Clinical articles

In the second commentary on echocardiography in the community, general practitioner Ed Southall writes about the new British Society of Echocardiography accreditation process and his own experiences in running a community echocardiography service in South Devon.

Peripartum cardiomyopathy (PPCM) is characterised by the development of left ventricular (LV) dilatation and dysfunction during the last month of pregnancy, or the first five months of the post-partum period, in the absence of any pre-existing cardiac disease. PPCM is a rare but serious complication of pregnancy, with a variable outcome. Symptoms such as breathlessness and peripheral oedema are common in normal pregnancy and it is easy to misdiagnose PPCM in its early stages. The aetiology of the condition is uncertain.
Treatment options are similar to those for other forms of dilated cardiomyopathy. However, there are important considerations when treating women with PPCM as they may be pregnant or breast feeding. Close communication is required between cardiologists, obstetricians and neonatologists, not only for the treatment of the PPCM patient but also for protection of the baby. Women who decide to continue with further pregnancies should be carefully monitored.

Hypertension is the most important modifiable risk factor for stroke. The risk of stroke increases directly in proportion to systolic and diastolic blood pressure, and lowering blood pressure can reduce the risk of a first stroke by up to 40%. Current evidence suggests that it is safe and effective to lower blood pressure with an ACE inhibitor and a thiazide diuretic in patients with established cerebrovascular disease. The reduction in subsequent stroke is present both in hypertensive and non-hypertensive patients and is most likely to be related directly to the blood pressure- lowering effect. Ongoing studies will help to determine whether other classes of drugs, such as the angiotensin receptor blockers, are also safe and effective in the secondary prevention of stroke, and whether blood pressure should be lowered in the first few days after a major stroke.

The objectives of this analysis were to ascertain the population need for out-patient cardiac rehabilitation in England, to estimate the current level of provision and associated costs, to identify economies of scale in service provision and to investigate budgetary implications of extending provision.
Discharge statistics from the Hospital Episode Statistics database (HES) in England in the year 2000, and data from centres contributing to the British Association for Cardiac Rehabilitation (BACR) survey were analysed. A short follow-up questionnaire was sent to respondents of the BACR survey.
The main outcome measures were: the number of patients eligible for cardiac rehabilitation; the percentage referred, joining and completing programmes; health service costs associated with current levels of provision; elasticity of costs; and costs associated with expanding services. Using an inclusive definition of need, about 267,000 people required cardiac rehabilitation in England in the year 2000. This figure fell to 100,000 if services were restricted to those aged below 75 years with acute myocardial infarction, unstable angina or following revascularisation. Health service costs per patient completing a programme were £354 (staff) and £486 (total). Out-patient cardiac rehabilitation represented a NHS cost of approximately £12.5–19.0 million per annum. A 1% increase in patients completing a programme is estimated to lead to a 0.25% fall in the staff cost per patient. A budget increase of 630% would be necessary to treat all eligible patients using moderate staffing configurations, which would fall to 170% if only those aged below 75 years with restricted diagnoses were to be treated.
We conclude that a substantial proportion of the population need for cardiac rehabilitation goes unmet and that achievement of current targets for provision is likely to require considerable additional resources. Reconfiguration of service provision towards less complex services would enable more patients to be treated. Current information systems in cardiac rehabilitation services are inadequate to provide indicators of performance and monitoring.

Integrated Care Pathways (ICPs) are one way of implementing protocol-based care. Healthcare professionals need to draft and implement ICPs in order to meet clinical governance targets. In a two-day workshop ‘Integrated healthcare delivery – let’s get practical’, 27 multidisciplinary delegates from four NHS Modernisation Teams progressed ICPs in the areas of stroke, post-myocardial infarction and heart failure. Good ICPs should include a clear assessment procedure for the clinical condition, consultation with all care providers, guidelines or best available clinical evidence, patient education and an audit tool.

The titles of the lectures at a recent Primary Care Cardiovascular Society (PCCS) meeting show the face of British cardiology is indeed changing. Control of NHS budgets and of patient care is shifting; guidelines for prevention of disease continue to change in line with new evidence; new ways of learning are being developed and yet more new laboratory tests are being pressed into service. As usual the PCCS speakers articulately covered the topics – they also had to be succinct as, after just 90 minutes, the session was over and it was ‘all change’ for the audience. Medical writer Ola Soyinka reports from the PCCS plenary session at the British Cardiac Society Annual Conference in Manchester on 25th May 2004.

The National Service Framework (NSF) for Coronary Heart Disease (CHD) requires practices to establish registers of patients with CHD and to implement audits of care for these patients. Little is known about the potential health impact of registers and audits. We therefore looked at the impact of establishing such systems on patients with CHD at Cleveleys Group Practice. All patients with CHD are recorded on a computerised register that is used to recall patients for an annual review to nurse-led clinics. Data from annual audits are used to estimate the number of adverse events prevented in the practice by the use of effective medications.
We found that the use of effective treatments was estimated to save approximately 27 lives and prevent 30 non-fatal myocardial infarctions each year. The increased use of effective treatments after the introduction of the register coincided with a reduction in average levels of systolic blood pressure and total cholesterol, preventing two deaths and three non-fatal myocardial infarctions each year. Based on the best available evidence from randomised controlled trials, the benefit of this care to a practice population is substantial.

The National Service Framework (NSF) for Coronary Heart Disease (CHD) requires practices to establish registers of patients with CHD and to implement audits of care for these patients. Little is known about the potential health impact of registers and audits. We therefore looked at the impact of establishing such systems on patients with CHD at Cleveleys Group Practice. All patients with CHD are recorded on a computerised register that is used to recall patients for an annual review to nurse-led clinics. Data from annual audits are used to estimate the number of adverse events prevented in the practice by the use of effective medications.
We found that the use of effective treatments was estimated to save approximately 27 lives and prevent 30 non-fatal myocardial infarctions each year. The increased use of effective treatments after the introduction of the register coincided with a reduction in average levels of systolic blood pressure and total cholesterol, preventing two deaths and three non-fatal myocardial infarctions each year. Based on the best available evidence from randomised controlled trials, the benefit of this care to a practice population is substantial.

Pneumopericardium is a rare condition, seen most commonly in the context of chest trauma in adults, and in mechanical ventilation in neonatal practice. Mortality is high, more so if pericardial gas is accompanied by pus and, ultimately, tamponade.¹ Here we present a case of tension pyopneumopericardium leading to cardiac tamponade which had a favourable outcome. The aetiology remains uncertain in this instance, although an oesophagopericardial fistula cannot be discounted. In addition, we review the causes and clinical features of this condition as reported in the literature.

Meta-analyses of exercise-based cardiac rehabilitation (CR) trials have shown improved survival^1,2 and significant improvements in cardio-respiratory fitness for individuals who have sustained a myocardial infarction (MI).³ According to the British Association of Cardiac Rehabilitation (BACR) Exercise Prescription Guidelines, phase 4 cardiac participants should exercise at a similar intensity level to that recommended for healthy adults to gain maximum benefits.⁴ To date, however, there has been a paucity of research to support or question these guidelines. This led to this pilot study, which aimed to compare the exercise intensity levels and ratings of perceived exertion of cardiac and non-cardiac participants during a phase 4 CR exercise class.