Clinical articles

Insulin remains an important treatment for patients with type 1 and type 2 diabetes. Insulin is given to patients with type 1 diabetes as a form of hormone replacement therapy to replace the loss of endogenous insulin secretion. Intensive insulin treatment with either continuous subcutaneous insulin infusion or basal–bolus therapy reduces diabetic complications, including macrovascular complications. For patients with type 2 diabetes, insulin therapy is given to try and overcome the combination of insulin resistance and beta-cell dysfunction that are the pathological hallmarks of the disease. There are concerns that weight gain and hypoglycaemia, which are common side-effects of intensive insulin therapy, may reduce or negate direct benefits of controlling hyperglycaemia on macrovascular outcomes. The best insulin regimen for patients with type 2 diabetes is not clear, and treatment should aim to minimise weight gain and the occurrence of hypoglycaemia.

Sonographer- and nurse-led clinics were developed at a cardiothoracic centre and a sonographer-led clinic at a district general hospital (DGH). Common database fields were adopted in 2007 and this is an audit over the subsequent two years. Data were analysed for the two-year period from 1 September 2007 to 31 August 2009. A total of 683 visits by 388 patients occurred at the cardiothoracic centre and 1,306 visits by 726 patients at the DGH. There were no unexpected adverse events. Cross-referral to a cardiologist occurred in 13% of visits at the cardiac centre and 11.5% at the DGH. The mortality rates were 2% and 3%, the discharge rates 6% and 2%, and the surgical rates 16% and 4% at the cardiac centre and the DGH, respectively. No unexpected events occurred.

Our observations suggest that devolved surveillance clinics are feasible, safe and generalisable as part of a specialist valve service.

Alcohol septal ablation (ASA) is an alternative therapeutic method to the gold-standard surgical myectomy in the treatment of symptomatic left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic cardiomyopathy (HCM). ASA is performed by injecting alcohol into the target septal branch of the left anterior descending coronary artery. In this article, we review the rationale and indications for ASA, provide a practical description of the technique and give an overview of the published data placing it in context with the surgical approach. We also report our experience of the technique in a typical sample of patients referred to a tertiary centre providing demographic, echocardiographic and clinical outcomes data during an average follow-up period of three years. Our data confirm that ASA is an effective non-surgical technique for treatment of symptoms related to LVOT obstruction in HCM. Medium-term follow-up demonstrates persistent reduction in LVOT obstruction and improvement in New York Heart Association (NYHA) functional class. Long-term studies of larger populations are necessary to determine the wider prognostic significance of the procedure.

In order to determine the taking of regular aspirin within a representative community sample of adults residing in the south Wales county of Caerphilly, we conducted a survey of a sample 9,551 adults resident in the county aged ≥18 years.

Questionnaires were returned by 4,558 individuals aged between 25 and 82 years. Nearly 12% of the respondents reported a previous vascular event. Of these, 68% of the men and 55% of the women stated that they took aspirin regularly. Among those with no previous vascular event, 22% of the men and 13% of the women stated that they took aspirin regularly. For those over 50 years of age, the respective figures were 28% of men and 19% of women. Of those taking aspirin, 47% stated that they took 300 mg tablets. There was a small inverse relationship found between aspirin taking and social class, namely 67% and 56% in the manual and non-manual classes respectively. 

The prevalence of prophylactic aspirin taking by persons who have had a vascular event should be increased, particularly in women. Knowledge of the benefits and the risks of aspirin prophylaxis could be promoted through the community and there should be ongoing monitoring of aspirin taking. 

Platelet activation is an important part of the pathophysiology of acute coronary syndromes. Inhibition of this by antiplatelet agents forms an important part of the management of this condition. Recently, there has been considerable interest in the variability of platelet response to these drugs and the need to tailor the dose of antiplatelet agents according to the response. 

Here, we present a patient who had repeated episodes of stent thrombosis and was found to have decreased response to clopidogrel and aspirin (clopidogrel and aspirin resistance) with the use of the Accumetrics VerifyNowTM analyser. We have also reviewed the literature on this subject.

