Clinical articles

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.

In the elderly, the investigation of symptoms potentially due to an arrhythmic cause is similar to that for a younger person. In many cases, however, a history obtained from a friend or relative can be valuable. Routine investigations should include tests of thyroid function, an electrocardiogram (ECG), and ambulatory ECG recording. In patients without cerebrovascular disease, carotid sinus massage with continuous ECG monitoring should be performed.
The role of device therapy in the management of arrhythmias in patients of all ages is increasing. Permanent pacing can improve symptoms and prognosis in patients with certain bradycardia, and the indications for pacing are available in contemporary international guidelines. Recent developments in device therapy include multisite pacing and implantable cardioverter defibrillators. Emerging data suggest that these devices can be used to good effect in selected elderly patients.

In the elderly, the investigation of symptoms potentially due to an arrhythmic cause is similar to that for a younger person. In many cases, however, a history obtained from a friend or relative can be valuable. Routine investigations should include tests of thyroid function, an electrocardiogram (ECG), and ambulatory ECG recording. In patients without cerebrovascular disease, carotid sinus massage with continuous ECG monitoring should be performed.
The role of device therapy in the management of arrhythmias in patients of all ages is increasing. Permanent pacing can improve symptoms and prognosis in patients with certain bradycardia, and the indications for pacing are available in contemporary international guidelines. Recent developments in device therapy include multisite pacing and implantable cardioverter defibrillators. Emerging data suggest that these devices can be used to good effect in selected elderly patients.

Current guidelines emphasise the importance of lipid management in secondary prevention of coronary heart disease (CHD). This audit of lipid levels and lipid-modifying therapy was undertaken in 1,736 patients, 919 men and 817 women, who were either attending a lipid clinic in inner-city Britain (n=1,035, 60%) or a general practice surgery covering 9,500 patients (n=701, 40%). Patient data were obtained from review of case notes and latest results for serum total, low-density lipoprotein (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were categorised in accordance with UK guideline targets (total cholesterol < 5 mmol/L, LDL-C < 3 mmol/L and HDL-C > 1 mmol/L). Overall, 48% of men and 61% of women had raised total cholesterol levels above target and 23% of men and 8% of women had low levels of HDL-C; these proportions were generally consistent for individual centre data. Amongst patients with established CHD who were receiving statin therapy, 31% of men and 47% of women had raised total cholesterol levels above target and 24% of men and 8% of women had low HDL-C levels. This suggests that a substantial proportion of patients at risk of developing or with established CHD, either attending general practice or a specialist lipid clinic, fail to meet recommended lipid targets. Redress of this failure requires more aggressive management, possibly with multidrug lipid-modifying therapy.

The recent EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) examined the effect of treatment with the angiotensin-converting enzyme (ACE) inhibitor perindopril in 12,218 patients with stable coronary artery disease (CAD). After 4.2 years, treatment with perindopril 8 mg once daily resulted in a 20% relative risk reduction in the primary end point, a composite of cardiovascular death, non-fatal myocardial infarction, and cardiac arrest (p=0.0003). Risk reductions were also observed for secondary end points, including fatal and non-fatal myocardial infarction (24% reduction, p<0.001) and hospitalisation for heart failure (39% reduction, p=0.002). These benefits were observed on top of standard recommended preventive therapies such as antiplatelet agents, beta blockers and lipid-lowering drugs. Benefits were consistent for all patients with CAD, irrespective of the presence or absence of risk factors such as age, diabetes, hypertension, previous myocardial infarction, or previous revascularisation. Perindopril, a lipophilic tissue ACE inhibitor which binds strongly to ACE, has several anti-atherogenic actions and vascular properties which may contribute to its protective effect. EUROPA is the first trial to show the benefit of ACE inhibition in a broad population often seen in daily clinical practice. The results suggest that perindopril should be added to other recommended preventive treatments in all patients with CAD.

Primary cardiac lymphomas (PCL) are rare neoplasms. They occur at any age and are rare in immunocompetent patients, accounting for 1.3% of all cardiac tumours and 0.5% of all extranodal lymphomas. PCL have been increasingly found in patients with acquired immune deficiency syndrome (AIDS).1 PCL are difficult to diagnose, especially during the early stages of the disease when their manifestations are non-specific.2
Discovery of a malignant cardiac tumour at operation would usually be managed by biopsy and closure without resection, and inevitably would result in early mortality. We report a patient who is alive 12 months after resection of a primary cardiac non-Hodgkin’s B cell lymphoma.