Clinical articles

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.

This study investigated the current level of provision of cardiac rehabilitation (CR) for automatic implanted cardioverter defibrillator (ICD) patients in the UK, the clinical and technical staff views on the need for such a service, and the current level of provision and the most commonly reported barriers to meeting these needs. The study was carried out via a postal questionnaire survey of all NHS implantation centres for ICD patients.
The majority of respondents (99%) believed they should provide rehabilitation for their patients, but only 14 (36%) centres had a programme for rehabilitation that ICD patients could access and only four (10%) of these were specifically designed for ICD patients. The majority of respondents (74%) believed they were not meeting their patients’ needs for rehabilitation. The most commonly endorsed barriers to providing and developing CR services were limited multidisciplinary staff, a wide geographical catchment area, and administrative and organisation difficulties. There was wide support for the potential of using a home-based, remotely monitored, rehabilitation package. This shows that the vast majority of staff in implantation centres agree with the recent NICE recommendations that there is an unmet need to provide CR for ICD patients.

This article describes the process used to arrive at the set of assessment measures and
minimum dataset for cardiac rehabilitation (CR) that has been endorsed by the British
Association for Cardiac Rehabilitation (BACR) and the British Heart Foundation (BHF) for
the national audit of CR.

Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are used to prevent rethrombosis and distal platelet embolisation in acute coronary syndromes. LMWH have a more predictable anticoagulant response and are less likely to result in bleeding. For the moment UFH should be used in primary percutaneous coronary intervention (PCI). It may also be preferable to use UFH in the setting of rescue PCI following tenecteplase (TNK) treatment. In those over 75 years of age, the combination of TNK with enoxaparin has been shown to be superior to TNK with UFH in reducing ischaemic end points without increasing the risk of haemorrhage. Results from TIMI IIB indicate that enoxaparin is superior to UFH for the acute management of non-ST elevation ACS (in patients managed conservatively). Enoxaparin and UFH appear to have similar efficacy and safety profiles when used in conjunction with glycoprotein IIb/IIIa blockade during PCI.

Hypertension is a major cardiovascular risk factor and its pathogenesis remains elusive. For a long time, hypertension and dyslipidaemia have been viewed as independent but synergistic cardiovascular risk factors increasing the risk of premature atherosclerosis. Recently, a growing body of evidence has indicated that hypercholesterolaemia promotes impairment in several mechanisms implicated in blood pressure control such as nitric oxide bioavailability, renin-angiotensin activity, the sympathetic nervous system, sodium and fluid homeostasis and ion transport/signal transduction. Moreover, recent clinical studies have pointed out a beneficial effect of cholesterol-lowering treatment in reducing blood pressure to a small but significant degree. Our assumption is that depending on the complex inter-relationships between genetic background and life style, hypercholesterolaemia may be a trigger to blood pressure elevation. An integrated approach to the treatment of hypertension and dyslipidaemia can, therefore, maximise both blood pressure control and prevention of cardiovascular disease. In this review, we discuss recent important data from our and other groups, demonstrating the clinical evidence of the hypertensinogenic effects of hypercholesterolaemia, and the biological mechanisms which underlie them.

The circadian rhythms of the cardiovascular system are related to the risk of events such as myocardial infarction and stroke. The so-called ‘morning surge’ in heart rate and blood pressure at around the time of waking is a particularly hazardous period. The sympathetic nervous system and the renin-angiotensin system are thought to be the main regulators of these rhythms and a potential target of antihypertensive medication is the blunting of the morning surge through action on these systems. This article reviews some of the mechanisms involved and recent therapeutic approaches to this problem.