Clinical articles

This study set out to evaluate the completeness of medical records of chest pain. A planned, multicentre, structured abstraction of data from case-notes was made at 20 adjacent acute hospitals in Yorkshire on 1,226 consecutive patients presenting with chest pain and validated myocardial infarction (MI). The hospital records included those collected by ambulance crews, accident and emergency staff, and admitting medical teams. The main outcome measure was completeness of medical records with regard to 10 commonly advocated descriptors of chest pain.
A mean number of 5.62 chest pain descriptors was recorded. This value differed with hospital (range 4.81 to 6.73 factors recorded; p<0.0001); place of admission (medical admissions unit = 6.10; coronary care unit 5.94; accident & emergency department = 5.62; general ward = 5.08; p<0.0001); gender (male = 5.74; female = 5.39; p=0.004) and age (< 68.4 years = 5.83; > 68.4 years = 5.43; p<0.0001). Mean chest pain scores were also significantly different for District General Hospitals (DGHs) without angiography facilities as compared to DGHs with angiogram facilities and tertiary centres (respectively 5.46 vs. 5.81 vs. 5.81 p<0.007).
Contrary to standard medical texts and teaching, we observed that documentation of chest pain histories was abbreviated in many cases.

Tailoring healthcare provision to fulfil patients” needs is a principal objective of health services. Data on needs are sparse, especially in patients with coronary heart disease, who tend to have a high mortality rate, who often require admission to hospital and have an impaired health-related quality of life. A novel questionnaire was administered concomitantly with generic and specific quality of life tools in a cross-sectional study of a random sample of patients (n=242) aged 31–93 years (median 71 years) admitted with suspected acute coronary syndromes.
Patients with confirmed infarction had fewer healthcare needs and reported less need for information on heart disease compared to those with other manifestations of coronary disease (p<0.01). Those recently seen by a general practitioner were better informed about their current treatment (p<0.01). Coronary disease patients with low quality of life scores were more likely to be anxious about cardiac problems (p<0.001). They were more likely to spend more time thinking about these concerns (p<0.001) and to seek help from, and to have increased expectations of, the family doctor or cardiologist (p<0.001), particularly in seeking greater commitment to their care. Reported deficiencies in service included difficulty accessing healthcare services, especially for men < 65 years (p=0.01) and availability of repeat prescriptions for the over 75-year-olds (p<0.05). Patients with coronary disease had unmet healthcare needs and worse health-related quality of life. Further investigation of healthcare needs among patients with coronary disease could lead to simply improved services and major health improvement. Assessment of quality of life appeared to be a surrogate for formal healthcare needs assessment.

The efficacy and tolerability of two candesartan treatment regimens were evaluated in 578 severely hypertensive patients already receiving a diuretic plus an angiotensin-converting enzyme (ACE) inhibitor, a calcium channel blocker (CCB) or a beta blocker. Existing treatments were standardised during a two-week run-in period. Patients with uncontrolled blood pressure (diastolic blood pressure [DBP] > 90 mmHg) were randomly switched to a regimen comprising candesartan 16 mg plus hydrochlorothiazide (HCT) 12.5 mg once daily for four weeks (switch regimen, n=291), or had candesartan 8 mg once daily added to their existing treatment (add-on regimen, n=287). After four weeks’ treatment, mean sitting DBP was reduced from baseline by 11.2 mmHg (SD 11.2) and 13.9 mmHg (SD 11.5) in the switch and add-on treatment groups, respectively. Mean sitting SBP was decreased by 15.3 mmHg (SD 18.7) and 20.7 mmHg (SD 20.3), respectively. During an additional four weeks’ treatment, ‘switch’ non-responders had their doses of study medications doubled, resulting in a further reduction of 5.4 mmHg (SD 9.8) DBP and 5.9 mmHg (SD 14.9) SBP. Both treatment regimens were well tolerated. Thus, in patients with severe hypertension, adding candesartan to a standard-dose two-drug combination, or switching from a pre-existing two-drug, standard-dose combination to high-dose candesartan plus HCT enables enhanced BP control, with superiority of the three- over the two-drug combination.

