2003, Volume 10, Issue 06, pages 401-488

The introduction of the first specialist registrar training programme in December 1995 brought a radical overhaul in higher specialist training. Each speciality produced a curriculum establishing specific training objectives against which the progress of an individual trainee could be judged.

The traditional role of the cardiac nurse, particularly at the inception of the coronary care unit (CCU), has been evolving since the early 60s.

Cardiac rehabilitation has historically been an underdeveloped service in the UK. It is now recognised as an essential component in the management of heart disease and will shortly encompass those at risk of developing cardiovascular disorders.

Hypertension is one of the major risk factors for vascular disease and its treatment to target requires not only careful monitoring with lifestyle advice and pharmacological intervention but also a good understanding of the condition by the patient.

During the second half of the twentieth century our knowledge of the aetiology of and pathophysiological mechanisms underlying hypertension have advanced immeasurably. Furthermore, few, if any, areas of medicine have as many major morbidity and mortality trials to inform optimal management as does hypertension.

The merits of reducing cholesterol to help prevent coronary heart disease (CHD) were questioned 10 years ago. There were great debates about the utility of reducing low-density lipoprotein cholesterol (LDL-C) and it is now clear, following the publication of at least eight different clinical drug trials, that reducing cholesterol with statin drugs helps to reduce total mortality, cardiovascular mortality and morbidity and interventional procedures.

The Primary Care Cardiovascular Society (PCCS) has come a long way since a small group of us met in an inauspicious hotel in middle England in the mid 1990s, to discuss the formation of a group through which to develop a network of general practitioners (GPs) with a particular interest in cardiovascular disease and its management.

Ten years ago, England had one of the worst death rates from circulatory diseases in Europe. Today, thanks to the expertise and hard work of thousands of NHS staff, major progress has been made in implementing the National Service Framework (NSF) for Coronary Heart Disease (CHD), and deaths from circulatory diseases are set to be reduced by 40%, three years ahead of the 10-year target set when the NSF was published in March 2000. As a result, we estimate that around 100,000 lives are being saved each year.

This is the tenth anniversary issue of the British Journal of Cardiology(BJC) and, to mark the occasion, we have invited editorials from medical and nursing groups officially associated with the journal.

‘New’ was the operative word at this year’s Primary Care Cardiovascular Society annual meeting, held in Dublin from 3rd–4th October 2003. Delegates heard about the ‘new’ GP contract, the ‘new’ science of pharmacogenetics, the ‘new’ breed of healthcare professionals (with special interests) and a ‘new’ diploma in cardiovascular disease.

The two National Service Frameworks for coronary heart disease, and for diabetes, share some common themes. This article discusses where they overlap with each other and with national targets for stroke outlined in the National Service Framework for Older People. It then details a simple 10-point plan on how Primary Care Trusts can develop strategies to implement NSF targets so they achieve national standards.

This study investigated the impact of the use of a computer programme to collect data on cardiovascular risk factors, which could also provide patient education. A retrospective analysis was carried out of data recorded over three years in a general practice in Barnsley, an area with the second highest prevalence of ischaemic heart disease in England. The study found that use of a simple computer-based system by the primary care team led to 55% of the population being assessed within three years. Consequent patient education and lifestyle changes led to a reduction of risk factors in those at high risk who were re-screened. A possible reduction on admissions to hospital for cardiovascular disease was also noted.

International travel to malarial areas is increasingly common. Chemoprophylaxis using chloroquine is common, but can cause cardiac problems. We describe a new problem, of reversible heart block, in a patient on both chloroquine and the frequently-used calcium channel blocker, diltiazem.

Data from epidemiological and intervention studies have conclusively shown that a low level of high-density lipoprotein cholesterol (HDL-C) is an important risk factor for cardiovascular disease. Increasing low HDL-C levels produces risk reduction comparable with that observed with decreasing low-density lipoprotein cholesterol (LDL-C) in the major statin trials. The latter have shown that, even with effective statin therapy, there is still an unacceptably high residual risk of major coronary events. A substantial proportion of patients with coronary heart disease (CHD) with acceptable levels of LDL-C will have low levels of HDL-C and increased serum triglycerides. Of the available lipid-modifying treatments, nicotinic acid is the most potent agent for increasing HDL-C (by about 30% from baseline). In addition, it effectively decreases triglycerides and has a relatively modest effect in decreasing LDL-C. Modified-release nicotinic acid has been developed to overcome the poor tolerability associated with earlier formulations while maintaining the efficacy of immediate-release nicotinic acid. Modified-release nicotinic acid is effective and safe for the treatment of dyslipidaemia, including the atherogenic dyslipidaemia associated with type 2 diabetes and the metabolic syndrome. Combination therapy with modified-release nicotinic acid and a statin offers complementary therapeutic benefits, as well as reducing the progression of, or even regressing, atherosclerosis. This strategy can represent an important advance for clinical management of at-risk patients with dyslipidaemia.

We summarise the natural history and pathophysiology of aortic stenosis and regurgitation, the indications for surgery, the advantages and disadvantages of tissue, mechanical, homograft and autograft aortic valve replacement, and the prediction of operative mortality for individual patients.