2002, Volume 09, Issue 03, pages 125-184

Percutaneous coronary intervention (PCI) is one of the mainstays in the treatment of coronary artery disease. Although the recent BCIS audit data indicate an improvement in the rate of PCI in the UK, it lags well behind the intervention rate in other European countries. The National Service Framework (NSF) for Coronary Heart Disease recommends an increase in the PCI rates to more than 750 per million population in order to achieve a target waiting time of three months. 1 To achieve this goal a major change in infrastructure is needed, with the opening of more interventional centres and the training and appointment of more interventional cardiologists. Within the current infrastructure and in a shorter time scale the targets may be met by performing more PCI through day-case work. The cardiologists directly control the day-case beds without any interference from the other medical specialities. Following the availability of modern low-profile stent technology and safer pre-treatment with oral antiplatelet agents, day-case intervention is a feasible option. 2 The RADICAL study A well-staffed day-case unit with an experienced senior sister and a pre-admission clinic has shown promising results in our unit at Blackpool for the management of day-case PCI through the radial route (Radial Approach for Day-case Intervention in Coronary Artery Lesions, the RADICAL study). Stable patients on the waiting list for PCI Table 1. The current status and future directions of day-case radial PCI PCI through the radial route is known to be safe, effective, economical and patient-friendly. In a pilot study we are evaluating its safety and efficacy in the day-case setting in selected patients with stable angina We believe that more day-case PCI will be the only way forward to achieve the NSF target rates for coronary revascularisation discharge of the patient. Following the procedure we take the sheath out immediately and apply a RADI Stop in the catheter lab.

Rapid technological advances in interventional cardiology have led to a marked change in practice over the past 20 years. Improvements in balloon dilation and stent catheter design, coupled with advances in guide catheter technology, have allowed routine percutaneous coronary interventions (PCI) to be performed through smaller guides. Initially there was a change from 10 to 9 French (F) catheters, and more recently from 8 to 6 F. These developments have not only led to a reduction in arterial complications, but also to changes in arterial access sites. The radial route has become increasingly popular, virtually eliminating access site complications. Moreover, this route has been shown to be preferred by many patients, the prime advantages being patient comfort, early mobilisation and reduced bleeding complications.

This short article aims to discuss the potential complications of transradial procedures and to set out approaches to minimising or avoiding them. Complications may relate to the operator, the patient, the equipment used or the nature of the procedure. Complications can simply be defined as minor (non-life-threatening, reversible, unlikely to extend hospital stay) or major (life-threatening, likely to cause permanent damage or to extend hospital stay). The complications of transradial procedures are rarely major and very rarely life-threatening – a major benefit of the radial approach. The potential complications can be divided into: neuro-vascular complications, spasm, vasovagal reactions and reflex ST segment changes. artery have been reported following transradial procedures. These include dissection, haematoma, perforation, bleeding, pseudo-aneurysm formation, arteriovenous fistula and even ischaemic con-tracture involving the hand. Most of these complications are minor, but they can result in access or procedural failure. Major vascular complications are very rare, occurring in only 0.06% of a recent series of 5,354 consecutive transradial procedures. Localised radial occlu-sion, which causes no untoward ischaemia, occurs in up to 5% of patients, but half of these occlusions recanalise within weeks. Spasm This is the most common complication of transradial procedures, and can vary from a minor event to a major painful stimulus ending the procedure.

