Clinical articles

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.

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.