Clinical articles

Inequalities in health care between men and women have been described extensively with regard to access to diagnostic and therapeutic procedures. These inequalities affect coronary heart disease care. Although survival rates differ for men and women following a myocardial infarction, this alone does not fully explain inequity in access to health services, especially diagnostic and treatment procedures, for infarct survivors.
A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients (41% female) admitted to the Acute Cardiac Unit, Nottingham.
Women expressed more dissatisfaction than men overall (p<0.05) and appeared to have more physical needs. Women were more likely to complain about transport, which influenced their access to healthcare facilities (p<0.001), to be concerned about getting help with cleaning (p<0.01), and to request information about rehabilitation services, potential limitations on their daily activities, and nutrition and diet (p<0.05).
Women had lower health-related quality of life scores in all the HRQL variables, which was significant in EQ-5D (usual activities, and pain/discomfort), Seattle angina questionnaire (angina stability), and both components of the Short Form-12.
This survey was the first attempt to apply a needs assessment tool combined with quality of life assessment for cardiac patients to identify potential gender disparities. Women reported greater health needs and greater dissatisfaction with current health services and had worse HRQL. Recognition of gender disparities in health needs and HRQL would clarify areas for improvement in healthcare services, and these might allow a better quality of life for infarct survivors.

There is no evidence from randomised controlled trials to guide oxygen treatment after stroke. This survey aims to establish a snapshot of views of clinicians on best current practice relating to the management of hypoxia early after acute stroke.
A postal questionnaire was sent to all 231 members of the British Association of Stroke Physicians (BASP). For 88% of the 130 respondents the decision to give oxygen was guided by the oxygen saturation, and for 67% it was guided by clinical criteria. The mean cut-off for oxygen supplementation suggested was ? 93% SD 2 (range 85–98%). Sixty-seven respondents would give oxygen by nasal cannulae and 74 via face mask. The oxygen concentration selected was 24% (n=17), 28% (n=31), 35% (n=15), 40% (n=3) and 100% (n=3).
This shows there is wide variation amongst stroke physicians about when to start oxygen, how much to give and by which route. There is a need for a randomised clinical trial to guide oxygen therapy after acute stroke.

The mainstay of heart failure management is angiotensin-converting enzyme inhibitor therapy initially as a vasodilator, followed by beta blockade at a varying time interval, based on clinical judgement. Early beta blockade has theoretical advantages in terms of possible protection against dysrhythmia or disease progression, although there may be short-term concerns regarding a possible deterioration in cardiac function and aggravation of heart failure.
The Cardiac Insufficiency Bisoprolol (CIBIS) III trial examined the optimum paradigm of initiating treatment for chronic heart failure (CHF). A large cohort of 1,010 systolic CHF patients, at least 65 years of age, with stable, mild-to-moderate symptomatic disease, were followed-up for a mean of 1.25 years. Patients were randomly allocated to initial monotherapy with bisoprolol for six months, followed by the addition of enalapril, or the opposite sequence. Efficacy and safety of the bisoprolol-first strategy versus the enalapril-first strategy was similar in terms of the combined primary end point of mortality or all-cause hospitalisation (hazard ratio 0.94, 95% confidence interval 0.77–1.16, non-inferiority p=0.02). The two approaches also showed similar safety. The bisoprolol-first strategy showed a 28% mortality reduction after the monotherapy phase (p=0.24) and a 31% borderline-significant mortality reduction during the first year (p=0.06), but was associated with a 25% increase in worsening of CHF events (p=0.23). This paper highlights important features of the study design and patient population. Both the clinical perspective and possible clinical implications of CIBIS III are discussed.

In spite of treatment with inhibitors of the renin-angiotensin system, plasma levels of aldosterone increase progressively in heart failure. This phenomenon of aldosterone escape is associated with adverse outcome. The aldosterone receptor antagonists spironolactone and eplerenone can improve prognosis for patients with heart failure. The commonest, and often problematic unwanted effect of these agents, hyperkalaemia, may limit their usefulness and brings with it the need for careful clinical and biochemical monitoring. Recent trials, however, have shown clear benefits for large groups of patients for spironolactone (in severe chronic heart failure) and eplerenone (heart failure soon after acute myocardial infarction). Due consideration should be given to the addition of the appropriate aldosterone antagonist in suitable patients.

