Clinical articles

People with peripheral arterial disease (PAD) have a high prevalence of modifiable risk factors for coronary artery disease (CAD). Whether these risk factors are adequately treated remains unknown. We investigated people admitted to hospital with PAD and CAD. We compared use of antiplatelet agents, statins and angiotensin-converting enzyme (ACE) inhibitors before and during admission. Multivariate analysis showed that before admission, compared to patients with CAD, patients with PAD had decreased use of antiplatelet agents (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2–6.1), statins (OR 3.8, 95% CI 1.5–9.3) and ACE inhibitors (OR = 5.8, 95% CI 2.3–14.3). During admission, treatment was significantly less likely to be initiated in patients with PAD. This shows how secondary prevention can be neglected in patients with PAD. This is an important missed treatment opportunity, with substantial public health implications.

Ultrasound guidance is a useful technique to aid central venous access. Alignment of the ultrasound probe and visualisation of the needle is a skill that takes some practice. This article describes how to perform ultrasound guidance to gain central venous access via the internal jugular, femoral and axillary/subclavian veins.

This case describes the discovery and subsequent attempts at removal of a migrated venous stent.

Major new trials reported at the American Heart Association 2007 Scientific Sessions, held in Orlando, Florida, US, on November 3rd–7th, showed mixed results for the new antiplatelet agent, prasugrel, and gave renewed hope for the high-density lipoprotein raising field. But there was disappointment regarding the use of statins in heart failure and beta blockers in general surgery.

A 78-year-old woman presented to the vascular surgeons for a routine varicose vein procedure. She was fit and well with no significant medical history and had no cardiovascular risk factors. Clinically she was asymptomatic with a good excercise tolerance and no signs of heart failure. During the pre-operative assessment, a loud systolic murmur was heard all over the precordium with greatest intensity at the upper left sternal edge. Her electrocardiogram was unremarkable. A subsequent two-dimensional echocardiogram revealed a dilated aortic root and a large, 6.6cm aneurysm of the right coronary sinus of valsalva (see figure 1), which extended into the right ventricular outflow tract causing obstruction with an associated gradient of 44 mmHg. Her right ventricle was hypertrophied and there was mild tricuspid regurgitation. Her left ventricular function was normal and there was evidence of mild aortic regurgitation. A cardiothoracic opinion was sought but the operative risks were deemed unacceptable to both the surgeon and patient.

Patients with diabetes are at particularly high risk for cardiovascular disease. Indeed diabetes has been appropriately described as ‘a state of premature cardiovascular death associated with chronic hyperglycaemia’.1 Recently, the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) have published joint guidelines on diabetes, pre-diabetes, and cardiovascular diseases.2 Broadly, they reflect the rigorous approach of the 2005 revised Joint British Societies’ guidelines on the Prevention of Cardiovascular Disease in Clinical Practice (JBS 2).3 In this article, we will revisit the main JBS 2 guidelines for individuals with diabetes and compare them with the recommendations from the ESC/EASD.

Many heart failure patients are eligible to receive financial support (Disability Living Allowance or Attendance Allowance) because of their impaired mobility. Those with a very limited prognosis can gain rapid access to these benefits by claiming under “special rules” with the support of a report (DS 1500) from their doctor.

Little is currently known of the effect of switching statin therapy on cardiovascular outcomes. Using The Health Improvement Network database, patients who had received atorvastatin for ≥ six months were identified. They were classified as ‘switch’ if they were subsequently switched to simvastatin, and were matched to up to four ‘control’ patients who remained on atorastatin. Time to death or first major cardiovascular event was compared, controlling for the matching co-variates, prior statin exposure and baseline cholesterol concentration.

Implementation of a new specialty training Curriculum in Cardiology from August 2007 will bring significant changes to specialist training in cardiology. The format, delivery and evaluation will differ, and these changes are relevant to both existing and newly appointed trainees. This article aims to summarise the changes and incorporates presentations by the Cardiology Specialist Advisory Committee at the British Cardiovascular Society conference in June 2007.

Several imaging modalities are available for the optimal management of patients with cardiovascular disease. When assessing any imaging technique, the radiation dose must be considered along with the value of the imaging technique. In this article, we summarise the radiation doses associated with cardiovascular imaging techniques, such as heart catheterisation, nuclear medicine and multi-slice computed tomography. The effective dose of the dual isotope scan, an image modality frequently used in cardiac patients, is higher (~25 mSv) than cardiac computed tomography (~10 mSv) or diagnostic heart catheterisation (~5 mSv). The physician should weigh carefully which test to recommend in each patient.