2006, Volume 13, Issue 03, pages 157-224

How much would you pay for an extra year of life? What if it was only a few months or even a few weeks? How much would you pay to stop a myocardial infarction (MI) happening to a close family member? As healthcare expenditure tries to grow faster than gross domestic product, these are questions increasingly being faced, incredible though it may seem, leaving difficult decisions.

Miniaturisation of machines has allowed echocardiography to be performed in the community as well as anywhere in the hospital. It has led to an expansion of the types of study performed: ultrasonic stethoscope, screening and focused studies, and standard echocardiograms. In expert hands, results compare favourably with standard studies on full systems. With focused studies, abnormalities may be missed in areas of the heart that are not imaged. For screening studies, the negative predictive accuracy is high while the positive predictive accuracy is lower. Portable echocardiography can save time and costs, but it is essential that studies are requested and performed within a tightly controlled clinical setting. Operators should be trained appropriately and be part of a broad echocardiography service that includes quality control, continuing education and expert supervision.

Familial hypercholesterolaemia (FH) affects about one in 500 in the UK population. There are no symptoms or signs of raised cholesterol in children and so individuals can only be identified by screening, usually as a 'cascade' from known probands. Once identified, such children should be treated to prevent premature atherosclerosis.

The effectiveness of rosuvastatin in improving lipid measurements and achieving guideline target levels in patients has been demonstrated in short-term randomised clinical trials. The Framingham Heart Study has provided some of the strongest evidence in establishing the relationship between risk factors such as smoking, hypertension and cholesterol and events from cardiovascular disease and subsequent mortality. Using Framingham risk equations for coronary heart disease, we used a Markov model to extrapolate beyond short-term trial evidence to calculate the cost-effectiveness of cholesterol-lowering therapy in 55-year-old men and women, with an initial total cholesterol: high-density lipoprotein cholesterol (TC:HDL) ratio of 5.5 and an untreated expected survival (under adjusted Framingham risk equations) of 17 years (men) and 19 years (women). After titration, cholesterol-lowering therapy reduced the weighted average TC:HDL ratio to 3.4 (rosuvastatin), 3.7 (atorvastatin), 3.9 (simvastatin), 4.1 (fluvastatin) and 4.2 (pravastatin). In comparison with no treatment, rosuvastatin produced the greatest health gain (0.71 quality-adjusted life-years [QALYS]) and pravastatin the smallest (0.42). In the base case analysis, rosuvastatin dominated atorvastatin and delivered additional benefits at the cost of £9,735 per QALY for men in comparison with generic simvastatin. Sensitivity analysis showed a high probability of rosuvastatin being cost-effective under conditions of uncertainty.

Although levels of total cholesterol are similar between populations with and without diabetes, there are important differences in lipid sub- fractions, with diabetic dyslipidaemia characterised by reduced levels of high-density lipoprotein (HDL) cholesterol and elevated triglycerides. In addition, small, dense, low-density lipoprotein (LDL) particles may increase atherogenicity. These differences may account for the increased vascular risk reported in diabetic populations. The benefit of HMG Co-A reductase inhibitors, primarily through LDL cholesterol reduction, has been demonstrated in populations with ischaemic heart disease. Fibrates are synthetic activators of the a subclass of the peroxisome proliferator-activated receptor (PPAR), and are reported to raise HDL cholesterol and lower triglyceride levels preferentially. The FIELD study was designed to assess whether the theoretical benefit offered by fibrates in diabetic dyslipidaemia was reflected in improved cardiovascular outcomes.

A major concern in cardiology in the UK has been the waiting times for patients referred from primary care to secondary care, which are often long. We have addressed this problem in our Trust. At various times the Trust had funded waiting list initiative clinics but, apart from small and transitory improvements, the situation continued to worsen. Various solutions to the out-patient services problems have been implemented. However, there is a lack of published information about system redesign. In this article we present some of the principles we are currently employing to redesign our out-patient service with a view to improve its efficiency. Our results are being published separately.

Cardiac angiosarcomas are malignant tumours that are rare, often with non-specific symptoms. They almost always have a rapid and fatal evolution, making diagnosis challenging. Therapeutic approaches include surgery, chemotherapy and radiotherapy alone, or in combination, but because the tumour is rare there are no randomised studies to guide treatment. Management is, therefore, usually individualised and often multidisciplinary.

National Institute for Health and Clinical Excellence (NICE) guidelines in the UK state that suspected heart failure patients should have an ECG in order to select patients for echocardiography. The research underpinning this recommendation comes from studies in which cardiologists interpreted the ECGs. In practice, however, it would be general practitioners (GPs) interpreting ECGs. The aims of this study were to assess both GPs and ECG machine interpretation in their ability to use ECGs to select suspected heart failure patients for echocardiography. Six GPs were asked to classify 90 ECGs taken from suspected heart failure patients either as normal or as having an abnormality present. The ECG machine report was also used to classify the ECG in the same way. These results were compared to a gold standard interpretation. The GPs and the ECG machine report would have not referred 17.8% and 8.3%, respectively, of the appropriate patients for echocardiography. In doing so, the GPs would have missed 5.6% of patients with left ventricular systolic dysfunction (LVSD) whereas the ECG machine report would have missed none. We conclude from our findings that there is heterogeneity between GPs in their interpretational skills. Some GPs could successfully use ECGs to select patients for echocardiography. The difference in cost between performing echocardiography on all patients and GPs screening with ECGs is £74 more per case. Screening with ECG machine interpretation costs virtually the same as performing echocardiography on all patients.

The study documents general practitioner (GP) consultations before and after a primary, acute myocardial infarction (MI) and examines how these relate to psychological distress. Data were derived from the numbers and category of consultations and their outcome, documented from medical records of 194 patients with a primary acute MI over a two-year period pre-MI and a six-month period post-MI. Objective measures of anxiety and depression were collated using the Hospital Anxiety and Depression Scale in four phased assessments over a six-month period following the MI. There was a high probability of consultation for cardiovascular and psychological symptoms before a MI. Post-MI, almost all patients receive an early consultation: high consultation rates continue for cardiovascular concerns but they are relatively low for psychological issues. However, questionnaire responses indicated a substantial minority of patients with clinical or borderline clinical levels of anxiety (30%) and depression (20%) post-MI. Patients are willing and able to make demands on their GPs post-MI, but not for psychological issues despite evidence of high levels of anxiety and depression; patients may be too accepting of distress. While GPs advise and are prepared to provide drug treatment for psychological concerns, they did not make referral for psychological support.