2008, Volume 15, Issue 05, pages 217-272

When any doctor or nurse refers to a colleague they should automatically ask themselves: is this referral necessary and will it benefit the patient? Referral should never be an automatic choice and the circumstances may dictate a different option.

The UK has witnessed a seismic shift in the delivery of healthcare to patients with coronary heart disease, but there is still a lot to be done. Promoted by the National Service Framework (NSF), and supported by a £775 million capital programme from the Department of Health and Lottery Funding (£122 million towards new cath labs), waiting lists have been slashed and patients are able to be investigated and treated nearer to home.1 In its annual audit reports for 2001, the British Cardiovascular Intervention Society (BCIS) reported on activity in 64 percutaneous coronary intervention (PCI) centres and 62 centres performing diagnostic invasive procedures only. The report for 2006 included data from 91 PCI centres and another 90 diagnostic-only centres.2 In this issue of the British Journal of Cardiology, Kelly and colleagues from Bournemouth provide the results of their initial experience in providing PCI to their local and surrounding communities (pages 244–7).3 Over a short period of time, activity has grown rapidly and they now perform over 1,500 PCIs per year. The centre is to be congratulated on the way it has established its PCI service because the programme was developed with some serious business planning, supported by its management, the local commissioners, its traditional tertiary centre, and the Strategic Health Authority. They sought and were given approval by BCIS, they ensured arrangements were made for surgical cover, and for the review of angiograms with off-site surgeons, and they committed themselves to appropriate clinical audit (collecting information on all patients undergoing treatment and downloading this to the Central Cardiac Audit Database [CCAD]).4 In line with the current BCIS policy, they have also evaluated their results against the predictive score generated by the North West Quality Improvement Programme (NWQIP), which has been both internally and externally validated.5,6 Their early results demonstrate complication rates within predicted limits. This is an example of a unit that not only has delivered considerable clinical activity but has also provided evidence of the quality of the service provided. Their reported experience raises two issues; the first relates to strategic thinking about how revascularisation is delivered on a regional basis and the second to measures of quality.

Recent studies have suggested that the safety, efficacy and feasibility of percutaneous coronary intervention (PCI) in hospitals without on-site surgical cover is equivalent to those with these facilities. In addition, recent UK figures suggest that PCI growth is in the region of 15% per year with a corresponding fall in coronary artery bypass grafts (CABGs) hence the ratio of PCI to CABG is increasing. In the UK 35% of PCI centres are without on-site surgical cover, however, these centres represent only 18% of total PCI procedures. The Dorset Heart Centre opened in April 2005 the nearest surgical centre being approximately 28 miles in distance. In addition to elective PCI, our centre provides a 9-to-5 Monday-to-Friday primary and rescue PCI service for the Dorset area. We compared the safety and efficacy of our newly opened non-surgical PCI centre with outcomes predicted using the North West Quality Improvement Programme (NWQIP) multi-variate prediction model to assess the risk of major adverse cardiac and cerebral events (MACCE) in patients undergoing PCI. Between opening and August 2006 we performed 1,454 PCIs. Our overall success rate was 1,363 (94%). Using the NWQIP multi-variate prediction model, the calculated MACCE estimate rate was 2.05%. The actual MACCE rate was 0.55%. We conclude that at our relatively new non-surgical centre we are able to provide an effective and high-volume PCI service to the Dorset region with MACCE rates below that expected for our patient population.

An exploratory study with individual interviews before seeing the cardiologist, one week after the appointment, and at three-month follow-up was conducted to explore how participants’ perception and experience of heart palpitations are affected by seeing a cardiologist. Eleven of 20 participants cited anxiety as a possible cause of palpitations. A similar number were worried about their heart. After seeing the cardiologist, 7/20 participants thought something serious may have been missed, only one out of seven of whom had a clinically significant arrhythmia. It was reported that cardiologists did not address the role of psychological factors. Seven of the 20 participants still had heart-related health concerns at three months. We conclude that many participants with palpitations without demonstrable cardiac pathology continued to experience high levels of health concern after seeing the cardiologist; this persisted at three months. The lack of resolution of the problem for these patients lay in not receiving a diagnosis or explanation. Participants reported that cardiologists did not address the possibility that psychological factors (particularly anxiety) could be relevant to the aetiology and management of palpitations. We suggest cardiologists should routinely address anxiety as a potential contributor to the cause of their patients’ symptoms.

The majority of patients with hypertension are treated in primary care and well controlled. Typically, a practice will achieve about 80% control as judged against the Quality Outcome Framework (QOF). The QOF only requires a practice to reach a target of 70%. A practice will need to control the blood pressure of about 18% of their patients and therefore about 3.5% of the practice population will not be controlled. Too many to refer to secondary care and therefore the practice needs a strategy to try and improve control in-house and to identify those in greatest need of referral.1

Much effort has been expended assessing the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CAGB) surgery. Much less energy has been directed towards understanding the potential of these two interventions for causing additional myocardial damage during the procedure and the means to avoid this injury. This review examines the impact of myocardial injury in elective PCI and CABG, principles of myocardial protection, and their efficacy in current coronary revascularisation. The objective of every coronary revascularisation should be a technically perfect result without producing myocardial damage. A patent graft that perfuses an area of myocardium with numerous pockets of myocyte necrosis serves no useful purpose.

Renal artery stenosis is a condition that has significant effects on the progression and outcomes of co-existent cardiac disease. The most important cause of renal artery stenosis is atherosclerotic renovascular disease (ARVD). As the drugs and techniques used to manage ARVD are similar to those used to treat coronary artery disease, cardiologists are increasingly becoming involved in its management. However, while there are similarities, there are also significant differences in the management of ARVD and coronary artery disease. There are also many differing opinions on the best management. This review maps the minefield of conflicting evidence and gives clear, pragmatic guidelines regarding the management of patients with cardiorenal disease.

To identify the knowledge of ionising radiation doses and radiation-related risk in common cardiac procedures among cardiology trainees, cardiologists and general practitioners with a specialist interest in cardiology, a face-to-face questionnaire survey of 47 cardiac specialists, both regular referrers and practitioners of radiation-based procedures, was conducted at the British Cardiovascular Society Annual Conference 2006. Of the 47 medical professionals surveyed, 21 (45%) provided the correct radiation dose for at least one imaging procedure. Most reported doses were below the lower limit of the reference range: the median (interquartile range) radiation dose reported by the respondents was 2 mSv (0.4 to 10 mSv) for coronary angiography (CA) and 6 mSv (1 to 15.8 mSv) for percutaneous coronary intervention (PCI); 2 mSv (0.5 to 15 mSv) and 6 mSv (1 to 20 mSv) for myocardial perfusion scintigraphy (MPS) and computed tomographic angiography (CTA), respectively. A risk of malignancy from ionising radiation exposure of one in 10,000 for CA (actual risk 1:5,000) and of one in 5,000 for MPS and CTA (actual risk 1:1,000) was reported by the majority of respondents. We conclude that there is significant underestimation of both dose and radiation-related risk to patients. Patients are unable to make informed decisions when consenting for these common procedures, as clinical staff are unaware of the correct radiation dose and associated risk, and therefore are unable to advise patients properly.

A 55-year-old smoker with no significant past medical history was admitted following an episode of dyspnoea and intrascapular pain. Clinical examination was normal. His blood pressure (BP) was 80/40 mmHg and his electrocardiogram (ECG) showed a sinus tachycardia and right bundle branch block.

Microscopic polyangiitis is a systematic necrotising vasculitis that affects small vessels without granulomata. Typically the most common manifestation is renal involvement. We report an unusual presentation of microscopic polyangiitis in a young male.