Clinical articles

The volume and complexity of patients undergoing percutaneous coronary intervention (PCI) is growing steadily. This, and the increasing tendency for these procedures to be unplanned, requires us to rethink the way we deliver care in this setting. This article addresses the processes involved, which include pooling of PCI lists, multidisciplinary team meetings and integrated care pathways for both elective and unplanned cases. The value of pre-assessment clinics, specific cardiac triage teams and “generic” catheter lab workers is also discussed. More traditional elements of the service such as on-call rotas are reappraised. Newer concepts, like dedicated PCI meetings to plan strategy and review previous problem cases for educational purposes, are also introduced.

Cardiac myxomas are the most common benign intracardiac tumour, and are more common in women. Since many patients suffer from cerebral or systemic embolism, early diagnosis is vital to plan for surgical intervention. Surgical excision is advocated as soon as possible, particularly in left atrial myxoma, because of the high risk of valvular obstruction and systemic embolisation. Patients with a family history of the disorder are at greater risk of tumour recurrence.

The new General Medical Services contract has introduced the term ‘maximally tolerated blood pressure treatment’, which it defines as a cut-off point at which a doctor might advise the patient to accept the current blood pressure level. Whilst this is a sensible idea, the contract does not give any guidance as to how the doctor should decide when that point has been reached. In this article the Primary Care Cardiovascular Society considers the issue, looking at available evidence, and publishes a consensus statement on the definition for maximally tolerated blood pressure treatment.

Aneurysms of the sinus of Valsalva associated
with infective endocarditis are rare. They can
present during an episode of acute endocarditis
or as late sequelae, with or without rupture. Their
management involves repair of the annulus and closure
of the aneurysm with a Dacron patch.

Interventions on individual risk factors are most effective when directed at those with highest absolute risk. Joint British Society Guidelines and National Service Frameworks (NSF) indicate that these individuals should be identified. There is a need to continuously categorise the population by risk to identify those for primary prevention. This article describes a project that was set up to use clinical information technology in an innovative way. It was introduced as an administrative routine for the whole population of a large district (Blyth Valley, Northumberland) through the general practices to which the patients belong.

Angiotensin-converting enzyme (ACE) is a key enzyme in the production of angiotensin II. The cloning of the ACE gene has made it possible to identify a deletion (D)-insertion (I) polymorphism that appears to affect the level of serum ACE activity. The aim of our study was to analyse the ACE gene I/D polymorphism in Turkish male athletes and to evaluate its relationship to left ventricular mass and function.
Forty male athletes (mean age 23.4+1.8 years) were included in this study, and they underwent both complete echocardiographic assessment and analysis of ACE I and D allele frequencies in peripheral blood by polymerase chain reaction. They were separated into three subgroups according to their ACE DD (n=13), DI (n=16) and II (n=11) genotypes. Thickness of the interventricular septum (IVS), the left ventricular posterior wall (LVPW) and left ventricular mass (LVM) and LVM index (LVMI) were measured by the M-mode. Left ventricular ejection fraction was calculated using Simpson’s method, and so was the myocardial performance index.
There was no statistically significant differences between the ACE DD, DI and II genotypes at the p>0.05 level by age, body mass index, heart rate, systolic and diastolic blood pressures. The thickness of the IVS (12 mm) and LVPW (10.7 mm), and LVM (302.8 g) and LVMI (157.3 g/m2) in ACE DD genotypes were higher than for both ACE DI (10.8 mm; 9.7 mm; 231.9 g; 125.3 g/m2) and II genotypes (9.0 mm; 8.6 mm; 185.0 g; 107.5 g/m2) in athletes. Left ventricular systolic and global functions among the three ACE genotypes were not different statistically.
Our findings suggest that left ventricular hypertrophy is partially determined by genetic disposition and DD genotype of ACE is a potential genetic marker associated with an elevated risk of left ventricular hypertrophy.

