Clinical articles

This paper discusses the uses of the Multi-functional probing catheter™ (Boston Scientific, Scimed) in the arena of percutaneous coronary intervention with specific reference to treating chronic total occlusions. This catheter is essentially a speedy monorail balloon without the balloon mounted on the end. Thus, it has a short monorail/rapid exchange port which exits at the distal tip of the catheter, and an over-the-wire port which exits proximally at the side of the catheter.

Tackling chronic total occlusions often results in the creation of a false passage intramurally rendering it difficult to redirect the guide-wire into the true lumen. The Multi-functional probing catheter™ allows introduction of a second wire in a different direction from this lumen via the over-the-wire port. The benefits of this equipment for guide-wire support and wire exchange are examined. In addition, this support catheter allows distal vessel visualisation, confirming intraluminal wire position. A further use of this catheter is for intracoronary drug delivery especially in the context of vascular spasm, no reflow or thrombotic occlusion.

The use of the Multi-functional probing catheter™ in two chronic total occlusion interventions cases is discussed in detail.

Optimum delivery of cardiac rehabilitation is not well defined. A retrospective analysis was conducted to determine the short-term effectiveness of once-weekly compared to twice-weekly supervised cardiac rehabilitation. The analysis included 206 post-myocardial infarction patients who participated in either once- or twice-weekly supervised exercise sessions for six weeks. The primary outcome measure was the incremental shuttle walking test (ISWT). Secondary measures of health-related quality of life were also completed. Once-weekly supervised rehabilitation was completed by 85 patients (65 men), mean (SD) age 61.89 (10.27) years, and twice-weekly supervised rehabilitation was completed by 121 (94 men) mean (SD) age of 59.24 (10.03) years. Both groups demonstrated a statistically significant increase in ISWT distance post-rehabilitation, with mean increases of 100.71 metres (p<0.001) and 88.44 metres (p<0.001) for the once- and twice-weekly groups respectively. A reduction in hospital anxiety and depression scores and improvements in the MacNew quality of life questionnaire was also found. On comparing the magnitude of these changes, there was no significant difference between the two groups.

There is no evidence of additional short-term benefit, in terms of cardiovascular fitness and improvement in health-related quality of life measures, for patients attending twice-weekly supervised cardiac rehabilitation compared to once-weekly.

The condition of a large deposit of adipose tissue in the atrial septum or lipomatous hypertrophy of interatrial septum (LHIS) was first described in 1964. It has been reported that LHIS is associated with atrial arrhythmias but its clinical presentation as angina is uncommon. We report such a case here and a short literature review.

Cardiovascular disease prevention is one of the major challenges of medicine in the UK and the developed world. Progress in the primary prevention of these diseases has been slow and patchy due to the difficulties and costs with the methods currently used.

We set out to see in an observational study, if computer-based opportunistic screening could be a practical and cost-effective method of cardiovascular disease prevention in a high-risk primary care practice population in Barnsley, South Yorkshire. We found that over five years, 86% of the practice population was screened and educated for their personal risk of cardiovascular disease. This was carried out at a low cost in terms of both professional and administrative time.

Using this computer-based opportunistic screening enables a profile of risk factors for both individuals and the practice to be de-veloped making the targetting of resources for prevention easy and effective. It is also possible that this programme could prove to be a cheap and targetted method of screening for coronary heart disease, diabetes and familial hyperlipidaemia.

We conclude that computer-based opportunistic screening in general practice is an effective method of reaching a whole population and can enable large-scale interventions at low cost.

The management of the ‘tidal wave’ of obesity and type 2 diabetes that is expected to hit the UK over the next 10 years was one of the major themes to emerge from the Primary Care Cardiovascular Society Annual Meeting and AGM, held in Gateshead, October 5th – 7th 2006. Medical journalist Jo Waters reports.

