- FH: recognising the unrecognised
- Anticoagulant strategies in STEMI
- What now for glitazones?
- Another NICE chapter in interventional cardiology
EditorialsBack to top
March 2008 Br J Cardiol 2008;15:63-4
So now we know ... drug-eluting stents (DES) are not to vanish from our armoury at the whim of a National Institute for Health and Clinical Excellence (NICE) appraisal committee containing not a single specialist in interventional cardiology. When the provisional guidance report was published in the fourth quarter of last year, stating “Drug-eluting stents are not recommended for use in PCI in patients with coronary artery disease” as point 1, paragraph 1, it was really difficult to comprehend how the committee had come to this ridiculous conclusion. Most interventional cardiologists can understand that there is a need to audit the use of novel technologies in order to ensure the maintenance of patient safety and protect Department of Health (DoH) expenditure. Not only do we understand it, but we are committed to such a process. The preliminary judgement from this NICE group, however, was in my opinion, a significant low point in the process of appraisals. The fact that the final appraisal determination now states, “Drug-eluting stents are recommended for use in PCI for the treatment of coronary artery disease, within their instructions for use, only if: (a) the target artery to be treated has less than a 3 mm calibre or the lesion is longer than 15 mm, and (b) the price difference between DES and bare-metal stents is no more than £300”, is undoubtedly a relief if you are committed to patient care at the front line, although it raises questions about the appraisal mechanism. There appear to be two schools of thought in relation to this latter issue. First, that the original analysis demonstrates that the process undertaken was fundamentally flawed in its design: expert witnesses only contributed to the appraisal rather than being built in as a core component of it there was a dependence upon health economists whose previous analyses betrayed an important degree of anti-DES, pro-coronary artery bypass graft (CABG) bias. Such factors would allow the more cynical to predict a negative appraisal, even in the face of powerful randomised and observational data to support clinical benefit: data that was never disputed, and in fact clearly stated, in the preliminary document. Second, by contrast, is that it is a triumph for the design of the appraisal process that there was such a substantial turnaround in the conclusion reached after the public consultation exercise. I am sure that NICE will claim vindication for the process based upon this argument.
March 2008 Br J Cardiol 2008;15:65-6
In recent years, general practitioners (GPs) have been swamped by the burden of diabetes in the UK. The incidence has been growing almost as fast as our national waistlines, with the number of patients affected increasing from 800,000 to 1.8 million between 1980 and 2004, and the figure is predicted to increase to 3 million by 2010. In addition, the landmark UK prospective diabetes study (UKPDS) has resulted in a gradual ‘rebranding’ of diabetes from a metabolic to a cardiometabolic disease. About 75–80% of patients with type 2 diabetes die, not from short-term complications of hyperglycaemia, but as a consequence of cardiovascular disease, which is more influenced by blood pressure and cholesterol management than by glycaemic control.1-3 Finally, far from being able to divert our energies from glycaemic control to tight control of blood pressure and cholesterol, we find glycaemic targets dropping ever lower. Poor glycaemic control is a major risk factor for microvascular complications, including diabetic retinopathy, peripheral neuropathy and nephropathy. While patients do not die of diabetic retinopathy, as the single most common cause of adult blindness it certainly causes huge morbidity. The burden of diabetic nephropathy is also increasing rapidly, with up to 45% of new cases of endstage renal failure accounted for by complications of diabetes.4 It is against this background that the National Institute for Health and Clinical Excellence (NICE) recommends a target glycosylated haemogloblin (HbA1c) of 6.5–7.5%, with a 6.5% target preferred, if feasible.5
Clinical articlesBack to top
March 2008 Br J Cardiol 2008;15:79–81
Familial hypercholesterolaemia is a common genetic disorder that remains under-recognised. At present a simple genetic test is not available, although targeted genetic screening is being piloted in the UK. Recognition and treatment of this condition could help prevent many incidences of coronary heart disease. This article provides an overview of the pathophysiology, epidemiology, diagnosis and treatment of familial hypercholestrolaemia.
March 2008 Br J Cardiol 2008;15:83-85
Stefanos Archontakis, Alison Pottle, Mahmoud Barbir
Low-density lipoprotein (LDL)-apheresis is the treatment of choice in homozygous familial hypercholesterolaemia as well as various other severe dyslipidaemic conditions. However, it appears to be under utilised in the UK. This article reviews the recent advances in (LDL)-apheresis techniques, as well as the beneficial effects and clinical outcomes of this therapeutic modality.
March 2008 Br J Cardiol 2008;15:87-94
New anticoagulant strategies in ST-elevation myocardial infarction treated with fibrinolytic therapy
Ian B A Menown
Anticoagulant therapy plays a key role in pharmacological reperfusion therapy for acute ST segment elevation myocardial infarction (STEMI). Until recently, the established role of unfractionated heparin (UFH) was unquestioned, but large trials with new agents including factor Xa inhibitors, direct thrombin inhibitors, and in particular, low molecular weight heparins (LMWHs), have shown potential advantages compared with UFH. This paper reviews the evidence base for the newer anticoagulants, with a focus on LMWH including the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment – Thrombolysis in Myocardial Infarction (ExTRACT TIMI)-25 study, which found that enoxaparin when appropriately adjusted for weight, age and renal function, provided superior net clinical benefit (balancing efficacy and safety) compared with UFH. In addition, new data from higher risk subgroups (the elderly, those with renal dysfunction or undergoing early coronary intervention) and the efficacy and safety of using concurrent clopidogrel are discussed to illustrate how these data may be integrated into contemporary practice.
