October 2002 Br J Cardiol 2002;9:538
David Platts, Mark Monaghan
These images are from a 65-year-old woman referred for stress echocardiography following a history of exercise-induced dizziness and shortness of breath. A dobutamine stress echocardiogram was performed. The resting heart rate was 90 beats per minute and resting blood pressure was 210/90 mmHg. The resting images showed severe concentric left ventricular hypertrophy with normal systolic function.
October 2002 Br J Cardiol 2002;9:533-7
In the last few years our ideas about the physiological and pathological roles of aldosterone have changed enormously. It is now widely recognised that this hormone not only plays a crucial role in normal salt and water regulation, and its abnormalities in congestive heart failure and some types of hypertension, but also has other effects. These may include the promotion of cardiac and vascular inflammation and fibrosis and increased likelihood of arrhythmias. These perspectives coincide with a revived interest in aldosterone antagonists, particularly since the RALES trial showing the benefits of spironolactone in patients with congestive heart failure. This long-established drug does unfortunately have serious adverse effects, notably gynaecomastia and menstrual abnormalities. New drugs, such as eplerenone, are being developed which are more selective for the aldosterone receptor and have less interaction with receptors for other steroid hormones. Early studies indicate that this drug may have comparable efficacy to spironolactone in patients with hypertension and heart failure, while adverse effects appear to be less frequent and severe. The development of such compounds will encourage greater emphasis on aldosterone antagonism in cardiovascular drug therapy.
October 2002 Br J Cardiol 2002;9:530-2
Kathryn E Griffith
The major objective for the diagnosis and treatment of hypertension should be the detection of those at increased risk of coronary heart disease (CHD) and stroke, and the reduction of this risk.
October 2002 Br J Cardiol 2002;9:524-30
Karen Rowland Yeo, Wilfred W Yeo
We examined the workload implications of the National Service Framework for Coronary Heart Disease and the 1999 British Hypertension Society guidelines for the management of hypertension in clinical practice. The 1998 Health Survey for England was used to estimate the proportion of the English population aged 35 to 74 years that may require antihypertensive therapy. Of 8,154 subjects with blood pressure measurements, 400 (4.9%; 95% CI 4.4 to 5.4%) with cardiovascular disease were taking antihypertensive drugs and a further 100 (1.2%; 1.0 to 1.5%) were at treatment thresholds for secondary prevention of cardiovascular disease. There were 848 (10.4%; 9.7 to 11.1%) subjects free of cardiovascular disease on antihypertensive therapy and an additional 1,083 (13.3%; 12.5 to 14.0%) were identified for treatment. We estimate that 29.8% (28.8 to 30.8%) of the English population aged 35 to 74 years were candidates for antihypertensive therapy, of which 15.3% (14.5 to 16.1%) were already being treated but only 5.4% (4.9 to 5.9%) had their blood pressure controlled. An additional 14.5% of the English population will need antihypertensive therapy and an extra 9.9 % will need to have their treatment intensified to attain the blood pressure targets set by the British Hypertension Society guidelines.
October 2002 Br J Cardiol 2002;9:519-23
Jo Chikwe, John Pepper
Heart transplantation is an accepted therapeutic option in selected patients with end-stage heart failure. Up to 10% of patients develop renal failure while on the waiting list for heart transplantation. Renal dysfunction is a relative contraindication to heart transplantation. In order to establish current practice in UK heart transplant centres and overall surgical outcomes for combined heart and kidney transplantation, we surveyed the eight units currently responsible for heart transplantation, all but one of which had carried out at least one combined heart and kidney transplant. We obtained outcome data from the United Kingdom Transplant organisation. We found a wide variability in the level of renal function considered a contraindication to heart transplantation, and no consensus on the criteria for combined heart and kidney transplantation. The 30-day mortality was 14% (4/28) and survival at one, three, five and 10 years was 66.5 (95% confidence interval 57.3–75.7), 50.2 (40.3–60.1), 45.6 (35.6–55.7), and 30.8 (19.2–42.4) respectively, with significant variability between centres.
A prospective, controlled trial is needed to address these issues, but such a study remains extremely unlikely in the context of the increasing scarcity of organ donors.