The benefits of statins for both primary and secondary prevention of coronary heart disease (CHD) are limited mainly to patients under 80. We examined the impact of the new General Medical Services (GMS) contract on measurement of lipids and prescribing of statins in patients over 80 years of age with CHD. We found that there has been a significant increase in both, with little evidence supporting this and substantial financial implications. National guidance on the assessment and management of lipids in the over 80s in the new GMS contract is urgently required.

If you speak to any general practitioner (GP) in the next few months, there are three letters that will be occupying his or her mind: QOF. Rather than an exotic hairdo, this stands for ‘Quality and Outcomes Framework’ and determines a considerable proportion of our income.

Cardiac disease has emerged as the leading cause of maternal death during pregnancy in the UK. Its incidence has been rising in the past two decades, largely due to increasing mortality from acquired heart disease, which currently exceeds mortality from congenital heart disease. According to the Confidential Enquiry, better care could have altered the course of 40% of the deaths from cardiac causes. Management of these patients is critical, because any maternal complication has major impacts on surviving children. Improvements in maternal cardiovascular medicine require concerted efforts through interdisciplinary collaboration of all specialties caring for pregnant cardiac patients. One important area for improvement is on how to identify and evaluate those at highest risks of pregnancy-related cardiac complications. Most assessments and clinical guidelines for the management of pregnant women with heart disease have been based on retrospective lesion-specific information. Direct evaluation of cardiac function during pregnancy may add further information, improving the cardiac care we can provide to individual pregnant cardiac patients. More research in this area is urgently needed. We also propose that improvement in training, research and exposure to the subspecialty of maternal cardiovascular medicine is needed to continue to raise standards of care for this patient population.

Smoking cessation substantially reduces the risk of cardiovascular disease in the prevention of primary and secondary cardiovascular events. Current first-line therapies include nicotine replacement therapy and bupropion, that approximately double a smoker’s chances of long-term success. Both therapies are safe in patients with cardiovascular disease. Novel treatments include rimonabant, nicotine vaccines and varenicline. To date, varenicline, an a4a2 nicotinic acetylcholine receptor partial agonist has been approved for smoking cessation and has been shown to be efficacious and well tolerated in clinical studies conducted in healthy smokers.

Clinical guidelines focus on statins for dyslipidaemia management for prevention of cardiovascular disease. It is clear, however, that there remains an unacceptably high residual risk of further events among patients who achieve target low-density lipoprotein (LDL) cholesterol levels. Low high-density lipoprotein (HDL) cholesterol levels, an independent predictive factor, is likely to be an important contributor to this excess risk, and is also common among dyslipidaemic patients. The ARBITER 2 study (ARterial Biology for the Investigation of the Treatment Effects of Reducing cholesterol) showed that raising HDL cholesterol with prolonged-release (PR) nicotinic acid in addition to lowering LDL cholesterol with a statin slows progression of atherosclerosis, and would therefore be expected to improve cardiovascular risk reduction in this setting. This economic analysis evaluated the cost-effectiveness of this strategy using computer simulation economic modelling incorporating two decision analytic sub-models.

In the first sub-model, a cohort of 2,000 patients was generated using baseline characteristics and statin effect from the Heart Protection Study. Treatment effects observed with PR nicotinic acid (1,000 mg/day) in the ARBITER 2 study were then applied. The second model evaluated long-term clinical and economic outcomes using Framingham risk estimates. Direct medical costs were accounted from a National Health Service (NHS) perspective and discounted by 3.5%. In the UK setting, the addition of PR nicotinic acid to statin therapy resulted in long-term reduction in CHD events and increased life expectancy in patients who had achieved target LDL cholesterol levels but had persistently low HDL cholesterol, and this was achieved at a cost well within the threshold (< £30,000 per life years gained) considered good value for money in the UK. This strategy was highly cost-effective in patients with diabetes. Thus, adding PR nicotinic acid to statin therapy in these patients is both clinically and cost-effective and could be recommended for routine use in this setting in the UK.