2007, Volume 14, Issue 03, pages 121-180

The Scottish Intercollegiate Guidelines Network (SIGN) recently published a comprehensive guideline of the management of cardiovascular disease (CVD). Here, Dr Kevin Jennings and Professor Lewis Ritchie, co-chairs of the SIGN coronary heart disease (CHD) guidelines steering group, look at the implications of the recent guidance for secondary care. The full five guidelines covering acute coronary syndromes, cardiac arrhythmias in CHD, chronic heart failure, stable angina, and risk estimation and the prevention of CVD, are available at www.sign.ac.uk. In the last issue of the journal, the implications for primary care were considered.

Coronary heart disease (CHD) is the leading cause of death in the UK (accounting for 105,000 deaths in 2004) and exerts a huge burden, both on our healthcare system (around £3,500 million in 2003) and on our economy (£7.9 billion per year). Following an acute myocardial infarction (AMI), the 30-day mortality remains significant at around 10%, despite successful reperfusion therapy, instituted by either thrombolysis or primary percutaneous coronary intervention (PCI), paving the way for novel cardioprotective strategies to be developed.

The demand for non-invasive diagnostic imaging in cardiology increases with the advancing age of the population. Whilst exercise testing and myocardial perfusion scintigraphy have provided non-invasive functional assessment of coronary artery disease there has been little alternative to invasive coronary angiography for anatomical assessment of the coronary tree. In recent years technological advances have enabled improvements in both temporal and spatial resolution such that multi-detector computed tomography (MDCT) is now able to reproducibly evaluate cardiac disease. The combination of this improved resolution with more advanced post-processing techniques now means that MDCT has the ability to perform both anatomical and functional assessment from a single study. This technique, therefore, not only provides a non-invasive alternative to conventional angiography but the same dataset allows concurrent assessment of cardiac function, assessment of aberrant vessels, graft patency studies and assessment of the coronary artery wall. Cardiac CT has the potential to provide a much more complete assessment than conventional coronary angiography. It is likely to become the non-invasive imaging modality of choice to exclude significant coronary artery disease in those with intermediate risk of coronary artery disease. This first part of a two-part article considers ECG-gated image reconstruction, image resolution, radiation dose, and post-processing protocols and limitations. The second part considers clinical applications and future developments.

Atherothrombosis is a leading cause of death worldwide. The REduction of Atherothrombosis for Continued Health (REACH) Registry aims to evaluate the long-term risk of atherothrombotic events in a global at-risk population, to assess the importance of cross-risk and to define predictors of atherothrombotic events. Over 69,000 people in 44 countries were recruited, of which 618 were in the UK. The majority (91%) of patients recruited in the UK had symptomatic disease (coronary artery disease, cerebrovascular disease or peripheral arterial disease) of which 14% had disease in more than one vascular bed. Classic cardiovascular risk factors were seen to be active and their management was found to be inadequate, albeit better in those with symptomatic disease than in those with risk factors only. UK data were in general typical of those found in the whole of the Western European sample.

The European Working Time Directive (EWTD) ensures doctors do not work excessive hours. On 1st August 2004, junior doctors were no longer excluded from the EWTD and their working hours were limited by law to 58 hours per week. By 2009, this will be reduced to 48 hours. Although benefits include improved patient care,1 the EWTD has implications for service provision and specialist registrar (SpR) training.

Complications of arterial access are an important cause of morbidity following percutaneous coronary intervention. Recently published data suggest a rate of around 3.5% of major vascular complications. We present an audit of vascular access site complications in a single centre over a 12-month period. Overall complication rates were low (1.2%) in a centre whose default strategy following femoral artery access is arterial closure using the Perclose™ device. Specific problems using the Starclose™ device in patients treated with abciximab are described. Infected femoral artery haematoma resulted in the most severe complications.

This short report describes a questionnaire study undertaken in two London teaching hospitals, addressing the true pharmacokinetic implications of aspirin use. It suggests that the real costs of aspirin treatment should include the cost of the therapies used for treatment of associated dyspepsia.

Viral myocarditis is a well-recognised complication of many viruses leading to subsequent cardiomyopathies (dilated type). There are limited data available with respect to dengue virus involvement, an infection which can be asymptomatic and can lead to undifferentiated viral fever syndrome, dengue fever, dengue haemorrhagic syndrome or dengue shock syndrome. Dengue has probably been endemic in Sri Lanka for a long time although no cases of dengue haemorrhagic fever was reported until 1965. Now, several hundred cases a year have been reported annually from 1991. The only two published articles from Sri Lanka on myocardial involvement described cardiac sequelae, diagnosed quite late, retrospectively, in the non-active phase of the illness. Recent epidemics of the disease in Sri Lanka led us to design a study to look at myocardial involvement in clinically and serologically confirmed cases of dengue infection.

Clinical practice should follow evidence-based medicine, which is derived from clinical trials. The outcomes of clinical practice, however, may not equal that of trials if there are differences in the patients or the quality of treatment they receive. We report the example of cardiac rehabilitation to illustrate this point, comparing the characteristics of patients and treatments offered in randomised controlled trials (RCTs) in this area with those included in two large surveys of cardiac rehabilitation in the UK. We found that cardiac rehabilitation as currently practised in the UK is unlikely to be as effective as clinical trials may suggest.