Clinical articles

National Institute for Health and Clinical Excellence (NICE) guidelines in the UK state that suspected heart failure patients should have an ECG in order to select patients for echocardiography. The research underpinning this recommendation comes from studies in which cardiologists interpreted the ECGs. In practice, however, it would be general practitioners (GPs) interpreting ECGs.

The aims of this study were to assess both GPs and ECG machine interpretation in their ability to use ECGs to select suspected heart failure patients for echocardiography.

Six GPs were asked to classify 90 ECGs taken from suspected heart failure patients either as normal or as having an abnormality present. The ECG machine report was also used to classify the ECG in the same way. These results were compared to a gold standard interpretation.

The GPs and the ECG machine report would have not referred 17.8% and 8.3%, respectively, of the appropriate patients for echocardiography. In doing so, the GPs would have missed 5.6% of patients with left ventricular systolic dysfunction (LVSD) whereas the ECG machine report would have missed none.

We conclude from our findings that there is heterogeneity between GPs in their interpretational skills. Some GPs could successfully use ECGs to select patients for echocardiography. The difference in cost between performing echocardiography on all patients and GPs screening with ECGs is £74 more per case. Screening with ECG machine interpretation costs virtually the same as performing echocardiography on all patients.

The study documents general practitioner (GP) consultations before and after a primary, acute myocardial infarction (MI) and examines how these relate to psychological distress. Data were derived from the numbers and category of consultations and their outcome, documented from medical records of 194 patients with a primary acute MI over a two-year period pre-MI and a six-month period post-MI. Objective measures of anxiety and depression were collated using the Hospital Anxiety and Depression Scale in four phased assessments over a six-month period following the MI. There was a high probability of consultation for cardiovascular and psychological symptoms before a MI. Post-MI, almost all patients receive an early consultation: high consultation rates continue for cardiovascular concerns but they are relatively low for psychological issues. However, questionnaire responses indicated a substantial minority of patients with clinical or borderline clinical levels of anxiety (30%) and depression (20%) post-MI.

Patients are willing and able to make demands on their GPs post-MI, but not for psychological issues despite evidence of high levels of anxiety and depression; patients may be too accepting of distress. While GPs advise and are prepared to provide drug treatment for psychological concerns, they did not make referral for psychological support.

Loss of the right ventricular artery (RVA) is generally thought to be of little consequence. Nonetheless, reperfusion can enhance right ventricular recovery and improve the clinical condition.
Five cases of percutaneous coronary intervention involving right ventricular branches are presented.
We advocate a more positive approach to a significant stenosis in the RVA in patients who have stable or unstable angina or non-ST segment elevation myocardial infarction. Re-establishment of flow should limit ischaemia and infarction of the right ventricle and limit their adverse effects.

A 69-year-old woman was referred for cardiac catheterisation following a positive exercise tolerance test.

Most coronary artery fistulae are asymptomatic but there may be complications such as rupture and myocardial infarction. Percutaneous intervention is an attractive alternative to open surgical repair that offers lower procedural risk.
Increasing numbers of fistulae are being discovered incidentally during angiography. They present challenges in assessment and management. For example, there is poor correlation between symptoms and the size and flow rate of fistulae.

Minimising the in-hospital stay of patients with chest pain, within safe limits, is crucial in reducing the cost of health care. The aim of this study was to determine whether the use of near-patient testing for cardiac troponin I could reduce the duration of in-hospital stay for patients presenting with chest pain who were considered to be at low risk of death or myocardial infarction.
This prospective observational study of consecutive patients admitted with chest pain of possible cardiac origin was conducted in a medium-sized district general hospital. A near-patient system for troponin I analysis was compared to traditional laboratory-based troponin I analysis to assess any effect on duration of in-hospital stay in low-risk chest pain patients. Of the 295 patients enrolled in the study, 191 (68.7%) were troponin-negative and were classified as having chest pain of non-cardiac origin or cardiac pain at low risk of major adverse events. The introduction of near-patient testing for cardiac troponin I reduced the mean duration of hospital stay from 30.04 hours to 17.10 hours (p<0.001). At 30-day follow-up no deaths or myocardial infarctions had occurred.

The case of a 70-year-old-woman affected by Friedrich’s ataxia (FRDA), unstable angina and heart failure with left main ‘equivalent’ lesions is presented. As the patient was in need of revascularisation but would have been at high risk with coronary artery bypass grafting surgery, she underwent coronary angioplasty assisted with percutaneous cardiopulmonary support (PCPS). Despite the onset of temporary complications, the procedure was performed successfully. On the basis of this case and of a review of pertinent literature, the authors discuss the role of PCPS in high-risk patients, with respect to its indications and performance technique.

Biventricular pacing is increasingly used in the management of severe heart failure. We report the successful use of biventricular pacing to aid weaning from mechanical ventilation in a patient with severe left ventricular dysfunction.

The second annual survey from the British Junior Cardiologists’ Association (BJCA) has new data on several areas, including the European Working Time Directive, modernising medical careers, and careers in academic cardiology. The surveys are becoming a strong and influential voice in cardiology. Last year’s survey was noted by many national bodies, including the British Cardiac Society (BCS) and the Royal College of Physicians. Over a third of BJCA members responded to this year’s survey and Dr Saul Myerson, BJCA President, highlights some of this year’s trends.

A constant abundance of food and a sedentary lifestyle has led to an increasing prevalence of obesity in the United Kingdom. This has resulted in a serious public health problem as obesity, in particular the presence of excess abdominal (visceral) fat, is associated with a high risk of cardiovascular disease, type 2 diabetes and the metabolic syndrome. Managing obesity by lifestyle changes alone has met with only limited success, so pharmacological intervention is often necessary to help patients reduce their cardiometabolic risk profile. The recent discovery of the role of the CB1 receptors of the endocannabinoid system, and how these receptors influence appetite and energy storage, has led to the development of promising new approaches to the management of obesity. This review charts the background to the development of novel antagonists (CB1 blockers) directed against the CB1 receptors and briefly summarises the available phase III data. The available phase III data suggest that CB1 blockers could have a major role to play in the management of multiple cardiovascular risk factors, by reducing visceral fat and directly improving lipid and glucose metabolism and insulin resistance.