Coronary angiography is an imperfect tool for assessing the functional significance of lesions: while this may be determined non-invasively using myocardial perfusion scintigraphy or stress echocardiography, it is often not done. In these circumstances the coronary pressure-derived fractional flow reserve (FFR) serves as an alternative, lesion-specific means of assessing physiological importance.
FFR is an invaluable tool not only in determining whether a lesion is functionally significant and should be tackled, but it also ensures that the appropriate physiological outcome is obtained from coronary intervention.

Early invasive management in patients with unstable angina and non-ST elevation myocardial infarct (NSTEMI) is now well established. However, patients can wait for weeks at district general hospitals (DGHs) for in-patient transfer to the cardiac centre for percutaneous coronary intervention (PCI), which results in inefficient bed utilisation.
At the Yorkshire Heart Centre (YHC), the referral process for unstable angina/NSTEMI was streamlined to minimise the delay between time of referral and PCI. We audited the waiting time from referral to the PCI procedure as well as the six- and 12-month outcomes for both acute and elective PCI and compared our outcome data to the published trials.
A total of 1,757 patients underwent PCI at YHC in 2002; of these 47% were acute cases. 72% of patients were treated within two days of referral and 97% within three days. The mean waiting time for patients referred from within the YHC was 1.9 days and for those referred from the DGHs was 2.2 days. The six-month mortality rate for the acute PCI group was 2.5%.

This article aims to provide a primer on decision modelling to assess the cost-effectiveness of interventions in cardiology. The paper uses a cost-effectiveness model developed to compare alternative coronary stents. This decision analytic model assesses costs to the UK health service and health benefits in terms of quality-adjusted life-years (QALYs). Data were taken from a range of sources, including 12-month follow-up data from three important double-blind randomised controlled trials: RAVEL, SIRIUS and E-SIRIUS. Methods are employed to show the uncertainty in cost-effectiveness.
Sirolimus-eluting stents were compared to ‘bare metal’ stents in constructing this decision model. The patients included were those individuals with stable coronary disease randomised to the three trials.
The main outcome measures were: mean QALYs, mean health service costs, incremental cost per additional QALY, and the probability that sirolimus- eluting stents are more cost-effective than bare metal stents.
Mean QALY gains per patient from the sirolimus-eluting stent range from 0.011 to 0.017 over 12 months. Although the list price of the sirolimus- eluting stent is £617 more than the bare metal stent, its additional total mean cost per patient, including ‘cost offsets’ from a lower rate of subsequent events, ranges from £53 to £166. The incremental cost of the sirolimus-eluting stent per additional QALY ranges from £3,181 to £15,198. The probability that the sirolimus-eluting stent is less costly than the bare metal stent ranges from 0.13 to 0.34. If the health service is willing to pay up to £40,000 per additional QALY, the probability of the newer stent being the more cost-effective ranges between 0.8 and 1.0. These results are sensitive to assumptions about the price differential between the two forms of stent.
Cost-effectiveness analyses based on models are used increasingly as a basis for decision making. It is essential that these models are developed with clinical input regarding appropriate assumptions and interpretation of evidence.

Due to advances in paediatric congenital heart surgery in recent years, the number of patients who survive into adulthood with complex congenital heart disease has increased remarkably. When these patients present to non-specialist hospitals with apparently specific symptoms, the diagnosis may not be as straightforward as initially thought. Here we highlight a case which demonstrates this.

The National Service Framework for Coronary Heart Disease (CHD) stated that individuals at greatest risk of CHD should be identified. This category included those with diagnosed peripheral vascular disease. Despite this, the condition was not included in the Quality and Outcomes Framework of the new General Medical Services contract. This article looks at the strong evidence to include peripheral arterial disease in the next update of the GMS contract, which is expected in April 2006. It also looks at what is being done to identify such patients, and their relative risk compared to other subpopulations at risk of atherothrombosis. The setting up of an international register – the REACH registry is also discussed.

Two surveys were carried out to look at statin prescribing in UK general practice. The first was a study of the Mediplus prescribing database in relation to coronary heart disease (CHD) patients prescribed a statin. The second was a postal survey of the attitudes and beliefs about statin prescribing among general practitioners (GPs) who had contributed to this database. Results showed that despite 80% of GPs believing they had achieved target cholesterol levels (< 5 mmol/L) in 80% of their CHD patients, this was initially only achieved in 65% of patients, rising to 78% after titrations and switching. Only 46% of patients achieved a chol-esterol reduction of 25%, which increased to 56% after titrations and switching.