Clinical articles

Erectile dysfunction (ED) is reported to coexist with cardiovascular disease. It may be the first clinical manifestation of cardiovascular disease making it a helpful, early marker. Psychogenic causes are also an important component of ED. Around half of all men over the age of 40 years are affected by ED but treatment is often not requested by the patient. ED can be successfully treated pharmacologically. PDE-5 inhibitors are currently the treatment of choice. Physicians should initiate discussion about sexual health and ED in the diagnosed cardiovascular patient.

Multiple lines of evidence show that high-density lipoproteins (HDL) protect against coronary heart disease (CHD), and that low blood levels of HDL cholesterol (HDLc) indicate high risk of a coronary event. Major epidemiological studies show that a low HDLc is a strong predictor of CHD, and this relationship occurs at any level of low-density lipoprotein cholesterol (LDLc) or triglycerides, demonstrating independence. When the HDLc level is raised by drug therapy, coronary atherosclerosis is decreased and CHD events are lessened. Increases in HDLc are in fact independently correlated with coronary angiographic and clinical benefit. HDL stimulates the removal of cholesterol from cells in the vascular wall. The cholesterol is taken up by HDL and shuttled in part to the liver for excretion in the bile.
Experiments in transgenic mice provide proof that increased HDL secretion protects against atherosclerosis caused by an atherogenic diet or genetic hyperlipidaemia. In humans, HDL has direct beneficial effects on coronary arterial vasodilation. This compelling scientific evidence thus justifies HDLc as a target to reduce risk of CHD. An international group of experts in epidemiology, clinical and basic science formed a consensus that an HDLc concentration of 1.0 mmol/L (40 mg/dL) is a realistic clinical guideline for patients at high risk of a coronary event. Specific diet and drug therapies were recommended.

Older patients represent the majority of those considered for coronary intervention but they are under-represented in most clinical trials in this area. Reviewing registry data and pooled data from clinical trials, this article discusses the effect of age on procedural mortality and morbidity. It also reviews the effect of age on interventional procedures in unstable patients, and on pharmacological intervention. Despite the higher initial risks in older patients, the authors argue that several risk factors are responsible for predicting poor outcome following interventional procedures. Percutaneous coronary intervention can be very successful in the elderly and its risks must be balanced against the many important benefits older patients stand to gain from the procedure.

Non-steroidal anti-inflammatory drugs (NSAIDs) have potentially dangerous side effects, which has led to intense interest in the development of the cyclo-oxygenase (COX) inhibitors. This article reviews the science, safety and clinical evidence to date with these drugs.
They appear to have fewer gastrointestinal and equivalent renal risks to NSAIDs. Reviewing the clinical evidence, particularly the complex cardiovascular effects of the COX inhibitors, the article discusses the clinical relevance of their thrombogenic and anti-atherosclerotic potential. Since many of the studies are retrospective analyses, randomised clinical trials are needed to ascertain whether these cardiovascular effects constitute a problem or an unexpected benefit, and whether there are differences between the different COX-2 inhibitors.

Epidemiological studies in the Netherlands first demonstrated an inverse relationship between ordinary (technically known as black) tea drinking and cardiovascular disease (CVD) mortality. Subsequent population-based studies have variously agreed with, been opposite to (notably in the UK) or produced null results. Currently, UK epidemiological studies look out of step with the rest of the world. This review highlights that, in the UK, tea drinking is more pronounced in the lower socio-economic (SE) groups, whilst tea drinking is associated with higher SE groups in the other countries that have linked tea to CVD. It is this key difference that may account for the apparent positive relationship between tea drinking and CVD mortality in the UK; low SE status (and high tea drinking) is also strongly associated with a high prevalence of the major CVD risk factors.
Any positive benefits from tea drinking are likely to be due to a high content of antioxidant flavonoids, particularly the catechins. In vitro and intervention studies support mechanisms, such as improved endothelial function, whereby tea flavonoids may be cardioprotective.
Whilst there is no evidence from population studies of positive cardiovascular benefit from tea drinking in the UK, tea is still contributing flavonoids to individual diets and these may well be beneficial. Tea drinking can safely be encouraged as part of a healthy diet. Further studies are required to clarify the situation.

Coronary heart disease (CHD) is the leading cause of death in the UK. Approximately 50% of myocardial infarctions occur in patients with no prior history of CHD or cardiovascular risk factors while sudden death is often the first manifestation of CHD in as many as 35% of patients. The realisation that standard risk factors incompletely predict incident CHD events has led to the development of several non-invasive imaging techniques to accurately assess the risk of CHD over the last decade. Several epidemiological studies have established that the total coronary atherosclerotic plaque burden is a powerful predictor of future hard coronary events (myocardial infarction and death). This article reviews the role of electron beam computed tomography (EBCT) in the early detection of subclinical coronary artery disease, the identification of ‘high-risk’ asymptomatic patients for intensive medical intervention, and its role in evaluating the progression of coronary artery disease and in monitoring the efficacy of medical therapies.

Anonymised data collected from 24 participating localities in England have been aggregated for this report. The data are taken from general practice computer records using a validated extraction tool Morbidity Information Query and Export SynTax (MIQUEST). The number of patients with heart disease, a cholesterol measure, whether they had been prescribed a statin, their quality of control, and its implications are reported.
In the population studied of 2.4 million, 89,422 patients had a diagnosis of ischaemic heart disease; a prevalence rate of 3.7%. Cholesterol measurement was available for half (48.3%) of these patients, of whom half (55.2%) were taking a statin. As a result of this treatment gap, 118 excess myocardial infarctions annually are predicted, equivalent to around 7,150 events nationally.
Compared to previous audits carried out in UK general practice, considerable progress has been made towards the achievement of treatment goals. The treatment gap is represented by a combination of lack of measurement and recording of data as well as poor quality of control.

Patients with Dressler syndrome generally present with malaise, fever, chest pain, leukocytosis, an elevated erythrocyte sedimentation rate and pericardial effusion.1 To the best of our knowledge, presentation of Dressler syndrome with pericardial tamponade is very rare. An investigation on Medline revealed that no cases had been reported in the last 10 years. We reported this case because of its rare presentation pattern and its successful treatment with percutaneous catheter drainage.

Statins are prescribed worldwide for patients with coronary heart disease (CHD) and also for those at risk of developing atherosclerotic vascular disease. This article looks at the prescribing of statins in the UK demonstrating how they are underprescribed in this country, how ineffective doses of statins are used due to many doctors not understanding how to implement guidelines, and how the greatest reductions in CHD risk are achieved by the greatest reductions in cholesterol.

Routledge et al. have addressed an increasingly topical issue. They demonstrate in a small cohort of patients with aortic stenosis (AS) that the use of angiotensin- converting enzyme (ACE) inhibitors may be safe, particularly with some degree of systemic hypertension.1 This adds to the evidence that the use of ACE inhibitors in this patient population should not be strictly contraindicated. However, the more searching question of whether they should be used remains unanswered.