2008, Volume 15, Issue 06, pages 274-328

For over 50 years cardiologists have routinely recommended antibiotic prophylaxis (ABP) at the time of dental procedures in patients deemed to be at risk of infective endocarditis (IE). Reviews and editorials all acknowledged the lack of robust evidence for effectiveness of ABP and from time to time the literature has been reviewed and expert opinion synthesised into guidelines. In the UK, the 2004 Joint Royal College of Physicians/British Cardiac Society guideline has been widely followed.1 In 2006 new guidelines were published by the British Society for Antimicrobial Chemotherapy (BSAC).2 These guidelines were important because this committee’s recommendations are incorporated into the British National Formulary. The BSAC guidelines recommended withdrawal of ABP for the majority of patients limiting them to individuals perceived to be at the highest risk of IE (e.g. a prior history of IE, prosthetic cardiac valves and surgically constructed pulmonary or system shunts/conduits). These guidelines were welcomed by the majority of dentists and microbiologists as a step in the right direction. However, many cardiologists, who had seen first-hand the horrors of IE, did not wish to see the rejection of a therapy that was thought by most to be effective and harmless. The lack of agreement between the medical and dental professions resulted in the issue being referred to the National Institute for Health and Clinical Excellence (NICE) for an authoritative statement.3

The field of clinical medicine is littered with the bodies of sacred cows. Recent examples include the demise of vagotomy and pyloroplasty as a standard treatment for peptic ulcers and the absolute contraindication of beta blockers in the treatment of heart failure. I would like to suggest that the next sacred cow to be dispensed with is the routine use of electrical cardioversion in the treatment of atrial fibrillation, despite its inclusion as a therapeutic option in the National Institute for Health and Clinical Excellence (NICE) atrial fibrillation guidelines.1 Direct electrical cardioversion has been a mainstay of therapy for the treatment of atrial fibrillation for many years. The theory underpinning its utilisation has some face validity, that by restoring sinus rhythm any problems associated with atrial fibrillation will be ameliorated. This, however, does not take into account the underlying cause of the arrhythmia, with the majority of atrial fibrillation caused by ischaemic heart disease. It is only relatively recently, however, that evidence for the ineffectiveness of cardioversion has begun to emerge. Paradoxically this evidence has derived from trials designed to prove the effectiveness of the procedure.

The announcement that Akira Endo has won the 2008 Lasker-DeBakey Clinical Medical Research Award is a fitting tribute to the man who discovered the first statin. The remarkable ability of these compounds to lower cholesterol has revolutionised medical practice, boosted the profits of the pharmaceutical industry and improved the health of millions. The story of this discovery illustrates how Endo’s single-minded pursuit of an idea changed the course of history, an achievement that has now been recognised by his peers in the scientific community.

Postgraduate medical training has undergone extensive reform in recent times. This article outlines the current state of affairs and possible future developments in cardiology specialist training.

Atrial fibrillation (AF) is a relatively common condition. The national prevalence for England on the latest quality and outcomes framework data is 1.3% and as many as 10% of patients aged over 75 may be in AF. On average, all of us have a 20–25% lifetime risk of developing AF. An average GP will have 16–20 cases on their personal list and can expect to diagnose three new cases per annum. However, it is recognised that many cases of AF go undiagnosed and opportunistic screening for AF has been recommended. Of note, AF is responsible for 45% of embolic strokes. With the increasing emphasis on AF from Chapter 8 of the National Service Framework for Coronary Heart Disease (NSF-CHD), the National Stroke Strategy1 and inclusion of AF in the Quality and Outcomes Framework – as well as publication of the National Institute for Health and Clinical Excellence (NICE) guidelines for AF management – it is important for GPs to diagnose, treat and refer AF patients correctly. There are three main areas to consider in AF patients: first, the diagnosis and treatment of any underlying co-morbid condition; second, symptom control by either a rate- or rhythm-control strategy; and third, the reduction of the accompanying risk of stroke and thromboembolism by appropriate prescription of antithrombotic therapy. Many straightforward cases of AF can be satisfactorily managed entirely in primary care, using the following structured approach.

