Clinical articles

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.

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.