2011, Volume 18 Issue 02, pages 49-96

He who knows syphilis knows medicine” said Father of Modern Medicine, Sir William Osler, at the turn of the 20th Century. So common was syphilis in days gone by, all physicians were attuned to its myriad clinical presentations. Indeed, the 19th century saw the development of an entire medical subspecialty – syphilology – devoted to the study of the great imitator, Treponema pallidum. But syphilis to many is a disease of old, consigned to the annals of history by infusions of mercury, arsenical magic bullets, and finally dealt a fatal blow by the advent of penicillin. The case report of a contemporary presentation of syphilitic aortitis by Aman et al. (see pages 94−6) presented in this issue is fascinating, but it seems most remarkable as a strange relic, a throwback to an era of medicine past. Or perhaps it is not. The UK has seen an explosion in venereal syphilis in the first decade of the 21st century. There were 3,762 diagnoses of early stage ‘infectious syphilis’ (comprising primary, secondary and early latent syphilis) made in 2007, more than in any other year since 1950. The trend has continued unabated with a similar figure seen in 2008 (2009 data are awaited). Between 1997 and 2007, annual diagnoses of infectious syphilis rose more than 1,200% (figure 1).(1)

As Chairman of HEART UK’s Familial Hypercholesterolaemia (FH) Guideline Implementation Team, I am well aware that little has been done in England to implement the recommendations of the National Institute for Health and Clinical Excellence (NICE) guideline for the identification and management of FH (CG71), published in August 2008. This is, of course, in stark contrast to developments in Wales, Scotland and Northern Ireland, where my colleagues have made significant progress in identifying and treating patients with FH. However, even I was surprised by the findings of a study, commissioned by HEART UK – The Cholesterol Charity, in which freedom of information (FOI) requests were sent to primary care trusts (PCTs) in England, requesting information about their progress to date.

The National Health Service (NHS) Health Check is a national screening programme to detect individuals in the 40–74-year-old age range who are at risk of developing cardiovascular disease (CVD). It was in January 2008 that, the then Prime Minister, Gordon Brown, announced the Government’s intention to shift the focus of the NHS towards empowering patients and preventing illness. As part of this, he set out to dramatically extend the availability of, what he called, ‘predict and prevent’ checks. Mr Brown’s vision was that these checks would give people information about their health, support lifestyle changes and, in some cases, offer earlier interventions. So, primary care trusts (PCTs) were required since late 2009 to commission services to deliver NHS Health Checks to 40–74 year olds, on a five-year, call–recall, cycle. The programme is specifically to detect risk and is not designed to cover those who are known to have an existing cardiovascular or related condition, such as diabetes or chronic kidney disease. Individuals participating in the checks will be given an assessment of the level of their own risk of developing CVD within the next 10 years and will be offered appropriate advice and interventions. For those with the least risk, this may be a simple discussion around healthy lifestyles. For moderate risk, the recommendations may include brief interventions around smoking, physical activity or referral to lifestyle support services. Those most at risk may require clinical interventions such as a statin prescription or referral to a specialist service. It is anticipated that the NHS Health Checks programme will be fully operational by April 2012.

Syphilis is a venereal disease that can also be acquired by exposure to infected blood and body fluids. The organism can cross the placenta and infect the unborn child. Untreated syphilis progresses through four stages: primary, secondary, latent, and tertiary stages. Syphilis is a great imitator; patients with syphilis can be a diagnostic challenge because of their wide-ranging clinical presentations. Although the incidence of syphilis has declined dramatically following the advent of penicillin therapy, it is still prevalent due to unsafe sex, multiple sexual partners and intravenous drug abuse. Primary and secondary syphilis can present with minor symptoms while tertiary syphilis can cause mortality in up to 20% of untreated patients due to neurological and cardiovascular complications.

This study aimed to describe adverse events associated with atrial fibrillation (AF), and the medications used to treat it, and to estimate the importance of these adverse events from the perspective of the condition-naïve general public. Fourteen adverse event health state descriptions associated with paroxysmal/persistent and permanent AF were produced based on EQ-5D survey data, a literature review, and qualitative input from patients and clinicians. Further interviews with clinicians and AF patients confirmed the content of the health states as descriptions appropriate to AF. In total, 127 members of the general public valued the health states in a time trade-off interview and ranking task. 

