Clinical articles

Anthracyclines are commonly used antineoplastic drugs. However, their clinical utility is tempered by a dose-dependent risk of cardiotoxicity and congestive heart failure. Current preventive measures focus on dose reduction, use of less cardiotoxic anthracycline analogues and prophylactic use of dexrazoxane. Recent research has focused on early monitoring and risk stratification to identify patients that are ‘at risk’ for cardiotoxicity, using biochemical markers and the prophylactic use of novel cardioprotectants. This article reviews the clinical course, pathogenesis, cardiac monitoring and new concepts in diagnosing and preventing anthracycline cardiotoxicity.

Co-administered niacin and statin may offer additional lipid management; however, niacin is underutilised due to flushing, mediated primarily by prostaglandin D2 (PGD2). A combination tablet containing 1 g extended-release niacin and 20 mg laropiprant (ERN/LRPT), a PGD2-receptor (DP1) antagonist, offers improved tolerability. To assess the efficacy and safety of ERN/LRPT + simvastatin versus ERN/LRPT and simvastatin alone in dyslipidaemic patients, in this 12-week study, 1,398 patients were randomised equally to ERN/LRPT 1 g/20 mg, simvastatin (10, 20 or 40 mg), or ERN/LRPT 1 g/20 mg + simvastatin (10, 20 or 40 mg) once-daily for four weeks. At week five, doses were doubled in all groups except simvastatin 40 mg (unchanged) and ERN/LRPT 1 g/20 mg + simvastatin 40 mg (switched to ERN/LRPT 2 g/40 mg + simvastatin 40 mg).

ERN/LRPT + simvastatin (pooled across simvastatin doses) significantly improved key lipid parameters versus ERN/LRPT and pooled simvastatin: mean percentage changes from baseline to week 12 for low-density lipoprotein cholesterol were –47.9%, –17.0% and –37.0%, respectively, and for high-density lipoprotein cholesterol were 27.5%, 23.4% and 6.0%, respectively. ERN/LRPT + simvastatin was generally well tolerated, with a low incidence of serious treatment-related adverse experiences (0.2%, 0.5% and 0.2% for ERN/LRPT + simvastatin, ERN/LRPT and simvastatin, respectively).

In conclusion, ERN/LRPT + simvastatin significantly improved the lipid profile compared with ERN/LRPT and simvastatin alone and was generally well tolerated in dyslipidaemic patients.

Heart disease is the leading cause of death in pregnancy. Although women with high-risk cardiac conditions can be identified, the majority of deaths occur without such pre-existing severe cardiac disease. Coronary artery disease is an increasing cause. Previous reports on heart disease in pregnancy have focused on tertiary-centre and non-UK populations. We report a UK District General Hospital (DGH) experience. We recorded all pregnant women referred to a dedicated DGH cardiology service in Bromley between August 2004 and August 2007. One hundred and three women were referred, including 37 with murmurs or known valve disease, 31 palpitations or arrhythmias, 13 congenital heart disease and eight hypertension. Of the women presenting with a murmur, only one, a recent immigrant, had a significant cardiac condition requiring treatment. Three women with arrhythmias required admission but none were life-threatening. Four women required admission for heart failure, two with peri-partum cardiomyopathy and two with previous hypertension. Only two women were referred with chest pain, neither had ischaemia. Tertiary referral was required in cases of heart failure, an increased risk of aortic rupture or severe mitral stenosis, but all other women were managed safely in a DGH. Seventy per cent of women only needed one clinic visit.

In conclusion, the majority of pregnant women referred to a DGH cardiology service are in the previously defined low-risk group. Cardiac symptoms or signs in UK-born pregnant women without known heart disease are unlikely to represent high-risk cardiac disease but recent immigrants may have significant undiagnosed disease. Chronic hypertension is a risk factor even if controlled at the start of pregnancy. Ischaemia is an increasing problem.

