Clinical articles

End-stage heart failure represents a major public health challenge and carries a poor prognosis. After a 30-year gestation period, mechanical assist devices are now poised to make a significant impact in the treatment of heart failure patients. This review gives a general overview of the subject and describes some of the devices currently available in greater detail.

Background: With an incidence rate of 30–50%, atrial fibrillation (AF) after bypass surgery continues to be one of the most common complications. The possibilities of haemodynamic instability and thromboembolism necessitate the initiation of antiarrhythmic and anticoagulant therapy. Despite early initiation of therapy, AF can increase post-bypass morbidity and mortality. It can also prolong intensive care unit and hospital stay and further increase resource utilisation. In this article we review the pathophysiology, risk factors, effect on resource utilisation, current prophylactic and therapeutic strategies, and risk-benefit assessment of anticoagulant therapy in post-bypass AF.
Methods: This is a review of the medical literature on post-bypass AF from January 1980 to March 2003. Relevant older references were also reviewed. Clinical and research studies on the mechanisms, pathophysiology, risk factors, complications, resource utilisation, prophylaxis and management were collected from the Medline, Embase, Cinhal and Sigle databases and reviewed.
Conclusion: AF significantly increases complications and resource utilisation after bypass surgery. Prophylactic therapy could significantly reduce the incidence of AF. In AF lasting more than 48 hours, anticoagulant or antiplatelet therapy based on individual risk assessment is recommended.

Pre-hospital thrombolysis has proven clinical benefits in the management of acute myocardial infarction (MI). If the targets for administering thrombolysis, in particular call-to-needle time, are to be met, then it seems likely that its use will be more widespread. With appropriate training and support, paramedics can competently perform 12-lead electrocardiograms (ECGs) and administer thrombolysis. Cardiologists should be prepared to undertake paramedic training and play a central role in the development of protocols and pathways for the administration of pre-hospital thrombolytic therapy.

A case of acute aortic valve endocarditis due to Erysipelothrix rhusiopathiae acquired from fish.

The Clinical Standards Board for Scotland (CSBS) was established in 1999 to develop a national system of quality assurance and accreditation of clinical services with the aim of promoting public confidence in the NHS in Scotland (NHSS). The coronary heart disease pathfinder project assessed services to patients following myocardial infarction. The quality assurance system involves comparison of performance against written standards developed by a multidisciplinary project group which included lay members. Six nationally applicable standards were the subject of comprehensive open consultation with both the public and the professions. All acute trusts in Scotland were issued with a self-assessment tool followed by a visit from a multidisciplinary external review team comprising of lay representatives and health service professionals who produced a verbal and written report. There was a pool of over 100 reviewers and each team numbered on average eight reviewers, two of whom were lay members. A national report of Scotland’s performance was published by CSBS in October 2001.
The main areas of concern in Scotland’s national performance were that few sites were able to meet the standard relating to thrombolysis times and there was an overall lack of robust audit material. It was noted, however, that the major strength of Scotland’s delivery of healthcare lay with the staff providing services.
The process of accreditation in Scotland differs from that of other countries and one of its strengths lies in the involvement of the public, patients and health professionals as peers in all stages. The process itself encouraged dissemination of good practice and highlighted areas of concern.

Increased attention to good glycaemic control in diabetic patients has encouraged more intensive use of insulin. To help achieve a steady ‘basal’ insulin supply, a new long-acting insulin analogue glargine (Lantus®) has been introduced. This provides a flatter ‘peakless’ circulating concentration of insulin than protamine (isophane) and lente insulins, facilitating dose escalation with reduced risk of hypoglycaemia. Another long-acting insulin analogue detemir (Levemir®) is advanced in development. Intensive insulin therapy requires ‘top-ups’ to coincide with mealtimes. The recently introduced rapid-acting monomeric analogues, lispro and aspart, are particularly useful in this respect. The monomeric analogues are quickly absorbed and short acting: hence they reduce post-prandial glucose excursions (which have been ascribed especial cardiovascular risk) with less risk of hypoglycaemia than conventional short-acting insulin. Premixed rapid-intermediate acting mixtures of monomeric analogues with protamine are also available. Continuous subcutaneous insulin infusion is receiving increased use as the pump technology advances, mainly incorporating the monomeric insulin analogues. Inhaled insulins continue in development, and various oral insulin formulations have entered clinical trials.

Atrial fibrillation (AF) is the commonest sustained arrhythmia affecting elderly people. It will become increasingly prevalent in Western societies, given the growing proportion of elderly people in these populations.>br> AF may lead to a variety of embolic phenomena, notably stroke. Furthermore, AF may complicate other conditions, such as hypertension and heart failure. AF is associated with an increased risk of death.
The management of AF can be a difficult problem, particularly in symptomatic, elderly patients. Results from recent large, multicentre clinical trials in sustained AF have demonstrated that a rate control strategy with conventional drugs, is at least as effective, and possibly superior, to rhythm control by chemical or electrical cardioversion over a three-year period. Whether these results can be extrapolated to longer time periods than the trials’ durations (approximately 3.5 years) is not known. Results from clinical trials of a new oral anticoagulant, ximelagatran, indicate that this agent is as good an anticoagulant as warfarin in sustained AF. Other results are awaited from on-going trials on the tolerability and side-effect profile of this drug. The possibility of an alternative anticoagulant which does not share warfarin’s need for routine monitoring of its anticoagulant effect, nor share warfarin’s potential for adverse interactions with other drugs, is very attractive, particularly in elderly patients.
In the longer term, radiofrequency ablation techniques might provide a more widely available, curative therapy, for elderly patients with AF.

Increasing numbers of patients are receiving warfarin therapy, with atrial fibrillation being the main indication. If warfarin therapy is to be effective, however, good therapeutic control is important. Recent advances in models of management, including primary care clinics and patient self-management, has meant that patients have an increasing choice as to how and where they have their warfarin monitored. Comparison of performance between these different models of care has been historically difficult due to the use of different reporting techniques. This paper highlights the different methods of reporting therapeutic control, including adverse event reporting, and recommends that at least two measures from a set of recognised parameters should be used. This makes comparison of control between centres possible.

The timing and effectiveness of a new protocol for organising direct current cardioversion (DCCV) for patients with atrial fibrillation (AF) was compared with the existing system in a medium-sized district general hospital in the United Kingdom. The new protocol comprised a monthly dedicated DCCV list in the operating theatres, with an anaesthetist and an Operating Department Assistant providing anaesthesia, and cardiology medical staff performing the cardioversion. The last 35 consecutive patients undergoing DCCV for AF before the new protocol was introduced were compared with the first 35 patients having DCCV under the new protocol.
The time to perform 35 consecutive cardioversions was reduced from 32 months to 10 months. The new system resulted in no cancellations for administrative reasons and only one patient for a clinical reason. Sinus rhythm (SR) was restored in 60% cases under the new protocol (double the success rate before the new protocol) and 76% patients discharged in SR under the new protocol, remained in SR at clinic follow-up.
A simple change in the method of delivering a clinical service has resulted in an improvement in both the administration and clinical outcome for patients. Such changes, requiring co-operation between anaesthetic and cardiology departments, could be implemented widely for the benefit of many patients.

This article explores the strengths and weaknesses of current treatment pathways of atrial fibrillation as discussed at a multidisciplinary meeting of healthcare professionals organised by the Thrombosis Quorum. By discussing case studies using a Socratic method of dialogue to elicit better questioning of management practices, the meeting reached a consensus on various issues in the care of the patient with atrial fibrillation.