Clinical articles

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.

Heart failure is an increasingly common condition for which device therapy, including the advanced pacing technique cardiac resynchronisation therapy, is becoming an accepted treatment. In this review we discuss the rationale, evidence base, indications, limitations and implant technique of this maturing treatment modality and speculate on expansion of its role in the near future.

Despite the availability of an array of medical therapies for the treatment of heart failure, quality of life is often poor for the majority of patients, and the mortality remains high. In addition, treatment is regularly not well tolerated and this results in frequent hospital admissions for some patients. This article reviews the management and medical treatment of acute heart failure, focusing on the emerging role of levosimendan.
Levosimendan is currently licensed in 10 European countries (Simdax, Orion Pharma, Finland) for the treatment of acute heart failure. It is a new inotropic drug with a dual mechanism of action: sensitisation of the cardiac myofilament to calcium, thus enhancing cardiac contractility, and vasodilation of vascular smooth muscle. The published clinical studies so far have utilised intravenous levosimendan. However, the agent is also well absorbed orally, and phase two trials of its use in stable patients with less severe heart failure are underway.1

Cardiac rehabilitation offers physical, psychological and survival benefits for patients recovering from cardiac illness. This questionnaire survey of all known cardiac rehabilitation units in the UK provides data on how well the National Service Framework targets for cardiac rehabilitation are being met.

There is a widespread lack of awareness amongst the British public of the link between myocardial infarction and stroke, and about secondary prevention.

Atrial fibrillation (AF) is the commonest sustained
arrhythmia encountered in clinical practice.
Depending upon its time course, AF can be
classified into three categories: paroxysmal, persistent
and permanent.