Clinical articles

A 75-year-old gentleman presented to his general practitioner with palpitations and dizziness. A 24-hour Holter monitor confirmed the diagnosis of paroxysmal sustained atrial flutter and episodes of less organised rhythm, that were thought to be atrial fibrillation. His symptoms failed to improve on combination treatment with digoxin and bisoprolol. He was referred for flutter ablation. Our aim was to replace the above pharmacological agents with a class 1C drug. The patient was not taking warfarin. A transoesophageal echocardiogram (TOE) was therefore arranged to exclude left atrial thrombus, prior to performing the ablation.

In 1993, a 61-year-old man underwent balloon angioplasty to the left anterior descending artery (LAD) after an anterior myocardial infarction. Repeat angiography in 1997 after a recurrence of symptoms revealed a severe proximal LAD stenosis, and this was again treated by balloon angioplasty. Two months later, the LAD had occluded and a 16 mm bare stainless steel stent (Nir®) was implanted with a 3 mm balloon (figure 1). Four months afterwards, angiography revealed severe in-stent restenosis (figure 2) and he was referred for coronary artery bypass grafting; the left internal mammary artery (LIMA) was grafted to the LAD.

He remained symptom-free for six years until 2004, when his angina recurred. Repeat coronary angiography demonstrated spontaneous regression of the previously stenosed LAD stent, which was now widely patent (figure 3). The LIMA graft had involuted. A new stenosis in a large obtuse marginal branch was treated with a drug-eluting stent.

This article describes the evaluation of a new postgraduate diploma in cardiology course run by the Bradford City Teaching Primary Care Trust.

Heart failure is a common condition, characterised by poor prognosis. Despite evidence that effective treatment improves symptoms and prognosis, management remains sub-optimal. General practitioners (GPs) have a key role in the assessment and treatment of patients with heart failure. This study was designed to ascertain the knowledge and attitude of GPs towards the management of heart failure.

Anonymised questionnaires were sent to 355 GPs in the Nottingham area in May 2003 and 227 (64%) responded. The mean (standard deviation) age of respondents was 45 (7) years and they had been in general practice for 15 (7.6) years. The questionnaires found that 223/227 (98%) of GPs were aware that angiotensin- converting enzyme (ACE) inhibitors have been shown in clinical trials to reduce mortality in heart failure; 155/224 (69%) were aware that beta blockers reduced mortality in heart failure; 53/225 (23.3%) believed diuretics improved prognosis. Almost 60% routinely initiated ACE inhibitors but 26% expressed concerns about their side effects and so were less likely to initiate this treatment.

Most GPs seemed able to manage heart failure effectively and ACE inhibitor prescription for patients with chronic heart failure (CHF) is now well established within primary care. Knowledge and prescription rates for the remaining effective therapies remain low.

Miniaturisation of machines has allowed echocardiography to be performed in the community as well as anywhere in the hospital. It has led to an expansion of the types of study performed: ultrasonic stethoscope, screening and focused studies, and standard echocardiograms. In expert hands, results compare favourably with standard studies on full systems. With focused studies, abnormalities may be missed in areas of the heart that are not imaged. For screening studies, the negative predictive accuracy is high while the positive predictive accuracy is lower.

Portable echocardiography can save time and costs, but it is essential that studies are requested and performed within a tightly controlled clinical setting. Operators should be trained appropriately and be part of a broad echocardiography service that includes quality control, continuing education and expert supervision.

Familial hypercholesterolaemia (FH) affects about one in 500 in the UK population. There are no symptoms or signs of raised cholesterol in children and so individuals can only be identified by screening, usually as a ‘cascade’ from known probands. Once identified, such children should be treated to prevent premature atherosclerosis.

The effectiveness of rosuvastatin in improving lipid measurements and achieving guideline target levels in patients has been demonstrated in short-term randomised clinical trials. The Framingham Heart Study has provided some of the strongest evidence in establishing the relationship between risk factors such as smoking, hypertension and cholesterol and events from cardiovascular disease and subsequent mortality. Using Framingham risk equations for coronary heart disease, we used a Markov model to extrapolate beyond short-term trial evidence to calculate the cost-effectiveness of cholesterol-lowering therapy in 55-year-old men and women, with an initial total cholesterol: high-density lipoprotein cholesterol (TC:HDL) ratio of 5.5 and an untreated expected survival (under adjusted Framingham risk equations) of 17 years (men) and 19 years (women). After titration, cholesterol-lowering therapy reduced the weighted average TC:HDL ratio to 3.4 (rosuvastatin), 3.7 (atorvastatin), 3.9 (simvastatin), 4.1 (fluvastatin) and 4.2 (pravastatin). In comparison with no treatment, rosuvastatin produced the greatest health gain (0.71 quality-adjusted life-years [QALYS]) and pravastatin the smallest (0.42). In the base case analysis, rosuvastatin dominated atorvastatin and delivered additional benefits at the cost of £9,735 per QALY for men in comparison with generic simvastatin. Sensitivity analysis showed a high probability of rosuvastatin being cost-effective under conditions of uncertainty.

Although levels of total cholesterol are similar between populations with and without diabetes, there are important differences in lipid sub- fractions, with diabetic dyslipidaemia characterised by reduced levels of high-density lipoprotein (HDL) cholesterol and elevated triglycerides. In addition, small, dense, low-density lipoprotein (LDL) particles may increase atherogenicity. These differences may account for the increased vascular risk reported in diabetic populations. The benefit of HMG Co-A reductase inhibitors, primarily through LDL cholesterol reduction, has been demonstrated in populations with ischaemic heart disease. Fibrates are synthetic activators of the a subclass of the peroxisome proliferator-activated receptor (PPAR), and are reported to raise HDL cholesterol and lower triglyceride levels preferentially. The FIELD study was designed to assess whether the theoretical benefit offered by fibrates in diabetic dyslipidaemia was reflected in improved cardiovascular outcomes.

A major concern in cardiology in the UK has been the waiting times for patients referred from primary care to secondary care, which are often long. We have addressed this problem in our Trust. At various times the Trust had funded waiting list initiative clinics but, apart from small and transitory improvements, the situation continued to worsen. Various solutions to the out-patient services problems have been implemented. However, there is a lack of published information about system redesign.

In this article we present some of the principles we are currently employing to redesign our out-patient service with a view to improve its efficiency. Our results are being published separately.

Cardiac angiosarcomas are malignant tumours that are rare, often with non-specific symptoms. They almost always have a rapid and fatal evolution, making diagnosis challenging. Therapeutic approaches include surgery, chemotherapy and radiotherapy alone, or in combination, but because the tumour is rare there are no randomised studies to guide treatment. Management is, therefore, usually individualised and often multidisciplinary.