Our recommendation is that patients who have recurrent stent thrombosis or thrombotic events on dual antiplatelet agents should have their antiplatelet therapy response checked and have their antiplatelet agents tailored accordingly. 

A 27-year-old Arab woman with history of seronegative rheumatoid arthritis for four years presented with a three-day history of multiple joint pains and swelling, along with fever. Clinically, she had bilateral rheumatoid hand deformities with signs of active arthritis of elbows, hands and knee joints. She was in sinus rhythm with normal cardiac examination. She was treated with steroids and was responding well except for mild fever, for which an echocardiogram was requested to rule out infective endocarditis. 

Outcome in patients with peripartum cardiomyopathy (PPCM) is variable. Recovery of left ventricular function is observed in between 23% and 51% of cases at six months after diagnosis. Despite standard medical therapy, both morbidity and mortality remain high. Recent evidence has suggested that dopamine-receptor agonists may be beneficial in the treatment of this condition. We describe a case of a patient with PPCM who developed rapid normalisation of left ventricular function following addition of carbergoline, a long-acting dopamine-receptor agonist, to her conventional heart failure therapy.

The glucagon-like peptide-1 (GLP-1) receptor agonists are a new class of injected drugs for the treatment of type 2 diabetes. They mimic the action of GLP-1 and increase the incretin effect in patients with type 2 diabetes, stimulating the release of insulin. They have additional effects in reducing glucagon, slowing gastric emptying, and inducing satiety. In clinical practice they are associated with significant reductions in glycosylated haemoglobin (HbA_1c), weight loss and a low risk of hypoglycaemia. Beneficial effects have also been observed on blood pressure and lipids. The possibility of cardiovascular benefit is now being formally examined in large randomised-controlled trials with primary cardiovascular end points.

We developed and piloted an innovative family-centred preventive cardiology programme (MyAction) that aimed to both integrate the care of patients with vascular disease with that of individuals identified at high multi-factorial risk and help them achieve recommended lifestyle, medical risk factors and therapeutic targets. The 16-week nurse-led programme was delivered by a multi-disciplinary team, including a dietitian, physical activity specialist and cardiologist, in a community setting. Of 206 patients who attended the initial assessment, 54% attended with their partner and 142 patients completed the programme (69%). By the end of the programme, there was a significant improvement seen in adherence to a Mediterranean diet, as well as substantial increases in physical activity levels supported by objective evidence of improved functional capacity. These changes contributed to significant reductions in body mass index (BMI), weight and abdominal obesity. Very similar changes were seen in partners. Blood pressure control also improved significantly, as did achievement of the low-density lipoprotein (LDL)-cholesterol target, and there was a significant increase in the use of cardioprotective medication. Quality of life also improved in both patients and partners. The significant changes achieved by the MyAction preventive cardiology programme should substantially reduce the cardiovascular risk of these patients and their partners in the future.

Reducing morbidity and mortality among post-myocardial infarction (MI) patients requires the implementation of effective secondary measures. This survey examined current practice by assessing the view on, and adherence to, National Institute for Health and Clinical Excellence (NICE) guidance on MI secondary prevention in a sample of general practitioners (GPs) and cardiologists. There were 303 respondents from Scotland and England, including at least 10 GPs and one cardiologist from each English Strategic Health Authority. Although drug treatment post-MI generally complied with NICE recommendations, diet and lifestyle aspects were not implemented fully. There appeared to be sub-optimal integration between primary and secondary healthcare providers. Both GPs and cardiologists underestimated the importance of tailoring secondary prevention services to the individual and the role of omega-3 fatty acid treatments (where required) to supplement dietary intake. There is a clear need to improve compliance of healthcare professionals with many of the key priorities for implementation outlined in the NICE guidelines. In addition, patient-centred cardiac rehabilitation services should be standardised and include strategies to improve patient uptake.