The study revealed how the public view the disutility of adverse health states associated with the treatment of AF. Each of the adverse events was associated with a perceived impairment from their respective base position. Interstitial lung disease showed the greatest perceived impact on quality of life (–0.17 paroxysmal/persistent base; –0.15 permanent base), whereas peripheral vasoconstriction had the least impact (–0.01 paroxysmal/persistent; –0.02 permanent). 

In conclusion, this study provides insight into the importance of treatment-related adverse events in AF. The quality of life estimates collected in this study may prove useful in populating cost-effectiveness analyses and informing clinical treatment decisions.

The role of clopidogrel after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) is well supported by strong clinical evidence, which has led to a dramatic increase in its use. 

The use of a combination of proton-pump inhibitors (PPIs) and clopidogrel has recently been questioned due to pharmacological interaction, with possible implications and effects on clinical outcome in patients using this combination. This has brought uncertainty and confusion into clinical practice. 

Enoxaparin is recommended for treatment of patients with acute coronary syndromes (ACS). While plasma monitoring of enoxaparin is not usually required, it may be assessed by measuring plasma anti-Xa levels (therapeutic range 0.5–1.2 IU/ml). Low anti-Xa activity is independently associated with increased 30-day mortality. Although the typical ACS enoxaparin dose is 1 mg/kg twice daily, in clinical practice some treatment protocols dose cap to reduce bleeding risk (for example, some local units cap at 60 mg twice daily). We studied 20 consecutive patients admitted with ACS. All received enoxaparin 60 mg twice daily. Peak plasma anti-Xa activity was measured four to six hours after the morning dose of enoxaparin after at least two subcutaneous doses. Mean Thrombolysis in Myocardial Infarction (TIMI) risk score 4.2/7 and mean weight 81.9 kg. One third of patients (five male, two female) were found to have subtherapeutic anti-Xa levels (mean 0.35 IU/ml, range 0.2–0.49 IU/ml). The remainder had anti-Xa levels within the therapeutic range (mean 0.73 IU/ml, range 0.5–1.12 IU/ml). Mean weight was higher in those with subtherapeutic compared with therapeutic anti-Xa levels (89.9 vs. 77.6 kg; p=0.041). In conclusion, dose capping of enoxaparin at 60 mg twice daily in ACS patients may result in a significant proportion achieving subtherapeutic anti-Xa levels, potentially correlating with poorer outcome.

Acarbose is an alpha-glucosidase inhibitor acting in the gastrointestinal tract producing modest reductions in postprandial hyperglycaemia, with negligible risk of hypoglycaemia and weight gain. In a subgroup of the United Kingdom Prospective Diabetes Study (UKPDS), acarbose showed glycaemic benefits irrespective of the type of concomitant therapy. Acarbose was shown to produce a significant reduction in the progression to diabetes in patients with impaired glucose tolerance in the Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM) trial, and in a post-hoc analysis of STOP-NIDDM a reduction in cardiovascular events was observed. Gastrointestinal side effects are the main limiting factor in clinical practice, leading to high rates of non-compliance and discontinuation.

As the proportion of patients above the age of 80 years in the UK is increasing it is likely that in the future cardiac centres will be treating an increasing number of octogenarians as part of their patient population. Despite this, there are little contemporary outcome data in this group of patients who often have complex coronary disease.

We aimed to assess, first, the change in demographics of patients undergoing percutaneous coronary intervention (PCI) over a 9-year period at a tertiary cardiac centre within the UK and, second, whether there has been a change in outcome for these patients in terms of major adverse cardiac and cerebrovascular events (MACCE). A retrospective review of registry data on patients who underwent PCI at our institute from 2000–2008 was undertaken. Patients were divided into three groups according to when they underwent PCI: Group A 2000–2002, Group B 2003–2005 and Group C 2006–2008. Demographic data were collected along with the nature of coronary disease treated and MACCE rates.

There were 3,108 patients in Group A, 4,744 patients in Group B and 3,860 patients in Group C. The use of rotablation increased from Group A (0.4%) to Group C (3.8%) (p<0.01), over-the-wire balloons from Group B (0.8%) to Group C (2.7%) (p<0.01), and microcatheters from Group B (0.1%) to Group C (1.25%) (p<0.01). This was accompanied by a decline in total MACCE rates from Group A (1%) to Group C (0.43%). The proportion of patients >80 years increased from Group A (5.8%) to Group C (12.2%) (p<0.01), and a similar decline in MACCE rates was also observed in this age group from Group A (4%) to group C (0.9%) (p<0.01). 

In conclusion, the proportion of elderly patients requiring PCI is increasing. In this group of patients, PCI appears safe and is associated with declining complication rates.