2004, Volume 11, Issue 04, pages 257-332

Most treatments administered to patients act to relieve symptoms. But in the name of saving life, having an implanted cardioverter defibrillator (ICD) leaves the patient prone to unpredictable episodes of symptoms including collapse, and abrupt and explosive chest pain, of which the informed patient may live in persistent fear.

The objectives of this analysis were to ascertain the population need for out-patient cardiac rehabilitation in England, to estimate the current level of provision and associated costs, to identify economies of scale in service provision and to investigate budgetary implications of extending provision. Discharge statistics from the Hospital Episode Statistics database (HES) in England in the year 2000, and data from centres contributing to the British Association for Cardiac Rehabilitation (BACR) survey were analysed. A short follow-up questionnaire was sent to respondents of the BACR survey. The main outcome measures were: the number of patients eligible for cardiac rehabilitation; the percentage referred, joining and completing programmes; health service costs associated with current levels of provision; elasticity of costs; and costs associated with expanding services. Using an inclusive definition of need, about 267,000 people required cardiac rehabilitation in England in the year 2000. This figure fell to 100,000 if services were restricted to those aged below 75 years with acute myocardial infarction, unstable angina or following revascularisation. Health service costs per patient completing a programme were £354 (staff) and £486 (total). Out-patient cardiac rehabilitation represented a NHS cost of approximately £12.5–19.0 million per annum. A 1% increase in patients completing a programme is estimated to lead to a 0.25% fall in the staff cost per patient. A budget increase of 630% would be necessary to treat all eligible patients using moderate staffing configurations, which would fall to 170% if only those aged below 75 years with restricted diagnoses were to be treated. We conclude that a substantial proportion of the population need for cardiac rehabilitation goes unmet and that achievement of current targets for provision is likely to require considerable additional resources. Reconfiguration of service provision towards less complex services would enable more patients to be treated. Current information systems in cardiac rehabilitation services are inadequate to provide indicators of performance and monitoring.

Integrated Care Pathways (ICPs) are one way of implementing protocol-based care. Healthcare professionals need to draft and implement ICPs in order to meet clinical governance targets. In a two-day workshop ‘Integrated healthcare delivery – let’s get practical’, 27 multidisciplinary delegates from four NHS Modernisation Teams progressed ICPs in the areas of stroke, post-myocardial infarction and heart failure. Good ICPs should include a clear assessment procedure for the clinical condition, consultation with all care providers, guidelines or best available clinical evidence, patient education and an audit tool.

The titles of the lectures at a recent Primary Care Cardiovascular Society (PCCS) meeting show the face of British cardiology is indeed changing. Control of NHS budgets and of patient care is shifting; guidelines for prevention of disease continue to change in line with new evidence; new ways of learning are being developed and yet more new laboratory tests are being pressed into service. As usual the PCCS speakers articulately covered the topics – they also had to be succinct as, after just 90 minutes, the session was over and it was ‘all change’ for the audience. Medical writer Ola Soyinka reports from the PCCS plenary session at the British Cardiac Society Annual Conference in Manchester on 25th May 2004.

The National Service Framework (NSF) for Coronary Heart Disease (CHD) requires practices to establish registers of patients with CHD and to implement audits of care for these patients. Little is known about the potential health impact of registers and audits. We therefore looked at the impact of establishing such systems on patients with CHD at Cleveleys Group Practice. All patients with CHD are recorded on a computerised register that is used to recall patients for an annual review to nurse-led clinics. Data from annual audits are used to estimate the number of adverse events prevented in the practice by the use of effective medications. We found that the use of effective treatments was estimated to save approximately 27 lives and prevent 30 non-fatal myocardial infarctions each year. The increased use of effective treatments after the introduction of the register coincided with a reduction in average levels of systolic blood pressure and total cholesterol, preventing two deaths and three non-fatal myocardial infarctions each year. Based on the best available evidence from randomised controlled trials, the benefit of this care to a practice population is substantial.

The National Service Framework (NSF) for Coronary Heart Disease (CHD) requires practices to establish registers of patients with CHD and to implement audits of care for these patients. Little is known about the potential health impact of registers and audits. We therefore looked at the impact of establishing such systems on patients with CHD at Cleveleys Group Practice. All patients with CHD are recorded on a computerised register that is used to recall patients for an annual review to nurse-led clinics. Data from annual audits are used to estimate the number of adverse events prevented in the practice by the use of effective medications. We found that the use of effective treatments was estimated to save approximately 27 lives and prevent 30 non-fatal myocardial infarctions each year. The increased use of effective treatments after the introduction of the register coincided with a reduction in average levels of systolic blood pressure and total cholesterol, preventing two deaths and three non-fatal myocardial infarctions each year. Based on the best available evidence from randomised controlled trials, the benefit of this care to a practice population is substantial.