March 2008 Br J Cardiol 2008;15:95-100
George Kassianos, John Reckless, Cathy Emmas, Marc Evans, Andrea Tree, Andrew Vance
Data from 101 practices that had completed a survey of cholesterol target achievement using rosuvastatin in routine general practice were pooled to assess effectiveness at a national level. A total of 10,396 patients, who had total cholesterol (TC) measured prior to, and on, rosuvastatin 10 mg daily, were included in the analysis. Of these, 6,375 patients had not received a statin prior to rosuvastatin. The remainder had been switched from another statin. Significant reductions were observed in TC (28%) and low-density lipoprotein cholesterol (40%) when comparing prior to and on rosuvastatin 10 mg (p<0.001). A significantly greater proportion of patients achieved the General Medical Services (GMS) Quality and Outcomes Framework (QOF) target of TC ≤5 mmol/L with rosuvastatin 10 mg compared with prior to rosuvastatin (81% vs. 19%; p<0.0001). Of the 580 patients who had failed to reach target on atorvastatin 10 mg daily, 70% reached target on rosuvastatin 10 mg. Similarly, 68% of 246 patients who had failed to reach target on simvastatin 40 mg daily reached target on rosuvastatin 10 mg. General practitioners across the UK also substantially achieved other national and international cholesterol targets in patients treated with rosuvastatin 10 mg, including second line to simvastatin 40 mg and where higher doses of other statins had failed to reach target.
March 2008 Br J Cardiol 2008;15:101-5
Martin Duerden, Maggie Tabberer
The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) showed that addition of eplerenone to optimal medical therapy reduced morbidity and mortality in patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure. This international study also showed that the addition of eplerenone reduced the number and duration of rehospitalisations for heart failure. A budget impact model has been developed to estimate the effect of adding eplerenone to standard care in the UK. The model is based on the results of the EPHESUS study, UK epidemiological data, UK drug acquisition costs and National Health Service (NHS) hospital in-patient costs and average length of stay for England. All costs are expressed in pounds sterling. It estimates the incremental costs and benefits of adding eplerenone to standard care in heart failure resulting from myocardial infarction, from the perspective of NHS healthcare decision makers over a three-year period. The model shows that if all eligible patients are treated with eplerenone the estimated cost per life year saved is £6,730 in year three. In a primary care trust with a population of 250,000, this level of treatment results in a reduction of 46 bed days for rehospitalisations due to heart failure, at a cost per bed day avoided of £1,469. With hospital in-patient care the biggest single healthcare cost in heart failure, reduction in hospitalisation is a key priority within the NHS in the UK. Models such as the one described here enable the budgetary consequences of using a new drug to be identified and clarify the role of drug treatment in delivering NHS priorities.
March 2008 Br J Cardiol 2008;15:106-9
Effect of ivabradine, a novel anti-anginal agent, on heart rate and symptom control: a first experience in a clinical ‘real-world’ setting
Tanuj S Lad, Glenda Osuoha, Shamara Fonseka, Julia S Hadley, Sandeep Gupta
Achieving a lower heart rate is important in treating angina. Established approaches include the use of beta blockers and certain calcium channel blockers. However, the use of these drugs may be limited by side effects or contraindications. Ivabradine (Procoralan®) is a novel agent that lowers heart rate through selective I(f) channel inhibition, acting specifically on the sinus node. We present a consecutive series of 30 patients initiated on ivabradine, within a district general hospital (DGH) setting. The aim of this study was to identify the heart rate-lowering and symptom-control properties of ivabradine, while monitoring adverse effects. Heart rate was measured on a baseline electrocardiogram (ECG) prior to starting ivabradine, and then within a 12-month follow-up period. The results identified a mean (standard deviation) 10 (14) beats per minute (bpm) decrease achieved on ivabradine (p<0.001), with greatest reduction in heart rate in those with a resting heart rate over 80 bpm prior to starting treatment (p<0.05), and in patients on a 5 mg twice-daily dosing regimen at follow-up (p<0.05). In parallel, the majority of patients reported favourable symptom benefit (21/30), and low rate of adverse events with discontinuation rate of only 2/30 felt directly related to the drug itself. We believe this to be the first report of using this novel drug in a ‘real-world’ DGH setting. The findings add confidence in using this anti-anginal agent in appropriate patients, and furthermore support conducting studies involving multiple centres, to further define and assess ivabradine in the clinical setting of angina.
March 2008 Br J Cardiol 2008;15:110
Peadar F McKeown, Ian B A Menown, Paul F Rice
A 63-year-old gentleman presented with palpitations and a sensation of chest fullness. He had previously undergone laparoscopic oesophageal fundoplication.
March 2008 Br J Cardiol 2008;15:111–2
Tushar Raina, Ever D Grech, David Cumberland
Dextrocardia is a rare anomaly with an estimated prevalence of about one in 10,000. The incidence of coronary artery disease is the same as in the general population. We report two cases of successful percutaneous treatment of coronary stenoses and aim to highlight some of the additional technical challenges that such patients present to the Interventional Cardiologist.
News and viewsBack to top
March 2008 Br J Cardiol 2008;15:71
March 2008 Br J Cardiol 2008;15:73-4
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March 2008 Br J Cardiol 2008;15:76–7
March 2008 Br J Cardiol 2008;15:68-9
March 2008 Br J Cardiol 2008;15:68-9
March 2008 Br J Cardiol 2008;15:68-9
March 2008 Br J Cardiol 2008;15:68-9