2002, Volume 09, Issue 04, pages 185-244

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2002, Volume 09, Issue 04, pages 185-244

Editorials Clinical articles News and views
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Editorials

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April 2002 Br J Cardiol 2002;9:233-40

What’s new in hypertension

Ola Soyinka

Abstract

Is it time to forget about diastolic blood pressure? Should we abandon the mercury sphygmomanometer? Is non-pharmacological intervention a waste of time? These were some of the questions discussed at the first Primary Care Cardiovascular Society (PCCS) meeting of 2002 which was carried out jointly with the British Hypertension Society (BHS) on 26th February.

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April 2002 Br J Cardiol 2002;9:195-7

The quest for diagnostic certainty: an unreal expectation in a real world

Paul Collinson, Peter Stubbs

Abstract

When is an infarct not an infarct? When it is an infarctlet, a necroset or a troponinosis.1 The advent of the cardiac-specific troponins as diagnostic tests has created confusion in the minds of some cardiologists. The fact that cardiac troponins may be used to diagnose previously unsuspected myocardial damage in patients presenting with acute coronary syndromes, when acute myocardial infarction (AMI) has been ruled out by conventional World Health Organization criteria, has been amply demonstrated since the original report by Hamm et al.

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Clinical articles

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April 2002 Br J Cardiol 2002;9:

The specialist nurse in coronary heart disease prevention:evidence for effectiveness

Lucy Wright

Abstract

Nurse-led interventions may improve the delivery of preventive care briefly discuss insights from parallel qualitative research; to present the preliminary results of the Bromley Changes care for coronary heart disease. In the SHIP trial, three cardiac liaison nurses co-ordinated care at the hospital-general practice interface. In the ASSIST trial, three different strategies of implementing secondary prevention were used. Although various measures improved, there was no difference in clinical outcome. Qualitative research indicates that specialist education for nurses is vital. The preliminary results of the Bromley Changes for Life Programme are described: this programme achieved significant risk factor and therapeutic targets. The way forward may lie with the cardiac specialist nurse.

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April 2002 Br J Cardiol 2002;9:

The evidence for guideline implementation strategies

Irwin Nazareth

Abstract

There is an enormous gap between the publication of new evidence and its clinical implementations. Research on interventions that are designed to change professionals’ clinical behaviour is detailed here: specific generic interventions, interventions specific to cardiovascular medicine, and continuing medical education. Barriers to change include information problems, stress and inertia. Further research and evaluation are required.

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April 2002 Br J Cardiol 2002;9:

Secondary prevention of coronary heart disease in primary care:the evidence

Jonathan Mant

Abstract

The National Service Framework for Coronary Heart Disease emphasises the role of primary care in secondary prevention. More than 20% of men and 12% of women aged 65 years and over suffer from ischaemic heart disease. Lifestyle changes and drug treatment may effectively reduce risk but uptake of the evidence base is patchy. There are a number of possible approaches to enhance the uptake. Nurse-led clinics and health promotion clinics can lead to improvement in reported lifestyle and self-reported health status. Audit and feedback may lead to more use of appropriate drugs. Systematic recall will lead to better documentation that care conforms to standard practice, and nurses are at least as effective as doctors in achieving this. The first step is to set up accurate morbidity registers.

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April 2002 Br J Cardiol 2002;9:

The evidence for secondary prevention and cardiac rehabilitation in hospitals

Jane Flint

Abstract

An integrated effort is needed to provide seamless care for patients between hospital and general practice. The use of protocols that are common to both sectors will lead to the best possible outcomes. It seems that secondary prevention may reduce sudden death and the 28-day mortality rate. The evidence base for the drugs used in secondary prevention is derived mostly from hospital trials. The relevant findings for aspirin, beta blockade, statins, ACE inhibitors and oral anticoagulants are discussed. After coronary revascularisation, special care is required if patients are to have a smooth path: both exercise and comprehensive cardiac rehabilitation are valuable.

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April 2002 Br J Cardiol 2002;9:241-4

Can we do more to get patients to cholesterol targets?

Richard Hobbs

Abstract

The role of cholesterol lowering in reducing cardiovascular risk is well established but a large proportion of qualifying patients at the highest risk are still not getting treatment with statins. Of those that do, most are not achieving recommended cholesterol targets. The cost of this, in terms of death and work days lost, is enormous. Patients should not be discharged after an acute event until secondary prevention has been initiated. Individual patient response to therapy should be subsequently monitored and adjusted as appropriate; patients should be reassured on statin safety.

