Clinical articles

Percutaneous coronary intervention (PCI) is expanding in terms of both the numbers of patients treated and the scope and severity of coronary artery disease tackled. These developments have occurred in parallel with increased awareness of the importance of accountability and clinical governance. Whilst cardiac surgeons have durable risk scores such as Parsonnet and EuroSCORE to assist them and their patients with estimating procedure-related risks, interventionists lack such universally accepted tools. Or do they? In this paper, we review the available PCI risk scores and point out the pressing need for the systematic use of a robust, simple and widely acceptable risk score for routine clinical use.

A 73-year-old man who had had a coronary bypass operation 15 years before presented with refractory angina despite full medication seven months after implantation of a 3.0 x 20mm non drugeluting stent in a saphenous vein graft (SVG) to the left circumflex artery.

A 73-year-old man presented with post-infarct angina. Cardiac catheterisation revealed mildly impaired left ventricular function and high-grade stenoses of the right, left anterior descending, ramus intermedius and left main coronary arteries (RCA, LAD, ramus and LMS respectively).

Recently, several techniques for non-invasive imaging of the coronary artery have emerged as promising alternatives to conventional coronary angiography for the diagnosis of coronary artery stenosis. Such imaging modalities include magnetic resonance imaging, electron-beam computed tomography and multi-slice computed tomography. With these technologies, images can be acquired rapidly with high temporal and spatial resolution. In their current state of development, non-invasive techniques can reliably be used to visualise significant stenosis of the proximal and mid portions of the coronary tree. However, complete assessment can be hindered by calcification in the vessel wall and by motion artefact.

As the population ages, so the prevalence of chronic heart failure (CHF) will rise. The majority of CHF patients in the future will be elderly, yet most of our current evidence for the management of this serious condition arises from trials that have largely excluded older patients. As a consequence, older patients who may derive the greatest benefit from treatments known to reduce morbidity and mortality in CHF, are often denied such treatments. The effects on quality of life of both the syndrome of CHF and its treatment in older CHF patients must be borne in mind, as must issues of compliance, prevalence of comorbidity, and requirement for physical and emotional support. We review the current epidemiology of CHF, and focus on the applicability and use of contemporary non-pharmacological and pharmacological therapy to older patients with CHF. The potential use of devices and surgery in older CHF patients is also discussed.

Chaucer’s characters in The Canterbury Tales meet on their journey to the shrine of Thomas à Becket. They are on a pilgrimage, a special kind of journey that brings a diverse group of people together in a common purpose. As they converge on the place of pilgrimage, the tales they tell are informed by the varied experiences of their lives. The stories we tell here are of individuals brought together by a single objective: to find a solution better than total root replacement for people whose lives are threatened by aortic dilatation due to Marfan syndrome. Chaucer’s pilgrims meet in the Tabard Inn in Southwark, where their journey to Canterbury is to begin. This modern journey began in St George’s Hospital at the 2000 meeting of the Marfan Association, when the surgeon [TT] told his tale, an account of best current practice and its attendant risks.

NAUTILUS (The multiceNtre, open, uncontrolled sAfety and tolerability stUdy of a modified-release nicoTinic acId formuLation in sUbjects with dySlipidaemia and low HDL cholesterol) was an open label, uncontrolled, phase IIIb study. The study population included a total of 566 patients with dyslipidaemia and low high-density lipoprotein (HDL) cholesterol (< 1.0 mmol/L [< 40 mg/dL] in men and < 1.2 mmol/L [< 46 mg/dL] in women) who were inadequately controlled by diet alone. Patients received once-daily treatment with prolonged release nicotinic acid (Niaspan^{®; target dose 2,000 mg/day), added to existing regimens for 15 weeks. At baseline, 40.5% of patients were receiving an HMG-CoA reductase inhibitor (statin), mostly simvastatin or atorvastatin.}

Patients taking and not taking concomitant statin therapy reported a similar incidence of all-cause adverse events (AE) of 64.6% vs. 57.9%, respectively, treatment- related AE (54.6% vs. 47.2%), all-cause serious AE (3.9% vs. 3.6%), treatment-related serious AE (0.9% vs. 0.3%), and withdrawals for AE (17.5% in each group). The incidence of flushing was similar in patients with and without statin treatment (45.0% vs. 40.1%), as was the proportion of patients withdrawing because of flushing (8.7% vs. 10.4%). Only about one quarter of patients flushed more than five times. There was no sign of serious hepatic or muscle toxicity. The addition of prolonged-release nicotinic acid markedly raised HDL cholesterol levels irrespective of statin treatment; it was well tolerated and effective when combined with a statin in patients with dyslipidaemia.

Older patients are often at high risk for cardiovascular disease. Low high-density lipoprotein (HDL) cholesterol is an independent risk factor for cardiovascular disease. Prolonged-release nicotinic acid (Niaspan^®) is a once-daily formulation of nicotinic acid with improved tolerability compared with the immediate-release formulation. It may be used to correct low levels of HDL cholesterol. NAUTILUS (the multiceNtre, open, uncontrolled sAfety and tolerability stUdy of a modified release nicoTinic acId formuLation in sUbjects with dySlipidaemia and low HDL cholesterol) evaluated prolonged-release nicotinic acid at doses of up to 2,000 mg/day once daily in 566 patients, of whom 33.6% were aged > 65 years.

A similar incidence of adverse events (AE) was observed following 15 weeks of prolonged-release nicotinic acid treatment in older vs. younger patients for all-cause AE (55.3% vs. 63.3%) and for treatment-related AE (46.3% vs. 52.1%). Most AE were related to flushing, which also occurred at similar frequency in older and younger patients (39.5% vs. 43.4%).

Gastrointestinal AE were the most common AE apart from flushing, and occurred in 12.1% of older patients and 14.4% of younger patients. Serious AE were uncommon. There was no hepatotoxicity or serious muscle toxicity. Marked improvements in indices of atherogenic dyslipidaemia were observed (increases from baseline in HDL cholesterol of 26% in older and 21% in younger patients and decreases in triglycerides of 16% and 9%, respectively).

Prolonged-release nicotinic acid is well tolerated and effective in older patients, and is suitable for correction of low HDL cholesterol in this population.

Heart failure has a comparable prognosis to many cancers and accounts for approximately 4% of deaths in the UK. Despite its poor prognosis, few patients have access to specialist palliative care services. The National Institute for Health and Clinical Excellence (NICE) acknowledges that the palliative care needs of patients with heart failure and their informal carers are not currently being met. Its recently published guidance recommends the development of an effective multidisciplinary service model for such patients.

Thrombolytic therapy in the management of acute myocardial infarction (MI) shows true evidence of benefit. Administration of a thrombolytic saves about 30 lives per 1,000 in those presenting within six hours of symptom onset but only 20 lives per 1,000 when patients receive treatment between six and 12 hours after symptom onset. After 12 hours there appears to be only a small and statistically uncertain benefit.

The aim in thrombolysis should be to increase the number of patients who achieve TIMI grade 3 flow as soon as possible after the occlusive event. Additional benefit in improving thrombolysis, particularly in reducing 30-day mortality, has been shown by adding the antiplatelet agent, aspirin, to thrombolytic therapy. The addition of a second antiplatelet agent, such as clopidogrel, has been shown to be of benefit in other, less immediately severe atherothrombotic manifestations (unstable angina and non-ST-elevation MI) and looks to be a promising development in the management of acute ST-elevation MI. The potential advantages of dual antiplatelet therapy in this setting, investigated in the recently published CLARITY study, are discussed.