Volume 11, Number 4, July-August 2004

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TOPICEDITORIALLiving with an ICD – the price of saving a life
Violet R Henry, Sharon Smart, Salma Akram, Katherine McGrath, Ian Wright, Sophie Blackman, Nicholas S Peters

Br J Cardiol 2004;11:261-262.

PRIMARY CAREAngiotensin II receptor blockers: a new lease of LIFE?
Michael Kirby, Rubin Minhas

Hypertension is a significant risk factor for both coronary artery disease and cerebrovascular disease. Isolated systolic hypertension and left ventricular hypertrophy are well-recognised risk factors for cardiovascular mortality. The management of hypertension in elderly patients, patients with isolated systolic hypertension or left ventricular hypertrophy is discussed in the context of recent British Hypertension Society guidelines, recent trial evidence and an appraisal of the LIFE study results. Compelling indications for the use of angiotensin II receptor blockers in the management of hypertension are examined and the need for combination therapy in achieving satisfactory blood pressure control is established through examination of the trial evidence.

Br J Cardiol 2004;11:315-320.

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TOPICPRIMARY CAREAn evidence-based audit of coronary heart disease clinics
Patrick McElduff, Richard Edwards, Andreas P Arvanitis, Janis Holloway,

The National Service Framework (NSF) for Coronary Heart Disease (CHD) requires practices to establish registers of patients with CHD and to implement audits of care for these patients. Little is known about the potential health impact of registers and audits. We therefore looked at the impact of establishing such systems on patients with CHD at Cleveleys Group Practice. All patients with CHD are recorded on a computerised register that is used to recall patients for an annual review to nurse-led clinics. Data from annual audits are used to estimate the number of adverse events prevented in the practice by the use of effective medications.
We found that the use of effective treatments was estimated to save approximately 27 lives and prevent 30 non-fatal myocardial infarctions each year. The increased use of effective treatments after the introduction of the register coincided with a reduction in average levels of systolic blood pressure and total cholesterol, preventing two deaths and three non-fatal myocardial infarctions each year. Based on the best available evidence from randomised controlled trials, the benefit of this care to a practice population is substantial.

Br J Cardiol 2004;11:323-325.

PRIMARY CAREThe new NHS: changing the face of British cardiology
The titles of the lectures at a recent Primary Care Cardiovascular Society (PCCS) meeting show the face of British cardiology is indeed changing. Control of NHS budgets and of patient care is shifting; guidelines for prevention of disease continue to change in line with new evidence; new ways of learning are being developed and yet more new laboratory tests are being pressed into service. As usual the PCCS speakers articulately covered the topics – they also had to be succinct as, after just 90 minutes, the session was over and it was ‘all change’ for the audience. Medical writer Ola Soyinka reports from the PCCS plenary session at the British Cardiac Society Annual Conference in Manchester on 25th May 2004.

Br J Cardiol 2004;11:326-328.

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TOPICPRIMARY CAREIntegrated Care Pathways – what can we do to make them happen?
Mark Davis

Integrated Care Pathways (ICPs) are one way of implementing protocol-based care. Healthcare professionals need to draft and implement ICPs in order to meet clinical governance targets. In a two-day workshop ‘Integrated healthcare delivery – let’s get practical’, 27 multidisciplinary delegates from four NHS Modernisation Teams progressed ICPs in the areas of stroke, post-myocardial infarction and heart failure. Good ICPs should include a clear assessment procedure for the clinical condition, consultation with all care providers, guidelines or best available clinical evidence, patient education and an audit tool.

Br J Cardiol 2004;11:329-332.

REVIEWThe National Cholesterol Education Program III scoring system for CHD risk estimation cannot be used with European recommendations
Navneet Singh, See Kwok, C Jeffrey Seneviratne, Michael France, Paul Durrington

To target statin therapy effectively in primary coronary heart disease (CHD) prevention, recommendations increasingly advocate the assessment of absolute CHD risk. Using methods from two recent sets of national recommendations, we estimated absolute CHD risk in 412 men and women whose general practitioners requested it on clinical grounds. Substantially fewer men and women had CHD risk exceeding 15%, 20% and 30% over 10 years with the National Cholesterol Education Program III (NCEP III) scoring system than with the Joint British charts. The latter agreed closely with the 1990 version of the Framingham risk equations.

Br J Cardiol 2004;11:282-286.

REVIEWDiurnal rhythms, the renin-angiotensin system and antihypertensive therapy
Michael Schachter

The circadian rhythms of the cardiovascular system are related to the risk of events such as myocardial infarction and stroke. The so-called ‘morning surge’ in heart rate and blood pressure at around the time of waking is a particularly hazardous period. The sympathetic nervous system and the renin-angiotensin system are thought to be the main regulators of these rhythms and a potential target of antihypertensive medication is the blunting of the morning surge through action on these systems. This article reviews some of the mechanisms involved and recent therapeutic approaches to this problem.

Br J Cardiol 2004;11:287-290.