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April 2002 Br J Cardiol 2002;9:230-2

Can left bundle branch block cause chest pain?

Mammen Ninan, Jonathan W Swan

Abstract

Can left bundle branch block cause chest pain? Mammen Ninan, Jonathan W Swan Exercise-induced left bundle branch block usually indicates underlying coronary artery disease or myocardial disease. Association of left bundle branch block (LBBB) with chest pain in the absence of coronary artery disease is rare. We describe the case history of a patient with chest pain associated with left bundle branch block with normal coronary arteries and review the literature on left bundle branch block associated with chest pain.

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April 2002 Br J Cardiol 2002;9:226-9

Five thousand echocardiograms: what have we done?

David J Bell, David A Sandler

Abstract

This article describes the use of transthoracic echocardiography (TTE) in a series of 5,000 consecutive echocardiograms in a mid-sized UK district general hospital. The report highlights the basic demographics, reasons for the requests, yield of abnormal results and sources of the requests. The authors comment on the percentage of abnormal results for the different request categories and on how TTE can be best utilised as a cardiac investigation.

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April 2002 Br J Cardiol 2002;9:223-5

Patent foramen ovale, a normal variant or a congenital abnormality requiring treatment?

Mark S Turner, Anthony P Salmon, Gareth Thomas, Andrew J Marshall

Abstract

It has now become possible to close a patent foramen ovale (PFO) using a percutaneous device. In addition, it has become increasingly clear that right-to-left shunting through a PFO can cause both stroke and decompression illness, due to paradoxical embolism of blood clots or gas bubbles. For these reasons, diagnosis of large PFO with significant right-to-left shunts has become important. The diagnosis can be made by transthoracic echocardiography with injection of bubble contrast, combined with multiple sustained Valsalva manoeuvres. Whilst transoesophageal echocardiography provides detailed anatomical information, functional information (with regard to right-to-left shunting) is better provided by transthoracic studies where a Valsalva can be properly performed. Device closure can prevent right-to-left shunting and can be achieved using a number of different devices. However, device closure has yet to be proven beneficial in a randomised trial. In light of the clear evidence implicating PFO, we undertake closure procedures in selected patients.

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April 2002 Br J Cardiol 2002;9:221-2

Cardiac troponins and the risk stratification of chest pain

Archana Rao, Mandie Evans

Abstract

We present three cases of patients who had chest pain with abnormal but non-diagnostic ECGs and negative troponin I, carried out in the appropriate time frame. All three went on to have extensive coronary artery disease demonstrated on coronary angiogram. These cases illustrate that use of troponin I alone as a marker for risk stratification of cardiac chest pain is not adequate: above all, a high index of clinical suspicion is of paramount importance.

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April 2002 Br J Cardiol 2002;9:215-20

Future perspectives in stroke management

Philip MW Bath

Abstract

Clinical research relating to stroke management is at something of a watershed. On the one hand, some therapies are well proven and established, and on the other some approaches have repeatedly failed. Examples of successes include antithrombotic (aspirin, dipyridamole, clopidogrel, warfarin) and antihypertensive therapies (diuretic, angiotensin-converting enzyme inhibitors), carotid endarterectomy for secondary prevention,1-4 and aspirin in acute ischaemic stroke.5 In contrast, several strategies have repeatedly failed, especially the use of anticoagulation and neuroprotection in acute ischaemic stroke. This review gazes into the crystal ball to see what we might be doing when managing patients with stroke in 10 years time.

