Clinical articles

Meig’s syndrome is a condition in which an ovarian tumour (usually a fibroma) is associated with ascites and pleural effusion. It resolves after resection of the tumour. We report here what we believe to be the first case of a patient with pericardial effusion complicating Meig’s syndrome.

The recent withdrawal of rofecoxib, a COX-2 inhibitor,
has focussed attention on the use of COX-2
inhibitors and other non-steroidal anti-inflammatory
drugs (NSAIDs) in patients with cardiovascular disease.

Selective inhibition of COX-2 preferentially inhibits the production of prostaglandins responsible for vasodilation and inhibition of platelet aggregation. This potentially creates a pro-thrombotic state. This review examines the evidence that selective COX-2 inhibitors have adverse effects on the heart and circulation. The risk of myocardial infarction and other vascular ischaemic events, the effects on blood pressure and decompensation of treated heart failure are discussed. Conclusions are drawn about the relative risk with the different members of the drug class, and recommendations for clinical practice presented.

Multiple randomised controlled trials have unequivocally shown that lowering low-density lipoprotein cholesterol (LDL-C) results in a predictable reduction of coronary events and it appears that there is no threshold beyond which lowering LDL-C does not result in further benefit.
Although statins are the mainstay of treating hyperlipidaemia, they cannot always succeed in achieving more stringent lipid targets in some patients as they inhibit only one element of cholesterol homeostasis: the endogenous pathway. Ezetimibe is a novel agent which inhibits the exogenous cholesterol pathway, with resultant complementary benefits with statins.
Ezetimibe co-administered with a statin may provide an additional 16–18% reduction in LDL-C, compared to only a 6% further reduction in LDL-C with each doubling of a statin dose. This concept of combination therapy, tackling different homeostatic pathways, may be akin to strategies used in management of hypertension, where a combination of antihypertensive agents from different pharmacological classes is the norm.

The National Service Framework for Coronary Heart Disease recommended in 2000 that cardiac rehabilitation (CR) should be offered to 85% of patients recovering from myocardial infarction or revascularisation. This target is a long way from being met.
Provision of CR might be improved by addressing the problems met by CR coordinators. This study, through a questionnaire and more detailed surveys of CR coordinator experiences, set out to identify these problems. CR coordinators’ problems were canvassed in the 2001/2 Annual Survey of CR programmes in the UK and their responses were compared with figures from the same survey and from surveys from the North West and the South East Regions of England. We found their main problems included lack of money (87%), lack of staff (90%), lack of space (74%), lack of sessions (74%), failure of referral of heart failure patients (66%), attendance problems (71%) and waiting lists (55%). All of these perceived problems were confirmed by the figures from at least one of the surveys – and, in most cases, by two or three of the surveys.
These findings point to measures for improving CR provision. These include proper funding on a cost per patient basis, the provision of adequate space and the better use of information technology.

The provision of cardiac rehabilitation (CR) services in the UK was surveyed in March 2003. Three hundred questionnaires were sent to Directors of Public Health based in Primary Care Trusts. One hundred and eighty-five replies were received, a 61.7% response rate. In 72.8% of cases CR services were provided in both the acute and community sectors, but in 22.8% services were only available in the acute sector. CR services were patchy, lacked integration and in only 31.3% of Primary Care Trusts (PCTs) were they described as adequately funded.
Many patients are not receiving this important treatment modality after either myocardial infarction or cardiac surgery.

The National Institute for Clinical Excellence (NICE) stent appraisal (2003) defined criteria for the use of drug-eluting stents (DES) on the basis of lesion length, vessel diameter and the absence of recent myocardial infarction or intra-luminal thrombus. The appraisal suggested that as many as one third of all stents may need to be DES.
In order to determine the requirement for DES and adherence to these guidelines, we assessed 1,673 consecutive patients undergoing coronary intervention over a 17-month period. A total of 2,513 stents were implanted, of which 50.1% were DES. In all, 77.4% of patients fulfilled NICE criteria for at least one DES. A further 7.3% of patients were excluded because of either a recent (< 24 hours) myocardial infarct or visible intra-luminal thrombus. A total of 33.4% of patients who did fulfil NICE criteria for DES deployment inappropriately received a bare-metal stent (BMS) whilst 5.7% patients inappropriately received a DES. These results would suggest that NICE have grossly underestimated the need for DES in ‘real world’ practice. Despite our centre using a high volume of DES, significant numbers of patients were inappropriately treated with BMS, with a smaller number inappropriately treated with DES, according to NICE criteria.

As confidence in the use of drug-eluting stents (DES) increases, they are being used in patients with progressively more complex disease. Diabetes is still an independent risk factor for restenosis along with lesion length and reference vessel diameter.
This article gives an overview of recent stenting trials, including those with more complex disease such as DIABETES, PORTO 1 and TAXUS V. It also looks at head-to-head randomised controlled trials of sirolimus-eluting stents against paclitaxel-eluting stents: ISAR-DESIRE, SIRTAX, ISAR-DIABETES and REALITY. These give a better indicator of comparative efficacy than meta-analyses which include differing patient populations and trial designs. Finally, studies comparing angioplasty with surgery are considered.

The objective of this study was to assess the feasibility and impact of providing a primary percutaneous coronary intervention (PCI) programme for ST elevation myocardial infarction (STEMI) in a district general hospital (DGH) in the UK.
A retrospective review of cardiac catheter laboratory PCI database records and hospital notes was carried out in a 950-bed teaching DGH in the West Midlands, serving a catchment population of 500,000. The patients consisted of 108 men and women aged 28–86 years presenting with thrombolysis-eligible STEMI, treated by primary PCI between November 2002 and August 2004. The main outcome measures used in this study were time from hospital presentation to PCI (‘door to coronary device’ time), mortality and hospital length of stay.
The median door to device time was 86 minutes (range 25 to 286). Some 78% and 52% of patients had door to device times of less than 120 and 90 minutes, respectively. Median length of hospital stay was five days (range 3–30), compared to eight days in patients treated with thrombolysis in the years 2000–2004. In-hospital mortality was seven patients (6.5%).
We conclude that, in the contemporary era of interventional cardiology, it is feasible to introduce a primary PCI service for STEMI in a DGH setting with acceptable ‘door to coronary device’ times and mortality.

A 62-year-old man presented with chronic stable angina, how coronary angiography revealed a chronic proximal occlusion of the right coronary artery (RCA) with retrograde filling of the vessel from the septal branches of the left anterior descending (LAD) artery.