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Clinical articles

July 2002 Br J Cardiol 2002;9:401-5

he effect of nifedipine GITS on outcomes in patients with previous myocardial infarction: a subgroup analysis of the INSIGHT study

Giuseppe Mancia, Luis M Ruilope, Moris J Brown, Christopher R Palmer, Talma Rosenthal, Alain Castaigne, Peter W de Leuw, Gilbert Wagener

Abstract

Post-myocardial infarction (MI) patients have a higher risk for subsequent cardiovascular and cerebrovascular events than the average population. This study was to test the effects on outcomes of nifedipine GITS compared to the diuretic combination co-amilozide in hypertensive patients with a history of MI on outcomes (subset of the INSIGHT study). The multinational, randomised, double-blind International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment (INSIGHT) study compared the treatment effects of nifedipine GITS 30 mg and co-amilozide (hydrochlorothiazide 25 mg plus amiloride 2.5 mg) in hypertensive patients aged 55–80 years with a blood pressure of 150/95 mmHg (or 160 mmHg systolic). This pre-specified subanalysis was performed in patients with a history of MI. The primary outcome was a composite of cardiovascular death, non-fatal stroke, MI, and heart failure. Of 6,321 randomised patients, 383 (6.1%) had a previous MI. The percentage of primary outcomes in post-MI patients did not differ between the two treatment groups (14.9%). The number of post-MI patients with composite secondary outcomes was 53 (27.2%) in the nifedipine GITS group and 60 (31.9%) in the co-amilozide group. The incidence rates of primary and secondary outcomes were higher in patients with a previous MI than in patients without a history of MI. For the randomised use of nifedipine GITS and co-amilozide in hypertensive patients with a previous MI, the choice seemed unimportant for outcomes and blood pressure lowering. The results of this subgroup analysis are consistent with INSIGHT’s overall findings of no significant differences in efficacy, suggesting that post-MI hypertensive patients are no more likely to suffer further events when treated with long-acting nifedipine than on co-amilozide.

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July 2002 Br J Cardiol 2002;9:394-400

Atherosclerosis imaging and coronary calcification

Matthew J Budoff

Abstract

Recently published data have greatly expanded the applicability of electron beam tomography and electron beam angiography. Guidelines and policy towards these modalities have shifted, with increased recognition of their importance among experts in cardiology, lipidology and preventive medicine. Given the high sensitivity of coronary calcification for the presence of obstructive coronary artery disease (CAD) (95–99%), exclusion of coronary calcium may be useful as a filter prior to invasive diagnostic procedures or hospital admission.

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June 2002 Br J Cardiol 2002;9:362-8

A case study from a Sussex Primary Care Group: improving secondary prevention in coronary heart disease using an educational intervention prevention guidance

Simon de Lusignan, N Hague, Claire Yates, M Harvey

Abstract

An educational intervention was developed to try to raise both data quality standards and those of clinical care in the secondary prevention of coronary heart disease. The intervention was used within primary care organisations utilising their own clinical data and with primary care professionals learning from each other. A special tool (MIQUEST) was used to extract the clinical data. Anony-mised data were then shared with the whole primary care organisation at six-monthly data quality workshops. Patients needing interventions were identified in individual practices and these practice visits were also used as learning opportunities. At the end of the study there was an increase in the recording of the diagnosis of ischaemc heart disease (IHD).

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June 2002 Br J Cardiol 2002;9:359-60

The NHS Plan: general practitioners with special interests

David Colin-Thome

Abstract

Many general practitioners (GPs) already have a special clinical interest. This role is now being developed and formalised by the Department of Health and by 2004, 1,000 posts of general practitioners with special interests (GPwSI) will have been created. Alongside their normal general practice work, these GPs will also offer a particular specialist service under contract to a Primary Care or Acute Trust taking referrals from fellow GPs. A National Develop-ment Group is currently consulting relevant bodies to publish advice on the commissioning and appointment of such GPs. It is hoped these appointments will help integrate primary care and hospital services under the new NHS Plan, leading to enhanced patient care and the delivery of the National Service Frameworks. It will also give continuing job satisfaction to GPs wanting to extend their role.

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June 2002 Br J Cardiol 2002;9:356-7

Serious interaction between digoxin and warfarin

Arpandev Bhattacharyya, Manju Bhavnani, David James Tymms

Abstract

Drug interaction with warfarin is a common cause of loss of anticoagulant control. An interaction between warfarin and digoxin has not previously been documented in the British National Formulary or datasheet. We report a case of digoxin toxicity responsible for prolongation of the INR to more than 10.