National guidance recommends specific durations for clopidogrel and aspirin dual therapy post ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and following percutaneous coronary intervention (PCI). Primary care clinicians highlighted that patients were frequently discharged from acute trusts without any communication as to the indication for or intended duration of clopidogrel therapy. An initial audit across four of the six acute trusts demonstrated significant variation in the use of clopidogrel and aspirin dual therapy across the sector, with 26% of discharge prescriptions giving no clear indication for therapy and 30% of discharge prescriptions giving no indication of the intended duration of therapy. The South East London Cardiac and Stroke Network (SELCSN) cardiac prescribing forum, with input from consultant cardiologists, GPs, pharmacists and others, developed and implemented a consensus guideline for the prescribing of clopidogrel across the sector. In addition, it was agreed that acute trust pharmacy departments would not dispense clopidogrel for discharge unless the duration was clearly documented on the discharge prescription. Re-audit demonstrated an increase in the proportion of discharge prescriptions with an indication for and duration of clopidogrel therapy: 92.5% and 85%, respectively. Failure to implement the SELCSN guidance in one trust had a significant impact on the overall results; however, four of the six trusts managed to achieve over 95% compliance in terms of communicating a clear indication for and duration of clopidogrel therapy. In addition, the number of different regimens in use was lower during the re-audit period indicating a move to more consistent prescribing of clopidogrel across the sector, although there remains significant variation between trusts. Next steps for the SELCSN are to address clopidogrel prescribing in the trust with poor outcomes in the audit to ensure full implementation of the local guidance, development of a tool to audit prescribing of clopidogrel in primary care to assess appropriate cessation of dual therapy and re-audit of acute trust discharge communication to ensure the good practice which has been implemented is maintained in the long term.

In June 2004 the Department of Health made a commitment to reduce waiting times from GP referral to hospital treatment to less than 18 weeks by 2008. Patients with chest pain are often now seen within two weeks thanks to the success of rapid-access chest pain clinics. Around 10–25% of these patients are referred for diagnostic coronary angiography (CAG) and of these, about 30% require percutaneous coronary intervention (PCI) to treat coronary stenoses. Conventionally, UK practice has been that such patients occupy two waiting lists: one for the CAG, which is often performed by a non-interventional cardiologist, and one for the PCI. This pathway makes achieving the 18-week target challenging. We introduced a new care pathway whereby all elective chest pain patients referred for CAG to one of the interventional cardiologists were listed for a standby coronary angiogram (SBCA), during which if PCI was indicated then it was performed immediately. We present the results of an audit of 102 consecutive patients since this pathway was introduced that demonstrates one method of achieving the 18-week target for this group of patients. This can now be further refined by aiming to achieve a higher proportion of day-case PCI cases.

Chronic kidney disease (CKD) is thought to affect approximately one in 10 people. Patients with CKD have significantly increased cardiovascular morbidity and mortality in comparison with the general population. This is thought to occur from a combination of increased atherosclerotic disease and medial calcification of arterial walls. Vascular calcification (VC) is recognised as an active, cell-mediated process with similarities to osteogenesis. Numerous systemic and local factors have been identified as inhibitors of calcification including fetuin-A, matrix Gla protein and pyrophosphate. There is also increasing evidence that increased serum phosphorus, serum calcium x phosphorus product, and/or calcium load is associated with increased VC. Current treatment strategies focus on the correction of markers of mineral metabolism bone disease such as phosphate, calcium, parathyroid hormone and vitamin D. The use of agents such as bisphosphonates and cinacalcet show promise, but further data are awaited before their widespread use as a treatment for VC can be advocated. Imaging techniques currently used to assess VC are also discussed. Research into the mechanisms underlying VC are still being investigated and further insight into these mechanisms will lead to the development of therapeutic agents, which could improve cardiovascular outcomes in patients.

Heart failure (HF) is an important cause of morbidity and mortality in the general hospital setting worldwide. The paucity of data on psychiatric co-morbidity in Nigeria necessitated this study. This study was carried out among adults in stable state of HF at the cardiology clinic of Lagos University Teaching Hospital (LUTH) with sex- and age-matched controls. Fifty-eight subjects were studied, made up of 27 (46.6%) males and 31 (53.4%) females. The mean age was 51.2±13.8 years. There were 44 age- and sex-matched controls with mean age of 50.1±13.6 years. Thirty-four of the subjects (58.6%) had General Health Questionnaire (GHQ) scores of ≥2 (cut-off score); out of which 14 (24.4%) were confirmed to have psychiatric disorders. One subject with GHQ score <2 also had a psychiatric diagnosis giving a sensitivity of 0.93 and specificity of 0.54 for GHQ-12 in this study. Thus, a total of 15 (25.9%) had psychiatric diagnoses which included: depression 7 (12.0%); generalised anxiety 6 (10.3%); paranoid schizophrenia 1 (1.7%), and somatisation disorder 1 (1.7%). It is concluded that clinically significant psychiatric co-morbidities exist among subjects with HF. The need for ‘liaison’ psychiatric services in the cardiology clinic is emphasised.

The use of drug-eluting stents (DES) has increased exponentially in recent years. There appears to be little difference in short- to medium-term safety compared with bare-metal stenting (BMS). Coronary thrombosis after stent implantation is well recognised, resulting in acute myocardial infarction and not uncommonly in death. Late (>6 months) stent thrombosis is rare with BMS, but there is a concern that DES might be susceptible to thrombosis due to delayed endothelialisation. The prolonged use of dual antiplatelet therapy (APT) with aspirin plus a thienopyridine (e.g. clopidogrel) is recommended. The premature discontinuation of APT in patients with DES without consultation with the treating cardiologist can result in stent thrombosis and adverse outcome.