Clinical articles

The impetus of national initiatives highlighting the importance of lipid modification, the sheer number of people involved, and the continuous nature of therapy, mean that lipid management has become an everyday primary care discipline.1 Most patients with dyslipidaemia can be investigated and treated effectively in primary care without referral to a specialist but, paradoxically, the increasing patient burden means an enhanced role for the specialist lipidologist as well.

Patients who should be referred to a specialist lipid clinic include:

Those with extreme values (primary care practitioners often feel less secure with mixed hyperlipidaemia and hypertriglyceridaemia than with pure hypercholesterolaemia). Generally, these can be defined as total cholesterol (TC) >7.5 mmol/L and/or fasting triglycerides (TG) >7.5 mmol/L. All patients with TG >20 mmol/L need to be referred given the risk of pancreatitis.
Those who fail to show an effective response to treatment (whether by virtue of the type and severity of their dyslipidaemia or their intolerance of first-line agents).
Those with familial dyslipidaemia (e.g. familial hypercholesterolaemia, familial combined hypercholesterolaemia and Fredrickson Types I or V [TG >20 mmol/L], or type III [TG=TC and >7 mmol/L]) should be managed by specialists as family tracking may be easier to co-ordinate, drug doses used are higher and combination therapies are more common.
Special cases (such as those requiring the help of joint paediatric, nephrology, neurology, vascular surgery and HIV clinics) or those requiring special investigations such as apolipoproteins, enzyme testing, DNA genotyping, or more detailed vascular assessment.

A 24-year-old male who had been bedridden for the last three weeks and was recovering from a traumatic injury to his leg presented to our echo lab for evaluation of abrupt onset dyspnoea preceded by presyncope. Clinically he was tachypnoiec, had a pulse rate of 142 beats per minute, blood pressure 100/70 mmHg, oxygen saturation at room air 97% and electrocardiogram (ECG) showing sinus tachycardia. Transthoracic echocardiography revealed dilated right heart chambers and a long multi-lobed vermicular mass in all four cardiac chambers. Trans-oesophageal echocardiography confirmed a large multi-lobed mass straddling the interatrial septum on both sides through a patent foramen ovale (figure 1). The highly mobile mass (consistent with thrombus) protruded like a worm into the aortic valve in systole through the left ventricular outflow tract (figure 2). Within three hours the patient had sudden bradycardia and cardiac arrest, probably from cerebral embolisation.

We surveyed 510 patients to measure levels of patient satisfaction with our cardiac rehabilitation service and to compare health-related outcomes between patients who did, and did not, attend cardiac rehabilitation. Two hundred and sixty-five patients responded (52.4%). Our results showed that cardiac rehabilitation was associated with improved health behaviours, such as diet and exercise, and was popular with patients. The majority of non-attenders would have attended cardiac rehabilitation if certain features had been available. Following the survey, various improvements were made to the rehabilitation service, including a re-design of the patient literature and a designated lead consultant.

Predicting uptake and adherence to cardiac rehabilitation (CR) continues to challenge providers of the service in the UK. This study included optimism with the more traditional predictors of adherence.

The study included 61 eligible patients (37 men, 24 women) referred to an eight-week phase III CR programme. Socio-demographic data were collected including age, gender, diagnosis, employment, marital status and deprivation. Depression was measured using the Hospital Anxiety and Depression (HAD) scale. Dispositional optimism was measured using the Revised Life Orientation Test (LOT-R). Stages of change (SOC) for exercise were assessed. Attendance and completion of the eight-week CR programme were recorded for all patients. There was adherence to CR by 46 (75%; 27 men and 19 women) and non-adherence by 15 (25%; 10 men and 5 women). Dispositional optimism and SOC were found to be significant predictors of adherence (p=0.001 and p=0.038, respectively), with depression tending towards significance (p=0.0614). Socio-demographic variables were not significant.

