2004, Volume 11, Issue 06, pages 413-496

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2004, Volume 11, Issue 06, pages 413-496

Editorials Clinical articles News and views
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Editorials

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November 2004 Br J Cardiol 2004;11:449-54

Statin safety in perspective – maximising the risk:benefit

Marc Evans

Abstract

Statins are prescribed worldwide for patients with coronary heart disease (CHD) and also for those at risk of developing atherosclerotic vascular disease. They represent a valuable treatment option for managing lipid levels. However, the well-publicised withdrawal of cerivastatin (Baycol®, Bayer) in 2001 led to concern and much subsequent discussion over the safety of statins. This review looks at the evidence in relation to the benefits and risks of statins and demonstrates that the benefits of statins far outweigh the risks.

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November 2004 Br J Cardiol 2004;11:425-6

Surgical delusions

David P Taggart, David W Pigott

Abstract

Over the last decade improvements in the anaesthetic, medical and surgical management of patients undergoing coronary artery bypass grafting (CABG), along with refinements in cardiopulmonary bypass, have resulted in better clinical outcomes.

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November 2004 Br J Cardiol 2004;11:421-3

Statin prescribing rises and infarct rates plateau. Why the mismatch?

Michael D Feher

Abstract

A recent report in the British Medical Journal has suggested that the incidence of myocardial infarctions has only plateaued with the rise in statin prescriptions (BMJ 2004;329:645). Although this observation does need to be interpreted with caution, there may be several reasons for this.

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Clinical articles

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November 2004 Br J Cardiol 2004;11:495-6

Education – the dawning of a new era?

Sally Smith

Abstract

The Calman Review of 1998 recognised that continuing medical education through the postgraduate education allowance scheme (PGEA) had failed to deliver improvements in patient care. Instead, continuing professional development (CPD) has been put forward, which is intended to identify and fulfil learning needs. The primary care team itself is recognised to be a valuable learning resource.

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November 2004 Br J Cardiol 2004;11:492-4

Palpitations and syncope in primary care

Amit KJ Mandal, George G Kassianos

Abstract

Palpitations are a common complaint. It is useful for the GP to determine which are benign and which are potentially life-threatening and require urgent referral. Two cases are presented here in which the GP used 24-hour electrocardiogram (ECG) monitoring to detect a prolonged daytime sinus pause. Both patients were referred, as a consequence, for permanent pacemaker insertion. A 24-hour ambulatory ECG monitoring machine allows the GP to reassure patients whose palpitations have a benign origin, to reduce inappropriate referrals to secondary care, and to produce a more informative referral letter.

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November 2004 Br J Cardiol 2004;11:487-91

Statins in primary care: bridging the treatment gap

Rubin Minhas

Abstract

Audits of cholesterol management in patients with coronary heart disease (CHD) demonstrate that many patients do not achieve targets set out in national guidelines. Under-treatment is a component of the treatment gap and many patients are prescribed low-dose statins. The delivery of systematic care and adoption of more efficacious initial doses will increase the number of patients who achieve recommended low-density lipoprotein cholesterol (LDL-C) levels and maintain their LDL-C goals. Current studies indicate that rosuvastatin, atorvastatin and simvastatin are the most efficacious agents for lowering LDL-C and triglycerides. Compliance and persistence with statin treatment are poor and represent significant barriers to delivering mortality reductions in clinical practice. Efforts to improve concordance are necessary to ensure that treatment benefits are realised in clinical practice.

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November 2004 Br J Cardiol 2004;11:483-5

Chest pain induced by 5-fluorouracil

David JB Thomas, Anita Sarker, Robert Glynne-Jones

Abstract

Five-fluorouracil (5-FU) is commonly used to treat solid tumours, and in palliative and adjuvant chemotherapy. The agent 5-FU is being used in ever-increasing dosage, and this results in more side effects.

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November 2004 Br J Cardiol 2004;11:479-82

Carotid artery disease: stenting, endarterectomy or medical therapy?

Mitchell M Lindsay, Keith G Oldroyd

Abstract

Carotid artery disease is a major cause of stroke. Carotid endarterectomy when performed with a low complication rate in patients with severe lesions has been shown to reduce the subsequent risk of stroke in a series of randomised controlled trials in both symptomatic and asymptomatic populations. The CAVATAS trial demonstrated that simple balloon angioplasty of carotid stenoses was as good as endarterectomy in terms of stroke prevention and was associated with a lower complication rate. Carotid stenting performed with the use of distal protection devices has been shown to be superior to endarterectomy in patients considered to be at increased perioperative risk as assessed by a variety of clinical and angiographic parameters. Comparisons of carotid stenting and endarterectomy in patients considered to be of normal perioperative risk are ongoing. Optimal medical therapy is mandatory for all patients with carotid artery disease.

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November 2004 Br J Cardiol 2004;11:478

Cerebral and pulmonary embolic disease in association with an atrial septal aneurysm

Paresh A Mehta, Simon W Dubrey, Richard Grocott-Maso

Abstract

This image shows a non-communicative atrial septal aneurysm (ASA), as seen on trans-oesophageal echocardiography, in a 57-year-old man with multiple cerebral and pulmonary emboli. He was a non-smoker, with no risk factors for cardiovascular disease.