The transradial approach for coronary angiography and angioplasty offers potential advantages over the femoral approach that include early patient ambulation, a reduced length of stay and reduced procedural cost. While many patients enjoy the freedom of early mobility, a proportion will experience forearm discomfort, either when catheters are manipulated during the procedure, or at the end of the procedure when the radial arterial sheath is withdrawn. This discomfort is caused by radial artery spasm. Spasm is induced both by mechanical stimulation of the arterial wall by the catheter shaft and arterial sheath, and by high levels of circulating catecholamines, which are raised by anxiety and pain. This review will examine data that address the pros and cons of a radial approach, particularly with respect to how well patients tolerate the procedure, the causes of radial artery spasm, and questions relating to potential benefits in terms of procedural cost. sheaths were used discomfort was usually experienced only at the end of the procedure, during sheath removal. Six years ago, a group from Argentina 2 reported some provisional data comparing femoral, percutaneous brachial and radial routes. They found significantly more pain with the radial procedures than with either the femoral or percutaneous brachial. Nevertheless, there were much earlier times to walking and to discharge in both the radi-al and percutaneous brachial groups. Later, Cooper 3 also compared femoral versus radial diagnostic angiography in 200 patients. Quality of life was assessed by the Medical Outcomes Study Short Form 36-item health status question-naire (SF-36). Procedure-specific questions were assessed using 0–10 visual analogue scales. Pain at the access site and preference for catheterisation method were also assessed with a visual analogue scale. In contrast to previous studies, they found that the radial route was better tolerated on SF-36 questionnaires and visual analogue scales at one week. When all patients were asked which route they preferred, most strongly preferred the radial route and when the 44 to a cocktail of verapamil and nitroglycerine was compared with the response to papaverine. 5 Verapamil plus nitroglycerine led to a much more rapid onset of vasodilatation, with a more pro-longed duration of action.

PCI via the radial artery: what is the learning curve? Michael S Norell, Angela Hoye Introduction A ssessing the process by which a new approach is adopted requires an appreciation of the climate into which that change is introduced. We are an average UK interventional centre in terms of volume (650 cases per year), under pressure to increase throughput in the face of competing demands for the time of both consultant and specialist registrar (SpR) trainee operators. We were attracted to the notion of the radial approach because we thought that it might enhance day-case activity when the number of beds available for elective cases was declining. Although femoral arterial closure devices might also address this, our experience has indicated that their impact is less predictable. Some patients may still have to stay in hospital overnight because of a groin problem, even though the interventional procedure itself was uneventful. All our consultant operators are well trained in the Sones technique, but this procedure is itself not without diagnostic and interventional activity, provides a refreshing change. There is a clear advantage to the patient, catheter lab and ward staff, and the ever-more-senior operator will be reassured to know that he is still capable of taking on change.

Transradial coronary angioplasty Simon S Eccleshall Introduction T he most commonly used access sites for interventional cardiology are the femoral, brachial and radial arteries. The selection of arterial approach significantly influences the cost of the procedure and the patient’s quality of life as well as vascular access site complication rates, affecting procedural morbidity and mortality figures. 1 The exponential rise in stent deployment combined with more aggressive antiplatelet and anticoagulant therapy has exacerbated femoral vascular complications, with major bleeding rates of 23% following rescue angioplasty with concurrent use of glycoprotein (GP) IIb/IIIa inhibitors. 2 A safer route of arterial access would therefore be highly desirable. whom preceding diagnostic films were performed by the femoral route. 4 The transradial technique therefore fulfils the requirements for a safer access site for interventional procedures, with the added advantages of cost savings and improved quality of life. This approach can be used in combination with the femoral artery for intra-aortic balloon pump insertion and in combination with per-cutaneous puncture of a vein for right heart catheterisation and temporary pacing, whilst still conferring the benefits of safer arte-rial access. Technique catheter is vitally important when using the transradial technique: it must provide support from the aortic wall whilst being co-axial with the coronary ostium.