Angiotensin-receptor blocking drugs have been shown to be an effective therapeutic strategy in a number of cardiovascular diseases. Many randomised controlled trials have demonstrated optimal doses of these drugs. We therefore investigated the doses of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers in patients admitted to hospital. We found from a total of 60 consecutive patients, only 38% (n=23) were on the top recommended dose and the average daily dose was 63.1±4.5% of the recommended dose. This study confirms that a significant number of patients are receiving suboptimal doses of angiotensin-blocking drugs and this under-dosing is likely to result in a failure to achieve the maximal therapeutic benefit.

Blackout is a common, alarming symptom occurring across patients of all ages, and can create enormous psychological and social distress. In this review, we describe a new clinical approach that improves healthcare delivery to patients suffering blackouts.

Congestive heart failure (CHF) is an increasingly widespread condition, the prognosis for moderate and severe heart failure is almost identical to colorectal cancer1 and worse than breast2or prostate cancer.3 CHF has an overall population prevalence of approximately 1–3% rising to approximately 10% in the very elderly

CHF accounts for about 5% of all medical admissions and approximately 2% of total healthcare expenditure.4 Nearly one million new cases are diagnosed annually worldwide, making it the most rapidly growing cardiovascular disorder.

The consequences of heart failure for primary care are profound. CHF has been reported to be second only to hypertension as a cardiovascular reason for a surgery appointment.5Despite improvements in medical management, undertreatment is common, many patients with CHF still do not receive treatment optimised according to current guidelines.4,6

The introduction of the 2009/10 heart failure Quality Outcomes Framework (QOF) additions will bring financial incentives for the prescribing of beta blockers for patients with a diagnosis of heart failure. This will apply to all diagnosed heart failure patients. There are, however, no additional QOF points for optimising medication or maximum tolerated levels, therefore, patient care will rely on good practice and receiving treatment according to current guidelines.

The prevalence of heart failure nationally in QOF is just over 1%. Because of the increase in survival after acute myocardial infarction and ageing of the population, the number of patients with heart failure will increase rapidly in most industrialised countries. Heart failure will continue to be a challenge to healthcare.

The profile of heart failure management has been raised with the publication of the Coronary Heart Disease (CHD) National Service Framework (NSF)

Chapter 6 in 20007 and the National Institute for Health and Clinical Excellence (NICE) Heart Failure Clinical Guideline 2003.8 The heart failure publications have supported the development of community heart failure services, and heart failure specialist nurse roles.

The development of the General Practitioner with Special Interest (GPSI) in cardiology qualification and the accreditation in community echocardiography in 2004 has enabled the development of community heart failure services. The training and development of the workforce in primary care has led to improvements in the treatment and management of heart failure patients. A referral to a community specialist heart failure service or secondary care will still be relevant in certain instances, however, the 10 steps will assist in the decision to continue the management in primary care or refer for expert advice and a future management plan.

The amyloidoses comprise a collection of disorders in which proteins, some native and some mutated, are deposited in tissues. These proteins self-assemble themselves to form an ordered fibrillar matrix termed amyloid. Currently, more than 20 different proteins have been identified, the most common with as many as 100 different mutations per protein. Despite these figures, the conditions that arise clinically are not that common. This undoubtedly results in a number of such individuals not being identified, or typically only when it is too late to effect a cure.

This article describes the features, diagnosis and treatments for the different types of amyloid that affect the heart.

A 52-year-old man presented to the emergency department with increasingly frequent anginal chest pain. He had had an anterior ST elevation myocardial infarction two years previously, for which he received thrombolysis. He was an ex-smoker, hypercholestrolaemic and had a family history of ischaemic heart disease. During stress electrocardiography, he developed chest pain at nine minutes of a standard Bruce protocol, but no significant ST changes.

Teaching and learning the three-dimensional anatomy of the heart can be challenging. The use of the hand to model structures in the heart has proven useful. In this article a more comprehensive model of the heart using a gloved hand is proposed.

The cardiovocal syndrome was first described by Otner, a Viennese physician, in 1897.1 It refers to a clinical syndrome of hoarseness due to dysfunction of the left recurrent laryngeal nerve, caused by cardiac diseases. Here, we describe a case of Otner’s syndrome following the second revision of mitral valve replacement.