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TOPICREVIEWHypercholesterolaemia and its potential role in the presentation and exacerbation of hypertension
Andrei C Sposito, Jose Augusto S Barreto-Filho

Hypertension is a major cardiovascular risk factor and its pathogenesis remains elusive. For a long time, hypertension and dyslipidaemia have been viewed as independent but synergistic cardiovascular risk factors increasing the risk of premature atherosclerosis. Recently, a growing body of evidence has indicated that hypercholesterolaemia promotes impairment in several mechanisms implicated in blood pressure control such as nitric oxide bioavailability, renin-angiotensin activity, the sympathetic nervous system, sodium and fluid homeostasis and ion transport/signal transduction. Moreover, recent clinical studies have pointed out a beneficial effect of cholesterol-lowering treatment in reducing blood pressure to a small but significant degree. Our assumption is that depending on the complex inter-relationships between genetic background and life style, hypercholesterolaemia may be a trigger to blood pressure elevation. An integrated approach to the treatment of hypertension and dyslipidaemia can, therefore, maximise both blood pressure control and prevention of cardiovascular disease. In this review, we discuss recent important data from our and other groups, demonstrating the clinical evidence of the hypertensinogenic effects of hypercholesterolaemia, and the biological mechanisms which underlie them.

Br J Cardiol 2004;11:292-299.

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TOPICREVIEWDevelopment of the BACR/BHF minimum dataset for cardiac rehabilitation
Robert JP Lewin, David R Thompson, Alun Roebuck

This article describes the process used to arrive at the set of assessment measures and minimum dataset for cardiac rehabilitation (CR) that has been endorsed by the British Association for Cardiac Rehabilitation (BACR) and the British Heart Foundation (BHF) for the national audit of CR.

Br J Cardiol 2004;11:300-301.

REVIEWProvision of rehabilitation services to patients with implanted cardioverter defibrillators: a survey of UK implantation centres
Dorothy J Frizelle, Robert JP Lewin, Gerry C Kaye

This study investigated the current level of provision of cardiac rehabilitation (CR) for automatic implanted cardioverter defibrillator (ICD) patients in the UK, the clinical and technical staff views on the need for such a service, and the current level of provision and the most commonly reported barriers to meeting these needs. The study was carried out via a postal questionnaire survey of all NHS implantation centres for ICD patients.
The majority of respondents (99%) believed they should provide rehabilitation for their patients, but only 14 (36%) centres had a programme for rehabilitation that ICD patients could access and only four (10%) of these were specifically designed for ICD patients. The majority of respondents (74%) believed they were not meeting their patients’ needs for rehabilitation. The most commonly endorsed barriers to providing and developing CR services were limited multidisciplinary staff, a wide geographical catchment area, and administrative and organisation difficulties. There was wide support for the potential of using a home-based, remotely monitored, rehabilitation package. This shows that the vast majority of staff in implantation centres agree with the recent NICE recommendations that there is an unmet need to provide CR for ICD patients.

Br J Cardiol 2004;11:302-305.

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TOPICREVIEWIs provision and funding of cardiac rehabilitation services sufficient for the achievement of the National Service Framework goals?
Ingolf Griebsch, Jackie Brown, Andrew D Beswick, Karen Rees, Robert West, Fiona Taylor, Rod Taylor, Jackie Victory, Margaret Burke, Sally Turner, Hugh Bethell, Shah Ebrahim

The objectives of this analysis were to ascertain the population need for out-patient cardiac rehabilitation in England, to estimate the current level of provision and associated costs, to identify economies of scale in service provision and to investigate budgetary implications of extending provision.
Discharge statistics from the Hospital Episode Statistics database (HES) in England in the year 2000, and data from centres contributing to the British Association for Cardiac Rehabilitation (BACR) survey were analysed. A short follow-up questionnaire was sent to respondents of the BACR survey.
The main outcome measures were: the number of patients eligible for cardiac rehabilitation; the percentage referred, joining and completing programmes; health service costs associated with current levels of provision; elasticity of costs; and costs associated with expanding services. Using an inclusive definition of need, about 267,000 people required cardiac rehabilitation in England in the year 2000. This figure fell to 100,000 if services were restricted to those aged below 75 years with acute myocardial infarction, unstable angina or following revascularisation. Health service costs per patient completing a programme were £354 (staff) and £486 (total). Out-patient cardiac rehabilitation represented a NHS cost of approximately £12.5–19.0 million per annum. A 1% increase in patients completing a programme is estimated to lead to a 0.25% fall in the staff cost per patient. A budget increase of 630% would be necessary to treat all eligible patients using moderate staffing configurations, which would fall to 170% if only those aged below 75 years with restricted diagnoses were to be treated.
We conclude that a substantial proportion of the population need for cardiac rehabilitation goes unmet and that achievement of current targets for provision is likely to require considerable additional resources. Reconfiguration of service provision towards less complex services would enable more patients to be treated. Current information systems in cardiac rehabilitation services are inadequate to provide indicators of performance and monitoring.

Br J Cardiol 2004;11:307-309.

