Acute & Interventional Cardiology 2005; Volume 12: pages AIC 1- AIC 104

July 2004 Br J Cardiol (Acute Interv Cardiol) 2004;11:AIC 45–AIC 52

Role of LMWH in ACS, with or without PCI and GP IIb/IIIa blockade

Diana A Gorog, Alamgir MN Kabir, Michael S Marber

Abstract

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....

| Full text

March 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 31–AIC 32

Complex cardiac myxoma

David J Fox, Geir J Grötte, Lawrence Cotter

Abstract

Cardiac myxomas are the most common benign intracardiac tumour, and are more common in women. Since many patients suffer from cerebral or systemic embolism, early diagnosis is vital to plan for surgical intervention. Surgical excision is advocated as soon as possible, particularly in left atrial myxoma, because of the high risk of valvular obstruction and systemic embolisation. Patients with a family history of the disorder are at greater risk of tumour recurrence....

| Full text

March 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 27–AIC 30

Delivering a modern PCI service: can we change with the times?

Michael S Norell, Saib S Khogali, James M Cotton, Michael R Cusack

Abstract

The volume and complexity of patients undergoing percutaneous coronary intervention (PCI) is growing steadily. This, and the increasing tendency for these procedures to be unplanned, requires us to rethink the way we deliver care in this setting. This article addresses the processes involved, which include pooling of PCI lists, multidisciplinary team meetings and integrated care pathways for both elective and unplanned cases. The value of pre-assessment clinics, specific cardiac triage teams and “generic” catheter lab workers is also discussed. More traditional elements of the service such as on-call rotas are reappraised. Newer concepts, like dedicated PCI meetings to plan strategy and review previous problem cases for educational purposes, are also introduced....

| Full text

March 2005 Br J Cardiol (Acute Interv Cardiol) 2006;13:AIC 14–AIC 18

Risk of death, MI and patterns of care delivered in non-ST elevation ACS patients with intermediate elevations in cardiac troponin T: a UK DGH experience

Kausik Ray, James Bolton, Alice Veitch, Paul Sheridan, Michael Gillett, Ahmed Al Rifai, Ramasamy ManivArmane, Alan Brennan, Gillian Payne, Wazir Baig

Abstract

Abstract Prior studies have suggested a gradation in clinical risk with increasing elevations of cardiac troponins in patients with non-ST elevation acute coronary syndromes (ACS). We hypothesised that patients with cardiac troponin-T (cTnT) between 0.01-0.1 μg/L might be perceived as a low-risk group and consequently receive less active medical treatment....

| Full text

March 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 9–AIC 14

Elevation of troponin I in acutely ill medical patients: a pilot study and literature review

Jonathan Watt, Andrew P Davie, Anne Cruickshank

Abstract

Previous studies have identified a significant incidence of clinically unrecognised myocardial ischaemia in intensive care unit (ICU) patients, as determined by elevation of serum troponin. This pilot study demonstrates a similar high frequency of such a phenomenon in patients who are acutely ill, but without clinical evidence of myocardial ischaemia, on the general medical wards of a large city hospital. Elevation of serum troponin in these patients is associated with higher hospital mortality and increased lengths of hospital stay. Recognition that slight elevation of troponin levels may occur in the context of significant medical illness in acute general medical ward patients is important as it may avoid erroneous diagnosis of myocardial infarction and subsequent unnecessary investigations. A literature review of the various causes of an elevated troponin result is then presented....

| Full text

March 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 5–AIC 7

Interventional cardiology training in the UK: time for a change?

Nick Curzen

Abstract

The current specialist registrar (SpR) training system in the UK is necessarily built on the foundation of general training in cardiology. The acquisition of skills in subspecialties such as intervention, electrophysiology and echocardiography is arranged informally and locally....

| Full text

July 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 62–AIC 67

Oral treatments for pulmonary arterial hypertension

Matt J Wright, J Simon R Gibbs

Abstract

The management of pulmonary arterial hypertension (PAH) has changed dramatically over the last decade. Where once the physician had only limited tools to combat this devastating condition, recent randomised controlled trials have shown that there are now treatments that both prolong the rate of progression and improve survival. The ‘gold standard’ of treatment, due to its beneficial effect on survival, is epoprostenol, a prostacyclin analogue. However, there are a number of problems with the prostacyclin analogues, mainly centred on their administration and cost, which led to their use only in severely ill patients. A better understanding of the pathophysiology of PAH has led to a number of other pharmacological targets, namely antagonism of endothelin (ET) receptors and increasing local levels of nitric oxide (NO) via inhibition of phosphodiesterase 5. The successful treatment of PAH means that there is now a growing population of patients on disease-modifying agents, so it is essential that physicians are aware of their use, benefits and side effects....

