Clinical articles

The National Service Framework for Coronary Heart Disease recommends that psychological support should be offered to those patients who require it. A six-month study carried out at Darlington Memorial Hospital looked at psychological support needed by patients following myocardial infarction (MI). The psychological status of MI patients was formally assessed using the Hospital Anxiety and Depression (HAD) scale and appropriate referrals were made to psychological support services to improve patient management. The study also measured the impact that formal assessment of the psychological status of MI patients would have on service providers.

Some 80 MI patients from the Darlington primary care trust (PCT) were eligible for inclusion in the study. Psychological assessment was undertaken at four stages during cardiac rehabilitation and 25 patients were eligible for referral for psychological support as a result of high HAD scores measured during the study period. Ten patients accepted referral, a higher number than during the previous six-month period when HAD scales had not been used. Eight patients were referred to occupational therapy services for help with anxiety issues, one patient was referred to the psychology service and one to liaison psychiatry. Both of these patients required help with depression.

The study also found a high degree of patient satisfaction. The support received may also be required by many other groups of patients.

This case describes, for the first time, the appearance of possible cutaneous embolic lesions in the pinna of the ear secondary to infective endocarditis

Although the majority of implantable cardioverter defibrillator (ICD) implants occur without complication, high defibrillation threshold (DFT) can occasionally be a problem. The usual resolution to this problem is to include a subcutaneous electrode in the defibrillation circuit. Use of the subcutaneous array, however, is unpopular as extensive subcutaneous dissection is time-consuming, uncomfortable for the patient and provides another focus for infection. We report the use of the coronary sinus for the placement of a second defibrillation shock coil in a patient with an unacceptably high DFT, which was successfully reduced.

This paper briefly reviews an analysis carried out in the West of Scotland of the Quality and Outcomes Framework data gathered for coronary heart disease under the new General Medical Services contract for general practitioners. It shows encouraging progress in achieving clinical outcome predictors.

The report from McCarlie and colleagues in this issue (pages 117–19) on the success of Scottish general practice in achieving cardiovascular disease (CVD) targets for clinical indicators within the Quality and Outcomes Framework (QOF) mirrors similar progress across England and Wales.

Patients with transposition of the great arteries (TGA) are now living longer due to improved medical and surgical care. Most of the current patients with TGA followed up at our district general hospital (DGH) grown-up congenital heart (GUCH) clinic have undergone a Mustard or a Senning atrial repair procedure between the early 1960s to mid 1980s. Complications found to be associated with the atrial repair procedure include arrhythmias, right ventricular impairment, tricuspid valve dysfunction, baffle-related problems and sudden death. This article reviews the outcome of patients with TGA in this DGH population and also addresses the issue of pregnancy and insurance.

This article aims to provide an overview of the management of atrial fibrillation (AF), with reference to the recently published National Institute for Health and Clinical Excellence (NICE) guidelines on AF management (http://www.nice. org.uk/CG36/guidance/pdf/english). This article is not meant to cover the whole guideline nor be a systematic review, as the full guideline contains all the search strategies and appraised evidence tables, and represents a comprehensive assessment of the evidence behind the recommendations in the NICE guideline (also available at http://rcplondon.ac.uk/pubs/books/af/index.asp).

The guidelines on atrial fibrillation (AF) produced by the National Institute for Health and Clinical Excellence (NICE) and published by the Royal College of Physicians are impressive in their scope and details. They are overtly evidence based and whilst there is some debate over some issues within the guidelines, there is no doubt that they represent much hard work from the Guidelines Development Group.

Intracardiac echocardiography (ICE) is an imaging technique that is becoming increasingly available as an alternative to transoesophageal echocardiography to guide percutaneous interventional procedures. The probe can be inserted under local anaesthesia and is principally used during closure of atrial septal abnormalities. The main advantages of ICE over transoesophageal echocardiography include the elimination of the need for general anaesthesia, clearer imaging, shorter procedure times and reduced radiation doses to the patient. Within this article we review some of the current applications of ICE and how to image from within the heart.

Coronary artery calcification (CAC) is a component of the development of atherosclerosis. Coronary computed tomography scanning (CCT) can detect calcification and may be useful in individuals considered asymptomatic. Oxidative stress and inflammation are linked through common pathways and both are thought to be involved in the pathogenesis of atherosclerosis. To investigate if CAC was associated with increased oxidative stress (plasma F2-isoprostanes) and inflammation (high sensitivity C-reactive protein [hs-CRP]), we invited 102 self-selected individuals (mean age 52+/-7 years) who were undergoing CCT to take part in a study. Height, weight and clinic blood pressure was measured, a blood sample taken and a health and lifestyle questionnaire completed.
CAC was found to be positively correlated with age (p<0.01) and alcohol intake (p<0.001). There was a trend for higher CAC in men compared to women (p=0.08). CAC was higher in ex- and current smokers versus non-smokers (115+/-45 vs. 28+/-12 Agatston score, p=0.05), and lower in non-drinkers versus drinkers (18+/-17 vs. 90+/-29 Agatston score, p=0.03). There were no univariate correlations between CAC and plasma F2-isoprostanes (p=0.25) or HS-CRP (p=0.36). In multivariate analysis, age, male gender and alcohol intake remained independent predictors of CAC. We concluded that CAC was not associated with inflammation or oxidative stress, but was related to lifestyle factors including; age, gender and alcohol consumption.