2003, Volume 10, Issue 01, pages 1-76

The concept of chronic disease self-management programmes together with the emerging expert patient has not been widely studied in the context of heart disease. But many of our patients with chronic heart disease are already experts. The knowledge and experience held by the patient has been untapped as a healthcare resource. Research from Stanford1 has shown that lay people with chronic conditions – when given a detailed leader’s manual – can be as effective as professionals in managing their disease and its impact on their daily life. It has also been acknowledged in the report ‘The expert patient: a new approach to chronic disease management for the 21st Century’,2 which recommends action over a six-year period to introduce lay led self-management training programmes for patients with chronic diseases within the NHS in England. A pilot phase between 2001 and 2004 will evaluate local programmes; between 2004 and 2007, programmes will be mainstreamed within all NHS areas.

A commentary on the sign guideline on cardiac rehabilitation, and links between the British Association for Cardiac Rehabilitation and the British Journal of Cardiology

In 2000, the European Society of Cardiology and American College of Cardiology issued a consensus document concerning the redefinition of myocardial infarction (MI). They proposed that the diagnosis of acute MI should be based on the rise and fall of specific markers combined with at least one of the following: ischaemic symptoms, ECG changes consistent with ischaemia or infarction, or coronary intervention. The implications of this redefinition are widespread, and it has been met with mixed opinions from physicians. Here we present the results of a survey, sent to 1,000 consultants in cardiology and general medicine, concerning the availability and their use of cardiac markers and their current working diagnosis of MI. Four case studies were included in the survey. Some 361 responses were analysed. Creatine kinase (CK) remains the most frequently used marker for the diagnosis of MI, but 23% of consultants had moved to a definition based on troponins. Fourteen per cent of consultants no longer used CK in their practice. Ninety-two per cent of consultants had access to troponin assays. Definitions varied widely between consultants, even within individual hospitals, as did the responses to the case studies.

Patients admitted to hospital with a diagnosis of acute myocardial infarction (AMI) have high motivation to stop smoking. Nicotine replacement therapy (NRT) is known to be valuable in helping smokers quit although it is not commonly prescribed in patients in the acute phase following AMI. Results from a full in-patient smoking cessation service were retrospectively analysed after the first 12 months, with particular reference to safety and efficacy in patients with AMI. Of 42 patients admitted with AMI who smoked and who were referred to the service, 32 (76%) received NRT with counselling as an in-patient, one as an out-patient and nine received counselling only. Assessment at four weeks showed 11 (26%) were still smoking, one (2%) had been lost to follow-up and 30 (71%) had successfully quit. Of these, six (20%) had not required NRT, one (3%) had received out-patient NRT and 23 (77%) had received in-patient NRT. There were no adverse outcomes in any patients. This suggests an in-patient smoking cessation programme, including prescription of NRT in the first five days following presentation with AMI, is a safe and effective means of helping vulnerable people to give up smoking.

The mode of action of non-steroidal anti-inflammatory drugs and the role of the cyclo-oxygenase enzymes COX1 and COX2 and their inhibitors is described. These can have potentially serious effects on the cardiovascular and renal system which are discussed. The alternative, widely-prescribed analgesic, paracetamol, is also discussed, as are two theories ‘confounded by indication’ and ‘protopathic bias’ to help explain why paracetamol is sometimes described as being linked to asthma and upper gastro-intestinal damage, both effects not expected from a knowledge of its mode of action.

Amiodarone is a potentially hazardous drug indicated for atrial and ventricular arrhythmias. The purpose of the audit was to assess the risk associated with amiodarone therapy and identify measures to improve patient safety. The setting was a rural practice with 13,000 patients in Lanark, Scotland. A computer search identified 16 patients (11 male, five female) receiving amiodarone. The mean age was 74 years (range 61–89 years). Action taken was raising doctor awareness and systematic biochemical and clinical review. Results showed that, in spite of substantial mortality and morbidity prior to the audit, there was no effective practice monitoring system for amiodarone therapy. The prevalence of clinical hypothyroidism and hyperthyroidism (29%) and ‘silent’ biochemical thyroid dysfunction (14%) exceeded published estimates (14–18% and 10% respectively). Although standards improved for biochemical monitoring, increasing awareness of the need for close surveillance did not appear to change the practice of some of the general practitioners (GPs), notably the clinical examination of pulse and blood pressure. The audit demonstrates a need for a more systematic approach to amiodarone monitoring. Recommenda-tions include enhancements to the patient information leaflet, the development of local protocols and patient involvement in quality improvements including improved communication, patient-held record cards, better quality follow-up information, and more effective reporting systems.

