Clinical articles

The Scottish Intercollegiate Guidelines Network (SIGN) 2002 acknowledge the multiprofessional membership of cardiac rehabilitation (CR) teams required to deliver comprehensive CR. The clinical groups chiefly involved in delivering CR in the UK are nurses followed by physiotherapists. The participation, skills and attributes of physiotherapists in the UK have already been identified. This paper reports on the findings of a similar survey for nurses. The survey was piloted and then sent to all registered centres on the British Association for Cardiac Rehabilitation (BACR) and the Scottish CR Interest Group databases (CRIGS).

In his contribution to The auditory culture reader, Murray Schafer introduces the notion of clairaudience. Clairaudience refers, most fundamentally, to an ability to hear and, more specifically, to a capacity to hear ‘through’ or ‘beyond’ the sensory horizons which normally present themselves. This is a very suitable concept through which to consider the ear of an experienced auscultator. Not only is he or she able to hear through the layers of tissue which constitute the body and which usually contain sound, rendering it inaudible, but the auscultator is also able to infer what certain sounds might mean and what significance they might hold for a patient’s well-being in the present and future. The auscultator is able to deduce the relevance of sounds which are ‘unheard’ to the patients, and which remain incomprehensible to those not trained in medicine. An experienced auscultator holds a very particular sensory power.

Alcohol septal ablation is a percutaneous alternative to surgical myotomy-myomectomy for symptomatic patients who have hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction. In the 11 years since its inception, the procedure has been proven safe and effective. While septal ablation may be more acceptable to patients than surgery, it lacks the long-term safety record of myotomy-myectomy. Here we discuss the mechanics of the procedure itself and examine its place in clinical practice, highlighting the importance of appropriate patient selection.

Pathological findings compatible with hypertrophic obstructive cardiomyopathy (HOCM) were first described in the nineteenth century by the French pathologists, Hallopeau and Liouiville. However, it was not until 1958 that Teare recognised the condition as a separate entity; Goodwin named it HOCM in 1960.

This paper considers the role for glitazones in the treatment of type 2 diabetes following publication of the PROactive study, the first major outcome study with this class of agents. The macrovascular benefits of glitazones are discussed. Recent guidance for glitazone prescribing from the Association of British Clinical Diabetologists is also given.

DISCOVERY-UK (the DIrect Statin COmparison of LDL-C Values: an Evaluation of Rosuvastatin therapY) was an open-label, parallel-group, multicentre study designed to compare the efficacy of recommended start doses of rosuvastatin with atorvastatin and simvastatin for reduction of low-density lipoprotein cholesterol (LDL-C) and goal attainment.

Patients with type IIa or type IIb hypercholesterolaemia and a 10-year coronary heart disease (CHD) risk > 20% or a history of CHD or other established atherosclerotic disease were randomised to receive rosuvastatin 10 mg, atorvastatin 10 mg or simvastatin 20 mg for 12 weeks.
Significantly greater LDL-C reductions were observed with rosuvastatin 10 mg compared with atorvastatin 10 mg and simvastatin 20 mg (50% versus 42% and 40%, both p<0.0001). The 1998 European goal (LDL-C < 3.0 mmol/L) was achieved by 89% of patients receiving rosuvastatin 10 mg, which was significantly more than patients receiving atorvastatin 10 mg (78%) and simvastatin 20 mg (72%) (both p<0.0001). Similar results were observed for the National Cholesterol Education Program Adult Treatment Panel III goal (LDL-C < 2.6 mmol/L) and 2003 European goals (LDL-C < 3.0 or < 2.5 mmol/L, depending on risk category). In conclusion, rosuvastatin is more effective than atorvastatin or simvastatin for lowering LDL-C and enabling patients to achieve lipid goals at recommended start doses.

Microvascular perfusion is considered a key factor with respect to preservation of left ventricular function and prognosis. No-reflow is recognised in the context of acute coronary syndromes and percutaneous intervention: myocardial blood flow at a tissue level remains impaired following restoration of epicardial flow. Once no-reflow is established, treatment is often ineffective and this phenomenon is associated with poor short- and long-term outcomes. A number of different pharmacological agents are used to prevent and treat this condition although data to support their use are limited. This article examines the pathophysiological aspects of this condition, its clinical correlates and proposed management strategies.

This study evaluated primary care hypertension management against UK quality targets and prescribing guidelines through a survey of 738 hypertensives in an urban three-partner personal list practice in April 2005. It looked at screening rates, prevalence, blood pressures of under 150/90 mmHg, measurement bias, ABCD prescribing and cost. The survey found that 94% of adults aged 25–79 years had been screened. With 738 confirmed cases, prevalence was 11.7% for all ages; 14.4% for those aged more than 16 years; and 46% in those over 65 years of age. Some 442 patients had ‘potential’ hypertension with their last blood pressure measurement being greater than 140/90 mmHg but inadequate follow-up. Blood pressure control of less than 150/90 mmHg was achieved in 83% of hypertensives with a six-fold terminal zero measurement bias. Looking at ABCD agents, 1,186 had been prescribed (1.84 per patient) costing £129,100 per annum. We believe that QOF hypertension prevalence in the practice (11.7%) and England (11.3%) is less than half the rate reported from community surveys. The practice demonstrated that QOF outcome targets are achievable by improving blood pressure targets to under 150/90 mmHg from 52% of patients in 2002 to 83% of patients by April 2005. Practice organisation, personal patient lists and quality targets were important factors in delivering successful care. Automated blood pressure measurement could eliminate observer bias. Restructuring therapy repeat instructions to include ABCD data encourages logical prescribing.

How well do primary care teams identify patients with CHD and diabetes? The British Women’s Heart and Health Study, a prospective cohort study, suggests that as many as half the women identified as having CHD on practice registers (and almost one third of diabetics) appear not to have the condition after a detailed manual review of records. The importance of auditing practice registers is highlighted.

Myocardial calcification is a rare finding usually
detected by computerised tomographic (CT)
scanning. It is often missed and, when found,
is often misdiagnosed. The addition of magnetic
resonance imaging (MRI) to our investigative
armamentarium enables correct diagnosis and
appropriate management(October 2002). She underwent
coronary angiography, which showed normal coronary arteries
but significant left ventricular impairment. She continued to be
managed medically for ventricular dysfunction.