September 2002 Br J Cardiol 2002;9:488-90
This study looks at how well cardiovascular risk factors were being controlled in a high-risk group of patients awaiting coronary artery bypass surgery. It shows significant short falls in the implementation of currently advocated strategies.
September 2002 Br J Cardiol 2002;9:481-7
This article explains how general practitioners can diagnose and treat heart failure in primary care. Diagnosis is difficult and four diagnostic tests – the electrocardiogram, chest x-ray, blood test for natriuretic peptides and echocardiography – are recommended as being of particular value in confirming the diagnosis in primary care.
A six-step treatment strategy is then given advising i) confirming the diagnosis, ii) excluding other treatable causes of heart failure, iii) giving general advice to the patient, iv) starting treatment with a diuretic, v) then adding an angiotensin-converting enzyme inhibitor, and, vi) finally adding a beta blocker. A 10-point plan explaining in detail how to start beta blockers in primary care concludes the article.
September 2002 Br J Cardiol 2002;9:478-80
Sanjiv Mahadeva, Pulak Sahay, Richard V Lewis
Pleuritic chest pain and hypoxia – a diagnostic dilemma Sanjiv Mahadeva, Pulak Sahay, Richard V Lewis Pulmonary thromboembolism (PE) is notoriously difficult to diagnose since it commonly presents in a non-specific manner. Only 15–30% of the patients identified at post-mortem as having a massive PE have been diagnosed correctly prior to death.1,2 However, large studies have shown that certain clinical symptoms and features such as dyspnoea, tachypnoea, pleuritic chest pain with a normal chest radiograph and a low PaO2 are present in more than 90% of patients with PE.2 Clinicians in a district hospital setting have to rely on these features, especially when facilities for detailed imaging such as computerised tomography (CT) or pulmonary angiography are not available. Occasionally, certain other diseases can mimic the clinical picture of PE and lead to delay in instituting appropriate treatment. We present two patients with symptoms and clinical investigations which were highly suggestive of acute PE but who turned out to have very different diagnoses in the end.
September 2002 Br J Cardiol 2002;9:476-7
Khaled Alfakih, Alistair Hall, Mike Robinson
Rapid appraisal of clinicians’ reactions to guidance from the National Institute of Clinical Excellence on use of glycoprotein IIb/IIIa antagonists for acute coronary syndromes Khaled Alfakih, Alistair Hall, Mike Robinson We conducted a postal survey of UK consultant cardiologists to assess reaction to the guidance issued by the National Institute of Clinical Excellence (NICE) on the use of glycoprotein IIb/IIIa antagonists (GPAs) for acute coronary syndromes.
September 2002 Br J Cardiol 2002;9:469-75
Donald B Hunninghake, Michael Davidson, Howard R Knapp, Helmut G Schrott, Sheryl Manfreda, and the Fluvastatin Study Group
A new extended-release (XL) formulation of fluvastatin has been developed for once daily treatment of primary hypercholesterolaemia. This study was designed to determine the safety and effect of fluvastatin XL 80 mg on a range of lipid parameters compared with the immediate-release (IR) formulation of fluvastatin 40 mg.
In a multicentre, double-blind study, 555 patients with primary hypercholesterolaemia (Fredrickson types IIa or IIb) were randomised to 24 weeks treatment with fluvastatin XL 80 mg or IR 40 mg, each given once daily at bedtime. The study found the least square mean reduction in LDL-C after 24 weeks treatment was 32.6% in the fluvastatin XL 80 mg group (n=312) and 23.9% in the fluvastatin IR 40 mg group (n=165), an 8.7% between-treatment difference (95% confidence interval: 6.5%, 10.9%) in favour of the XL formulation (p<0.001). A higher proportion of patients in the fluvastatin XL 80 mg group achieved ≥ 35% reductions in low-density lipoprotein cholesterol (42.3% vs. 13.3%). High-density lipoprotein cholesterol levels were increased by 9.1% and 7.0%, respectively in the XL and IR groups; median triglyceride levels fell by 19% and 13%, respectively. Tolerability was comparable in the two groups, and there were no laboratory safety concerns.
The study concluded that fluvastatin XL 80 mg once daily is safe as a starting dose and effectively lowers low-density lipoprotein cholesterol and triglyceride levels in patients with primary hypercholesterolaemia.