2009, Volume 16, Issue 04, pages 153-200

The Myocardial Ischaemia National Audit Project (MINAP) represents one of the largest observational databases of acute coronary syndrome (ACS) events.1-3 Since its inception in 2000, it has accumulated rich data (including timing and method of admission, emergency and subsequent treatments, and long-term mortality data through linkage to the UK Statistics Authority) for over 650,000 ACS events from all acute hospitals (n=228) in England and Wales (figure 1). Initially designed to monitor standards set by the National Service Framework for Coronary Heart Disease4 with the generation of annual reports of hospital-level ST elevation myocardial infarction (STEMI) performance,5 the provision of contemporary online performance analyses has facilitated improvements in the care of ACS patients.6 Moreover, MINAP is more than a resource for the purposes of audit, it is also a key research tool for the evaluation of cardiovascular care and outcomes.7,8 Although it is primarily focused on clinical need, its research potential has been recognised by several grant-giving bodies, and a committee (the MINAP Academic Group [MAG]) dedicated to overseeing MINAP research has been established.3 The Clinical Performance Group (University of Leeds), a multi-disciplinary team comprising clinical cardiologists, health service researchers and health economists draws on MINAP data to investigate clinical care at multiple levels (patient, population, process and healthcare professional).

The relationship between cardiac and gastrointestinal disease is widely regarded as being a complex one – disorders of the two systems commonly co-exist, and the symptoms of angina pectoris are notoriously difficult to differentiate from gastro-oesophageal problems. In addition, it has commonly been observed that patients suffering with gastrointestinal disturbance suffer from cardiac symptoms whose aetiology can be attributed to their primary gut problems. Recent evidence has shown that this is a relatively common manifestation and that the incidence of these secondary cardiac complications has been underestimated in patients with gastroenterological disease. This article reviews the evidence for secondary cardiological complications of gastrointestinal disorders and discusses the potential mechanisms behind them. The three main areas outlined in the review include rhythm disturbances related to oesophageal disease, linked angina and the cardiac manifestations of inflammatory large bowel disorders.

Palpitations are a common presentation in general practice(1) and a frequent reason for cardiology referrals. This symptom often causes considerable distress and anxiety for the patient(2) and can evoke a similar feeling in the consulted healthcare professional. However, palpitations are often benign.(3) Less than half of patients with palpitations suffer from an arrhythmia and not every identified arrhythmia is of clinical or prognostic significance.(4 )There is also a high incidence of anxiety disorders among patients presenting with palpitations.(5) The skill lies in identifying patients with a significant heart rhythm abnormality who can be either helped by treatment or are at risk of adverse outcome. This can be achieved in primary care by taking a careful history and simple investigations.(5) The provision of services for patients with arrhythmic illness has lagged behind those who suffer from coronary heart disease (CHD). This has been recognised by the addition of Chapter 8 to the National Service Framework for CHD.(6) Timely access to appropriate clinicians and patient support are among the quality requirements, which have been much welcomed by patients.

Considerable variation exists in adherence to and implementation of post-myocardial infarction (post-MI) clinical guidelines in the UK. The Follow Your Heart Steering Group has consolidated existing clinical evidence and published guidance into a consensus of succinct recommendations for optimal post-MI management, which includes separate healthcare professional and patient-focused components. This guidance should help encourage two-way dialogues between patients and healthcare professionals, reduce practice variation, raise standards of care, maximise healthcare resource utilisation and improve outcomes in post-MI patients. It is our intention to develop and widely disseminate a simple algorithm for healthcare professionals and for patients that summarises the guidance.

In the case of coronary artery disease the glut of diagnostic terms like Q-wave infarction, non-Q infarction, ST elevation infarction, non-ST elevation infarction, intermediate syndrome, unstable angina, stable angina, silent ischaemia, and exertional angina do not reflect the present day realities and are neither rational nor systematic. The term ‘acute coronary syndrome’ is too vague. A diagnostic term should be based on the cause rather than the effects. The present terms are symptom and effect based. These were relevant when there was no effective treatment. With the availability of powerful treatments these terms have become outdated. Terminology relating to the present day realities is required. In this paper I propose a system of terminology based on the assumed pathology.

Most people do not wish to die in hospital, yet most people do. Patients with chronic heart failure (CHF) appear to be particularly disadvantaged in this regard, partly because it can be difficult to recognise when the issue should be broached. This review by two integrated cardiology–palliative care services of 235 CHF deaths, shows that only about a third of patients died in an acute hospital bed. End-of-life discussions were possible, with the majority of patients given the opportunity to express a preferred place of dying achieving their wish.

The authors describe a case of Takotsubo-like syndrome in a 59-year-old Caucasian woman.

A 37-year-old man presented with palpitations and recurrent episodes of pre-syncope. He had a past medical history of atrial septal defect (ASD) repair aged seven.