2010, Volume 17, Issue 04, pages 153-200

As from May 2009 the National Institute for Health and Clinical Excellence (NICE) have removed transmyocardial laser revascularisation (TMLR) from the list of treatments for refractory angina.¹ From their analysis of efficacy they found no evidence of improved myocardial perfusion, ejection fraction or prognosis. There was also no evidence for improvement in exercise tolerance or Canadian Cardiovascular Society (CCS) class when compared with other treatments. Furthermore, looking at the data on safety, randomised controlled trials showed evidence of increased myocardial infarction in the TMLR-treated patient group, as well as evidence of left ventricular perforation. 

There have been reservations regarding this technique for many years and it would seem to be a valid decision on behalf of the specialist advisers. It seems appropriate, therefore, to look at how to best treat this complex group of patients. 

The prevalence of atrial fibrillation (AF) in the UK alone is estimated to be 1% of the population (approximately 610,000) and rises with age from 1.5% in people in their 60s to more than 10% in those over 90 years old. It is also more common in males than females. Because prevalence increases with age, it is expected to increase over time as the proportion of people aged 65 and over is projected to increase from 16% of the UK population in 2006 to 22% by 2030.¹ AF is the most common supraventricular arrhythmia; it is predicted that catheter ablation (CA) as a management strategy will be one of the most commonly performed electrophysiological procedures in the next decade.

Over recent years data have accumulated suggesting that sinus rhythm (SR) is associated with increased survival.² Whether this association of SR with improved survival is actually a causal relationship is yet to be proven. CA has proven to be an effective curative treatment particularly when used for paroxysmal AF.³ 

Depression and anxiety are commonly experienced by cardiac patients and are associated with reduced quality of life and mortality, but the evidence for the effectiveness of medical and psychological treatments for depression has been mixed.

Coronary heart disease is a leading cause of mortality and morbidity worldwide. Risk factor modification through a robust cardiac rehabilitation programme is rewarding and accounts for the major decline in mortality due to coronary heart disease in the long term,1 thus, making it an essential part of the curriculum. With this in mind, we conducted an observational study based on the feedback of 114 medical students over a four-year period about exercise tutorial in cardiac rehabilitation. Data were collected on a 10-point scale questionnaire. An overwhelming majority of students (more than 90%) were deeply impressed by this novel approach of being taught about cardiac rehabilitation. They strongly recommended this unique approach, as not only an effective tutorial on cardiac rehabilitation, but also advocated it enthusiastically as a general teaching method.

Low-dose aspirin is of value in the long-term management of vascular disease, and the giving of aspirin to patients believed to be experiencing an acute myocardial infarction (AMI) is standard practice for paramedics and doctors in most countries. Given during infarction, aspirin may disaggregate platelet microthrombi and may reduce the size of a developing thrombus. Effects of aspirin other than on platelets have also been suggested and these include an increase in the permeability of a fibrin clot and an enhancement of clot lysis. Animal experiments have also shown a direct effect of aspirin upon the myocardium with a reduction in the incidence of ventricular fibrillation. Randomised trials have shown that the earlier aspirin is taken by patients with myocardial infarction, the greater the reduction in deaths. We suggest, therefore, that patients known to be at risk of an AMI, including older people, should be advised to carry a few tablets of soluble aspirin at all times, and chew and swallow a tablet immediately, if they experience severe chest pain. 

Intra-coronary imaging has become a cornerstone of visualising atherosclerotic coronary artery disease and also to guide the therapy in selected high-risk cases. Optical coherence tomography (OCT) is an imaging modality quite similar to intravascular ultrasound (IVUS), but uses light instead of sound. In the second article on contemporary coronary imaging, the potential of OCT is discussed.

Infective endocarditis (IE) causes high rates of morbidity and mortality. Clinical management is problematic if there are uncertainties over the identity, viability or antibiotic susceptibility of the causative organism. Between 10% and 30% of IE blood cultures are negative, usually a result of prior antimicrobial therapy, but also occurring when causative micro-organisms are non-cultivable or fastidious. While evidence-based guidelines exist for treatment of IE caused by defined agents, clinicians are often faced with the dilemma of IE of unproven aetiology. Duration of empirical therapy is usually titrated against overall clinical response and non-specific laboratory markers of inflammation, but these may bear little relation to ongoing microbial activity in the heart valve. There is an increasing need for more specific, sensitive and rapid tests for the identification of causative organisms. Nucleic acid amplification technologies (NAATs) show promise for rapid detection of pathogen nucleic acid in blood or tissue. This review discusses the developments in this field, and the potential for the application of NAATs to improve aetiological identification in IE.