Transradial coronary angiography DAVID HILDICK-SMITH T he transradial approach to coronary angiography was first considered to be a serious possibility in 1989. Gradual miniaturisation of equipment, coupled with the continuing desire to reduce patient discomfort and procedural risks, allowed the introduction of 6 French (6F) catheters. At 2 mm diameter, these fit without difficulty into most radial arteries. After Campeau experimented with this approach, others saw the potential, both for angiography and for angioplasty. From the diagnostic point of view, a simple transfemoral catheterisation is quick, uncomplicated, requires limited bed rest afterwards and can be accomplished with ease on a day-case basis in most patients. An arm approach is required in some patients because of difficulties with peripheral vascular disease, haemostasis or an inability to lie flat. These patients have formed the focus of our transradial diagnostic programme at Papworth Hospital. the transfemoral and transradial routes for diagnostic coronary angiography. 1 This study gave clear results: even allowing for the learning curve, the transradial route took longer, was more com-plicated, and resulted in a greater degree of pain in a significant proportion of patients. We therefore decided that the radial route should be reserved for patients in whom there is a relative con-traindication to the femoral approach, and we have continued with this policy ever since, though other authors have suggested that the transradial route is preferred by patients for diagnostic as well as interventional work. 2 We then compared the transradial route with the brachial cut-down procedure in a randomised study of 100 patients with con-traindications to the femoral approach. (~5%) and therapeutic anticoagulation (~10%). Diagnostic coronary angiography from the radial artery begins with a modi-fied Allen test to assess dual palmar arch circulation.

F doctors, catheter lab and nursing staff find the procedures difficult, technically demanding and time- consuming. Laboratory throughput is reduced, and some patients experience considerable discomfort or unpleasant vasovagal reactions. There is a high rate of puncture and procedure failure in the early stages, but these procedures can be easily completed from another access site if necessary. It is important that all the staff are clear about the reasons for starting a transradial programme (reduced vascular access site complication rate, easy and reliable haemostasis even when aggressive antithrombotic therapy is used, immediate patient mobilisation) and that there exists an important learning curve. Starting a transradial programme Jim Nolan The radial sheath should be removed at the end of the procedure, before the patient leaves the catheterisation laboratory. 2 In the rare situation of early re-intervention, an alternative access site can be used. When removing long sheaths, exert steady constant pressure

Continuity of care is much valued by patients and doctors. It is seen as a core feature of the discipline in general practice, although there is little supporting evidence that it leads to improvement in the care given during the management of patients with chronic disorders. This study shows that increased continuity is not associated with improved clinical care in the secondary prevention of coronary heart disease. The study also shows that it is possible to maintain high continuity for a chronic condition in a group practice with flexible working arrangements. This has implications for recruitment of future general practitioners.

The Omada programme, a nurse-delivered model of care, has achieved improved levels of evidence-based intervention for patients with chronic heart failure in nine secondary care centres in the UK. It may provide an appropriate model for audit and delivery of care, in line with the requirements of the National Service Framework for Coronary Heart Disease.

Recurrent syncope in a patient with Andersen’s syndrome Wayne R Arthur, Gerry C Kaye, Robert F Mueller Most common inherited diseases with cardiac involvement are associated with structural abnormalities of the heart and/or great vessels. Discussions of inherited cardiac electrophysiological abnormalities were once limited to Jervell and Lange-Nielsen syndrome and Romano-Ward syndrome. Subsequently, other genetically distinct arrhythmogenic cardiovascular disorders have been discovered.1 These result from mutations in the fundamental cardiac ion channels that orchestrate the action potential of the human heart. Most of these genetic channelopathies are depicted by marked QT prolongation on the electrocardiogram.

Coronary heart disease (CHD) and stroke frequently coexist, partly because they share many risk factors. After myocardial infarction (MI), there is a significant risk of mural thrombus formation, left ventricular aneurysm, impaired left ventricular function and atrial fibrillation; all these increase the risk of stroke. The risk of neurological deficit after cardiac surgery is higher in those patients who have already had a stroke. Cognitive decline after cardiac surgery is common: it may follow a pattern of early improvement but later decline. Lipid-lowering therapy has been shown to reduce non-fatal stroke in patients at risk of developing or with coronary artery disease. Clopidogrel with aspirin may be of benefit in patients with unstable angina and non-ST elevation MI. Antihypertensive treatment and stopping smoking are helpful. The HOPE trial results showed a powerful and preventative role for ACE inhibitors.

The renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathogenesis of cardiovascular disease. Blockade of this system results in a number of biologically important beneficial effects, including inhibition of the breakdown of bradykinin, reduction in blood pressure and inhibition of neuroendocrine activity, as well as reversal of endothelial dysfunction. Angiotensin-converting enzyme (ACE) inhibitors have an established role in the management of hypertension and heart failure. More recently, for instance in the HOPE trial, they have been investigated in patients with a history of coronary artery disease, stroke, peripheral vascular disease, or diabetes plus at least one other cardiovascular risk factor, but with preserved left ventricular function. Treatment with ramipril was shown to reduce cardiovascular events significantly, especially in patients who had diabetes. Two further ongoing trials – EUROPA (with perindopril) and PEACE (with trandolapril) – are described, which have important differences in trial design and which will further assess the protective effects of ACE inhibition in patients with stable coronary artery disease.

The aim of this survey was to review the awareness and efficacy amongst patients and general practitioners (GPs) in controlling coronary risk factors following coronary artery bypass graft surgery (CABG). It was a prospective cohort study based on an inclusive registry at our department 230 patients who underwent CABG between April 1999–July 2000 and who had a history of hypertension and hypercholesterolaemia were selected. Frequency of blood pressure (BP) and cholesterol monitoring, blood glucose control, current smoking status, weight and medications were established via telephone interview of patients. BP and cholesterol levels were confirmed by written questionnaires to GPs. BP and cholesterol were considered to be controlled if they were ≤ 140/85 mmHg and ≤ 5.0 mmol/L respectively. Of the 230 patients, 213 were successfully contacted. After surgery, 181 (85%) patients had BP checks at least six-monthly by their GPs, 13 (6.1%) less frequently and 19 (8.9%) not at all. Cholesterol levels were checked at least six-monthly in 128 (60.1%), less frequently in 47 (22.1%) and not at all in 38 (17.8%). Thirteen of the 20 patients who were smoking at the time of surgery continued to smoke. BP and cholesterol readings were obtained for 169 of the 213 patients. Of these, BP was well controlled in 92 (54.4%), uncontrolled in 61 (36.1%) and not checked in 16 (9.5%). Cholesterol was well controlled in 106 (62.7%), uncontrolled in 35 (20.7%) and not checked in 28 (16.6%) patients. Although patients and GPs are generally aware of the importance of controlling coronary disease risk factors, more effort is required if we are to meet the Joint British recommendations on prevention of coronary heart disease.

Restenosis following PTCA or intracoronary stent insertion remains the greatest challenge to interventional cardiology. Intracoronary brachytherapy may use either beta- or gamma- radiation. The target cells are most likely in the adventitial layer of the vessel wall. The principle of using brachytherapy post-angioplasty to reduce restenosis has been proven in animal models. Multiple randomised trials have shown brachytherapy to be the current optimal therapy to treat in-stent restenosis. The data for the use of intracoronary radiation for treatment of de novo coronary lesions are less strong. Potential complications of brachytherapy include ‘edge effect’ and ‘late late stent thrombosis’. These problems are being minimised with the use of long sources and prolonged antiplatelet therapy. Drug delivery stents may challenge the role of brachytherapy in preventing and treating restenosis in the near future.

PROGRESS in the secondary prevention of stroke Scott W Muir, Kennedy R Lees Over the last 10 years there has been considerable progress in the development of secondary prevention strategies for ischaemic stroke. No longer is aspirin the cornerstone of stroke secondary prevention. Trials like ESPS-21 and CAPRIE,2 have established the place of antiplatelet agents in secondary prevention. The 4S3 and CARE4 studies, among others, and the recently presented Heart Protection Study5 have alluded to the benefits of statins, not only in the setting of ischaemic heart disease, but now also in the setting of cerebrovascular disease. Until the publication of the PROGRESS study6 in September of last year, the question of blood pressure reduction in the setting of secondary prevention was unanswered and contentious.

Caffeine-containing drinks are increasingly available but excessive consumption can give rise to health hazards. A case is described here of a 31 year old man with no history of cardiovascular disease but a very high caffeine intake; he developed atrial fibrillation, which required treatment with flecainide. He has reduced his caffeine intake and remains well to date.