clinics at New Cross Hospital. One hundred and seventy-one patients with uncontrolled or variable blood pressure underwent 24-hour ambulatory blood pressure monitoring and 153 results were analysed.
Following ambulatory blood pressure monitoring, 56% of the patients had their treatment regimens either decreased, unaltered or did not require antihypertensive therapy. The study found 24-hour ambulatory blood pressure monitoring helps in the assessment of overall 24-hour blood pressure control of patients and may also help in the better management of difficult groups of patients.

Br J Cardiol 2003;10:105-109.

REVIEWAmbulatory blood pressure measurement is indispensable to good clinical practice: a comment
Eoin O’Brien

Br J Cardiol 2003;10:110-112.

REVIEWHomocysteine and cardiovascular disease: time to routinely screen and treat?
Patrick O’Callaghan, Deirdre Ward, Ian Graham

Modest elevations in plasma homocysteine from either genetic or acquired causes appear to relate to cardiovascular disease on the basis of strong epidemiological evidence. We know that homocysteine can be lowered with varying doses of folic acid, with or without vitamins B₆ and B₁₂, although we do not yet know the potential cardiovascular benefit of vitamin supplementation in these subjects. Several multicentre interventional trials are underway to address this question and, until these are complete, we recommend a healthy diet high in folate replete foodstuffs. We also recommend oral folic acid supplements in some subjects with cardiovascular disease and high homocysteine, mindful that definitive evidence of benefit is lacking.

Br J Cardiol 2003;10:115-117.

HOT
TOPICREVIEWThe role of homocysteine in the clinical assessment of cardiovascular risk
Jennifer Bexley

Clinical and epidemiological studies suggest elevated levels of total plasma homocysteine (> 15 µmol/L) are associated with an increased risk of cardiovascular disease, independent of other known risk factors. This review outlines the causes of hyperhomocysteinaemia, current evidence of a positive association with cardiovascular disease, and how such findings may have important implications for future assessments of risk and nutritional recommendations, particularly for those with a previous or family history of cardiovascular disease.

Br J Cardiol 2003;10:118-122.

HOT
TOPICREVIEWHeart disease in older patients: myocardial infarction
Lewis E Vickers, Jacqueline Taylor, Adrian JB Brady

Almost a half of all myocardial infarctions occur in those over 70 years of age and this is projected to rise further as the number of older patients in the total population increases. Following myocardial infarction, complications are more common in the older patient and the mortality outlook is much worse in those aged over 75 years. Guidelines generally favour the administration of thrombolysis post-myocardial infarction to older patients, although there is a lack of randomised clinical trials with thrombolysis in this group. Observational data, however, suggest that there is a significantly increased risk of mortality in patients aged over 75 years and this means the elderly are less likely to receive thrombolytic therapy, even when no contraindications are present. Randomised trials have shown that percutaneous coronary intervention is associated with a better outcome in the older patient. With the advances in antiplatelet therapy and the advent of intracoronary stents, this outcome is expected to improve further. The article also discusses therapeutic options in secondary prevention.

Br J Cardiol 2003;10:123-127.

HOT
TOPICREVIEWAntidiabetic drugs
Clifford J Bailey, Caroline Day

Achieving good glycaemic control is an important part of the treatment strategy to minimise vascular complications in diabetes. An expanding range of differently acting oral antidiabetic agents provides new choices for type 2 patients. This review considers the attributes and limitations of these agents, and their positioning in the treatment process.

Br J Cardiol 2003;10:128-136.

REVIEWSibutramine: a safety profile
Omar Ali

Sibutramine is one of two anti-obesity agents approved by the National Institute of Clinical Excellence. It inhibits the re-uptake of noradrenaline and serotonin in the brain. By enhancing the sensation of satiety after a meal and reducing the fall in basal metabolic rate which usually occurs during weight loss, sibutramine is a useful aid to achieving weight loss and weight maintenance. Randomised controlled trials have shown that sibutramine 10 mg/day, in combination with diet and exercise, produces and maintains a dose-related weight loss of 5–10% in the majority of obese patients studied. This is accompanied by a range of important health benefits, including improvements in cholesterol and triglyceride levels.
Adverse publicity led to the European Commission's Committee for Proprietary Medicinal Products recently carrying out an in-depth investigation into the use of sibutramine in over 12,000 patients across Europe. Its findings support the use of sibutramine in obesity management, with no causal link found between the use of the drug and mortality. No change has been made to the Summary Product of Characteristics regarding the cardiovascular safety of sibutramine and the drug has been re-instated for use in Italy.
Prescribers should be aware of the cautions surrounding sibutramine use. While it is not advisable for those with a history of coronary heart disease or cardiac arrhythmias, published data reveal that most patients on sibutramine experience a drop in blood pressure and it may be used safely in patients with controlled hypertension. A small number of patients treated may show increases in blood pressure, particularly those who appear to be non-responders. Regular blood pressure monitoring is therefore advised.

