2007, Volume 14, Issue 02, pages 61-120

The Scottish Intercollegiate Guideline Network (SIGN) has published five new guidelines on heart disease with the aim of helping reach the Scottish Executive’s target of reducing deaths from coronary heart disease (CHD) in those aged under 75 years by 60% for the period 1995–2010. It is hoped the new guidance will help further reduce mortality, which has already fallen by one third between 1995 and 2005. The new guidance covers acute coronary syndromes (SIGN 93), cardiac arrhythmias in coronary heart disease (SIGN 94), the management of chronic heart failure (SIGN 95), the management of stable angina (SIGN 96), and risk estimation and the prevention of cardiovascular disease (SIGN 97). The full guidance is available at www.sign.ac.uk. Here, Dr Alan Begg gives a primary care perspective on the new guidance.

For nearly 40 years it has been suggested that high levels of homocysteine are associated with an increased risk of cardiovascular disease and that lowering these levels might be beneficial. On the basis of recently-published evidence, however, it appears that this hypothesis no longer holds and it is, perhaps, now time to move on in the search for non-conventional cardiovascular risk factors and other markers of disease risk.

Peri-operative transoesophageal echocardiography (TOE) has become part of the routine management of patients undergoing cardiac surgery. Its use in guiding not only surgery, but also the haemodynamic management of the patient, has made TOE an indispensable tool in the cardiac operating theatre. Practical aspects of intra-operative TOE are outlined and its application in differing clinical situations is reviewed.

Stress echocardiography has a high diagnostic accuracy for the detection of coronary disease. It is as effective as myocardial perfusion imaging for the stratification of risk in patients with coronary disease and can detect myocardial hibernation after myocardial infarction or in heart failure.

This paper is an executive summary of a recent postal survey carried out by the British Society of Echocardiography to guide future planning.

Individuals with diabetes have an increased risk of developing coronary artery disease and a poorer prognosis once coronary artery disease has developed, compared to patients without diabetes. To avoid confounding, most cardiovascular trials display profiles of traditional risk factors but additional factors are also important in patients with diabetes. We examined the information provided on patients with diabetes included in cardiovascular trials published in general medical journals.

The National Service Framework for Coronary Heart Disease recommends that psychological support should be offered to those patients who require it. A six-month study carried out at Darlington Memorial Hospital looked at psychological support needed by patients following myocardial infarction (MI). The psychological status of MI patients was formally assessed using the Hospital Anxiety and Depression (HAD) scale and appropriate referrals were made to psychological support services to improve patient management. The study also measured the impact that formal assessment of the psychological status of MI patients would have on service providers. Some 80 MI patients from the Darlington primary care trust (PCT) were eligible for inclusion in the study. Psychological assessment was undertaken at four stages during cardiac rehabilitation and 25 patients were eligible for referral for psychological support as a result of high HAD scores measured during the study period. Ten patients accepted referral, a higher number than during the previous six-month period when HAD scales had not been used. Eight patients were referred to occupational therapy services for help with anxiety issues, one patient was referred to the psychology service and one to liaison psychiatry. Both of these patients required help with depression. The study also found a high degree of patient satisfaction. The support received may also be required by many other groups of patients.

This case describes, for the first time, the appearance of possible cutaneous embolic lesions in the pinna of the ear secondary to infective endocarditis

Although the majority of implantable cardioverter defibrillator (ICD) implants occur without complication, high defibrillation threshold (DFT) can occasionally be a problem. The usual resolution to this problem is to include a subcutaneous electrode in the defibrillation circuit. Use of the subcutaneous array, however, is unpopular as extensive subcutaneous dissection is time-consuming, uncomfortable for the patient and provides another focus for infection. We report the use of the coronary sinus for the placement of a second defibrillation shock coil in a patient with an unacceptably high DFT, which was successfully reduced.

This paper briefly reviews an analysis carried out in the West of Scotland of the Quality and Outcomes Framework data gathered for coronary heart disease under the new General Medical Services contract for general practitioners. It shows encouraging progress in achieving clinical outcome predictors.

The report from McCarlie and colleagues in this issue (pages 117–19) on the success of Scottish general practice in achieving cardiovascular disease (CVD) targets for clinical indicators within the Quality and Outcomes Framework (QOF) mirrors similar progress across England and Wales.