2006, Volume 13, Issue 05, pages 301-372

The many advances made in treating myocardial infarction and coronary artery disease has brought a new challenge – that of refractory angina. This is defined as chronic stable angina that persists despite optimal medical treatment in patients where revascularisation is unfeasible or where the risks are unjustified.

Patent foramen ovale (PFO) is defined as a communication at the fossa ovalis between the primum and secundum atrial septa that persists after the first year of life. In utero the PFO functions as a physiological conduit for right to left shunting and it functionally closes at birth once the pulmonary circulation is established and there is a rise in left atrial pressure. This is followed by anatomical closure of the septum primum and septum secundum by one year of age.

Recent presentations at the joint meeting of the European Society of Cardiology and World Congress of Cardiology in Barcelona, Spain, highlighted the potential problem of very late stent thrombosis and increased non-cardiac death occurring in drug-eluting stents (DES) (see pages 317–18). The presentations received major publicity, not least because of the comments of the designated discussant Professor Salim Yusuf (McMaster University, Hamilton, Canada) at one of the conference Hot Line sessions.

The benefits of statins for both primary and secondary prevention of coronary heart disease (CHD) are limited mainly to patients under 80. We examined the impact of the new General Medical Services (GMS) contract on measurement of lipids and prescribing of statins in patients over 80 years of age with CHD. We found that there has been a significant increase in both, with little evidence supporting this and substantial financial implications. National guidance on the assessment and management of lipids in the over 80s in the new GMS contract is urgently required.

If you speak to any general practitioner (GP) in the next few months, there are three letters that will be occupying his or her mind: QOF. Rather than an exotic hairdo, this stands for ‘Quality and Outcomes Framework’ and determines a considerable proportion of our income.

Lifestyle modifications are an essential initial approach to the management of blood pressure. To review the current evidence in this area, The British Journal of Cardiology recently convened a round table meeting to look at the lifestyle management of raised blood pressure. It considered the role of dietary changes, exercise, alcohol and weight, and ways of changing patients’ behaviour, on blood pressure. The meeting, held at The Royal Society of Medicine, London, and supported by an unrestricted educational grant from Unilever, was attended by investigators involved in the EUROACTION study. EUROACTION is a European Society of Cardiology demonstration project in preventive cardiology which has just been completed in eight countries in both hospital and primary care. It is evaluating whether a nurse-led multidisciplinary team can help patients and families achieve recommended lifestyle and risk factor reduction targets for cardiovascular disease prevention.

Most doctors have only heard of Ernest Starling through his law of the heart, although this was not a particularly important part of his research output. Shortly after qualifying in medicine at Guy’s Hospital, London, in 1888 (where he won the university gold medal in medicine), he began investigating the formation of lymph. To explain his findings, he proposed an inward osmotic force at the capillary: the only possible source of this force was the plasma proteins. At the capillary there was a balance between an inward (osmotic) force and an outward (hydrostatic) force. This became Starling’s ‘Filtration Principle’, which, in retrospect, was a paradigm shift in our understanding of the circulation.

Excretion of excess urinary albumin is a marker of generalised endothelial dysfunction and both progressive renal disease and cardiovascular events in those with and without diabetes; its detection provides a simple way of identifying patients at particularly high risk. Effective management of cardiovascular risk factors and the use of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors have been shown to retard or prevent progression of microalbuminuria to more profound albuminuria. Microalbuminuria can be reversed by such therapy and recently an ACE inhibitor has been shown to prevent the development of microalbuminuria in hypertensive patients with type 2 diabetes. Given the increasing prevalence of type 2 diabetes and the corresponding ascendancy of ensuing cardiovascular disease and renal failure, strict control of multiple risk factors, including microalbuminuria, is to be encouraged.

The aim of this study was to assess whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) affected blood pressure control in patients with essential hypertension who were being treated with lercanidipine, a vasoselective dihydropyridine calcium channel blocker. A total of 334 patients (mean [+ SD] age 61+10 years, 51% females) with mild-to-moderate essential hypertension and a history of osteoarthritis received lercanidipine (10 mg/day, up-titrated to 20 mg/day) for four to eight weeks until blood pressure control was achieved. At that point, treatment with NSAIDs (mostly diclofenac and naproxen) was started. Treatment with NSAIDs was maintained for four weeks. At baseline, mean systolic blood pressure (SBP) was 157=/-10 mmHg, diastolic blood pressure (DBP) 92=/-6 mmHg, and heart rate 75=/-9 beats per minute. The administration of lercanidipine was associated with a significant decrease of SBP (to 139=/-9 mmHg) and DBP (to 82=/-7 mmHg) (p<0.001), without changes of heart rate. SBP and DBP readings were not affected by the concomitant use of NSAIDs. Among 156 patients whose blood pressure was well controlled with lercanidipine, 128 (82%) continued to have well controlled SBP and DBP readings. The remaining 28 patients had SBP and DBP > 140 and/or 90 mmHg, but differences in blood pressure between the two groups were not significant. Eight patients (2.3%) had mild side effects and three were withdrawn due to ankle oedema. We conclude that the use of NSAIDs did not significantly modify the antihypertensive effect of lercanidipine in essential hypertension. Therefore, lercanidipine is a useful drug for hypertensive patients with osteoarthritis who require treatment with NSAIDs.

The aim of this study was to understand patients’ satisfaction with the Angina Plan (AP). Comments from the satisfaction questionnaire help us to understand why patients were satisfied with the AP.