Clinical articles

This study investigated the impact of the use of a computer programme to collect data on cardiovascular risk factors, which could also provide patient education. A retrospective analysis was carried out of data recorded over three years in a general practice in Barnsley, an area with the second highest prevalence of ischaemic heart disease in England. The study found that use of a simple computer-based system by the primary care team led to 55% of the population being assessed within three years. Consequent patient education and lifestyle changes led to a reduction of risk factors in those at high risk who were re-screened. A possible reduction on admissions to hospital for cardiovascular disease was also noted.

International travel to malarial areas is increasingly common. Chemoprophylaxis using chloroquine is common, but can cause cardiac problems. We describe a new problem, of reversible heart block, in a patient on both chloroquine and the frequently-used calcium channel blocker, diltiazem.

Data from epidemiological and intervention studies have conclusively shown that a low level of high-density lipoprotein cholesterol (HDL-C) is an important risk factor for cardiovascular disease. Increasing low HDL-C levels produces risk reduction comparable with that observed with decreasing low-density lipoprotein cholesterol (LDL-C) in the major statin trials. The latter have shown that, even with effective statin therapy, there is still an unacceptably high residual risk of major coronary events. A substantial proportion of patients with coronary heart disease (CHD) with acceptable levels of LDL-C will have low levels of HDL-C and increased serum triglycerides. Of the available lipid-modifying treatments, nicotinic acid is the most potent agent for increasing HDL-C (by about 30% from baseline). In addition, it effectively decreases triglycerides and has a relatively modest effect in decreasing LDL-C. Modified-release nicotinic acid has been developed to overcome the poor tolerability associated with earlier formulations while maintaining the efficacy of immediate-release nicotinic acid. Modified-release nicotinic acid is effective and safe for the treatment of dyslipidaemia, including the atherogenic dyslipidaemia associated with type 2 diabetes and the metabolic syndrome. Combination therapy with modified-release nicotinic acid and a statin offers complementary therapeutic benefits, as well as reducing the progression of, or even regressing, atherosclerosis. This strategy can represent an important advance for clinical management of at-risk patients with dyslipidaemia.

We summarise the natural history and pathophysiology of aortic stenosis and regurgitation, the indications for surgery, the advantages and disadvantages of tissue, mechanical, homograft and autograft aortic valve replacement, and the prediction of operative mortality for individual patients.

Recent developments in the management of non-ST elevation acute coronary syndromes (ACS) have included the introduction of glycoprotein (GP) IIb/IIIa inhibitors. The National Institute for Clinical Excellence (NICE) has published guidelines on their use, which state that these agents should be given to all high-risk patients.
Here, we present the results of a national survey of 1,000 consultant cardiologists and general physicians. A total of 361 replies were analysed: 98% of respondents treated patients with ACS and 92% of respondents had access to troponin assays. Overall, 241 (67%) of respondents prescribed GP IIb/IIIa inhibitors for ACS. There was a significant difference between cardiologists and generalists, with 194 (77%) cardiologists and 46 (42%) general physicians prescribing GP IIb/IIIa inhibitors in ACS (p=0.0013).
Despite the presence of government guidelines regarding the administration of GP IIb/IIIa antagonists in ACS, we calculate that only 32% of respondents are prescribing IIb/IIIa inhibitors as recommended by NICE

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.