2006, Volume 13, Issue 01, pages 1-76

According to World Health Organization estimates, 16.7 million people die of cardiovascular diseases each year. By the year 2010, it is estimated that cardiovascular disease will become the leading cause of death in developing countries and by 2020 it will contribute to nearly 25 million deaths worldwide. Although therapies including drugs, lifestyle modification and revascularisation procedures have been demonstrated in clinical trials to be beneficial, they are under-utilised. Paradoxically, in spite of the under-use of evidence-based therapies, patients actively seek complemen- tary and alternative medicine (CAM) treatments. While many alternative therapies involve oral vitamin and mineral supple- ments that are unlikely to cause harm, chelation therapy is one of the most aggressive and intensive CAM modalities.

Our understanding of the pathophysiology of acute coronary syndromes and, in particular, the interplay of a number of complex parallel processes, continues to develop.1 These processes include inflammation, thrombosis and matrix turnover with potential gene and environmental influences. Vitamin D, known primarily as a hormone of bone metabolism, can affect the transcription of a number of genes which play a pivotal role in both the development of acute coronary syndromes and the pathogenesis of coronary artery disease (CAD). The purpose of this review is to examine the mechanisms by which vitamin D and the vitamin D receptor (VDR) might influence the development of acute coronary syndromes.

Studies indicate that increased heart rate is a risk factor for ischaematic cardiac events; accordingly heart rate reduction may improve outcome. Beta blockers and some calcium channel blockers reduce heart rate but their use may be limited by negative inotropic effects and several contraindications. Ivabradine, a selective sinus node If channel inhibitor, represents a therapeutic innovation in the treatment of ischaemia. Preclinical and early clinical studies show that ivabradine can reduce heart rate without affecting cardiac systolic function, suggesting that If inhibition may be an effective approach to minimise both angina and the underlying ischaemia. In clinical studies ivabradine has anti-anginal and anti-ischaemic effects in patients with stable angina and has comparable efficacy to atenolol and amlodipine. This anti-ischaemic effect is also observed in elderly patients in whom there is a greater incidence of stable angina. Furthermore, the absence of additional cardiac effects associated with If inhibition suggest that this approach may be effective in other patient groups, such as those at risk of acute coronary events or compromised left ventricular function. Further clinical trials with ivabradine to evaluate fully the therapeutic potential of If inhibition are ongoing.

Coronary heart disease (CHD) remains the leading cause of premature death in the United Kingdom. The mortality from myocardial infarction (MI) can be reduced by reperfusion of the infarct-related artery with thrombolytic agents.2,3 The best results for survival are achieved in those patients who are thrombolysed early.4,5 We set out to investigate whether the time between arrival to hospital of a patient with acute MI and administration of thrombolytic therapy (door-to-needle time) could be improved by the introduction of a bolus thrombolytic in the accident and emergency (A&E) department in a busy inner city hospital. This study of 13 months’ duration compared the door-to-needle times and the proportion of patients thrombolysed within 30 minutes before and after the introduction of a bolus thrombolytic agent – reteplase. The findings demonstrated a 37% reduction in door-to-needle time (from 27 minutes to 16 minutes) and a 22% improvement in the proportion of patients thrombolysed within 30 minutes (from 68% to 86%) with reteplase. Our findings suggest that bolus thrombolytic agents such as reteplase can be used in a strategy to meet the National Service Framework (NSF) targets for door-to-needle time.

Converging from a number of disciplines, non-linear systems theory and, in particular, chaos theory, offers new descriptive and prescriptive insights into physiological systems that may more accurately reflect underlying mechanisms. This paper describes the implications of these new perspectives and briefly outlines how they might be applied to the study of cardiology.

In an observational study, we sought to determine the effect of applying the Duke’s treadmill score on patient assessment and prioritisation to coronary angiography waiting lists within a rapid access chest pain clinic in a UK district general hospital. After attending the rapid access chest pain clinic, patients requiring subsequent coronary angiography were placed on either an urgent or a routine waiting list. We determined the number of patients subsequently shown to have severe coronary artery disease (left main stem or three-vessel disease) in both waiting lists. We then assessed the effect of applying the Duke’s treadmill score retrospectively on these patients to produce regraded waiting lists (urgent and routine); these were compared with the actual lists generated clinically. The actual urgent list had 43/111 (39%) patients with severe disease; the actual routine list had 28/98 (29%) patients with severe disease (p=NS). Application of the Duke’s treadmill score to produce re-graded lists reduced the total number of patients on the urgent list from 111 to 68. Thirty-three of 68 (49%) patients on the Duke’s treadmill score urgent list had severe disease compared to 43/111 (39%) on the actual urgent waiting list. Specificity for allocating patients with severe disease to the urgent waiting list improved from 50% to 75% by application of the Duke’s treadmill score compared with the clinically generated list. Thus, the Duke’s treadmill score could be used in a rapid access chest pain clinic to prioritise patients objectively for cardiac catheterisation in a resource-limited system.

