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Clinical articles

January 2003 Br J Cardiol 2003;10:70-2

Amiodarone monitoring: involving patients in risk management

Jill Murie

Abstract

Amiodarone is a potentially hazardous drug indicated for atrial and ventricular arrhythmias. The purpose of the audit was to assess the risk associated with amiodarone therapy and identify measures to improve patient safety. The setting was a rural practice with 13,000 patients in Lanark, Scotland. A computer search identified 16 patients (11 male, five female) receiving amiodarone. The mean age was 74 years (range 61–89 years).
Action taken was raising doctor awareness and systematic biochemical and clinical review. Results showed that, in spite of substantial mortality and morbidity prior to the audit, there was no effective practice monitoring system for amiodarone therapy. The prevalence of clinical hypothyroidism and hyperthyroidism (29%) and ‘silent’ biochemical thyroid dysfunction (14%) exceeded published estimates (14–18% and 10% respectively). Although standards improved for biochemical monitoring, increasing awareness of the need for close surveillance did not appear to change the practice of some of the general practitioners (GPs), notably the clinical examination of pulse and blood pressure.
The audit demonstrates a need for a more systematic approach to amiodarone monitoring. Recommenda-tions include enhancements to the patient information leaflet, the development of local protocols and patient involvement in quality improvements including improved communication, patient-held record cards, better quality follow-up information, and more effective reporting systems.

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January 2003 Br J Cardiol 2003;10:59-68

Current progress in lipid therapy

Rubin Minhas

Abstract

There is strong evidence to support a causal relationship between the level of circulating plasma cholesterol and the risk of clinically overt coronary heart disease (CHD) events. Current UK guidelines recommend reductions of total cholesterol levels to below 5.0 mmol/L. Statins remain the drugs of first choice for reducing low-density lipoproteins (LDL). Rosuvastatin has already been approved in the Netherlands and is likely to become more widely available in the next year. It has a potent effect in lowering LDL and it also appears to raise high-density lipoproteins (HDL). It has a similar safety profile compared with other statins.
Cholesterol absorption inhibitors are a new treatment option for the management of hypercholesterolaemia. Ezetimibe, the first drug in this class, has recently been approved for use in the US and Germany. It selectively inhibits the uptake of dietary and biliary cholesterol at the level of the enterocyte. The site of action of ezetimibe may be the ‘sterol permease’ transport protein. As monotherapy, the role of ezetimibe appears limited at present. However, in combination with a low-dose statin, significant reductions in plasma LDL levels are seen. It may also be a useful agent for patients with homozygous familial hypercholesterolaemia.

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January 2003 Br J Cardiol 2003;10:56-7

Pregnancy following heart transplantation: a case report

Thomas A Barker, Lawrence Cotter

Abstract

The success of developments in heart transplantation has given women recipients the opportunity to have children. The first successful pregnancy in a patient who had received a heart transplant was reported by Lowenstein et al. in 1988.1 The cardiovascular effects of pregnancy demonstrate the durability of transplanted hearts. We report a successful pregnancy in a 20-year-old patient who had previously had a heart transplant; we also discuss the management of such patients.

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January 2003 Br J Cardiol 2003;10:50-4

National survey of emergency department management of patients with acute undifferentiated chest pain

Steve Goodacre, Jon Nicholl, Jo Beahan, Deborah Quinney, Simon Capewell

Abstract

Acute, undifferentiated chest pain (chest pain ?cause) presents a frequent and difficult challenge to clinicians working in the emergency setting. We aimed to survey current management of this problem in UK accident and emergency departments by sending a postal questionnaire to the lead clinician or first named consultant in every major A&E department in the UK.
Responses were received from 177/238 departments (74%). Although 74 departments (42%) had formal guidelines, many referred only to diagnosed coronary syndromes. Guidelines for undifferentiated chest pain usually recommended observation for six to 12 hours followed by troponin testing. Short-stay facilities were available in 38 departments (21%) and were planned for 55 departments (31%). Provocative cardiac testing could be accessed by 38 departments (21%). Patients were admitted by general physicians in 152 hospitals (86%) and cardiologists in 18 (10%). The estimated proportion of patients admitted was extremely variable. Although 45 departments (25%) employed specialist nurses, only in 20 did they manage patients with undifferentiated chest pain.
Reported management of acute, undifferentiated chest pain in the UK shows wide variation. Innovative technologies and diverse methods of service delivery are being adopted in a number of departments. These innovations require thorough evaluation.

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January 2003 Br J Cardiol 2003;10:45-48

The future of cardiology – heart disease in older patients

Andrew Docherty, Jacqueline Taylor, Adrian JB Brady

Abstract

Cardiovascular death is steadily decreasing but still accounts for 40% of deaths (235,000) in this country per year. More than 85% occur in older patients over the age of 65 years. The future of cardiology lies in the delivery of care to this rapidly expanding population of older people, whose growing numbers will account for an increasing trend upwards in the prevalence of cardiovascular morbidity in the UK. There will be increasing numbers of heart failure, hypertension, myocardial infarction, angina, atrial fibrillation, pacemaker implants and heart valve implantation in older patients. Randomised clinical trials often exclude the treatment of these conditions in patients over 75 years and results cannot always be easily extrapolated. Older patients often seem to be disadvantaged when compared with younger patients with cardiovascular disease. This article is the first in a series examining the treatment of older patients with cardiovascular disease.

