Clinical articles

Patients with Eisenmenger syndrome generally die prematurely from complications directly due to their pulmonary hypertension and cyanosis, or due to intercurrent events that are poorly tolerated because of the underlying inadequate cardiopulmonary reserve. To date, clinical management has aimed at avoiding situations that would destabilise their condition and treatment of its complications. However, therapeutic prospects are starting to look more encouraging. Results from a small study with the oral dual endothelin receptor antagonist, bosentan, have shown improved exercise capacity. Additionally, there appears to be a possible role for the phosphodiesterase-5-inhibitor, sildenafil, in the treatment of Eisenmenger pulmonary hypertension.

The European Resuscitation Council guidelines for the management of cardiac arrest have been updated. The following commentary discusses the major changes, the evidence on which they are based and the practical issues of their introduction.

This short report looks at the incidence of vitamin D deficiency, which is an important problem in patients who take amiodarone and also in those who avoid sunlight exposure.

This case report discusses a 54-year-old woman who presented to hospital with recurrent bilateral pleural effusions. She was eventually found to have constrictive pericarditis secondary to malignant mesothelioma. This disease presents a challenge to the physician with considerable difficulties in diagnosis, classification and treatment. This particular presentation of malignant mesothelioma is highlighted in the article.

This study set out to assess whether the effectiveness and tolerability of lercanidipine for the treatment of essential hypertension in daily clinical practice is affected by body mass index (BMI) or body fat percent (BFP). A total of 2,793 out-patients (mean age 59.8 years) with mild-to-moderate hypertension participated in a multi-centre, prospective, open-label study. All patients received oral treatment over 12 weeks with lercanidipine 10 mg, which was titrated to 20 mg if blood pressure (BP) control was not attained. They were visited at baseline and at four, eight and 12 weeks. BFP was measured by the bioelectrical impedance analysis using an Omron BF-302 body fat monitor. Patients who were overweight or obese were also prescribed a hypocaloric diet.

Results showed that, at baseline, sytolic BP was 159.4+/-11.7 mmHg, diastolic BP was 94.5+/-7.5 mmHg, BMI was 30.9+/-8.4 kg/m2, and BFP 27.7+/-6.3%. At 12 weeks, BP was lowered to 138+/-10.1 mmHg (systolic) and 81+/-7.2 mmHg (diastolic) (p<0001). BMI and BFP significantly decreased to 29.3+8 kg/m2 and 27.3+4.1% (p<0.05), respectively, which was most likely to be diet-related. Antihypertensive effectiveness was independent of baseline BMI and BFP values. There was a low incidence of adverse effects (5.5%), with headache (3.4%) and pedal oedema (1.5%) being the most frequent. Some 93% of patients completed the 12-week treatment period.

The study showed that lercanidipine is an effective and well tolerated antihypertensive drug in daily clinical practice and its antihypertensive properties are not influenced by BMI and BFP.

Lifestyle modifications are an essential initial approach to the management of blood pressure. To review the current evidence in this area, The British Journal of Cardiology recently convened a round table meeting to look at the lifestyle management of raised blood pressure. It considered the role of dietary changes, exercise, alcohol and weight, and ways of changing patients’ behaviour, on blood pressure. The meeting, held at The Royal Society of Medicine, London, and supported by an unrestricted educational grant from Unilever, was attended by investigators involved in the EUROACTION study. EUROACTION is a European Society of Cardiology demonstration project in preventive cardiology which has just been completed in eight countries in both hospital and primary care. It is evaluating whether a nurse-led multidisciplinary team can help patients and families achieve recommended lifestyle and risk factor reduction targets for cardiovascular disease prevention.

Most doctors have only heard of Ernest Starling through his law of the heart, although this was not a particularly important part of his research output. Shortly after qualifying in medicine at Guy’s Hospital, London, in 1888 (where he won the university gold medal in medicine), he began investigating the formation of lymph. To explain his findings, he proposed an inward osmotic force at the capillary: the only possible source of this force was the plasma proteins. At the capillary there was a balance between an inward (osmotic) force and an outward (hydrostatic) force. This became Starling’s ‘Filtration Principle’, which, in retrospect, was a paradigm shift in our understanding of the circulation.

Excretion of excess urinary albumin is a marker of generalised endothelial dysfunction and both progressive renal disease and cardiovascular events in those with and without diabetes; its detection provides a simple way of identifying patients at particularly high risk. Effective management of cardiovascular risk factors and the use of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors have been shown to retard or prevent progression of microalbuminuria to more profound albuminuria. Microalbuminuria can be reversed by such therapy and recently an ACE inhibitor has been shown to prevent the development of microalbuminuria in hypertensive patients with type 2 diabetes. Given the increasing prevalence of type 2 diabetes and the corresponding ascendancy of ensuing cardiovascular disease and renal failure, strict control of multiple risk factors, including microalbuminuria, is to be encouraged.

The aim of this study was to assess whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) affected blood pressure control in patients with essential hypertension who were being treated with lercanidipine, a vasoselective dihydropyridine calcium channel blocker. A total of 334 patients (mean [+ SD] age 61+10 years, 51% females) with mild-to-moderate essential hypertension and a history of osteoarthritis received lercanidipine (10 mg/day, up-titrated to 20 mg/day) for four to eight weeks until blood pressure control was achieved. At that point, treatment with NSAIDs (mostly diclofenac and naproxen) was started. Treatment with NSAIDs was maintained for four weeks.

At baseline, mean systolic blood pressure (SBP) was 157=/-10 mmHg, diastolic blood pressure (DBP) 92=/-6 mmHg, and heart rate 75=/-9 beats per minute. The administration of lercanidipine was associated with a significant decrease of SBP (to 139=/-9 mmHg) and DBP (to 82=/-7 mmHg) (p<0.001), without changes of heart rate.

SBP and DBP readings were not affected by the concomitant use of NSAIDs. Among 156 patients whose blood pressure was well controlled with lercanidipine, 128 (82%) continued to have well controlled SBP and DBP readings. The remaining 28 patients had SBP and DBP > 140 and/or 90 mmHg, but differences in blood pressure between the two groups were not significant. Eight patients (2.3%) had mild side effects and three were withdrawn due to ankle oedema.

We conclude that the use of NSAIDs did not significantly modify the antihypertensive effect of lercanidipine in essential hypertension. Therefore, lercanidipine is a useful drug for hypertensive patients with osteoarthritis who require treatment with NSAIDs.

The aim of this study was to understand patients’ satisfaction with the Angina Plan (AP). Comments from the satisfaction questionnaire help us to understand why patients were satisfied with the AP.