Clinical articles

The use of coronary angiography as a diagnostic tool in modern hospital medicine continues to rise. With the increasing use of therapeutic coronary interventions, and the increases in procedure times and volumes of contrast media, incidence rates of contrast-induced nephropathy (CIN) have also been seen to climb over recent years. CIN has subsequently been shown to be a significant contributor to morbidity and mortality during hospitalisation. In this current clinical setting, it is incumbent on the modern cardiologist to be aware of this potentially serious complication of angiography, to be familiar with its presentation and treatment, and to be able to recognise at-risk groups and institute prophylactic measures where appropriate.

To target statin therapy effectively in primary coronary heart disease (CHD) prevention, recommendations increasingly advocate the assessment of absolute CHD risk. Using methods from two recent sets of national recommendations, we estimated absolute CHD risk in 412 men and women whose general practitioners requested it on clinical grounds. Substantially fewer men and women had CHD risk exceeding 15%, 20% and 30% over 10 years with the National Cholesterol Education Program III (NCEP III) scoring system than with the Joint British charts. The latter agreed closely with the 1990 version of the Framingham risk equations.

The pulmonary artery catheter (PAC) was introduced into critical care medicine without objective evidence of its efficacy. The direct risks from the PAC are around 1.5% for a serious complication and 0.2% for death.
The Connors study on 5,735 intensive care patients used case-matching techniques, and demonstrated a worse outcome in the PAC cohort. However, in this study the need for inotropes and the response to treatment were excluded from the regression analysis. Three further studies have failed to show an association between PAC placement and outcome after case-mix adjustment.
It has proved extremely difficult to recruit enough intensive care patients to exclude a clinically important mortality benefit of the PAC.
New techniques such as the oesophageal Doppler, pulse contour continuous cardiac output and lithium dilution cardiac output machines offer simpler, and perhaps better, alternatives to the PAC. Nonetheless, even if future trials are negative, the PAC should remain available for treatment of patients with unusual conditions or combinations of conditions.

Isolated ventricular non-compaction is a rare cardiomyopathy, which is probably underdiagnosed. We describe a case manifested by chest pain, indistinguishable from acute myocardial infarction.

Ventricular tachycardia (VT) and sudden cardiac death are feared complications of severe heart failure, whatever the aetiology. VT has the propensity to become incessant, and this carries an adverse prognosis. In some cases incessant VT is refractory to a combination of electrical cardioversion and pharmacological therapy such that emergency catheter ablation is required. Even when the conventional endocardial approach fails, ablation can be performed safely and effectively via the epicardial route.

The latest British Hypertension Society guidelines, BHS IV, have particular implications for primary care. This article discusses 10 key areas on which general practitioners should focus as a result of the new guidance, with a comment about the significance of each in a primary care setting.

We assessed whether the presence of a Rapid Access Heart Failure Clinic (RAHFC) had an impact on the angiotensin-converting enzyme (ACE) inhibitor prescribing habits of primary care physicians. We selected 10 general practices (GP) that referred and 10 practices that did not refer patients to the RAHFC. The study covered a period of two years immediately preceding the commencement of the RAHFC and about 1.5 years afterwards. A total of 309 patients, divided into two groups, were studied. Cohort 1 consisted of 198 patients (103 from referring and 95 from non-referring GP) with a new diagnosis of chronic heart failure (CHF) made by the GP pre-RAHFC. Cohort 2 consisted of 111 patients (48 from referring and 63 from non-referring GP) diagnosed as having CHF post-RAHFC. In cohort 1, 27.1% of patients in the referring practices were on ACE inhibitor versus 40.0% in the non-referring practices (p=0.056).
ACE inhibitor prescription was reassessed 1.5 years post-RAHFC: it had significantly increased to 51.4% (p<0.001) in the referring practices, but not in the non-referring practices (43.1%, p=0.659). Interestingly, the increase in ACE inhibitor prescription among referring practices was predominantly due to initiation by the primary care physicians themselves (76% of cases) rather than by the RAHFC. The baseline trend of lower ACE inhibitor prescription rate in cohort 1 in the referring practices compared to non-referring practices was not seen in cohort 2 (54.1% vs. 50.7%, p=0.844).
Using ACE inhibitor prescription status as an indicator of diagnostic certainty of CHF by primary care physicians, it has sensitivity, specificity, positive and negative predictive values of 45.5%, 52.9%, 38.5% and 60.0%, respectively, for the presence of CHF as confirmed by the RAHFC.
In conclusion, RAHFC facilitated increased ACE inhibitor prescription by primary care physicians. However, CHF was commonly misdiagnosed in the community and this might lead to inappropriate ACE inhibitor prescription.

Paradoxical embolism is a relatively uncommon clinical condition. Only a few hundred cases have been reported in the literature.1 Despite sophisticated technological advances, it remains an under-diagnosed clinical entity.2 Blood clots formed either in the right side of the heart or in the venous circulation escape via an intra- or extra-cardiac right-to-left shunt into the systemic circulation. This results in an arterial embolism, hence the term paradoxical embolism. The condition can cause significant morbidity and mortality. We report a case of cerebral infarction secondary to paradoxical embolism. This is the first case to be reported in the literature with the unique and rare association of patent foramen ovale and pulmonary arteriovenous malformation with hereditary haemorrhagic telangiectasia.

Many common cardiovascular conditions preclude patients from driving for a period of time. These regulations often affect previously fit people and may have far-reaching consequences for an individual. The doctors caring for these patients are responsible for informing them of any relevant driving restrictions. We present a survey of general physicians’ and cardiac specialist nurses’ understanding of the current Driver and Vehicle Licensing Authority (DVLA) regulations. Overall, there is a limited knowledge of driving regulations among physicians as a group (36% correct responses). In contrast to their poor knowledge with respect to cardiovascular conditions (30% correct), a far higher proportion of physicians knew when a patient could return to driving following an epileptic seizure (76%, p<0.001). Consultants fared better than their junior colleagues, with 41% of questions answered correctly; specialist cardiac nurses had a correct response rate of 57% for cardiac events. Most of the wrong responses overestimated the duration of the restrictions, suggesting a conservative attitude to advice offered.

Recent years have shown a diverse array of new antithrombotic drugs in development or appearing in clinical practice. Until now, warfarin has remained the anticoagulant drug of choice despite the numerous disadvantages associated with its use. Ximelagatran, an oral direct thrombin inhibitor (DTI), has now emerged as a serious contender to replace warfarin as standard anticoagulation. Its use in prophylaxis and treatment of venous thromboembolic disease is already well established and recent data also suggest the benefits of ximelagatran over warfarin in non-valvular atrial fibrillation, both in terms of safety and efficacy. This review will examine ximelagatran as a novel anticoagulant with its application in numerous clinical settings, such as venous thromboembolism and non-valvular atrial fibrillation, and how it may one day replace warfarin as the anticoagulant of choice.