The Scottish Intercollegiate Guidelines Network (SIGN) 2002 acknowledge the multiprofessional membership of cardiac rehabilitation (CR) teams required to deliver comprehensive CR. The clinical groups chiefly involved in delivering CR in the UK are nurses followed by physiotherapists. The participation, skills and attributes of physiotherapists in the UK have already been identified. This paper reports on the findings of a similar survey for nurses. The survey was piloted and then sent to all registered centres on the British Association for Cardiac Rehabilitation (BACR) and the Scottish CR Interest Group databases (CRIGS).

In his contribution to The auditory culture reader, Murray Schafer introduces the notion of clairaudience. Clairaudience refers, most fundamentally, to an ability to hear and, more specifically, to a capacity to hear ‘through’ or ‘beyond’ the sensory horizons which normally present themselves. This is a very suitable concept through which to consider the ear of an experienced auscultator. Not only is he or she able to hear through the layers of tissue which constitute the body and which usually contain sound, rendering it inaudible, but the auscultator is also able to infer what certain sounds might mean and what significance they might hold for a patient’s well-being in the present and future. The auscultator is able to deduce the relevance of sounds which are ‘unheard’ to the patients, and which remain incomprehensible to those not trained in medicine. An experienced auscultator holds a very particular sensory power.

Alcohol septal ablation is a percutaneous alternative to surgical myotomy-myomectomy for symptomatic patients who have hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction. In the 11 years since its inception, the procedure has been proven safe and effective. While septal ablation may be more acceptable to patients than surgery, it lacks the long-term safety record of myotomy-myectomy. Here we discuss the mechanics of the procedure itself and examine its place in clinical practice, highlighting the importance of appropriate patient selection.

Pathological findings compatible with hypertrophic obstructive cardiomyopathy (HOCM) were first described in the nineteenth century by the French pathologists, Hallopeau and Liouiville. However, it was not until 1958 that Teare recognised the condition as a separate entity; Goodwin named it HOCM in 1960.

This paper considers the role for glitazones in the treatment of type 2 diabetes following publication of the PROactive study, the first major outcome study with this class of agents. The macrovascular benefits of glitazones are discussed. Recent guidance for glitazone prescribing from the Association of British Clinical Diabetologists is also given.

DISCOVERY-UK (the DIrect Statin COmparison of LDL-C Values: an Evaluation of Rosuvastatin therapY) was an open-label, parallel-group, multicentre study designed to compare the efficacy of recommended start doses of rosuvastatin with atorvastatin and simvastatin for reduction of low-density lipoprotein cholesterol (LDL-C) and goal attainment. Patients with type IIa or type IIb hypercholesterolaemia and a 10-year coronary heart disease (CHD) risk > 20% or a history of CHD or other established atherosclerotic disease were randomised to receive rosuvastatin 10 mg, atorvastatin 10 mg or simvastatin 20 mg for 12 weeks.
Significantly greater LDL-C reductions were observed with rosuvastatin 10 mg compared with atorvastatin 10 mg and simvastatin 20 mg (50% versus 42% and 40%, both p<0.0001). The 1998 European goal (LDL-C < 3.0 mmol/L) was achieved by 89% of patients receiving rosuvastatin 10 mg, which was significantly more than patients receiving atorvastatin 10 mg (78%) and simvastatin 20 mg (72%) (both p<0.0001). Similar results were observed for the National Cholesterol Education Program Adult Treatment Panel III goal (LDL-C < 2.6 mmol/L) and 2003 European goals (LDL-C < 3.0 or < 2.5 mmol/L, depending on risk category). In conclusion, rosuvastatin is more effective than atorvastatin or simvastatin for lowering LDL-C and enabling patients to achieve lipid goals at recommended start doses.