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April 2002 Br J Cardiol 2002;9:209-14

Acute effects of low-dose statins on serum cholesterol and creatinine kinase activity

Yohan P Samarasinghe, Graham Ball, Michael D Feher

Abstract

One of the potential side effects of the HMG CoA reductase inhibitors (statins) is a rise in creatinine kinase (CK) activity. This is sometimes accompanied by myalgia and rarely by rhabdomyolysis. Statins are increasingly being started earlier in the presentation of acute coronary syndromes but the rise in CK activity that they may cause could be a potential confounding factor in the diagnosis of myocardial infarction (MI) in this population. In this open-labelled, prospective study, 12 hypercholesterolaemic, Caucasian subjects, with a significant cardiovascular risk, were commenced on low-dose statin therapy. Blood samples were taken prior to commencing the statin then on day three and seven for lipid profile and CK activity. Patients maintained their normal lifestyles and usual medication. Interviews were conducted at each visit. A consistent fall in total and low density lipoprotein (LDL) cholesterol levels was shown over the study period of one week. Apart from one participant, who had a CK rise on day three with accompanying myalgia, there was no consistent change in CK activity within the group. High density lipoprotein (HDL) cholesterol levels also did not show any significant change over the week. We conclude that the rapid and consistent fall in both total and LDL cholesterol levels with low-dose statin was not paralleled by any consistent change in CK activity. The lack of change in CK activity over one week, following acute initiation of statin therapy, is unlikely to cause difficulty in the diagnosis of MI. If the beneficial effects of statin therapy are due to cholesterol reduction, then acute initiation in coronary syndromes would be favourable.

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April 2002 Br J Cardiol 2002;9:193-4

Statins: myalgia and myositis

Anthony S Wierzbicki

Abstract

Statins: myalgia and myositis Anthony S Wierzbicki The topic of side effects of statin therapy has become more prominent since the precautionary withdrawal of cerivastatin following reports of death and rhabdomyolysis with this particular statin, especially when given in simultaneous combination therapy with gemfibrozil. In addition, many patients complain of myalgia with statins; this side effect has an incidence of up to 5%. There is a tendency for earlier use of statins in coronary care units because of improved compliance and the possibility of a reduction in peri-infarction events in registry studies, although the MIRACL trial of atorvastatin in acute coronary syndromes did not show any significant differences in hard end points at 16 weeks

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April 2002 Br J Cardiol 2002;9:

The National Service Framework for Coronary Heart Disease

Richard Hobbs

Abstract

Cardiovascular disease is the most important cause of illness in Britain. The focus of the National Service Framework for Coronary Heart Disease (NSF for CHD) is appropriate since the burden of CHD is high in the UK. Interventions for primary and secondary prevention include advice on reducing modifiable risk factors, smoking, maintaining blood pressure < 140/85 mmHg and using statins and dietary advice to lower serum cholesterol. Identification of those at greatest risk will require practice-based registers. Audits will be needed to ensure that the stipulated interventions are offered to those on the disease registers. The biggest implication for primary prevention will be selection of patients at increased risk of CHD. Implementation of the NSF will increase GPs’ workload.

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April 2002 Br J Cardiol 2002;9:

Lipid control:the interface between specialist clinics and general practice

Mary Seed

Abstract

The lipid-lowering trials have shown positive results in terms of reducing cardiovascular events. It is mandatory to measure lipid levels in patients with other cardiovascular risk factors, such as diabetes and hypertension. Explaining cardiovascular risk and lifestyle changes takes longer than the standard 7–9 minute consultation and might be more appropriate in a nurse-led clinic. Good communication between GPs and specialists can still be difficult to achieve: face-to-face meetings are helpful and email should be playing a major role. The National Service Framework for CHD prevention puts a great deal of pressure on GPs. Secondary prevention is non-controversial although ideal levels of LDL are not being reached.

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April 2002 Br J Cardiol 2002;9:

Cardiovascular disease in diabetes care: a preventative strategy

Vinod Patel

Abstract

An effective strategy for the prevention of cardiovascular disease in patients with diabetes is needed with the epidemic of diabetes mellitus around the world. The aims are to cut morbidity and mortality from coronary heart disease by risk factor reduction and to reduce the diabetic complications of retinopathy, renal disease and peripheral vascular disease. Findings of the United Kingdom Prospective Diabetes Study (UKPDS) imply that all diabetics should be subject to intensive glycaemia control and tight blood pressure control. GISSI-3 and the DIGAMI studies showed the benefits of lisinopril and an insulin/glucose infusion, respectively, post-MI. The HOPE study set out to examine whether ramipril reduced cardiovascular events in patients at high risk: the results were highly significant. The statin studies 4S, CARE and WOSCOPS showed the value of statins in primary and secondary prevention of cardiovascular events in patients with diabetes. Low-dose aspirin therapy should be used in patients with diabetes who are at high risk of cardiovascular events.

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News and views

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