March 2002 Br J Cardiol 2002;9:168-70
Wayne R Arthur, Gerry C Kaye, Robert F Mueller
Recurrent syncope in a patient with Andersen’s syndrome Wayne R Arthur, Gerry C Kaye, Robert F Mueller Most common inherited diseases with cardiac involvement are associated with structural abnormalities of the heart and/or great vessels. Discussions of inherited cardiac electrophysiological abnormalities were once limited to Jervell and Lange-Nielsen syndrome and Romano-Ward syndrome. Subsequently, other genetically distinct arrhythmogenic cardiovascular disorders have been discovered.1 These result from mutations in the fundamental cardiac ion channels that orchestrate the action potential of the human heart. Most of these genetic channelopathies are depicted by marked QT prolongation on the electrocardiogram.
March 2002 Br J Cardiol 2002;9:163-7
Diana R Holdright
Coronary heart disease (CHD) and stroke frequently coexist, partly because they share many risk factors. After myocardial infarction (MI), there is a significant risk of mural thrombus formation, left ventricular aneurysm, impaired left ventricular function and atrial fibrillation; all these increase the risk of stroke. The risk of neurological deficit after cardiac surgery is higher in those patients who have already had a stroke. Cognitive decline after cardiac surgery is common: it may follow a pattern of early improvement but later decline. Lipid-lowering therapy has been shown to reduce non-fatal stroke in patients at risk of developing or with coronary artery disease. Clopidogrel with aspirin may be of benefit in patients with unstable angina and non-ST elevation MI. Antihypertensive treatment and stopping smoking are helpful. The HOPE trial results showed a powerful and preventative role for ACE inhibitors.
March 2002 Br J Cardiol 2002;9:158-62
Abba Gomma, John Henderson, Henry Purcell, Kim Fox
The renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathogenesis of cardiovascular disease. Blockade of this system results in a number of biologically important beneficial effects, including inhibition of the breakdown of bradykinin, reduction in blood pressure and inhibition of neuroendocrine activity, as well as reversal of endothelial dysfunction. Angiotensin-converting enzyme (ACE) inhibitors have an established role in the management of hypertension and heart failure. More recently, for instance in the HOPE trial, they have been investigated in patients with a history of coronary artery disease, stroke, peripheral vascular disease, or diabetes plus at least one other cardiovascular risk factor, but with preserved left ventricular function. Treatment with ramipril was shown to reduce cardiovascular events significantly, especially in patients who had diabetes. Two further ongoing trials – EUROPA (with perindopril) and PEACE (with trandolapril) – are described, which have important differences in trial design and which will further assess the protective effects of ACE inhibition in patients with stable coronary artery disease.
March 2002 Br J Cardiol 2002;9:153-7
Mohd R Abdul-Rahman, Saveena S Ghaie, Justo R Sadaba, Levent T Guvendik, Alexander R Cale, Michael E Cowen, Steven C Griffin
The aim of this survey was to review the awareness and efficacy amongst patients and general practitioners (GPs) in controlling coronary risk factors following coronary artery bypass graft surgery (CABG). It was a prospective cohort study based on an inclusive registry at our department 230 patients who underwent CABG between April 1999–July 2000 and who had a history of hypertension and hypercholesterolaemia were selected. Frequency of blood pressure (BP) and cholesterol monitoring, blood glucose control, current smoking status, weight and medications were established via telephone interview of patients. BP and cholesterol levels were confirmed by written questionnaires to GPs. BP and cholesterol were considered to be controlled if they were ≤ 140/85 mmHg and ≤ 5.0 mmol/L respectively. Of the 230 patients, 213 were successfully contacted. After surgery, 181 (85%) patients had BP checks at least six-monthly by their GPs, 13 (6.1%) less frequently and 19 (8.9%) not at all. Cholesterol levels were checked at least six-monthly in 128 (60.1%), less frequently in 47 (22.1%) and not at all in 38 (17.8%). Thirteen of the 20 patients who were smoking at the time of surgery continued to smoke. BP and cholesterol readings were obtained for 169 of the 213 patients. Of these, BP was well controlled in 92 (54.4%), uncontrolled in 61 (36.1%) and not checked in 16 (9.5%). Cholesterol was well controlled in 106 (62.7%), uncontrolled in 35 (20.7%) and not checked in 28 (16.6%) patients. Although patients and GPs are generally aware of the importance of controlling coronary disease risk factors, more effort is required if we are to meet the Joint British recommendations on prevention of coronary heart disease.