There is strong evidence to support a causal relationship between the level of circulating plasma cholesterol and the risk of clinically overt coronary heart disease (CHD) events. Current UK guidelines recommend reductions of total cholesterol levels to below 5.0 mmol/L. Statins remain the drugs of first choice for reducing low-density lipoproteins (LDL). Rosuvastatin has already been approved in the Netherlands and is likely to become more widely available in the next year. It has a potent effect in lowering LDL and it also appears to raise high-density lipoproteins (HDL). It has a similar safety profile compared with other statins. Cholesterol absorption inhibitors are a new treatment option for the management of hypercholesterolaemia. Ezetimibe, the first drug in this class, has recently been approved for use in the US and Germany. It selectively inhibits the uptake of dietary and biliary cholesterol at the level of the enterocyte. The site of action of ezetimibe may be the ‘sterol permease’ transport protein. As monotherapy, the role of ezetimibe appears limited at present. However, in combination with a low-dose statin, significant reductions in plasma LDL levels are seen. It may also be a useful agent for patients with homozygous familial hypercholesterolaemia.

The success of developments in heart transplantation has given women recipients the opportunity to have children. The first successful pregnancy in a patient who had received a heart transplant was reported by Lowenstein et al. in 1988.1 The cardiovascular effects of pregnancy demonstrate the durability of transplanted hearts. We report a successful pregnancy in a 20-year-old patient who had previously had a heart transplant; we also discuss the management of such patients.

Acute, undifferentiated chest pain (chest pain ?cause) presents a frequent and difficult challenge to clinicians working in the emergency setting. We aimed to survey current management of this problem in UK accident and emergency departments by sending a postal questionnaire to the lead clinician or first named consultant in every major A&E department in the UK.
Responses were received from 177/238 departments (74%). Although 74 departments (42%) had formal guidelines, many referred only to diagnosed coronary syndromes. Guidelines for undifferentiated chest pain usually recommended observation for six to 12 hours followed by troponin testing. Short-stay facilities were available in 38 departments (21%) and were planned for 55 departments (31%). Provocative cardiac testing could be accessed by 38 departments (21%). Patients were admitted by general physicians in 152 hospitals (86%) and cardiologists in 18 (10%). The estimated proportion of patients admitted was extremely variable. Although 45 departments (25%) employed specialist nurses, only in 20 did they manage patients with undifferentiated chest pain.
Reported management of acute, undifferentiated chest pain in the UK shows wide variation. Innovative technologies and diverse methods of service delivery are being adopted in a number of departments. These innovations require thorough evaluation.

Cardiovascular death is steadily decreasing but still accounts for 40% of deaths (235,000) in this country per year. More than 85% occur in older patients over the age of 65 years. The future of cardiology lies in the delivery of care to this rapidly expanding population of older people, whose growing numbers will account for an increasing trend upwards in the prevalence of cardiovascular morbidity in the UK. There will be increasing numbers of heart failure, hypertension, myocardial infarction, angina, atrial fibrillation, pacemaker implants and heart valve implantation in older patients. Randomised clinical trials often exclude the treatment of these conditions in patients over 75 years and results cannot always be easily extrapolated. Older patients often seem to be disadvantaged when compared with younger patients with cardiovascular disease. This article is the first in a series examining the treatment of older patients with cardiovascular disease.

Angiotensin-converting enzyme (ACE) inhibitors and statins improve prognosis in patients with coronary artery disease. Effective secondary prevention strategies, however, are frequently under-utilised. We sought to determine prescribing habits for ACE inhibitors and statins in 324 patients undergoing coronary artery bypass graft surgery (CABG) at two regional cardiac centres in the United Kingdom. We prospectively recorded ACE inhibitor and statin use on admission and discharge, ACE inhibitor and statin initiation and withdrawal during the hospital stay, and sought associations with treatment withdrawal. 82 (25.3%) patients were taking an ACE inhibitor on admission compared with 37 (11.4%) at discharge (p<0.0005). An ACE inhibitor was initiated during the hospital stay in five (1.5%) patients and was withdrawn in 50 (15.4%). On admission, 157 (48.5%) patients were receiving statin therapy compared with 154 (47.5%) at discharge (p=ns). Statin treatment was initiated in 23 (7.1%) patients, but was withdrawn in 20 (6.2%) others. Thus, only a minority of patients were receiving ACE inhibitors and statins on admission for isolated elective CABG. ACE inhibitor treatment was discontinued during the hospital stay in over 60% of these patients. Furthermore, statin therapy was no more common at discharge than on admission. This study highlights a missed opportunity for effective secondary prevention in a high risk population.

The SIGN guideline on cardiac rehabilitation was published in January 2002 and endorsed by the British Association of Cardiac Rehabilitation. This paper summarises the recommendations, which cover all four phases of recovery and the three main cardiac rehabilitation interventions.