Br J Cardiol 2003;10:137-140.

HOT
TOPICREVIEWBetter care without delay: acute myocardial infarction
CHD Collaborative

Br J Cardiol 2003;10:101-104.

HOT
TOPICCASE REPORTSyncope and chest pain at rest in aortic stenosis
Simon G Williams, Steven J Lindsay

Angina pectoris occurs in 30–40% of patients with aortic stenosis, despite a normal coronary circulation. This along with syncope, classically occurs during exercise. There are a number of suggested pathophysiological mechanisms for these symptoms, all of which lead to an imbalance between myocardial oxygen supply and demand. We report an 81-year-old patient who had several episodes of chest pain occurring at rest, leading to syncope resulting in electro-mechanical disassociation (EMD) cardiac arrest. The electrocardiogram (ECG) during these episodes showed profound ST depression, leading to the hypothesis that the underlying pathophysiology was due to myocardial ischaemia caused by the aortic stenosis alone.

Br J Cardiol 2003;10:143-144.

HOT
TOPICHEART BRAINMemories are made of this
Philip MW Bath

Br J Cardiol 2003;10:HB2-HB3.

HEART BRAINTreating the symptoms of vascular dementia
Clive G Ballard

Historically, the approach towards dementia associated with vascular disease has been to manage risk factors. Recent findings also suggest that symptomatic treatment is a realistic option, and cardiologists should be aware of treatments that are, or may soon be, available for their patients. Here, agents that have been evaluated for the symptomatic treatment of vascular dementia (VaD) are reviewed. In particular, the role of cholinesterase inhibitors is discussed. These agents are commonly used worldwide to treat the symptoms of Alzheimer’s disease (AD). Since most patients with VaD have concomitant AD, cholinesterase inhibitors may provide some benefits in these patients. In addition, these agents have demonstrated some efficacy in patients with possible or probable VaD.

Br J Cardiol 2003;10:HB4-HB7.

HEART BRAINVascular dementia
Lawrence J Whalley, Alison D Murray

Vascular disease is the most common treatable cause of dementia. Contemporary epidemiological models suggest that in developed Western societies, vascular disease alone accounts for about 15% of all dementia. In association with Alzheimer’s disease, however, it is suspected to be involved in at least 50% of all dementia. Recent research points to shared risk factors in vascular dementia and Alzheimer’s disease, and common pathogenetic processes are likely.
The exact criteria required for a diagnosis of vascular dementia remain imprecise and poorly developed. Advances in brain structural and functional imaging provide the best prospects for improvement in vascular dementia diagnosis.
Here we set out the major processes that impinge upon the health of neurones and may contribute to vascular dementia. Clinical trials of interventions that might slow progression of cognitive impairment to vascular dementia are fully justified and are likely to improve the care of many old people at particular risk of dementia.

Br J Cardiol 2003;10:HB8-HB14.

HEART BRAINAntihypertensive treatment and the prevention of stroke and dementia in elderly patients
Arduino A Mangoni, Stephen HD Jackson

Stroke, cognitive impairment and dementia are well-established complications of long-standing hypertension. There is a considerable time lag, usually several decades, between the onset of hypertension and the occurrence of these complications. Although antihypertensive treatment has been shown to decrease the risk of a first stroke, little evidence is available on the effects of antihypertensive treatment on the incidence of recurrent cerebrovascular events, cognitive impairment and dementia. The results of recent studies addressing this issue are discussed, along with directions for future research.

Br J Cardiol 2003;10:HB15-HB19.

HEART BRAINVascular dementia – a suitable case for treatment
Roger Bullock

Vascular dementia (VaD) and Alzheimer's disease (AD) are often described as distinct entities. Recent literature suggests that they may be part of a continuum, where pure VaD is quite rare, Alzheimer's disease is only 40% of the total and AD with cerebrovascular disease makes up the majority of cases that present to memory clinics. This relationship between VaD and AD is highlighted by their common risk factors – especially cardiovascular. Pure VaD is a heterogeneous entity, now separated clinically and radiologically into cortical, subcortical and strategic infarct subtypes. The treatment of VaD includes the primary and secondary prevention of cardiovascular and cerebrovascular disease; and early signs of a dementia may not always involve memory loss. This can lead to late presentations of patients when the more obvious signs and symptoms occur. Consequently, dementia services should work more closely with cardiology and stroke services in order to detect early cases of VaD. This will be increasingly important as new treatments become available.

Br J Cardiol 2003;10:HB20-HB23.