Clinical articles

Atrial fibrillation (AF) is a relatively common condition. The national prevalence for England on the latest quality and outcomes framework data is 1.3% and as many as 10% of patients aged over 75 may be in AF. On average, all of us have a 20–25% lifetime risk of developing AF.

An average GP will have 16–20 cases on their personal list and can expect to diagnose three new cases per annum. However, it is recognised that many cases of AF go undiagnosed and opportunistic screening for AF has been recommended. Of note, AF is responsible for 45% of embolic strokes. With the increasing emphasis on AF from Chapter 8 of the National Service Framework for Coronary Heart Disease (NSF-CHD), the National Stroke Strategy1 and inclusion of AF in the Quality and Outcomes Framework – as well as publication of the National Institute for Health and Clinical Excellence (NICE) guidelines for AF management – it is important for GPs to diagnose, treat and refer AF patients correctly.

There are three main areas to consider in AF patients: first, the diagnosis and treatment of any underlying co-morbid condition; second, symptom control by either a rate- or rhythm-control strategy; and third, the reduction of the accompanying risk of stroke and thromboembolism by appropriate prescription of antithrombotic therapy. Many straightforward cases of AF can be satisfactorily managed entirely in primary care, using the following structured approach.

National guidance recommends specific durations for clopidogrel and aspirin dual therapy post ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and following percutaneous coronary intervention (PCI). Primary care clinicians highlighted that patients were frequently discharged from acute trusts without any communication as to the indication for or intended duration of clopidogrel therapy. An initial audit across four of the six acute trusts demonstrated significant variation in the use of clopidogrel and aspirin dual therapy across the sector, with 26% of discharge prescriptions giving no clear indication for therapy and 30% of discharge prescriptions giving no indication of the intended duration of therapy.

The South East London Cardiac and Stroke Network (SELCSN) cardiac prescribing forum, with input from consultant cardiologists, GPs, pharmacists and others, developed and implemented a consensus guideline for the prescribing of clopidogrel across the sector. In addition, it was agreed that acute trust pharmacy departments would not dispense clopidogrel for discharge unless the duration was clearly documented on the discharge prescription.

Re-audit demonstrated an increase in the proportion of discharge prescriptions with an indication for and duration of clopidogrel therapy: 92.5% and 85%, respectively. Failure to implement the SELCSN guidance in one trust had a significant impact on the overall results; however, four of the six trusts managed to achieve over 95% compliance in terms of communicating a clear indication for and duration of clopidogrel therapy. In addition, the number of different regimens in use was lower during the re-audit period indicating a move to more consistent prescribing of clopidogrel across the sector, although there remains significant variation between trusts.

Next steps for the SELCSN are to address clopidogrel prescribing in the trust with poor outcomes in the audit to ensure full implementation of the local guidance, development of a tool to audit prescribing of clopidogrel in primary care to assess appropriate cessation of dual therapy and re-audit of acute trust discharge communication to ensure the good practice which has been implemented is maintained in the long term.

In June 2004 the Department of Health made a commitment to reduce waiting times from GP referral to hospital treatment to less than 18 weeks by 2008. Patients with chest pain are often now seen within two weeks thanks to the success of rapid-access chest pain clinics. Around 10–25% of these patients are referred for diagnostic coronary angiography (CAG) and of these, about 30% require percutaneous coronary intervention (PCI) to treat coronary stenoses. Conventionally, UK practice has been that such patients occupy two waiting lists: one for the CAG, which is often performed by a non-interventional cardiologist, and one for the PCI. This pathway makes achieving the 18-week target challenging. We introduced a new care pathway whereby all elective chest pain patients referred for CAG to one of the interventional cardiologists were listed for a standby coronary angiogram (SBCA), during which if PCI was indicated then it was performed immediately. We present the results of an audit of 102 consecutive patients since this pathway was introduced that demonstrates one method of achieving the 18-week target for this group of patients. This can now be further refined by aiming to achieve a higher proportion of day-case PCI cases.

Chronic kidney disease (CKD) is thought to affect approximately one in 10 people. Patients with CKD have significantly increased cardiovascular morbidity and mortality in comparison with the general population. This is thought to occur from a combination of increased atherosclerotic disease and medial calcification of arterial walls. Vascular calcification (VC) is recognised as an active, cell-mediated process with similarities to osteogenesis. Numerous systemic and local factors have been identified as inhibitors of calcification including fetuin-A, matrix Gla protein and pyrophosphate. There is also increasing evidence that increased serum phosphorus, serum calcium x phosphorus product, and/or calcium load is associated with increased VC.

Current treatment strategies focus on the correction of markers of mineral metabolism bone disease such as phosphate, calcium, parathyroid hormone and vitamin D. The use of agents such as bisphosphonates and cinacalcet show promise, but further data are awaited before their widespread use as a treatment for VC can be advocated. Imaging techniques currently used to assess VC are also discussed. Research into the mechanisms underlying VC are still being investigated and further insight into these mechanisms will lead to the development of therapeutic agents, which could improve cardiovascular outcomes in patients.