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January 2003 Br J Cardiol 2003;10:36-43

Prescribing of ACE inhibitors and statins after bypass surgery: a missed opportunity for secondary prevention?

R Andrew Archbold, Azfar G Zaman, Nicholas P Curzen, Peter G Mills

Abstract

Angiotensin-converting enzyme (ACE) inhibitors and statins improve prognosis in patients with coronary artery disease. Effective secondary prevention strategies, however, are frequently under-utilised. We sought to determine prescribing habits for ACE inhibitors and statins in 324 patients undergoing coronary artery bypass graft surgery (CABG) at two regional cardiac centres in the United Kingdom. We prospectively recorded ACE inhibitor and statin use on admission and discharge, ACE inhibitor and statin initiation and withdrawal during the hospital stay, and sought associations with treatment withdrawal. 82 (25.3%) patients were taking an ACE inhibitor on admission compared with 37 (11.4%) at discharge (p<0.0005). An ACE inhibitor was initiated during the hospital stay in five (1.5%) patients and was withdrawn in 50 (15.4%). On admission, 157 (48.5%) patients were receiving statin therapy compared with 154 (47.5%) at discharge (p=ns). Statin treatment was initiated in 23 (7.1%) patients, but was withdrawn in 20 (6.2%) others. Thus, only a minority of patients were receiving ACE inhibitors and statins on admission for isolated elective CABG. ACE inhibitor treatment was discontinued during the hospital stay in over 60% of these patients. Furthermore, statin therapy was no more common at discharge than on admission. This study highlights a missed opportunity for effective secondary prevention in a high risk population.

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January 2003 Br J Cardiol 2003;10:29-34

The SIGN guideline on cardiac rehabilitation

Chris Isles

Abstract

The SIGN guideline on cardiac rehabilitation was published in January 2002 and endorsed by the British Association of Cardiac Rehabilitation. This paper summarises the recommendations, which cover all four phases of recovery and the three main cardiac rehabilitation interventions.

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November 2002 Br J Cardiol 2002;9:624-7

Early thrombolysis for the treatment of acute myocardial infarction. Who will provide this treatment in the UK? Part II.

Terry McCormack

Abstract

This article describes the successful provision of a thrombolysis service by general practitioners in the isolated rural area of Whitby, North Yorkshire, and also in rural areas of Sweden. It discusses the difficulties in providing such a service, particularly the rural/urban paradox whereby specialist pre-hospital thrombolysis services can be much more easily provided in urban areas than rural areas where the need is normally much greater.
The results of a small straw poll on thrombolysis amongst Primary Care Cardiovascular Society members show that rural general practitioners are much more interested in providing a pre-hospital thrombolysis service than their urban colleagues; paying a fee for such a service should be considered in future planning. The article also reviews the various thrombolytic agents favouring the use of fibrin-specific thrombolytic agents by bolus for pre-hospital thrombolysis.

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November 2002 Br J Cardiol 2002;9:640-4

Hypertension trials – the current evidence base and forthcoming trials

Peter Sever, Neil Poulter

Abstract

Recently reported and ongoing morbidity and mortality trials in hypertensive patients are addressing important unanswered questions in hypertension management. What is the optimal first-line treatment for hypertension, what is the ideal combination of antihypertensive drugs, how are these influenced in particular patient subgroups, and what are the treatment thresholds and blood pressure goals of treatment for optimal prevention of cardiovascular disease? Limitations of some recent trials are highlighted and emphasise the need for further prospective meta-analyses of studies to provide adequate power to address some of these important questions. Current ongoing large scale studies, including ALLHAT and ASCOT, will shortly be reporting results to the scientific community and are likely to influence management decisions across a wide range of patient subgroups.

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November 2002 Br J Cardiol 2002;9:634-8

The HEARTS collaboration – delivering improved secondary prevention of CHD for patients with heart disease

Frank Sullivan, Stuart D Pringle, Hamish Dougall, Neill McEwan, Gavin Murphy, Douglas Boyle, Andrew D Morris

Abstract

Full implementation of the available evidence on secondary prevention should ensure that all patients after myocardial infarction should be offered both effective treatment and be maintained on treatment. This article describes the Heart disease Evidence-based Audit and Research in Tayside Scotland (HEARTS) collaboration which has been set up to try and achieve this. HEARTS can collect electronic data from many sources; prioritise data from multiple sources, such as hospital and general practice; process and link patient records; and, allow manual validation of electronic data. It can also facilitate clinical governance issues in general practice and hospital plus disseminate information to patients. It is hoped that, in addition to secondary prevention, it will be able to extend its focus to other aspects of cardiovascular disease in the future as well as being used for epidemiological and qualitative projects. The system maintains the security and rights of patients at all times.

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