Clinical articles

From the days of Virchow and the analysis of post-mortem coronary specimens, an enormous amount of knowledge has been built about coronary pathophysiology. In the 1950s the dream of in vivo coronary imaging became a reality with the invention of coronary arteriography under the guidance of Mason Sones. As we fast forward 50 years, it has become clear that angiography has helped us focus on areas of stenosis and flow limitation, but the main problem of coronary artery disease is much more complex than can appear on a luminal silhouette. The finding of ‘normal coronary arteries’ following angiography is short-sighted and does not take into account the potential of unstable disease lurking within the vessel wall. We begin the series with intravascular ultrasound.

In UK cardiac rehabilitation programmes, exercise training is often set at a percentage of maximal heart rate or heart rate reserve, either predicted or measured. Problems may arise when using this method for chronic heart failure (CHF) patients who often have chronotropic incompetence and are treated with beta blockers. A safer approach is to use cardiopulmonary exercise testing to prescribe training below the ventilatory threshold, thus ensuring that the exercise is moderate. The aim of this study was to determine whether British Association for Cardiac Rehabilitation (BACR) heart rate guidelines prescribe moderate intensity exercise for CHF patients. The only target heart rate range to prescribe exercise below the ventilatory threshold was 60–80% measured maximum heart rate. Target heart rates calculated from predicted maximum values were higher than those from measured values, and the heart rate reserve method resulted in the highest target heart rates. Cardiac rehabilitation exercise practitioners should be aware that these methods may well result in CHF patients performing heavy rather than moderate exercise.

Diabetes mellitus is caused by an absolute or relative lack of insulin.¹ This article covers people with type 2 diabetes, as most people with type 1 diabetes will be under the care of a secondary care team for at least some of their care. Type 2 diabetes is not primarily about sugar, but about moderating the vascular and neurological damage resulting from chronic hyperglycaemia. Many people with type 2 diabetes will also have components of the metabolic syndrome,² namely hypertension, dyslipidaemia and obesity, all of which need separate and sometimes overlapping interventions.

To establish whether the medication received by patients post-myocardial infarction was prescribed at therapeutic doses, we performed a retrospective audit of discharge summaries. Over three quarters (75.1%) of all patients in the study group were discharged on sub-therapeutic doses of angiotensin-converting enzyme (ACE) inhibitors and beta blockers. In contrast, nearly all (94–97%) patients received a statin at a therapeutic dose. Aspirin and clopidogrel, where prescribed, were also within the therapeutic range in 100% of patients. These findings illustrate the difficulty in optimising the doses of drugs that have a wide range of possible doses during short hospital admissions.

Cardiac magnetic resonance (CMR) has much to offer in the clinical assessment of intra-cardiac space-occupying lesions (SOL). Below we describe the use of CMR as a second-line investigation complementing the use of other imaging modalities, using the example of three patients with atrial SOL. We briefly review the literature and discuss the use of CMR within the context of multi-modality imaging of cardiac SOL.

There are no guidelines on the practice of antibiotic prophylaxis in pacemaker implantation resulting in wide variation in practice. We sought to investigate this and identify areas for further study and improvement. Using an email questionnaire, followed up with a telephone call if no response, all 121 adult National Health Service hospitals in England implanting pacemakers were asked about use of systemic prophylactic antibiotics at implantation. Data were obtained from 61 hospitals (50.4% of total contacted), covering a wide geographic distribution.

Until recently, supportive and palliative care for patients with heart failure has been neglected in primary and secondary care. Patients dying from cancer have benefited from a co-ordinated approach to ensure all aspects of care, including advanced planning and financial assistance, are considered.

Plasma natriuretic peptide (NP) testing is not widely used in heart failure clinical practice in the UK or Ireland, despite a large evidence base. This article reports the views of a consensus group that was set up to develop guidance on the place of NP testing for clinicians in primary and secondary care.

Chronic kidney disease (CKD) has been redefined by the American National Kidney Foundation with stages based on the estimated glomerular filtration rate (eGFR) or other evidence of kidney abnormality.(1) Five stages were originally described by the Kidney Disease Outcomes and Quality initiative. 

Direct current cardioversion (DCCV) to restore sinus rhythm (SR) in patients with persistent atrial fibrillation (AF) remains a therapeutic option, though recent studies have questioned its need and value in the longer term.