Clinical articles

Renal artery stenosis is a condition that has significant effects on the progression and outcomes of co-existent cardiac disease. The most important cause of renal artery stenosis is atherosclerotic renovascular disease (ARVD). As the drugs and techniques used to manage ARVD are similar to those used to treat coronary artery disease, cardiologists are increasingly becoming involved in its management. However, while there are similarities, there are also significant differences in the management of ARVD and coronary artery disease. There are also many differing opinions on the best management. This review maps the minefield of conflicting evidence and gives clear, pragmatic guidelines regarding the management of patients with cardiorenal disease.

To identify the knowledge of ionising radiation doses and radiation-related risk in common cardiac procedures among cardiology trainees, cardiologists and general practitioners with a specialist interest in cardiology, a face-to-face questionnaire survey of 47 cardiac specialists, both regular referrers and practitioners of radiation-based procedures, was conducted at the British Cardiovascular Society Annual Conference 2006.

Of the 47 medical professionals surveyed, 21 (45%) provided the correct radiation dose for at least one imaging procedure. Most reported doses were below the lower limit of the reference range: the median (interquartile range) radiation dose reported by the respondents was 2 mSv (0.4 to 10 mSv) for coronary angiography (CA) and 6 mSv (1 to 15.8 mSv) for percutaneous coronary intervention (PCI); 2 mSv (0.5 to 15 mSv) and 6 mSv (1 to 20 mSv) for myocardial perfusion scintigraphy (MPS) and computed tomographic angiography (CTA), respectively. A risk of malignancy from ionising radiation exposure of one in 10,000 for CA (actual risk 1:5,000) and of one in 5,000 for MPS and CTA (actual risk 1:1,000) was reported by the majority of respondents.

We conclude that there is significant underestimation of both dose and radiation-related risk to patients. Patients are unable to make informed decisions when consenting for these common procedures, as clinical staff are unaware of the correct radiation dose and associated risk, and therefore are unable to advise patients properly.

A 55-year-old smoker with no significant past medical history was admitted following an episode of dyspnoea and intrascapular pain. Clinical examination was normal. His blood pressure (BP) was 80/40 mmHg and his electrocardiogram (ECG) showed a sinus tachycardia and right bundle branch block.

Microscopic polyangiitis is a systematic necrotising vasculitis that affects small vessels without granulomata. Typically the most common manifestation is renal involvement. We report an unusual presentation of microscopic polyangiitis in a young male.

New data gathered via a survey undertaken on behalf of the British Cardiac Patients Association (BCPA) confirm not only that angina itself has an adverse impact on lifestyle, but that the side effects associated with some of the currently prescribed therapies for angina may be exacerbating the situation for patients.

In primary care, the significant burden of heart failure is exacerbated by problematic, inaccurate diagnosis that may produce inefficient triaging of patients to echocardiography. UK guidelines recommend using natriuretic peptides in the diagnostic pathway. The costs and consequences of providing a definitive diagnosis for symptomatic heart failure have not been established for peptide testing in primary care. We provide a cost-consequence analysis to compare alternative diagnostic strategies for symptomatic heart failure patients presenting to their GP.

Health economic evaluation using decision-tree modelling taking a cohort of patients presenting in primary care with symptomatic heart failure to a definitive diagnosis was performed. The model compared a diagnostic strategy using electrocardiograms (ECGs) interpreted by consultants with the use of B-type natriuretic peptide (BNP) assays. The base-case used data from the UK Natriuretic Peptide (UKNP) study, which used a ‘point-of-care’ assay. Two alternative scenarios were modelled reflecting data from key studies, as was sensitivity to costs. The model demonstrates that, for the base-case scenario, an initial diagnostic strategy of BNP is superior to ECG in terms of diagnosis of symptomatic heart failure in patients presenting in primary care, despite slightly more initial false negatives and a marginally higher cost. The alternative scenarios and sensitivity analyses show that the results are very sensitive to test accuracies and costs, but that, under plausible assumptions, BNP could be both cheaper and clinically superior.

The model suggests that, despite parameter uncertainty, the adoption of BNP in primary care is likely to be clinically preferable, be more satisfactory for most patients, and lead to fewer unnecessary echocardiography referrals, at a very small increase in cost.

A clinical audit of ezetimibe in the treatment of refractory hyperlipidaemia was conducted in 100 high-risk patients who failed to achieve desirable levels of total and low-density lipoprotein (LDL)-cholesterol on statins. Of these, 59 had familial hypercholesterolaemia (FH), the remainder had other aetiologies (non-FH). The percentage of patients achieving the total and LDL-cholesterol targets of the International Panel on the Management of FH or the Second Joint British Societies’ guidelines in non-FH patients was determined.

Ezetimibe significantly decreased mean LDL-cholesterol when used as an adjunct to statins or as monotherapy, from 3.9 to 3.1 mmol/L in FH, from 3.4 to 2.4 mmol/L in non-FH and from 6.0 to 4.4 mmol/L in statin-intolerant patients. The decrease in LDL-cholesterol on statins was inversely correlated with the decrement after adding ezetimibe (r= -0.67, p<0.0001) but 15% of patients showed no further decrease. The percentage of patients achieving target levels of LDL-cholesterol was 27% on statins and 63% on statins plus ezetimibe (p<0.007). None of the non-FH patients achieved target levels on statins but 33% did so when ezetimibe was added (p<0.001).

Ezetimibe is an effective adjunct to statins for lowering LDL-cholesterol in refractory hyperlipidaemia, except in a minority of patients, and is a useful substitute in statin-intolerant subjects.

Nicotinic acid (for treatment of low high-density lipoprotein [HDL]) combined with a statin has been shown previously to improve cardiovascular outcomes. To evaluate tolerability and safety of prolonged-release nicotinic acid added to statin therapy in patients at high cardiovascular risk, the Niaspan®-induced HDL-Elevation for Optimizing Risk Control (NEMO) study focused on 179 patients with atherogenic dyslipidaemia treated under usual-care conditions. Flushing was the most common treatment-related adverse drug reaction (ADR) in Ireland (32% flushed during the first month), followed by cutaneous (6.2%) and gastrointestinal (3.9%) ADRs. Mean HDL-cholesterol increased by 20%. Half of the patients elected to continue treatment after the study. In conclusion, the tolerability and safety of prolonged-release nicotinic acid was similar in Ireland compared with the overall NEMO population. It is important to take practical measures to optimise patient compliance to minimise overall cardiovascular risk.

We present a case in which the use of cardiovascular magnetic resonance (CMR) allowed the full pathology underlying syncope to be established.

Despite the major role of primary care in the management of people with, or at risk of developing, cardiovascular disease, little is known about the availability and state of readiness of cardiovascular diagnostic and monitoring equipment in general practice premises. We surveyed 170 general practices in one cardiac network. Our findings suggest that both provision of cardiac equipment, and training of staff in its use, is variable.