Clinical articles

Five case histories are described to illustrate the importance of patent foramen ovale and atrial septal aneurysm as risk factors in stroke aetiology. Diagnostic methods, and the current and future management of these atrial septal defects, are briefly discussed.

The Framingham Heart Study investigators have recently developed new coronary risk appraisal functions which relate risk factors to the short-term probability of experiencing cardiovascular disease events. We populated the risk appraisal functions with UK data and estimated that approximately 256,000 new coronary artery disease (CAD) events occur annually in the UK. Approximately half of the estimated CAD events were acute myocardial infarctions (AMI) and almost three quarters occurred in men. Our estimates fit well with hospital in-patient data but less well with British Heart Foundation estimates of AMI and angina. Differences between US and UK relative risks, clinical practice and populations may account for these discrepancies. Our estimates may be considered as a lower limit of the annual number of UK CAD events.

Assisting smokers to stop smoking is often seen as a difficult task but is crucial for health improvement, especially for those with established cardiovascular disease. Healthcare professionals are now, more than ever, in a position to help smokers who want to stop. For the greatest chance of success smokers should be referred to stop smoking services that provide multi-session treatment combining intensive behavioural support with nicotine replacement therapy or bupropion. Promising new medications are being developed that will add to the current treatment strategies and may give smokers a greater chance of stopping for good.

The renin-angiotensin system (RAS) plays a fundamental role in cardiovascular pathophysiology. In particular, angiotensin II (AII) has been identified as a culprit in endothelial and vascular damage, elevated blood pressure, and cardiac failure. Pharmacological inhibition of this system is available through two mechanisms; the reduction of AII formation by inhibition of angiotensin-converting enzyme (ACE), and by direct blockade of the type 1 angiotensin II receptor by angiotensin II receptor blockers (ARBs).
Angiotensin-converting enzyme (ACE) inhibitors have a proven role in the management of elevated blood pressure and diabetes and may confer specific vascular benefit. In patients with chronic heart failure (CHF) secondary to left ventricular systolic dysfunction (LVSD), there is extensive evidence that, when compared to placebo, ACE inhibitors reduce morbidity and mortality. Randomised placebo controlled trials have also shown ACE inhibitors reduce all-cause mortality and major cardiovascular events after myocardial infarction.
Given the unequivocal benefit of ACE inhibitors, initial studies with ARBs in patients with LV dysfunction (in CHF and following myocardial infarction) have focused on two areas: the role of ARBs when compared with ACE inhibitors, and when combined with ACE inhibitors.
Only recently, with the results of the CHARM study, have the role of ARBs when compared to placebo in a population with CHF been clarified. This study also addressed the benefit of ARBs in patients with heart failure and preserved LV systolic function.

The Calman Review of 1998 recognised that continuing medical education through the postgraduate education allowance scheme (PGEA) had failed to deliver improvements in patient care. Instead, continuing professional development (CPD) has been put forward, which is intended to identify and fulfil learning needs. The primary care team itself is recognised to be a valuable learning resource.

Palpitations are a common complaint. It is useful for the GP to determine which are benign and which are potentially life-threatening and require urgent referral.
Two cases are presented here in which the GP used 24-hour electrocardiogram (ECG) monitoring to detect a prolonged daytime sinus pause. Both patients were referred, as a consequence, for permanent pacemaker insertion.
A 24-hour ambulatory ECG monitoring machine allows the GP to reassure patients whose palpitations have a benign origin, to reduce inappropriate referrals to secondary care, and to produce a more informative referral letter.

Audits of cholesterol management in patients with coronary heart disease (CHD) demonstrate that many patients do not achieve targets set out in national guidelines. Under-treatment is a component of the treatment gap and many patients are prescribed low-dose statins. The delivery of systematic care and adoption of more efficacious initial doses will increase the number of patients who achieve recommended low-density lipoprotein cholesterol (LDL-C) levels and maintain their LDL-C goals. Current studies indicate that rosuvastatin, atorvastatin and simvastatin are the most efficacious agents for lowering LDL-C and triglycerides. Compliance and persistence with statin treatment are poor and represent significant barriers to delivering mortality reductions in clinical practice. Efforts to improve concordance are necessary to ensure that treatment benefits are realised in clinical practice.

Five-fluorouracil (5-FU) is commonly used to treat
solid tumours, and in palliative and adjuvant
chemotherapy. The agent 5-FU is being used in
ever-increasing dosage, and this results in more side
effects.

Carotid artery disease is a major cause of stroke. Carotid endarterectomy when performed with a low complication rate in patients with severe lesions has been shown to reduce the subsequent risk of stroke in a series of randomised controlled trials in both symptomatic and asymptomatic populations. The CAVATAS trial demonstrated that simple balloon angioplasty of carotid stenoses was as good as endarterectomy in terms of stroke prevention and was associated with a lower complication rate. Carotid stenting performed with the use of distal protection devices has been shown to be superior to endarterectomy in patients considered to be at increased perioperative risk as assessed by a variety of clinical and angiographic parameters. Comparisons of carotid stenting and endarterectomy in patients considered to be of normal perioperative risk are ongoing. Optimal medical therapy is mandatory for all patients with carotid artery disease.