The plasminogen activator inhibitors have an important therapeutic role in controlling bleeding in patients with congenital and acquired coagulation disorders. They are being increasingly used in patients with blood loss and to prevent bleeding. However, these antifibrinolytic agents can also facilitate the development of thrombosis. We report a patient with severe gastrointestinal bleeding who developed acute myocardial infarction following the administration of the antifibrinolytic agent, tranexamic acid.

Atherosclerotic cardiovascular disease (CVD) is common in patients with diabetes, and antiplatelet therapy has been the cornerstone of preventative therapy for many years. The majority of the evidence for the use of aspirin in patients with diabetes comes from subgroup analysis of major secondary prevention trials. Secondary prevention data from the Antiplatelet Trialist’s Collaboration meta-analysis suggests that the benefit derived from aspirin is similar in diabetic and non-diabetic populations. In the general population, data from primary prevention studies have shown the benefit of aspirin in terms of cardiovascular mortality, but there is little evidence to suggest that aspirin is beneficial in terms of total or cardiovascular mortality for primary prevention in a diabetic population. Clopidogrel may have advantages over aspirin and combined therapy may be superior for certain types of coronary artery disease and stroke, although this is offset by an increased risk of haemorrhage in the latter setting. The use of aspirin in the prevention of CVD in patients with diabetes should therefore be focused on those with a history of vascular events or aggressively treated hypertension.

In the previous article, Dr Sarah Jarvis provides a useful perspective
on the management of heart failure in primary care. Recent reports
from the Department of Health and the Healthcare Commission have
highlighted the lack of progress in implementing evidence-based practice
in heart failure. It is essential that primary and secondary care
work together to improve the situation.

Increasing rates of coronary heart disease and the increasing longevity of the UK population mean that the number of cases of heart failure seen in general practice is rising rapidly. Simultaneously, this disease area has been recognised by the National Institute for Clinical Excellence, which has published guidelines for its management, and it has been made a target for remuneration under the new General Medical Services contract. This, together with the latest clinical trial evidence, has dramatically changed how heart failure is managed in primary care. Considering these recommendations and the latest clinical trial evidence, a logical management plan for heart failure is suggested.

The management of heart failure has altered greatly and good outcomes are dependent on an accurate, specific diagnosis and modern therapy. In 50% of cases, heart failure is diagnosed in hospital, with high readmission rates. There is evidence of variations in the diagnosis and management practices between specialists and hospitals, compromising uniformly high standards. In turn, this is likely to affect the quality of ongoing management in primary care.
This qualitative study explores specialists’ attitudes and practices in the diagnosis and management of heart failure with a view to identifying barriers to provision of uniformly high standards of care.

Coronary artery spasm is an uncommon presentation of angina and may be associated with other vasospastic diseases such as Raynaud’s disease. It is widely accepted that local imbalance of production and removal of nitric oxide (NO) and other endothelium-derived factors is generally responsible for the arterial spasm in variant angina. Very rarely, diffuse spasm can herald ventricular arrhythmias due to sudden reduction in perfusion.

Hypokalaemia and hyperkalaemia are common complications of heart failure and its treatment: either may increase markedly the risk of arrhythmias and sudden cardiac death. Hypokalaemia predominates in the early stages of heart failure. The risk of hyperkalaemia increases as renal function declines, usually in the context of advancing heart failure. For patients with heart failure, serum potassium levels of between 4.5–5.5 mmol/L are recommended. Monitoring of serum potassium is essential, with more frequent monitoring in patients with moderate renal failure, relatively high serum potassium, or in those at high risk of renal impairment, e.g. elderly or diabetic patients. Hypokalaemia can be ameliorated by a potassium-sparing diuretic or an aldosterone receptor antagonist; increasing dietary potassium intake or taking potassium supplements is less effective. Doses of loop or thiazide diuretics should be optimised. Hyperkalaemia is more often seen in advanced heart failure. Restriction of dietary potassium and withdrawal of potassium supplements are standard. Temporary discontinuation of angiotensin-converting enzyme inhibitor and/or aldosterone receptor antagonist therapy may be appropriate but attempts should be made to reintroduce these. Excessive diuretic therapy should be avoided. With routine potassium monitoring and pre-emptive intervention included in heart failure protocols, the risks to patients can be minimised.