Heart failure (HF) is an important cause of morbidity and mortality in the general hospital setting worldwide. The paucity of data on psychiatric co-morbidity in Nigeria necessitated this study. This study was carried out among adults in stable state of HF at the cardiology clinic of Lagos University Teaching Hospital (LUTH) with sex- and age-matched controls.

Fifty-eight subjects were studied, made up of 27 (46.6%) males and 31 (53.4%) females. The mean age was 51.2±13.8 years. There were 44 age- and sex-matched controls with mean age of 50.1±13.6 years. Thirty-four of the subjects (58.6%) had General Health Questionnaire (GHQ) scores of ≥2 (cut-off score); out of which 14 (24.4%) were confirmed to have psychiatric disorders. One subject with GHQ score <2 also had a psychiatric diagnosis giving a sensitivity of 0.93 and specificity of 0.54 for GHQ-12 in this study. Thus, a total of 15 (25.9%) had psychiatric diagnoses which included: depression 7 (12.0%); generalised anxiety 6 (10.3%); paranoid schizophrenia 1 (1.7%), and somatisation disorder 1 (1.7%).

It is concluded that clinically significant psychiatric co-morbidities exist among subjects with HF. The need for ‘liaison’ psychiatric services in the cardiology clinic is emphasised.

The use of drug-eluting stents (DES) has increased exponentially in recent years. There appears to be little difference in short- to medium-term safety compared with bare-metal stenting (BMS). Coronary thrombosis after stent implantation is well recognised, resulting in acute myocardial infarction and not uncommonly in death. Late (>6 months) stent thrombosis is rare with BMS, but there is a concern that DES might be susceptible to thrombosis due to delayed endothelialisation.

The prolonged use of dual antiplatelet therapy (APT) with aspirin plus a thienopyridine (e.g. clopidogrel) is recommended. The premature discontinuation of APT in patients with DES without consultation with the treating cardiologist can result in stent thrombosis and adverse outcome.

Recent studies have suggested that the safety, efficacy and feasibility of percutaneous coronary intervention (PCI) in hospitals without on-site surgical cover is equivalent to those with these facilities. In addition, recent UK figures suggest that PCI growth is in the region of 15% per year with a corresponding fall in coronary artery bypass grafts (CABGs) hence the ratio of PCI to CABG is increasing. In the UK 35% of PCI centres are without on-site surgical cover, however, these centres represent only 18% of total PCI procedures. The Dorset Heart Centre opened in April 2005 the nearest surgical centre being approximately 28 miles in distance. In addition to elective PCI, our centre provides a 9-to-5 Monday-to-Friday primary and rescue PCI service for the Dorset area.

We compared the safety and efficacy of our newly opened non-surgical PCI centre with outcomes predicted using the North West Quality Improvement Programme (NWQIP) multi-variate prediction model to assess the risk of major adverse cardiac and cerebral events (MACCE) in patients undergoing PCI. Between opening and August 2006 we performed 1,454 PCIs. Our overall success rate was 1,363 (94%). Using the NWQIP multi-variate prediction model, the calculated MACCE estimate rate was 2.05%. The actual MACCE rate was 0.55%. We conclude that at our relatively new non-surgical centre we are able to provide an effective and high-volume PCI service to the Dorset region with MACCE rates below that expected for our patient population.

An exploratory study with individual interviews before seeing the cardiologist, one week after the appointment, and at three-month follow-up was conducted to explore how participants’ perception and experience of heart palpitations are affected by seeing a cardiologist. Eleven of 20 participants cited anxiety as a possible cause of palpitations. A similar number were worried about their heart. After seeing the cardiologist, 7/20 participants thought something serious may have been missed, only one out of seven of whom had a clinically significant arrhythmia. It was reported that cardiologists did not address the role of psychological factors. Seven of the 20 participants still had heart-related health concerns at three months.

We conclude that many participants with palpitations without demonstrable cardiac pathology continued to experience high levels of health concern after seeing the cardiologist; this persisted at three months. The lack of resolution of the problem for these patients lay in not receiving a diagnosis or explanation. Participants reported that cardiologists did not address the possibility that psychological factors (particularly anxiety) could be relevant to the aetiology and management of palpitations. We suggest cardiologists should routinely address anxiety as a potential contributor to the cause of their patients’ symptoms.

The majority of patients with hypertension are treated in primary care and well controlled. Typically, a practice will achieve about 80% control as judged against the Quality Outcome Framework (QOF). The QOF only requires a practice to reach a target of 70%. A practice will need to control the blood pressure of about 18% of their patients and therefore about 3.5% of the practice population will not be controlled. Too many to refer to secondary care and therefore the practice needs a strategy to try and improve control in-house and to identify those in greatest need of referral.1

Much effort has been expended assessing the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CAGB) surgery. Much less energy has been directed towards understanding the potential of these two interventions for causing additional myocardial damage during the procedure and the means to avoid this injury.

This review examines the impact of myocardial injury in elective PCI and CABG, principles of myocardial protection, and their efficacy in current coronary revascularisation. The objective of every coronary revascularisation should be a technically perfect result without producing myocardial damage. A patent graft that perfuses an area of myocardium with numerous pockets of myocyte necrosis serves no useful purpose.