Clinical articles

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. 

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.

Thiazolidinediones (glitazones) are a relatively new addition to the type 2 diabetes drug armoury, but they have caused considerable controversy since they were introduced into the routine management of patients with type 2 diabetes. Until recently there were two thiazolidinediones licensed for use in the treatment of type 2 diabetes: rosiglitazone and pioglitazone, but the European Medicines Agency (EMEA) on the 23^rd September 2010 removed rosiglitazone’s marketing authorisation across Europe because of concerns about cardiovascular safety. There is no evidence to show a similar cardiovascular safety concern for pioglitazone, apart from increased fluid retention and reported heart failure. Pioglitazone may still have a therapeutic role in the management of selected patients. 

The increasing population of elderly patients undergoing surgery has implications for care and resource utilisation, and the potential to meet operating targets. We prospectively reviewed collected data for 6,971 patients who underwent coronary bypass and/or heart valve operation from March 1998 through January 2007. Resource utilisation between young (<70 years) and elderly (≥70 years) patients was compared. 

The elderly (n=2,664) were a higher operative risk than young patients (n=4,127). Peri-operative requirement for additional medications (inotropes, anti-arrhythmics, antibiotics), blood transfusions, further interventions (resternotomy, sternal re-wiring, gastrointestinal surgery, renal replacement therapy) and device implantation (intra-aortic balloon pump, ventricular assist device, Swan Ganz catheter, permanent pacemaker) in the elderly exceeded young patients by 32%, 20%, 5% and 2%, respectively. ‘Progression through care’ (intensive care management >24 hours, intensive care re-admission, hospitalisation >12 days, and discharge to convalescence) was delayed in elderly patients. The elderly had a 91% cumulative excess risk for incurring extra resource utilisation.

Clinical resource utilisation after cardiac surgery was substantially higher for elderly compared with young patients. With a growing elderly population of cardiac patients, new clinical measures and organisational changes are needed to maintain clinical productivity, the ability to meet targets, and improve operative outcomes. 

Cardiac Networks always promised to be effective health communities across which sharing good practice and ultimately redesigning ideal care pathways for patients including Cardiac Rehabilitation (CR) could be made. The Black Country Cardiovascular Network in collaboration with the NHS Improvement programme conducted this observational study aiming at assessing and encouraging CR development across the English Cardiac Networks.

Balloon aortic valvuloplasty (BAV), first developed last century for the management of symptomatic aortic stenosis, was met with great enthusiasm due to its new and minimally invasive technique, but it has now largely been abandoned due to suboptimal results and a high restenosis rate. However, with the development of new techniques and the arrival of transcatheter aortic valve implantation (TAVI), BAV’s use is starting to increase. In this article we put forward the case for a revival in BAV by exploring the traditional uses and safety of BAV as a procedure as well as a novel role as a bridge to TAVI.