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June 2002 Br J Cardiol 2002;9:355

On-call seen as a pathophysiologic state

Johan EP Waktare, Alex Stewart, John P Lyons

Abstract

On-call seen as a pathophysiologic state Johan EP Waktare, Alex Stewart, John P Lyons Recently, one of us (AS) underwent 24-hour Holter (ambulatory ECG) monitoring for investigation of minor cardiac symptoms. The recording was performed during a night as medical registrar on-call. We feel the result provides some interesting insights into the pathophysiology of life as a modern junior doctor.

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June 2002 Br J Cardiol 2002;9:351-4

Patients of Southern Asian descent treated with valsartan (POSATIV) study

Jatin KV Patel and Richard Leaback, on behalf of the POSATIV investigators

Abstract

Southern Asians in the UK have a substantially increased (50%) risk of coronary heart disease compared with the general population, in part due to a high prevalence of hypertension and diabetes. This patient group has not been specifically studied in a clinical trial using modern antihypertensive therapy such as the angiotensin II receptor antagonists (AIIRAs). A multi-centre, double-blind, randomised, parallel-group study compared the effects of treatment with valsartan 80 mg once daily (o.d.) with control therapy (bendrofluazide 2.5 mg o.d.) in 116 patients with mild hypertension (diastolic blood pressure [DBP] ≥ 90 mmHg and ≤ 105 mmHg) after a four-week run-in period. Sitting blood pressure was measured at baseline (end of run-in) and after four and eight weeks of treatment using the OMRON automatic oscillometric blood pressure monitor. The study medication dosage was doubled if patients had < 4 mmHg decrease in DBP after four weeks. Compared with the control group (n=62), the addition of valsartan 80/160 mg o.d. (n=51) resulted in a significantly greater reduction in blood pressure at eight weeks (mean change in blood pressure -15.6 mmHg [95% CI -19.9 to -11.2 mmHg] for systolic blood pressure [SBP] and -9.3 mmHg [95% CI -11.8 to -6.8 mmHg] for DBP; p<0.001). Both treatments were well tolerated. Valsartan is effective and well tolerated, and would be an appropriate treatment option in Southern Asian hypertensive patients.

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June 2002 Br J Cardiol 2002;9:343-50

Efficacy of micronised fenofibrate in patients with primary hyperlipidaemia: a comparison with pravastatin

Jean Ducobu, Luc Van Haelst, Herva Salomon

Abstract

This randomised, double-blind, six-month trial assessed the efficacy and tolerability of micronised fenofibrate and pravastatin in 265 patients (18–75 years of age) with primary hyperlipidaemia (pure hypercholesterolaemia, type IIa; and mixed dyslipidaemia, type IIb) recruited from 28 European centres. After a first three-month phase in which patients received once daily either micronised fenofibrate 200 mg or pravastatin 20 mg, type IIa patients attaining low density lipoprotein cholesterol (LDL) < 4.14 mmol/L and type IIb patients attaining LDL < 4.14 mmol/L and triglycerides < 2.26 mmol/L continued with the same dose in a three-month extension phase. Patients not meeting these criteria received a double dose of drug in this extension phase.

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June 2002 Br J Cardiol 2002;9:339-42

Complications associated with 64 temporary pacing wires implanted at a district general hospital – should this procedure be reserved for specialist centres?

Adam Brown, Barnaby Thwaites

Abstract

This study assessed complication rates in 64 emergency temporary pacing procedures, of which atrioventricular block formed the largest group (72%). Of the in-hospital deaths, most (76%) were due to myocardial infarction, and none due to the procedure. Immediate complications occurred in 22%: arrhythmia or arterial puncture, and one hemiparesis. Late complications occurred in 34%: loss of capture, infection including one instance of staphylococcal septicaemia. No complications occurred in 59%. Involvement of a consultant in the procedure did not reduce complication rates. In such potentially unstable patients, the risks of not pacing or delaying pacing probably far outweigh those of immediate intervention.

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June 2002 Br J Cardiol 2002;9:337-8

Primary pulmonary hypertension: a GP comment

Ross Price

Abstract

General practitioners (GPs) are subject to bombardments of medical information from many sources – local pharmaceutical formularies, local and national guidelines, national service frameworks, medical newspapers, peer-reviewed national journals and special interest publications.

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