Greater optimism is associated with attendance at phase III CR. In addition, being in a higher stage of the SOC model is also associated with adherence. These findings can enable CR staff to identify patients at risk of failing to adhere, facilitating focused interventions to encourage adherence.

A 58-year-old woman presented with a five-month history of epigastric pain, lower extremity oedema and orthopnoea. On examination she had postural hypotension, raised jugular venous pressure, hepatomegaly and pitting pedal oedema. Electrocardiogram (ECG) showed sinus tachycardia, low QRS voltage and a Q-wave in precordial leads V1–V4. A coronary angiogram was normal. IgG kappa monoclonal protein was detected in her serum and urine

The relationship between cardiac and gastrointestinal disease is widely regarded as being a complex one – disorders of the two systems commonly co-exist, and the symptoms of angina pectoris are notoriously difficult to differentiate from gastro-oesophageal problems. In addition, it has commonly been observed that patients suffering with gastrointestinal disturbance suffer from cardiac symptoms whose aetiology can be attributed to their primary gut problems. Recent evidence has shown that this is a relatively common manifestation and that the incidence of these secondary cardiac complications has been underestimated in patients with gastroenterological disease. This article reviews the evidence for secondary cardiological complications of gastrointestinal disorders and discusses the potential mechanisms behind them. The three main areas outlined in the review include rhythm disturbances related to oesophageal disease, linked angina and the cardiac manifestations of inflammatory large bowel disorders.

Palpitations are a common presentation in general practice(1) and a frequent reason for cardiology referrals. This symptom often causes considerable distress and anxiety for the patient(2) and can evoke a similar feeling in the consulted healthcare professional. However, palpitations are often benign.(3) Less than half of patients with palpitations suffer from an arrhythmia and not every identified arrhythmia is of clinical or prognostic significance.(4 )There is also a high incidence of anxiety disorders among patients presenting with palpitations.(5)

The skill lies in identifying patients with a significant heart rhythm abnormality who can be either helped by treatment or are at risk of adverse outcome. This can be achieved in primary care by taking a careful history and simple investigations.(5)

The provision of services for patients with arrhythmic illness has lagged behind those who suffer from coronary heart disease (CHD). This has been recognised by the addition of Chapter 8 to the National Service Framework for CHD.(6) Timely access to appropriate clinicians and patient support are among the quality requirements, which have been much welcomed by patients.

Considerable variation exists in adherence to and implementation of post-myocardial infarction (post-MI) clinical guidelines in the UK. The Follow Your Heart Steering Group has consolidated existing clinical evidence and published guidance into a consensus of succinct recommendations for optimal post-MI management, which includes separate healthcare professional and patient-focused components. This guidance should help encourage two-way dialogues between patients and healthcare professionals, reduce practice variation, raise standards of care, maximise healthcare resource utilisation and improve outcomes in post-MI patients. It is our intention to develop and widely disseminate a simple algorithm for healthcare professionals and for patients that summarises the guidance.

In the case of coronary artery disease the glut of diagnostic terms like Q-wave infarction, non-Q infarction, ST elevation infarction, non-ST elevation infarction, intermediate syndrome, unstable angina, stable angina, silent ischaemia, and exertional angina do not reflect the present day realities and are neither rational nor systematic. The term ‘acute coronary syndrome’ is too vague. A diagnostic term should be based on the cause rather than the effects. The present terms are symptom and effect based. These were relevant when there was no effective treatment. With the availability of powerful treatments these terms have become outdated. Terminology relating to the present day realities is required. In this paper I propose a system of terminology based on the assumed pathology.

Most people do not wish to die in hospital, yet most people do. Patients with chronic heart failure (CHF) appear to be particularly disadvantaged in this regard, partly because it can be difficult to recognise when the issue should be broached. This review by two integrated cardiology–palliative care services of 235 CHF deaths, shows that only about a third of patients died in an acute hospital bed. End-of-life discussions were possible, with the majority of patients given the opportunity to express a preferred place of dying achieving their wish.