Clinical articles

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.

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