Clinical articles

Ranolazine has been evaluated in three trials in patients with stable angina (MARISA, CARISA and ERICA) and one large trial of patients with non-ST elevation acute coronary syndromes (MERLIN-TIMI 36). It has shown an improvement in exercise performance and a decrease in angina attacks. Ranolazine has similar efficacy in younger and elderly patients. Observational experience with ranolazine from a large UK centre is described.

This study examined the effect of a community-based intervention on the natural rise with age of the Framingham 10-year risk score. Patients in the 45–64-year-old age group from 10 general practices were sent an invite card including five self-screening questions. Those with any of the prescribed risk factors were invited to arrange an appointment to assess their risk of heart disease, where a Framingham risk score was calculated and advice given, and then invited for re-assessment around 18 months later. 

Of 6,704 individuals contacted, 2,017 individuals (30.1%) arranged a health check, 982 followed up, and risk scores were calculated on 727. A significant reduction in the geometric mean Framingham risk was observed (from 10.65% to 10.34%), largely attributable to improvements in systolic blood pressure, high-density lipoprotein (HDL), reduced smoking and, perhaps, increased fruit and vegetable consumption. Although participants were 1.5 years older at follow-up, their risk profile corresponded to being 0.55 years younger, and, arguably, progression of risk was wound back by just over two years. Some self-selection bias was apparent, as those followed up had higher mean anxiety/depression scores at baseline.

In conclusion, community interventions can reduce cardiovascular risk even in deprived communities, although further analysis is required to establish cost-effectiveness.

National Institute for Health and Clinical Excellence (NICE) guidelines for the management of chest pain suggest a care pathway based on symptoms and clinical risk, which differs from that currently used in most hospitals. To compare the impact on workload, and costs of these guidelines with the current ‘exercise electrocardiogram (ECG)’-based service, a retrospective review of 150 patients referred to our rapid access chest pain clinic was performed. We compared investigations under the current system with that expected under the NICE guidelines. Cost analysis was performed to compare the two methods. GP questionnaires investigated likely changes in primary care referrals.

Heart failure is one of the most common conditions in industrialised society. Plasma N-terminal prohormone of brain natriuretic peptide (NT-ProBNP) levels are raised in heart failure and increase with severity and New York Heart Association functional class. A NT-ProBNP level guided community echocardiogram service has been in place at Southend University Hospital since 2005. A previous audit of the service in 2006 showed that a cut-off point of 300 pg/ml provided a negative predictive value of 97% for detecting significant left ventricular systolic dysfunction, defined as an estimated ejection fraction of less than 40%. We have now repeated the audit for the calendar year 2008 and have shown that an additional cut-off point of 450 pg/ml can be applied to the over 75 age group with a reassuring negative predictive value of 96%. 

The National Institute for Health and Clinical Excellence (NICE) has issued guidance on the investigation of patients with recent onset of chest pain, recommending CT calcium scoring (CAC) as the preferred test in some low-risk groups. This reflects concern about the low sensitivity (high false positive rate) of exercise stress tests (EST). This represents a major shift away from traditional rapid-access EST clinics and has generated concern. We looked at 125 consecutive ungraded patients with equivocal ESTs referred for CAC, and CT coronary angiography (CTA), if required. We found that 53% of patients had a CAC = 0 and would need no further testing under the NICE protocol. We estimate this would rise up to 70–80% if only low likelihood patients were studied. Two per cent of patients with a CAC = 0 required coronary intervention.

As per NICE protocol, all patients with a CAC between 1 and 400 underwent CTA, and, of these, 25% required invasive coronary angiography (ICA) and 17% underwent coronary intervention. 

The overall strategy of CAC followed by CTA (if CAC between 1 and 400) and ICA (if CAC >400) produced a final sensitivity of 88% (higher than EST) and a negative predictive value of 98% (similar to EST). We believe the strategy is a useful way to assess recent onset chest pain but concerns about radiation dose, availability and patients with obstructive non-calcific plaque remain.

Varicose veins and haemorrhoids both involve the venous circulatory system, but it is unclear whether they are predictors of elevated rates of other circulatory diseases. Our aim was to determine whether they are. 