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TOPICCASE REPORTPhase 4 cardiac rehabilitation: a comparison of exercise intensity levels and ratings of perceived exertion between cardiac and non-cardiac participants
Lynn H Angus, Heather G Gray

Meta-analyses of exercise-based cardiac rehabilitation (CR) trials have shown improved survival^1,2 and significant improvements in cardio-respiratory fitness for individuals who have sustained a myocardial infarction (MI).³ According to the British Association of Cardiac Rehabilitation (BACR) Exercise Prescription Guidelines, phase 4 cardiac participants should exercise at a similar intensity level to that recommended for healthy adults to gain maximum benefits.⁴ To date, however, there has been a paucity of research to support or question these guidelines. This led to this pilot study, which aimed to compare the exercise intensity levels and ratings of perceived exertion of cardiac and non-cardiac participants during a phase 4 CR exercise class.

Br J Cardiol 2004;11:310-311.

CASE REPORTA case of spontaneous tension pneumopericardium
Simon Stacey, Alex W Green, Richard A Best

Pneumopericardium is a rare condition, seen most commonly in the context of chest trauma in adults, and in mechanical ventilation in neonatal practice. Mortality is high, more so if pericardial gas is accompanied by pus and, ultimately, tamponade.¹ Here we present a case of tension pyopneumopericardium leading to cardiac tamponade which had a favourable outcome. The aetiology remains uncertain in this instance, although an oesophagopericardial fistula cannot be discounted. In addition, we review the causes and clinical features of this condition as reported in the literature.

Br J Cardiol 2004;11:312-314.

AICFollow-on angioplasty via the radial artery – a personal view
Nicholas MK Robinson

Br J Cardiol 2004;11:AIC35-AIC37.

AICStatin therapy following percutaneous coronary revascularisation: time to make LIPS stick?
Arun Natarajan, Scott A Gall, Azfar Zaman

Br J Cardiol 2004;11:AIC38-AIC40.

AICRole of LMWH in ACS, with or without PCI and GP IIb/IIIa blockade
Diana A Gorog, Alamgir MN Kabir, Michael S Marber

Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are used to prevent rethrombosis and distal platelet embolisation in acute coronary syndromes. LMWH have a more predictable anticoagulant response and are less likely to result in bleeding. For the moment UFH should be used in primary percutaneous coronary intervention (PCI). It may also be preferable to use UFH in the setting of rescue PCI following tenecteplase (TNK) treatment. In those over 75 years of age, the combination of TNK with enoxaparin has been shown to be superior to TNK with UFH in reducing ischaemic end points without increasing the risk of haemorrhage. Results from TIMI IIB indicate that enoxaparin is superior to UFH for the acute management of non-ST elevation ACS (in patients managed conservatively). Enoxaparin and UFH appear to have similar efficacy and safety profiles when used in conjunction with glycoprotein IIb/IIIa blockade during PCI.

Br J Cardiol 2004;11:AIC45-AIC52.

AICContrast-induced nephropathy
Tadhg G Gleeson, John O’Dwyer, SuDi Bulugahapitiya, David P Foley

The use of coronary angiography as a diagnostic tool in modern hospital medicine continues to rise. With the increasing use of therapeutic coronary interventions, and the increases in procedure times and volumes of contrast media, incidence rates of contrast-induced nephropathy (CIN) have also been seen to climb over recent years. CIN has subsequently been shown to be a significant contributor to morbidity and mortality during hospitalisation. In this current clinical setting, it is incumbent on the modern cardiologist to be aware of this potentially serious complication of angiography, to be familiar with its presentation and treatment, and to be able to recognise at-risk groups and institute prophylactic measures where appropriate.

Br J Cardiol 2004;11:AIC53-AIC61.

AICThe pulmonary artery catheter – a personal view
Adrian Steele

The pulmonary artery catheter (PAC) was introduced into critical care medicine without objective evidence of its efficacy. The direct risks from the PAC are around 1.5% for a serious complication and 0.2% for death.
The Connors study on 5,735 intensive care patients used case-matching techniques, and demonstrated a worse outcome in the PAC cohort. However, in this study the need for inotropes and the response to treatment were excluded from the regression analysis. Three further studies have failed to show an association between PAC placement and outcome after case-mix adjustment.
It has proved extremely difficult to recruit enough intensive care patients to exclude a clinically important mortality benefit of the PAC.
New techniques such as the oesophageal Doppler, pulse contour continuous cardiac output and lithium dilution cardiac output machines offer simpler, and perhaps better, alternatives to the PAC. Nonetheless, even if future trials are negative, the PAC should remain available for treatment of patients with unusual conditions or combinations of conditions.

Br J Cardiol 2004;11:AIC62-AIC67.

AICIsolated ventricular non-compaction presenting as acute myocardial infarction
Divaka Perera, Dudley J Pennell, Barry J Kneale

Br J Cardiol 2004;11:AIC68-AIC69.

AICEmergency non-surgical epicardial catheter ablation of incessant ventricular tachycardia in a man with dilated cardiomyopathy
Mark J Earley, Michael AJ Park, Richard J Schilling

Br J Cardiol 2004;11:AIC70-AIC72.