Pneumopericardium is a rare condition, seen most commonly in the context of chest trauma in adults, and in mechanical ventilation in neonatal practice. Mortality is high, more so if pericardial gas is accompanied by pus and, ultimately, tamponade.¹ Here we present a case of tension pyopneumopericardium leading to cardiac tamponade which had a favourable outcome. The aetiology remains uncertain in this instance, although an oesophagopericardial fistula cannot be discounted. In addition, we review the causes and clinical features of this condition as reported in the literature.

Meta-analyses of exercise-based cardiac rehabilitation (CR) trials have shown improved survival^1,2 and significant improvements in cardio-respiratory fitness for individuals who have sustained a myocardial infarction (MI).³ According to the British Association of Cardiac Rehabilitation (BACR) Exercise Prescription Guidelines, phase 4 cardiac participants should exercise at a similar intensity level to that recommended for healthy adults to gain maximum benefits.⁴ To date, however, there has been a paucity of research to support or question these guidelines. This led to this pilot study, which aimed to compare the exercise intensity levels and ratings of perceived exertion of cardiac and non-cardiac participants during a phase 4 CR exercise class.

This study investigated the current level of provision of cardiac rehabilitation (CR) for automatic implanted cardioverter defibrillator (ICD) patients in the UK, the clinical and technical staff views on the need for such a service, and the current level of provision and the most commonly reported barriers to meeting these needs. The study was carried out via a postal questionnaire survey of all NHS implantation centres for ICD patients. The majority of respondents (99%) believed they should provide rehabilitation for their patients, but only 14 (36%) centres had a programme for rehabilitation that ICD patients could access and only four (10%) of these were specifically designed for ICD patients. The majority of respondents (74%) believed they were not meeting their patients’ needs for rehabilitation. The most commonly endorsed barriers to providing and developing CR services were limited multidisciplinary staff, a wide geographical catchment area, and administrative and organisation difficulties. There was wide support for the potential of using a home-based, remotely monitored, rehabilitation package. This shows that the vast majority of staff in implantation centres agree with the recent NICE recommendations that there is an unmet need to provide CR for ICD patients.

This article describes the process used to arrive at the set of assessment measures and minimum dataset for cardiac rehabilitation (CR) that has been endorsed by the British Association for Cardiac Rehabilitation (BACR) and the British Heart Foundation (BHF) for the national audit of CR.

Hypertension is a major cardiovascular risk factor and its pathogenesis remains elusive. For a long time, hypertension and dyslipidaemia have been viewed as independent but synergistic cardiovascular risk factors increasing the risk of premature atherosclerosis. Recently, a growing body of evidence has indicated that hypercholesterolaemia promotes impairment in several mechanisms implicated in blood pressure control such as nitric oxide bioavailability, renin-angiotensin activity, the sympathetic nervous system, sodium and fluid homeostasis and ion transport/signal transduction. Moreover, recent clinical studies have pointed out a beneficial effect of cholesterol-lowering treatment in reducing blood pressure to a small but significant degree. Our assumption is that depending on the complex inter-relationships between genetic background and life style, hypercholesterolaemia may be a trigger to blood pressure elevation. An integrated approach to the treatment of hypertension and dyslipidaemia can, therefore, maximise both blood pressure control and prevention of cardiovascular disease. In this review, we discuss recent important data from our and other groups, demonstrating the clinical evidence of the hypertensinogenic effects of hypercholesterolaemia, and the biological mechanisms which underlie them.

The circadian rhythms of the cardiovascular system are related to the risk of events such as myocardial infarction and stroke. The so-called ‘morning surge’ in heart rate and blood pressure at around the time of waking is a particularly hazardous period. The sympathetic nervous system and the renin-angiotensin system are thought to be the main regulators of these rhythms and a potential target of antihypertensive medication is the blunting of the morning surge through action on these systems. This article reviews some of the mechanisms involved and recent therapeutic approaches to this problem.

To target statin therapy effectively in primary coronary heart disease (CHD) prevention, recommendations increasingly advocate the assessment of absolute CHD risk. Using methods from two recent sets of national recommendations, we estimated absolute CHD risk in 412 men and women whose general practitioners requested it on clinical grounds. Substantially fewer men and women had CHD risk exceeding 15%, 20% and 30% over 10 years with the National Cholesterol Education Program III (NCEP III) scoring system than with the Joint British charts. The latter agreed closely with the 1990 version of the Framingham risk equations.