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November 2004 Br J Cardiol 2004;11:474-7

Adherence to anticoagulation guidelines for atrial fibrillation: a district general hospital survey

Paresh A Mehta, Richard Grocott-Mason, Simon W Dubrey

Abstract

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and a significant cause of hospital admission, morbidity and mortality. AF significantly increases the risk of embolic stroke, and anticoagulation with warfarin can reduce this risk by up to 61%. International guidelines recommend the use of warfarin for atrial fibrillation in patients considered at higher risk for stroke. This prospective observational study evaluates current adherence to anticoagulation guidelines for patients with atrial fibrillation. It was carried out in a district general hospital in London on 93 patients with atrial fibrillation admitted via the emergency department over a four-month period. Patients’ mean age was 77 years and the mean age of onset of AF was 75 years. Eighty-eight per cent of patients were > 75 years and/or had another risk factor for embolic stroke requiring warfarin therapy. Anticoagulation treatment did not adhere to guidelines in 56% of patients at the time of hospital admission. This proportion fell slightly to 52% at the time of hospital discharge. A total of 20% of patients were discharged on no anticoagulation at all. The adherence to anticoagulation guidelines for patients with atrial fibrillation, who are at risk of embolic stroke, appears inadequate. Despite the evidence supporting oral anticoagulation, clinical practice seems resistant to change. The future may include patient self-monitoring and the use of oral direct thrombin inhibitors to improve stroke prophylaxis.

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November 2004 Br J Cardiol 2004;11:468-73

Maximising the benefit from pre-operative cardiac evaluation for elective, non-cardiac surgery

Jonathan MT Pierce, Oliver Allenby-Smith, Jonathan Goddard

Abstract

The objective of this study was to examine the association of delusional and real memories for events with both the pre-operative and early post-operative clinical condition and to examine interventional, supportive and therapeutic factors. Its design was retrospective, using a questionnaire and review of clinical records. The study was carried out in a university teaching hospital cardiothoracic intensive care unit (ICU) on 161 patients without professional experience of intensive care, who had received four days or more in intensive care after cardiac surgery. Its main outcome measures were the prevalence of delusional memory persisting after recovery and the recall of real events whilst in intensive care. Seventy-eight (48%) patients recalled events apparently occurring whilst in intensive care, which were delusional or hallucination-like (‘dreamers’). This group recalled a mean of 2.6 of a possible 10 normal intensive care events compared with 1.0 of 10 for those who were not able to recall delusions or hallucinations (‘non-dreamers’). Dreamers were younger at the time of surgery (mean age 63.6 vs. 68.9 years, p=0.003). Dreaming was more common in patients who received intravenous glucose (to treat hypoglycaemia), midazolam, steroids and in those with episode(s) of sepsis. We concluded vivid memory of unreal events is common after discharge from intensive care. The aetiology is probably multifactorial. The retrospective nature and the inexact methods preclude confirming that midazolam is a direct, much less a causal, risk factor. However, the association is strong enough to warrant prospective studies.

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November 2004 Br J Cardiol 2004;11:462-66

Delusional memories following cardiac surgery and prolonged intensive care: a retrospective survey and case note review

Jonathan MT Pierce, Oliver Allenby-Smith, Jonathan Goddard

Abstract

The objective of this study was to examine the association of delusional and real memories for events with both the pre-operative and early post-operative clinical condition and to examine interventional, supportive and therapeutic factors. Its design was retrospective, using a questionnaire and review of clinical records. The study was carried out in a university teaching hospital cardiothoracic intensive care unit (ICU) on 161 patients without professional experience of intensive care, who had received four days or more in intensive care after cardiac surgery.
Its main outcome measures were the prevalence of delusional memory persisting after recovery and the recall of real events whilst in intensive care. Seventy-eight (48%) patients recalled events apparently occurring whilst in intensive care, which were delusional or hallucination-like (‘dreamers’). This group recalled a mean of 2.6 of a possible 10 normal intensive care events compared with 1.0 of 10 for those who were not able to recall delusions or hallucinations (‘non-dreamers’). Dreamers were younger at the time of surgery (mean age 63.6 vs. 68.9 years, p=0.003). Dreaming was more common in patients who received intravenous glucose (to treat hypoglycaemia), midazolam, steroids and in those with episode(s) of sepsis.
We concluded vivid memory of unreal events is common after discharge from intensive care. The aetiology is probably multifactorial. The retrospective nature and the inexact methods preclude confirming that midazolam is a direct, much less a causal, risk factor. However, the association is strong enough to warrant prospective studies.

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November 2004 Br J Cardiol 2004;11:455-60

Should all diabetic patients receive a statin? Results from recent trials

Gillian Marshall, Claire McDougall, Adrian JB Brady, Miles Fisher

Abstract

Diabetes is associated with the development of premature cardiovascular disease. In the three early trials of statin therapy for patients with established coronary heart disease there were many patients with diabetes; subgroup analysis has confirmed the benefits of cholesterol lowering with statin therapy in these patients. In the two early primary prevention trials, however, there were few patients with diabetes and so, initially, there was little evidence supporting the use of statins in diabetic patients without cardiovascular disease. The Heart Protection Study (HPS) and Collaborative AtoRvastatin Diabetes Study (CARDS) have now provided this evidence and firmly established that cholesterol lowering is of benefit in reducing cardiovascular events in patients with type 2 diabetes, regardless of the level of baseline cholesterol, or the presence or absence of cardiovascular disease. A few recent studies have failed to find benefit in diabetic patients but there are explanations for these negative findings. Ideally all patients with diabetes, especially the middle-aged and elderly, should be treated with statins but it remains uncertain at what age therapy should start and how low to reduce the cholesterol for maximum benefit.

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