| Full text

July 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 61

Sub-intimal dissection guided by retrograde angiography to recanalise a chronic coronary artery occlusion

Amal Louis, Julian Gunn

Abstract

A 62-year-old man presented with chronic stable angina, how coronary angiography revealed a chronic proximal occlusion of the right coronary artery (RCA) with retrograde filling of the vessel from the septal branches of the left anterior descending (LAD) artery....

| Full text

July 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 56–AIC 59

Introduction of primary percutaneous coronary intervention for ST elevation myocardial infarction in a district general hospital

Sohail Qaisar, Melanie Fellows, Hannah Whitlam, Rumi Jaumdally, James M Beattie, Patricia J Lowry, Nadia El-Gaylani, Robert G Murray, Jerome Ment, Michael Pitt

Abstract

The objective of this study was to assess the feasibility and impact of providing a primary percutaneous coronary intervention (PCI) programme for ST elevation myocardial infarction (STEMI) in a district general hospital (DGH) in the UK. A retrospective review of cardiac catheter laboratory PCI database records and hospital notes was carried out in a 950-bed teaching DGH in the West Midlands, serving a catchment population of 500,000. The patients consisted of 108 men and women aged 28–86 years presenting with thrombolysis-eligible STEMI, treated by primary PCI between November 2002 and August 2004. The main outcome measures used in this study were time from hospital presentation to PCI (‘door to coronary device’ time), mortality and hospital length of stay. The median door to device time was 86 minutes (range 25 to 286). Some 78% and 52% of patients had door to device times of less than 120 and 90 minutes, respectively. Median length of hospital stay was five days (range 3–30), compared to eight days in patients treated with thrombolysis in the years 2000–2004. In-hospital mortality was seven patients (6.5%). We conclude that, in the contemporary era of interventional cardiology, it is feasible to introduce a primary PCI service for STEMI in a DGH setting with acceptable ‘door to coronary device’ times and mortality....

| Full text

July 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 49–AIC 53

Diabetic revascularisation by coronary angioplasty: is one stent better than another?

Jeremy N Butts, Kenneth P Morgan, Kevin J Beatt

Abstract

As confidence in the use of drug-eluting stents (DES) increases, they are being used in patients with progressively more complex disease. Diabetes is still an independent risk factor for restenosis along with lesion length and reference vessel diameter. This article gives an overview of recent stenting trials, including those with more complex disease such as DIABETES, PORTO 1 and TAXUS V. It also looks at head-to-head randomised controlled trials of sirolimus-eluting stents against paclitaxel-eluting stents: ISAR-DESIRE, SIRTAX, ISAR-DIABETES and REALITY. These give a better indicator of comparative efficacy than meta-analyses which include differing patient populations and trial designs. Finally, studies comparing angioplasty with surgery are considered....

| Full text

July 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 45–AIC 48

Drug-eluting stents: NICE guidelines and the reality

Tim Wells, Keith Dawkins

Abstract

The National Institute for Clinical Excellence (NICE) stent appraisal (2003) defined criteria for the use of drug-eluting stents (DES) on the basis of lesion length, vessel diameter and the absence of recent myocardial infarction or intra-luminal thrombus. The appraisal suggested that as many as one third of all stents may need to be DES. In order to determine the requirement for DES and adherence to these guidelines, we assessed 1,673 consecutive patients undergoing coronary intervention over a 17-month period. A total of 2,513 stents were implanted, of which 50.1% were DES. In all, 77.4% of patients fulfilled NICE criteria for at least one DES. A further 7.3% of patients were excluded because of either a recent (< 24 hours) myocardial infarct or visible intra-luminal thrombus. A total of 33.4% of patients who did fulfil NICE criteria for DES deployment inappropriately received a bare-metal stent (BMS) whilst 5.7% patients inappropriately received a DES. These results would suggest that NICE have grossly underestimated the need for DES in ‘real world’ practice. Despite our centre using a high volume of DES, significant numbers of patients were inappropriately treated with BMS, with a smaller number inappropriately treated with DES, according to NICE criteria....

| Full text

July 2005 Br J Cardiol (Acute Interv) Cardiol 2005;12:AIC 42–AIC 44

Are drug-eluting stents living up to the hype?

