Clinical articles

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.

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.