Acute & Interventional Cardiology 2006; Volume 13: pages AIC 1- AIC5 6

Ischaemic heart disease (IHD) is the leading cause of mortality worldwide.¹ It is a debilitating, life-changing illness that can reduce quality of life and life-expectancy. While surgical, percutaneous and optimal medical interventions can significantly improve the clinical course of the disease, our understanding of the biopsychosocial mechanisms promoting survival following an acute IHD event, such as an acute coronary syndrome (ACS), is still limited. 

Across the UK, there are wide variations in the strategies used to manage patients presenting with acute coronary syndromes (ACS).

Following the Bristol Inquiry, the Kennedy report in 2001 listed 198 recommendations. Among these was the recommendation that "patients and the public must be able to obtain information as to the relative performance of the Trust and the services and consultant units within the Trust’.

Platelet inhibition is a prerequisite for successful percutaneous coronary interventions (PCI). Aspirin was the first antiplatelet agent with proven benefit in ST-elevation infarction (STEMI) in the era of thrombolysis, significantly lowering death rate and the recurrence of ischaemic events.

Percutaneous coronary intervention (PCI) is expanding in terms of both the numbers of patients treated and the scope and severity of coronary artery disease tackled. These developments have occurred in parallel with increased awareness of the importance of accountability and clinical governance. Whilst cardiac surgeons have durable risk scores such as Parsonnet and EuroSCORE to assist them and their patients with estimating procedure-related risks, interventionists lack such universally accepted tools. Or do they? In this paper, we review the available PCI risk scores and point out the pressing need for the systematic use of a robust, simple and widely acceptable risk score for routine clinical use.

A 73-year-old man who had had a coronary bypass operation 15 years before presented with refractory angina despite full medication seven months after implantation of a 3.0 x 20mm non drugeluting stent in a saphenous vein graft (SVG) to the left circumflex artery.

A 73-year-old man presented with post-infarct angina. Cardiac catheterisation revealed mildly impaired left ventricular function and high-grade stenoses of the right, left anterior descending, ramus intermedius and left main coronary arteries (RCA, LAD, ramus and LMS respectively).

Recently, several techniques for non-invasive imaging of the coronary artery have emerged as promising alternatives to conventional coronary angiography for the diagnosis of coronary artery stenosis. Such imaging modalities include magnetic resonance imaging, electron-beam computed tomography and multi-slice computed tomography. With these technologies, images can be acquired rapidly with high temporal and spatial resolution. In their current state of development, non-invasive techniques can reliably be used to visualise significant stenosis of the proximal and mid portions of the coronary tree. However, complete assessment can be hindered by calcification in the vessel wall and by motion artefact.

Loss of the right ventricular artery (RVA) is generally thought to be of little consequence. Nonetheless, reperfusion can enhance right ventricular recovery and improve the clinical condition. Five cases of percutaneous coronary intervention involving right ventricular branches are presented. We advocate a more positive approach to a significant stenosis in the RVA in patients who have stable or unstable angina or non-ST segment elevation myocardial infarction. Re-establishment of flow should limit ischaemia and infarction of the right ventricle and limit their adverse effects.

A 69-year-old woman was referred for cardiac catheterisation following a positive exercise tolerance test.

Most coronary artery fistulae are asymptomatic but there may be complications such as rupture and myocardial infarction. Percutaneous intervention is an attractive alternative to open surgical repair that offers lower procedural risk. Increasing numbers of fistulae are being discovered incidentally during angiography. They present challenges in assessment and management. For example, there is poor correlation between symptoms and the size and flow rate of fistulae.

Minimising the in-hospital stay of patients with chest pain, within safe limits, is crucial in reducing the cost of health care. The aim of this study was to determine whether the use of near-patient testing for cardiac troponin I could reduce the duration of in-hospital stay for patients presenting with chest pain who were considered to be at low risk of death or myocardial infarction. This prospective observational study of consecutive patients admitted with chest pain of possible cardiac origin was conducted in a medium-sized district general hospital. A near-patient system for troponin I analysis was compared to traditional laboratory-based troponin I analysis to assess any effect on duration of in-hospital stay in low-risk chest pain patients. Of the 295 patients enrolled in the study, 191 (68.7%) were troponin-negative and were classified as having chest pain of non-cardiac origin or cardiac pain at low risk of major adverse events. The introduction of near-patient testing for cardiac troponin I reduced the mean duration of hospital stay from 30.04 hours to 17.10 hours (p<0.001). At 30-day follow-up no deaths or myocardial infarctions had occurred.

The case of a 70-year-old-woman affected by Friedrich's ataxia (FRDA), unstable angina and heart failure with left main 'equivalent' lesions is presented. As the patient was in need of revascularisation but would have been at high risk with coronary artery bypass grafting surgery, she underwent coronary angioplasty assisted with percutaneous cardiopulmonary support (PCPS). Despite the onset of temporary complications, the procedure was performed successfully. On the basis of this case and of a review of pertinent literature, the authors discuss the role of PCPS in high-risk patients, with respect to its indications and performance technique.

Biventricular pacing is increasingly used in the management of severe heart failure. We report the successful use of biventricular pacing to aid weaning from mechanical ventilation in a patient with severe left ventricular dysfunction.