Clinical articles

The ACTION (A Coronary disease Trial Investigating Outcome with Nifedipine GITS) study is the largest ever performed randomised trial of an anti-anginal drug in patients with chronic stable angina. Its aim is to assess the effect of nifedipine GITS 60 mg versus placebo on standard therapy for coronary artery disease on event-free survival; its composite end point includes death from any cause, acute myocardial infarction, hospitalisation for overt heart failure, emergency coronary angiography, disabling stroke and procedures for peripheral revascularisation.
ACTION is one in a series of trials assessing drug effects in chronic stable coronary artery disease. The IONA (Impact Of Nicorandil in Angina) and EUROPA (EURopean trial On reduction of cardiac events with Perindopril in stable coronary artery disease) studies demonstrated that the K-ATP channel activator nicorandil and the angiotensin-converting enzyme inhibitor perindopril reduced the primary composite end point for cardiac events by 17% and 20%, respectively.
Nifedipine GITS is an effective antihypertensive and anti-anginal drug. In the INSIGHT trial, nifedipine GITS 30/60 mg demonstrated comparable outcomes to a diuretic combination therapy with significant effects on intermediate end points. ENCORE I (Evaluation of Nifedipine and Cerivastatin on Recovery of coronary Endothelial function) demonstrated that nifedipine GITS 30/60 mg positively affected the pathophysiology of coronary artery disease. We therefore anticipate that nifedipine will affect blood pressure, anginal symptoms and resulting complications, and the coronary atherosclerotic process in those patients randomised to receive this agent in the ACTION study.

Arrhythmias are more common in the elderly and in many situations are of prognostic importance. The incidence of arrhythmias in the elderly is increasing, most likely due to enhanced longevity. Alterations in heart rate and rhythm may occur because of age-related change within the heart. Elderly people are more likely to experience co-morbid health problems, intercurrent illness and adverse drug reactions, all of which may result in arrhythmias. Falls are a common problem in elderly people; an arrhythmic cause should always be considered.

Angiotensin-converting enzyme (ACE) inhibitor therapy only partially suppresses aldosterone production and ‘aldosterone escape’ occurs in up to 40% of patients with congestive heart failure (CHF). The RALES and EPHESUS studies show clearly that even in the presence of ACE inhibitor therapy, aldosterone contributes to mortality in CHF. There are many mechanisms for this. Firstly, aldosterone contributes to endothelial dysfunction and attenuates endothelium-dependent vasodilatation, at least partly by reducing nitric oxide bioavailability. Aldosterone also promotes myocardial fibrosis and cardiac remodelling by enhancing collagen synthesis, resulting in increased myocardial stiffness and increased left ventricular mass. These mechanisms mediated by aldosterone contribute to increased risk of ventricular arrhythmias and sudden cardiac death. Inhibition of aldosterone’s effect on mineralocorticoid receptors should now be considered standard therapy in populations of CHF patients. Aldosterone blockers also reduce the blood pressure in all types of hypertensive patients and may have an additional role as add-on therapy in hypertension, especially to lessen target organ damage.

Some patients with initial normal levels of high-density lipoprotein cholesterol (HDL-C) have lower HDL-C levels during lipid-lowering treatment. The aim of this study was to estimate the prevalence of low HDL-C (< 1.0 mmol/L; < 40 mg/dL) before and during lipid-lowering treatment. Additionally, the prevalence of low HDL-C during fibrate and statin treatment was compared. All patients attending two Health Insurance Associations during February and March 2002 for continuing reimbursement of their lipid-lowering drug were included in this study. Date of birth, sex and the actual lipid-lowering drug were recorded. The most recent lipoprotein levels and those after a three-month diet before the start of the treatment were recorded. In total, 2,259 patients (56% women) were included; 69% were treated with statins and 31% with fibrates. Low HDL-C levels were found before the initiation of the treatment in 7% of the statin patients and in 11% of the fibrate patients. During treatment, 10% of the statin patients and 13% of the fibrate patients had low HDL-C levels. The proportion of patients whose HDL-C decreased below 1.0 mmol/L (40 mg/dL) during treatment was 6% for statins and 4% for fibrates. Although lipid-lowering drugs are known to increase HDL-C levels slightly, not all patients benefit from this effect.

We summarise the natural history and pathophysiology of mitral valve stenosis and regurgitation. The indications for surgery, and the various surgical options including mitral valvotomy, mitral valve repair and mitral valve replacement with bioprosthetic and mechanical valves are discussed. The results of surgery for mitral valve disease in the UK are summarised.

In 2000, the European Society of Cardiology and American College of Cardiology issued a consensus document concerning the redefinition of myocardial infarction (MI). They proposed that the diagnosis of acute MI should be based on the rise and fall of specific markers combined with at least one of the following: ischaemic symptoms, ECG changes consistent with ischaemia or infarction, or coronary intervention. The implications of this redefinition are widespread, and it has been met with mixed opinions from physicians. Here we present the results of a survey, sent to 1,000 consultants in cardiology and general medicine, concerning the availability and their use of cardiac markers and their current working diagnosis of MI. Four case studies were included in the survey. Some 361 responses were analysed. Creatine kinase (CK) remains the most frequently used marker for the diagnosis of MI, but 23% of consultants had moved to a definition based on troponins. Fourteen per cent of consultants no longer used CK in their practice. Ninety-two per cent of consultants had access to troponin assays. Definitions varied widely between consultants, even within individual hospitals, as did the responses to the case studies.

We summarise the natural history and pathophysiology of mitral valve stenosis and regurgitation. The indications for surgery, and the various surgical options including mitral valvotomy, mitral valve repair and mitral valve replacement with bioprosthetic and mechanical valves are discussed. The results of surgery for mitral valve disease in the UK are summarised.

In 2000, the European Society of Cardiology and American College of Cardiology issued a consensus document concerning the redefinition of myocardial infarction (MI). They proposed that the diagnosis of acute MI should be based on the rise and fall of specific markers combined with at least one of the following: ischaemic symptoms, ECG changes consistent with ischaemia or infarction, or coronary intervention. The implications of this redefinition are widespread, and it has been met with mixed opinions from physicians. Here we present the results of a survey, sent to 1,000 consultants in cardiology and general medicine, concerning the availability and their use of cardiac markers and their current working diagnosis of MI. Four case studies were included in the survey. Some 361 responses were analysed. Creatine kinase (CK) remains the most frequently used marker for the diagnosis of MI, but 23% of consultants had moved to a definition based on troponins. Fourteen per cent of consultants no longer used CK in their practice. Ninety-two per cent of consultants had access to troponin assays. Definitions varied widely between consultants, even within individual hospitals, as did the responses to the case studies.

‘New’ was the operative word at this year’s Primary Care Cardiovascular Society annual meeting, held in Dublin from 3rd–4th October 2003. Delegates heard about the ‘new’ GP contract, the ‘new’ science of pharmacogenetics, the ‘new’ breed of healthcare professionals (with special interests) and a ‘new’ diploma in cardiovascular disease.

The two National Service Frameworks for coronary heart disease, and for diabetes, share some common themes. This article discusses where they overlap with each other and with national targets for stroke outlined in the National Service Framework for Older People. It then details a simple 10-point plan on how Primary Care Trusts can develop strategies to implement NSF targets so they achieve national standards.