Adrian P Banning

Abstract

Drug-eluting stents (DES) have been available commercially in the UK for over three years. The National Institute for Clinical Excellence (NICE) produced a technology appraisal in October 2003 and that initial review is about to be updated. Well, has this technology delivered on its promise? Have we embraced it too quickly or is 100% DES usage around the corner?...

| Full text

November 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 98–AIC 100

An unusual pulmonary embolus

Umeer Waheed, Phang Boon Lim, Jeremy Cordingley, Mike Mullen

Abstract

Due to advances in paediatric congenital heart surgery in recent years, the number of patients who survive into adulthood with complex congenital heart disease has increased remarkably. When these patients present to non-specialist hospitals with apparently specific symptoms, the diagnosis may not be as straightforward as initially thought. Here we highlight a case which demonstrates this....

| Full text

November 2005 Br J Cardiol (Acute Interv Cardiol) 2005:12:AIC 83–AIC 91

Modelling the cost-effectiveness of cardiac interventions: the case of sirolimus-eluting stents

Neil Hawkins, Mark Sculpher, Martin Rothman

Abstract

This article aims to provide a primer on decision modelling to assess the cost-effectiveness of interventions in cardiology. The paper uses a cost-effectiveness model developed to compare alternative coronary stents. This decision analytic model assesses costs to the UK health service and health benefits in terms of quality-adjusted life-years (QALYs). Data were taken from a range of sources, including 12-month follow-up data from three important double-blind randomised controlled trials: RAVEL, SIRIUS and E-SIRIUS. Methods are employed to show the uncertainty in cost-effectiveness. Sirolimus-eluting stents were compared to ‘bare metal’ stents in constructing this decision model. The patients included were those individuals with stable coronary disease randomised to the three trials. The main outcome measures were: mean QALYs, mean health service costs, incremental cost per additional QALY, and the probability that sirolimus- eluting stents are more cost-effective than bare metal stents. Mean QALY gains per patient from the sirolimus-eluting stent range from 0.011 to 0.017 over 12 months. Although the list price of the sirolimus- eluting stent is £617 more than the bare metal stent, its additional total mean cost per patient, including ‘cost offsets’ from a lower rate of subsequent events, ranges from £53 to £166. The incremental cost of the sirolimus-eluting stent per additional QALY ranges from £3,181 to £15,198. The probability that the sirolimus-eluting stent is less costly than the bare metal stent ranges from 0.13 to 0.34. If the health service is willing to pay up to £40,000 per additional QALY, the probability of the newer stent being the more cost-effective ranges between 0.8 and 1.0. These results are sensitive to assumptions about the price differential between the two forms of stent. Cost-effectiveness analyses based on models are used increasingly as a basis for decision making. It is essential that these models are developed with clinical input regarding appropriate assumptions and interpretation of evidence....

| Full text

November 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 81–AIC 82

Percutaneous coronary interventions in West Yorkshire for the year 2002: an audit

Khaled Alfakih, Elizabeth Rennie, Stacey Hunter, James Mclenachan

Abstract

Early invasive management in patients with unstable angina and non-ST elevation myocardial infarct (NSTEMI) is now well established. However, patients can wait for weeks at district general hospitals (DGHs) for in-patient transfer to the cardiac centre for percutaneous coronary intervention (PCI), which results in inefficient bed utilisation. At the Yorkshire Heart Centre (YHC), the referral process for unstable angina/NSTEMI was streamlined to minimise the delay between time of referral and PCI. We audited the waiting time from referral to the PCI procedure as well as the six- and 12-month outcomes for both acute and elective PCI and compared our outcome data to the published trials. A total of 1,757 patients underwent PCI at YHC in 2002; of these 47% were acute cases. 72% of patients were treated within two days of referral and 97% within three days. The mean waiting time for patients referred from within the YHC was 1.9 days and for those referred from the DGHs was 2.2 days. The six-month mortality rate for the acute PCI group was 2.5%....

| Full text

November 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 74–AIC 79

The coronary pressure wire for decision- making in the real world

Williams Omorogiuwa, Michael Fisher

Abstract

Coronary angiography is an imperfect tool for assessing the functional significance of lesions: while this may be determined non-invasively using myocardial perfusion scintigraphy or stress echocardiography, it is often not done. In these circumstances the coronary pressure-derived fractional flow reserve (FFR) serves as an alternative, lesion-specific means of assessing physiological importance. FFR is an invaluable tool not only in determining whether a lesion is functionally significant and should be tackled, but it also ensures that the appropriate physiological outcome is obtained from coronary intervention....

| Full text

November 2005 Br J Cardiol (Acute Interv Cardiol) 2005;12:AIC 92–AIC 97

The ‘no-reflow’ phenomenon

Lucy Blows, Divaka Perera, Simon Redwood

Abstract

Microvascular perfusion is considered a key factor with respect to preservation of left ventricular function and prognosis. No-reflow is recognised in the context of acute coronary syndromes and percutaneous intervention: myocardial blood flow at a tissue level remains impaired following restoration of epicardial flow. Once no-reflow is established, treatment is often ineffective and this phenomenon is associated with poor short- and long-term outcomes. A number of different pharmacological agents are used to prevent and treat this condition although data to support their use are limited. This article examines the pathophysiological aspects of this condition, its clinical correlates and proposed management strategies....

| Full text