We analysed an epidemiological database of hospital admission and day-case statistics, constructing cohorts of people admitted for care for varicose veins or haemorrhoids, and comparing their experience of subsequent circulatory diseases with a control cohort. Compared with the control cohort, there was an elevated risk of deep vein thrombosis (DVT) in the varicose veins cohort (rate ratio 1.20; 95% confidence interval 1.08–1.33) but not in the haemorrhoids cohort (0.90; 0.78–1.03). No other circulatory diseases showed significantly elevated risks associated with varicose veins or haemorrhoids. The rate ratio for coronary heart disease in the varicose veins cohort was 0.91 (95% confidence interval 0.88–0.95) and that in the haemorrhoids cohort was 0.98 (0.94–1.03). 

We conclude that neither varicose veins nor haemorrhoids showed strong association, either positive or negative, with other circulatory diseases. There was a significant, but numerically modest, elevated risk of DVT associated with varicose veins. The risk of coronary heart disease in people with varicose veins was, if anything, a bit low.

The dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of oral drugs for the treatment of type 2 diabetes. They inhibit the breakdown of glucagon-like peptide-1 (GLP-1) and increase the incretin effect in patients with type 2 diabetes. In clinical practice they are associated with significant reductions in HbA_1c, no weight gain and a low risk of hypoglycaemia. Initial cardiovascular safety studies have shown no increase in cardiovascular risk. Indeed, the suggestion of possible cardiovascular benefit seen in the safety studies is now being formally examined in large randomised-controlled trials with primary cardiovascular end points.

Hyponatraemia has been shown to be an independent predictor of mortality in selected patients with heart failure (HF) enrolled in clinical trials. The predictive value of hyponatraemia has not been evaluated in ambulatory heart failure patients in the community.

We evaluated 426 patients with left ventricular systolic dysfunction and hyponatraemia (between 125 and 135 mmol/L) under the care of a regional nurse-led community heart failure team between June 2007 and November 2008. Of all patients, 92% were on loop diuretics, 81% on angiotensin-converting enzyme (ACE) inhibitors, 90% on beta blockers and 48% on aldosterone antagonists. Mean age of the patients was 78.9 ± 4.7 years, 43% were females and mean New York Heart Association (NYHA) class was 2.3 ± 0.7. Patients were assigned into four groups based on their serum sodium: Group 1 (n=210), 133–135 mmol/L; Group 2 (n=123), 129–132 mmol/L; Group 3 (n=93), 125–128 mmol/L; Group 4 (n=200), >135 mmol/L. Mean follow-up was 12.2 ± 4.9 months. One-year survival was 93% in patients in Groups 1 and 2, 88% in those in Group 3 and 97% in Group 4 (p<0.0001). Risk-adjusted hazard ratios for six and 12-month re-hospitalisations for worsening HF were 2.9 (1.4–3.8) for Group 1 and 2 and 3.6 (1.4–4.2) for Group 3.  

Persistent hyponatraemia is common in ambulatory HF patients in the community and is associated with worse clinical outcomes. It is also an independent predictor for mortality and HF hospitalisations. General practitioners are uniquely positioned to identify patients with hyponatraemia and ensure regular monitoring and appropriate referrals are instigated. 

Mitral valve stenosis (MS) is attributed mainly to rheumatic fever and may remain unrecognised for several years. Early diagnosis of this lesion is important in order to implement the necessary management when either severe or complicated by atrial fibrillation. However, its incidence in a multi-ethnic community has not yet been recognised. We retrospectively studied 2,099 consecutive subjects for the presence of MS. All the patients were newly referred by general practitioners to a community general cardiology clinic and hypertension clinic in a district of London because of different cardiac symptoms, significant cardiac history or because of uncontrolled hypertension. All the patients underwent echocardiography routinely. Classical clinical signs of MS were present in four patients. Echocardiography showed MS in eight patients, in four of whom the MS was mild, moderate in three and severe in one patient. None of the patients had symptoms related to the MS and all were in sinus rhythm both clinically and during Holter monitoring. Only one patient was Caucasian, two were of Caribbean origin and five were of Indo-Asian origin. Subsequent cardiac catheterisation and mitral valve replacement were successfully carried out in two patients. It is concluded that rheumatic MS is still prevalent in the UK population and is more common in subjects of Indo-Asian origin than either Caucasian or Afro-Caribbean subjects. MS was not recognised by the general practitioners: its diagnosis was only made possible by echocardiography. 

Spontaneous coronary artery dissection is a rare entity leading to acute coronary syndrome and sudden cardiac death. Most of these reported cases have occurred in young pregnant women and therapeutic management options are variable. We describe a case of a young patient who presented with ST-elevation myocardial infarction (STEMI) due to coronary artery dissection secondary to cocaine abuse.