2013, Volume 20, Issue 4, pages 121-160

Despite the high and growing prevalence of hypertension worldwide, and the increasing attention focused on the challenge of resistant hypertension (RHTN), it is somewhat extraordinary to note the lack of data attesting to the epidemiology and management of RHTN at the present time. Few studies have described the incidence and prevalence of this condition, yet, it is very clear that, once diagnosed with RHTN, patients are at strikingly elevated risk of cardiovascular events, and thus clearly defined treatment strategies are urgently required.1 Quite remarkably, when reviewing the evidence base in RHTN for the recent National Institute for Health and Care Excellence (NICE) hypertension guidelines, the authors could find just one head-to-head randomised-controlled trial in this patient cohort, and only six retrospective cohort studies, with the largest being a post hoc analysis of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) study, where the use of spironolactone as a fourth-line agent was associated with blood pressure (BP) reductions of ~20/10 mmHg.2 Currently, we are hopeful that trials, such as the British Hypertension Society (BHS)-led Pathway 2 study (UKCRN.org.uk ID 4500) and the Resistant Hypertension Optimal Treatment (ReHOT) study (Clinicaltrials.gov ID NCT01643434), will help improve our drug therapy of RHTN. Nonetheless, it should be recognised that, while pharmacotherapy of hypertension is proven (at least up until the point of RHTN), issues with physician inertia, poor concordance and drug intolerance continue to undermine our efforts to get patients to target BP. 

Hypertension is a growing clinical burden associated with significant morbidity and mortality. Those patients who remain with uncontrolled blood pressure despite multiple appropriate tablets are labelled as resistant hypertension. This cohort faces the highest risk. A key driving factor in resistant hypertension is an abnormally elevated sympathetic nervous system (SNS). It is now possible to attenuate this non-pharmacologically by performing radiofrequency ablation to the renal sympathetic nerves using a transcatheter approach. Currently available trial data show impressive blood pressure reductions with this therapy and, more importantly, its relative safety. The National Health Service (NHS) experience with this procedure is at an early stage, but is likely to grow with guidance already published by the joint British Societies and National Institute for Health and Care Excellence (NICE).

A 34-year-old Filipino computer engineer with no previous medical history presented to the emergency department with sudden onset exertional breathlessness and intermittent palpations for 10 days. He had no associated dizziness, syncope or chest pain, and no significant family history or recent travel. Blood pressure was 126/69 mmHg and pulse 104 bpm, regular with normal volume and character. The jugular venous pressure was normal. A 4/6 continuous murmur with diastolic accentuation was heard loudest at the left lower sternal edge, associated with a diastolic thrill. Electrocardiogram (ECG) showed sinus tachycardia and no other abnormality.

 A 68-year-old male with a background fhistory of squamous cell carcinoma of the epiglottis presented with recurrent syncope. During a witnessed collapse in Accident and Emergency (A&E), his heart rate decreased to 38 bpm and blood pressure dropped to 74/50 mmHg. Electrocardiogram (ECG) confirmed sinus bradycardia. Magnetic resonance imaging (MRI) of his neck revealed disease recurrence with a mass encasing the left internal carotid artery. He was diagnosed with reflex syncope secondary to mechanical stimulation of the carotid sinus. He had a dual-chamber pacemaker inserted, and re-presented with one further episode of collapse shortly afterwards. This report discusses the different options in managing this rare but debilitating symptom in head and neck cancers invading the carotid sinus.

In this new regular series ‘ECGs for the fainthearted’ Dr Heather Wetherell will be interpreting ECGs in a non-threatening and simple way. She hopes this will help keep the art alive in primary care. In this first article, she looks at ECG methodical analysis

An increased cardiothoracic ratio (CTR) on chest X-rays is a not uncommon reason for requesting echocardiography. To assess how often the echocardiogram was abnormal in patients with an increased CTR, the results of 62 open-access echocardiograms requested with this indication were analysed. 

We continue our series looking at pacing in patients with congenital heart disease. In the second article, we discuss the challenge of device implantation in patients with more complex congenital structural cardiac defects.

The National Institute for Health and Care Excellence (NICE) guidelines on chest pain recommended the use of computed tomography coronary angiography (CTCA) in patients with low pre-test probability, functional tests in patients with moderate pre-test probability, and invasive coronary angiography (ICA) in patients with high pre-test probability, of having coronary artery disease (CAD). A previous audit demonstrated low incidence of CAD in patients with moderate and high pre-test probabilities. We investigated these patients non-invasively and assessed outcome.

Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is recommended for up to one year following acute coronary syndrome (ACS). Gastrointestinal bleeding is the main hazard of this treatment and proton pump inhibitors (PPIs) are often prescribed in selected patients to reduce this risk. The main purpose of this study was to analyse the effect of PPIs in reducing the subsequent risk of gastrointestinal bleeding. 

The medical records of 177 consecutive patients treated with DAT following ACS, were specifically reviewed for the study parameters over a 12-month period. 

The mean age was 66 years (range 24–96) with a median value of 68 years; 67% were males and 33% females, 74% Caucasians and 26% Asians. Patients were divided into two groups: the PPI group (patients on DAT and PPIs, n=91) and the control group (patients on DAT only, n=86). In the PPI group, 55% were on lansoprazole, 34% on pantoprazole and 11% on omeprazole. 

Out of the 177 patients, evidence of upper gastrointestinal bleeding was found in 10 patients, with the mean age of these patients being 77 years in the PPI group and 53 years in the control group. In the PPI group, endoscopy findings from six patients (6.6%) revealed gastritis in four, bleeding angiodysplasia in one, and bleeding oesophagitis in one; while the findings for the four patients in the control group (4.6%) showed gastritis in two, gastric ulcer in one and Mallory Weiss tear in one (odds ratio: 1.45, 95% confidence interval 0.39–5.32, p=0.58). None of these patients had a previous history of gastrointestinal bleeding.

In conclusion, empirical prophylactic prescription of PPIs for patients on DAT following ACS is of no significant benefit in reducing their predisposition to upper gastrointestinal bleeding. However, studies utilising larger populations are warranted to confirm this conclusion.