March 2002 Br J Cardiol 2002;9:147-52
Dougal R McClean, Martyn R Thomas
Restenosis following PTCA or intracoronary stent insertion remains the greatest challenge to interventional cardiology. Intracoronary brachytherapy may use either beta- or gamma- radiation. The target cells are most likely in the adventitial layer of the vessel wall. The principle of using brachytherapy post-angioplasty to reduce restenosis has been proven in animal models. Multiple randomised trials have shown brachytherapy to be the current optimal therapy to treat in-stent restenosis. The data for the use of intracoronary radiation for treatment of de novo coronary lesions are less strong. Potential complications of brachytherapy include ‘edge effect’ and ‘late late stent thrombosis’. These problems are being minimised with the use of long sources and prolonged antiplatelet therapy. Drug delivery stents may challenge the role of brachytherapy in preventing and treating restenosis in the near future.
March 2002 Br J Cardiol 2002;9:131-4
Scott W Muir, Kennedy R Lees
PROGRESS in the secondary prevention of stroke Scott W Muir, Kennedy R Lees Over the last 10 years there has been considerable progress in the development of secondary prevention strategies for ischaemic stroke. No longer is aspirin the cornerstone of stroke secondary prevention. Trials like ESPS-21 and CAPRIE,2 have established the place of antiplatelet agents in secondary prevention. The 4S3 and CARE4 studies, among others, and the recently presented Heart Protection Study5 have alluded to the benefits of statins, not only in the setting of ischaemic heart disease, but now also in the setting of cerebrovascular disease. Until the publication of the PROGRESS study6 in September of last year, the question of blood pressure reduction in the setting of secondary prevention was unanswered and contentious.
March 2002 Br J Cardiol 2002;9:122-24
Saul G Myerson, Yohan Samarasinghe, Chris Taylor, Michael D Feher
Caffeine-containing drinks are increasingly available but excessive consumption can give rise to health hazards. A case is described here of a 31 year old man with no history of cardiovascular disease but a very high caffeine intake; he developed atrial fibrillation, which required treatment with flecainide. He has reduced his caffeine intake and remains well to date.
February 2002 Br J Cardiol 2002;9:120-21
Suneel Talwar, Khalid Khan
Myocardial infarction in a patient with hypertrophic cardiomyopathy Hypertrophic cardiomyopathy (HC) is a disease characterised by marked heterogeneity in its morphology and natural history. The prevalence of significant coronary artery disease in this population has been estimated to be just over 10%.1 On the other hand, the prevalence of transmural myocardial infarction in the absence of significant coronary atherosclerosis is about 15% in a population of patients who have died from HC.2 Although electrocardiographic criteria for diagnosis of acute myocardial infarction (AMI) in adults are well known and accepted, no general criteria exist for diagnosis of AMI in patients with HC. Further, there are no clear-cut guidelines for the management of patients with HC who present with a suspected AMI.
February 2002 Br J Cardiol 2002;9:115-19
Clifford J Bailey, Ian W Campbell
One of the purposes of the United Kingdom Prospective Diabetes Study (UKPDS) was to compare the efficacy of different antidiabetic drugs in the long-term treatment of type 2 diabetes. In overweight type 2 patients, use of metformin as the initial antidiabetic drug therapy reduced overall mortality and reduced various long-term complications to a greater extent than other first-line treatments tested (sulphonylureas and insulin) whilst controlling hyperglycaemia to a similar extent. The benefit of early intervention with metformin may be due, at least in part, to its actions against insulin resistance and associated cardiovascular risk factors. Thus the UKPDS has provided evidence that early intensive glucose control with metformin in overweight type 2 diabetic patients is a particularly effective approach to reduce vascular complications and improve survival.
February 2002 Br J Cardiol 2002;9:109-14
Roman Casciano, John J Doyle, Alistair McGuire, Raúl Arocho, Steve Arikian, JuliaN Casciano, Heather Kugel, Nick Marchant, Renee Kim
The objective of this paper was to quantify the impact on overall cardiovascular disease treatment costs resulting from the use of amlodipine in the coronary artery disease (CAD) population in the UK. A Markov cohort simulation model was developed to estimate the overall average healthcare costs of patients with CAD in the UK and to determine the cost-effectiveness of the use of amlodipine as part of their treatment regimen. Outcome probabilities used in the model were based on patient-level data from the Prospective Evaluation of the Vascular Effects of Norvasc Trial (PREVENT). Cost estimates for in-patient and out-patient care associated with each outcome were applied to quantify the overall average healthcare cost for each arm of the study. The hospitalisation rate per patient in the placebo cohort was 61.8% while that in the amlodipine cohort was 44.3%. This corresponds to an average cost per patient for cardiovascular disease (CVD) treatment of £1,858.64 for amlodipine patients and £1,800.49 for placebo patients over three years of follow-up. Calculations yield a cost per hospitalisation avoided of £331.67. In conclusion, the inclusion of amlodipine in the treatment regimen for patients with CAD is expected to result in improved clinical outcomes through a marginal investment in cost.