Clinical articles

The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) showed that addition of eplerenone to optimal medical therapy reduced morbidity and mortality in patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure. This international study also showed that the addition of eplerenone reduced the number and duration of rehospitalisations for heart failure. A budget impact model has been developed to estimate the effect of adding eplerenone to standard care in the UK. The model is based on the results of the EPHESUS study, UK epidemiological data, UK drug acquisition costs and National Health Service (NHS) hospital in-patient costs and average length of stay for England. All costs are expressed in pounds sterling.

It estimates the incremental costs and benefits of adding eplerenone to standard care in heart failure resulting from myocardial infarction, from the perspective of NHS healthcare decision makers over a three-year period.

The model shows that if all eligible patients are treated with eplerenone the estimated cost per life year saved is £6,730 in year three. In a primary care trust with a population of 250,000, this level of treatment results in a reduction of 46 bed days for rehospitalisations due to heart failure, at a cost per bed day avoided of £1,469. With hospital in-patient care the biggest single healthcare cost in heart failure, reduction in hospitalisation is a key priority within the NHS in the UK. Models such as the one described here enable the budgetary consequences of using a new drug to be identified and clarify the role of drug treatment in delivering NHS priorities.

Achieving a lower heart rate is important in treating angina. Established approaches include the use of beta blockers and certain calcium channel blockers. However, the use of these drugs may be limited by side effects or contraindications. Ivabradine (Procoralan®) is a novel agent that lowers heart rate through selective I(f) channel inhibition, acting specifically on the sinus node. We present a consecutive series of 30 patients initiated on ivabradine, within a district general hospital (DGH) setting. The aim of this study was to identify the heart rate-lowering and symptom-control properties of ivabradine, while monitoring adverse effects. Heart rate was measured on a baseline electrocardiogram (ECG) prior to starting ivabradine, and then within a 12-month follow-up period. The results identified a mean (standard deviation) 10 (14) beats per minute (bpm) decrease achieved on ivabradine (p<0.001), with greatest reduction in heart rate in those with a resting heart rate over 80 bpm prior to starting treatment (p<0.05), and in patients on a 5 mg twice-daily dosing regimen at follow-up (p<0.05). In parallel, the majority of patients reported favourable symptom benefit (21/30), and low rate of adverse events with discontinuation rate of only 2/30 felt directly related to the drug itself. We believe this to be the first report of using this novel drug in a ‘real-world’ DGH setting. The findings add confidence in using this anti-anginal agent in appropriate patients, and furthermore support conducting studies involving multiple centres, to further define and assess ivabradine in the clinical setting of angina.

A 63-year-old gentleman presented with palpitations and a sensation of chest fullness. He had previously undergone laparoscopic oesophageal fundoplication.

Dextrocardia is a rare anomaly with an estimated prevalence of about one in 10,000. The incidence of coronary artery disease is the same as in the general population. We report two cases of successful percutaneous treatment of coronary stenoses and aim to highlight some of the additional technical challenges that such patients present to the Interventional Cardiologist.

A 60-year-old male was admitted acutely unwell with prolonged ischaemic chest pain. Seven weeks earlier he had undergone percutaneous coronary intervention (PCI) following admission with an acute coronary syndrome (ACS). Two paclitaxel-eluting stents to his left anterior descending (LAD) artery (2.75 x 32 mm, 2.75 x 16 mm), a 3 x 12 mm Tecnic stent to his obtuse marginal artery and 3.5 x 9 mm Tecnic stent to his proximal circumflex artery were inserted. The patient received intravenous heparin plus abciximab and an excellent angiographic result was achieved (figure 1A). He was discharged home on six months’ dual antiplatelet therapy.

Although cardiac electrostimulation was recognised centuries ago, the technology of implantable heart rhythm monitoring and therapeutic devices has only been established in the last few decades. Recent advances in such technology have led to simpler implantation techniques, greater patient convenience with smaller device sizes, extended battery longevity, increased device safety and reliability, and improved clinical outcomes.

Despite huge advances in hypertension care in recent times, some important aspects of treatment are not routinely considered in practice, in particular the need for good 24-hour blood pressure (BP) control. Insufficient access to ambulatory blood pressure monitors (ABPM) in primary care and a lack of clear guidance limits routine use in BP management.

ABPM, which measures BP over a full 24-hour period and captures BP fluctuations, may provide a more accurate reflection of patients’ ‘true’ BP than traditional office readings. Since uncontrolled 24-hour BP is linked to increased incidence of cardiovascular (CV) events and target organ damage, the panel believed the use of ABPM is beneficial to both patient and doctor. ABPM can aid compliance and guide treatment choices, given that there are marked differences in the duration of action of many commonly used BP treatments. A treatment with a long duration of action may be important in managing BP over 24 hours.

Heart failure (HF) is common and the current gold-standard diagnostic modality for left ventricular systolic dysfunction (LVSD) is transthoracic echocardiography (TTE). To comply with the National Service Framework (NSF) for Coronary Heart Disease, an open access TTE service was established and this paper reports on the diagnostic yield of LVSD and valvopathy of TTE services in that service.

Diagnostic services were made available to patients from both primary and secondary care. As part of the assessment, all patients were evaluated by TTE to assess left ventricular function and any valvular pathology. Overall, 61% of patients had normal left ventricular ejection fraction, 16% mild LVSD, 9% moderate LVSD and 14% severe LVSD. Forty-three per cent of patients had no evidence of valvopathy, 31% had mild, 19% moderate and 7% severe valvopathy. Valvopathy was the primary pathology in 15.8% of patients and 13.5% had LVSD as their primary pathology: 30.4% had no valvopathy or LVSD. In the remainder, it was not possible to determine the dominant pathology causing HF due to concomitant LVSD and valvopathy.

TTE has a very high diagnostic yield in both primary and secondary care. Significant levels of valvopathy and LVSD are found in populations from both primary and secondary care.

Cardiac dysfunction is common in patients with thalassaemia and is the leading cause of mortality in adult patients. Transfusional iron overload can affect heart function by directly damaging tissue through iron deposition or via iron-mediated effects at other sites. The main cardiac abnormalities reported in patients with thalassaemia and iron overload are left ventricular systolic and diastolic dysfunction, pulmonary hypertension, valvulopathies, arrhythmias and pericarditis. Prevalence varies according to the type of thalassaemia. However, even though patients with thalassaemia intermedia require fewer transfusions than those with thalassaemia major, they are still at high risk for cardiac complications. With the introduction of new technologies such as cardiac magnetic resonance T2*, the early detection of cardiac iron overload and associated cardiac dysfunction is now possible, allowing time for reversal through iron chelation therapy. Although chelation therapy can reverse iron-mediated cardiac disease by removing iron from iron-loaded cardiomyocytes and by alleviating the systemic iron overload contributing to heart failure, the challenges of deferoxamine infusions can significantly impact on compliance and, therefore, prognosis. The introduction of new oral iron chelators, together with improved understanding of the mechanisms and consequences of transfusional iron overload, should allow the continued improvement in cardiac outcomes for patients with thalassaemia and other transfusion-dependent anaemias.

An 86-year-old woman presented with a six-month history of severe peripheral oedema and limiting breathlessness. A dual chamber pacemaker had been implanted 12 years earlier for complete heart block, and she had recently been prescribed amiodarone for paroxysmal atrial fibrillation. Previous echocardiography had demonstrated a small hypertrophied left ventricle with an end-diastolic diameter of 3.9 cm and good systolic function.