Clinical articles

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.

Aortic valve stenosis is a common cause of left ventricular hypertrophy (LVH). Severe LVH in association with aortic stenosis does not always regress following valve replacement surgery and is associated with a poor prognosis. The importance of angiotensin II in the hypertrophic process is increasingly recognised and the benefits of angiotensin-converting enzyme (ACE) inhibition in reducing LVH associated with hypertension are well established. Although ACE inhibitors are currently contraindicated in aortic stenosis (AS) on theoretical grounds there are very few data to support this. We have audited the current use of ACE inhibitors in a group of patients with AS and found that 27% of this group are currently taking an ACE inhibitor with no documented adverse effects. Trials to investigate the therapeutic benefit of ACE inhibition in preventing adverse left ventricular remodelling are merited but must be preceded by safety and tolerability studies.

Patients admitted to hospital with a diagnosis of acute myocardial infarction (AMI) have high motivation to stop smoking. Nicotine replacement therapy (NRT) is known to be valuable in helping smokers quit although it is not commonly prescribed in patients in the acute phase following AMI.
Results from a full in-patient smoking cessation service were retrospectively analysed after the first 12 months, with particular reference to safety and efficacy in patients with AMI. Of 42 patients admitted with AMI who smoked and who were referred to the service, 32 (76%) received NRT with counselling as an in-patient, one as an out-patient and nine received counselling only. Assessment at four weeks showed 11 (26%) were still smoking, one (2%) had been lost to follow-up and 30 (71%) had successfully quit. Of these, six (20%) had not required NRT, one (3%) had received out-patient NRT and 23 (77%) had received in-patient NRT. There were no adverse outcomes in any patients.
This suggests an in-patient smoking cessation programme, including prescription of NRT in the first five days following presentation with AMI, is a safe and effective means of helping vulnerable people to give up smoking.

Persistent left superior vena cava (PLSVC) is the most common anomaly involving central venous return in thorax. Anatomically it is a mirror image of the right superior vena cava and is usually asymptomatic but can cause difficulties during Swan-Ganz catheterisation and insertion of pacing systems. This article presents a comprehensive review of this anomaly and clinical scenarios in which it can prove problematic, illustrated by an example.

Thrombolytic therapy for acute ischaemic stroke improves outcome in a highly selected group of patients. It will shortly be licensed in the UK for this indication. Implementation of this treatment will be difficult as current stroke services are ill-equipped to meet the challenges associated with aggressive management of hyperacute stroke.
This article evaluates the published literature concerning thrombolytic therapy in the context of ischaemic stroke and briefly discuss the obstacles which prevent more widespread use of this treatment in the UK. It also considers the effect of age on efficacy and tolerability of thrombolytic therapy.

The objective of this survey was to estimate the proportion of episodes of acute coronary syndromes (ACS) without ST segment elevation in relation to the total number of acute chest pain presentations. We attempted to estimate costs associated with glycoprotein (GP) IIb/IIIa inhibitor treatment in patients with high-risk features.
This was a prospective survey set in a typical British district general hospital, serving a population of about 300,000. It took place over a 14-week period.
The participants were all patients presenting with chest pain of possible cardiac origin, identified by intensive surveillance of all emergency medical admissions (EMAs) in patients over 16 years of age and all adult and elderly medicine in-patients. At the time of the study, the upper limit of normal for troponin T (TnT) used in this hospital was 0.05 µg/L.
The main outcome measures were: the proportion of EMAs due to chest pain of likely cardiac origin; the number of episodes of ACS without ST elevation as a proportion of all EMAs; and the projected prescribing costs of GPIIb/IIIa inhibitor treatment for high-risk cases.
We found that 22% (CI 20.07–23.5%) of all EMAs were due to chest pain likely to be of cardiac origin. One event of ACS without ST elevation was generated for every 25.6 (CI 23.8–28.6) EMAs. Using a TnT value of > 0.1 µg/L to define high risk and suitability for GPIIb/IIIa inhibitor treatment, a minimum of 66% of patients with ACS without ST elevation would be eligible for treatment. In the study hospital, this translates to an annual cost of £131,000 (equivalent to £43,600 per 100,000 catchment population) or £11.45 per all-cause hospital EMA.
In conclusion, about two thirds of patients with ACS without ST elevation have high-risk features and would potentially benefit from treatment with GPIIb/IIIa inhibitors. The costs of drug treatment are appreciable, but financial planning can be assisted by the data presented here.