The benefits of angiotensin-converting enzyme (ACE) inhibitors occur early in the treatment period and may be dose-dependent. The utilisation of ACE inhibitors in cardiovascular patients is often suboptimal. This current study evaluates the clinical use of a specific ACE inhibitor dose-escalation pack.
Fifty hospital in-patients with a definite indication for ACE inhibitor therapy were randomised to receive either a dose-escalation pack or ‘usual’ initiation and escalation of ramipril. Patients and general practitioners received an information sheet outlining the benefits and risks of ACE inhibitors and the need for monitoring of serum urea and electrolytes. The groups were matched for age, gender, deprivation score and blood pressure. One patient died in each group and one patient withdrew from the control group. More patients in the dose-escalation group reached target dose by six weeks (72% vs. 33%; p< 0.01) and three months (67% vs. 35%; p<0.05). At three months, there were no differences in serum creatinine, urea or potassium (all p>0.05). Cough was the most commonly reported side effect although there was no difference in its incidence between the dose-escalation and control groups (8% vs. 6%, p>0.05). This study demonstrates that the use of a specific dose-escalation pack for the ACE inhibitor ramipril is a simple, reliable and safe mechanism for reaching a target dose. This approach could find utility with other drug therapies.

Blockade of the renin-angiotensin system by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) has been shown to be effective in treating hypertension and heart failure. There are currently seven ARBs in clinical practice, of which olmesartan medoxomil (Olmetec®) is the newest agent in the class. This article reviews the pharmacokinetics, pharmacodynamics, safety, efficacy, clinical use, dosing and cost of olmesartan medoxomil. This information is based on published data from human efficacy, safety and drug comparison studies. Olmesartan medoxomil (10–40 mg) has been shown consistently to achieve significant reductions in both systolic and diastolic blood pressures in human studies, which persist over the course of one year. There are limited, mainly experimental, data on its use in heart failure and atherosclerosis.
It is an effective and well-tolerated agent with a long duration of action, allowing once-daily dosage in the treatment of hypertension.

Diabetes is associated with both premature cardiovascular disease and renal disease. The presence of microalbuminuria is itself an independent risk factor for the development of cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors were initially shown to slow the progression of established renal disease in patients with type 1 diabetes. Subsequent trials have demonstrated a similar benefit in patients with type 2 diabetes and with the use of angiotensin II receptor blockers (ARBs). The use of ACE inhibitors to prevent cardiovascular events in patients with established cardiovascular disease but not left ventricular dysfunction was established in two large randomised trials – HOPE and EUROPA. These benefits were maintained within the diabetic subgroups of these trials and appear to be independent of blood pressure lowering. The LIFE trial also provides evidence of the benefits of ARBs in reducing cardiovascular events in a high-risk population of diabetic patients with hypertension and left ventricular hypertrophy. Ideally, therefore, all diabetic patients with renal or cardiovascular disease should be treated with ACE inhibitors or ARBs.

Lowering elevated blood pressure reduces mortality and the risk of stroke, coronary heart disease and heart failure.
The presence of benign prostatic hyperplasia (BPH) is a compelling indication for the use of an alpha blocker in the treatment of hypertension. Alpha blockers are first-line therapy for men with lower urinary tract symptoms (LUTS) and prostatic hyperplasia. In men with prostates larger than 30 cm3 or prostate-specific antigen > 1.4 ng/ml, 5-alpha reductase inhibitors may also be added. Typically, alpha blockers improve LUTS by 30–40% and maximum urinary flow rates by 16–25%, with clinical improvement within two weeks. The 5-alpha antagonists are only effective in men with a large prostate and may take up to six months to achieve their full effect.
The Medical Treatment of Prostatic Symptoms (MTOPS) study assessed the long-term effects of doxazosin, finasteride and combination treatment on symptom scores, the clinical progression of BPH and the long-term risk of complications. Combination treatment reduced the risk of clinical progression by 66%, a significantly greater reduction than that induced by either agent alone. The improvement in the symptom score was also significantly greater in the combination treatment group.
Erectile dysfunction (ED) may be a marker for other diseases, such as hypertension. ED is both more prevalent and more severe among patients with hypertension than among the general population. The link may be related to nitric oxide/cyclic GMP pathways and endothelial function. Many prescription drugs are associated with ED, including antihypertensive agents. The alpha blockers and angiotensin receptor blockers are the drugs least likely to cause ED, and may even improve the situation. All currently licensed ED treatments are suitable for managing ED in the cardiovascular patient, when used according to the manufacturer’s instructions. PDE5 inhibitors and alpha blockers should be temporally separated, or selective alpha blockers may be preferable, in order to avoid postural hypotension.