2009, Volume 16, Issue 03, pages 105-152

The British Society of Rheumatology have published guidelines on the management of rheumatoid arthritis, which call for an increased awareness of rheumatoid arthritis as an independent risk factor for ischaemic heart disease.(1) This increased cardiovascular risk is related to the severity and duration of inflammation, and the magnitude of additional cardiovascular risk in severe rheumatoid arthritis has been compared with that seen in diabetes mellitus.(1) Life expectancy is reduced due to an excess of cardiovascular death, with increased standardised mortality ratios ranging from 1.28 to 3.00 in rheumatoid patients compared with the general population.(2) Women with rheumatoid arthritis are twice as likely to suffer from a myocardial infarction as those without.(2) There is also an increased risk of congestive cardiac failure,2 asymptomatic coronary heart disease and sudden cardiac death.(3)

“My interest is in the future because I am going to spend the rest of my life there.” – C F Kettering Cardiovascular diseases are a massive public health problem in both the developed and developing world. UK statistics show, according to death certification, half a million people die annually, about 180,000 due to circulatory disease, 130,000 from neoplastic disease and 70,000 due to respiratory disease. With advancing age, the likelihood of dying from circulatory disease increases. So let’s face it, most of us are going to die from clogged blood vessels, most commonly some manifestation of coronary disease. Add in the millions who will live with symptoms of coronary disease and the numbers stack up even higher. In 1948, the US public health service financed an epidemiological study on a previously unprecedented scale to investigate why millions of Americans were dying prematurely from heart disease. The result was the Framingham study, from which we have a pretty good idea of what increases our chances of developing coronary disease – smoking, cholesterol, blood pressure and diabetes – well recognised now but unknown until 40 years ago. In fact, Framingham introduced cardiovascular risk and cardiovascular risk factors into the medical vocabulary in a landmark paper in 1961. A risk scoring system soon followed. Despite listing several important caveats, the Framingham risk score was widely adopted around the world, largely because of its novelty, simplicity and practicality. Some four decades later, there is mounting criticism of the Framingham risk score. First, because it does not predict cardiovascular risk ‘accurately’ enough – when applied to different populations, the score tends to overestimate risk in low-risk populations and underestimate risk in high-risk populations. Second, because it does not take into account other factors such as family history or socio-economic status. New risk scoring systems have been proposed, each claiming to predict, with greater accuracy than Framingham, the risk of a future cardiovascular event, at least in the population in which each was developed. Will ‘better’ scoring systems help us manage our patients better? “A good forecaster is not smarter than everyone else – he merely has his ignorance better organised.”

The management of acute coronary syndromes (ACS) has changed greatly over recent years. Trial evidence encouraged clinicians to consider early invasive management in high-risk patients and this has created a large clinical burden. We instituted a comprehensive system of nurse-led diagnosis and management of ACS. In-patients are seen by a cardiac outreach nursing team and depending on their risk profile may be managed in a designated acute cardiac unit (ACU) by cardiologists. We also piloted an ‘ACS clinic’ where patients with higher risk are seen within two weeks of discharge. We conducted audits to assess the impact of these new services. A total of 158 consecutive patients from ACU with unstable angina or non-ST elevation myocardial infarction (NSTEMI) were identified. The in-patient coronary angiography rate was 48%, percutaneous coronary intervention (PCI) rate 15% and coronary artery bypass graft (CABG) rate 4%. The six-month re-admission rate was 28.5%, of whom 44.4% were within one month of discharge. In-patient coronary angiography almost halved the rate of re-admission (20.0% vs. 36.6%; p=0.026). We also audited the first 12 months of the ACS clinic. The six-month re-admission rate was 14.2%, a significant reduction compared with the first audit (p=0.0002). In conclusion, the strategy of nurse-led identification and follow-up of ACS patients promotes effective use of resources and reduces re-admissions.

The transradial approach is increasingly used in a wide range of percutaneous coronary interventions (PCIs) with few reported complications. It is established as a safe procedure with improved patient comfort and early mobilisation.1-3 This has translated into early discharge with reduced procedural cost leading to out-patient day-case PCI.4,5 However, with this increasing use, unusual and new complications will be recognised.

Research has shown that, following angiogram with femoral puncture, prolonged bed rest increases patient discomfort during recovery. This audit aimed to measure the effects of reducing the period of immobilisation from the local standard of four hours to only two hours. Almost 500 consecutive patients were selected for early ambulation at two hours post-angiogram. Overall, 86.8% of patients suffered no vascular complications. In addition to the beneficial effects on patient comfort, earlier ambulation will enable cardiology units to treat more patients, thereby maximising efficiency and income generation.

Vascular surgery is associated with a substantial risk of cardiovascular events and death. Cardiac troponin I (cTnI) is a contractile protein that is a highly sensitive and specific marker of myocardial necrosis. This case series examines the clinical course of 10 patients who had an asymptomatic pre-operative elevation in cTnI and underwent a vascular surgical procedure. A prospective, two-year, observational, single-centre cohort study of all patients undergoing a vascular procedure with an expected cardiac event rate of >5% was performed. Pre-operative cTnI was carried out (cTnI >0.02 ng/ml positive). Post-operative screening for cardiac events at post-operative days two and five was performed. Two-hundred and thirteen patients were recruited, of whom 11 (5.2%) had an asymptomatic elevated pre-operative cTnI. Ten patients in whom the pre-operative cTnI was not known prior to surgery, or in whom a procedure could not be delayed proceeded with the operation. One patient had surgery deferred. Four patients suffered a post-operative cardiac event and five died. The outcome in this case series was poor with death in 50% of those taken to theatre and cardiac events in 40%. An elevated pre-operative cTnI in an otherwise asymptomatic patient identifies a very high-risk group of patients.

Clinical guidelines are vital to improving patient outcomes by helping reduce practice variation, raising care standards, improving efficiency and maximising resource utilisation. To investigate the implementation/local adaptation of national guidance and approaches to post-myocardial infarction (MI) care across the UK, an assessment of the availability and implementation of local post-MI guidelines in England among primary care trusts (PCTs) and cardiac networks (CNs) was conducted. Secondly, a survey of UK GPs and nurses (n=1,003) was performed to establish awareness of guidelines and to investigate whether there are regional variations in the management of post-MI patients. Fifteen post-MI clinical guidelines were obtained (PCTs – 8; CNs – 7) and analysed according to the following topics: lifestyle modifications, cardiac rehabilitation, therapeutic intervention, therapeutic targets and communication between primary and secondary care. Considerable regional variation in the recommendations were found – particularly with regard to therapeutic interventions and targets – with differing targets for blood pressure and cholesterol management. This was mirrored in the survey results, which also showed significant inconsistencies in clinical practice as reported by UK healthcare practitioners. In conclusion, little consistency in the availability and content of local post-MI clinical guidelines, coupled with disparities in national guidelines, suggest the need for national post-MI guidance, built on existing evidence, endorsed by clinicians and patients, which will promote optimal care and reduce practice variation.

A patient with inappropriate tachycardia is described who failed to respond to beta blockers or calcium channel blockade but had clinical improvement with ivabradine. The heart rate slowing with this drug was illustrated by the change in the R–R interval histogram.