Clinical articles

There is a lack of standards pertaining to stopping antiplatelet agents in patients with acute coronary syndromes prior to coronary surgery. We conducted a national survey of all centres performing cardiac surgery in the UK and Ireland into practices and standards in relation to clopidogrel and aspirin before coronary artery surgery (n=36).
The response rate was 89%. The majority of centres used combination antiplatelet therapy in either some or all pre-operative acute coronary syndrome patients (79%). Aspirin alone is given in 19% of this surgical subpopulation. Aspirin is stopped 4.9 + 0.5 days (mean + SEM) and clopidogrel 6.5 + 0.5 days prior to surgery. There are no clear departmental policies in most cases (21 of 32 units) regarding cessation of clopidogrel. A subjective increase in bleeding was reported in 69% of centres; in 15 centres (47%) patients had returned to theatre for bleeding.
Many units in the UK still do not have a policy regarding antiplatelet therapy in those patients with acute coronary syndromes who are awaiting coronary bypass surgery. A randomised controlled trial is probably the correct way of evaluating the best strategy on use and omission of aspirin and clopidogrel in this setting.

Interventions to aid smoking cessation post-myocardial infarction Celine Adams Smoking kills. Almost a fifth (19%) of all coronary heart disease deaths in the UK are attributable to smoking.1 Many of these could be prevented. Smoking cessation significantly decreases mortality and – in the setting of myocardial infarction – this reduction is estimated at 35%.2 Smoking cessation is also cost effective with interventions in the UK ranging from £212 to £873 per life year gained.3 But in the setting of unstable cardiovascular disease, safe and efficacious methods of helping patients to stop smoking are yet to be demonstrated.

Cardiopulmonary bypass and the median sternotomy incision have revolutionised cardiac surgery, helping coronary artery bypass to become a routine procedure. Cardiopulmonary bypass was originally developed to allow open-heart surgery, but was adopted for coronary surgery because it provided a still operating field. However, the cost of good surgical access has been a large scar, with slow recovery and occasional serious wound complications.
Adaptation of robotic technology from production engineering provides a new way of performing coronary artery bypass grafting (CABG) without large incisions, and often without cardiopulmonary bypass. Although the first endoscopic robotic cases were reported several years ago, widespread adoption of the new technique is still some way off. We review the progress of robotic CABG to date, and discuss current research fields.

Early angiography and revascularisation are beneficial for patients with non-ST segment elevation myocardial infarction (NSTEMI). However, the Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK) demonstrated low levels of revascularisation in the UK in patients at high cardiovascular risk.
In the study described here, the authors attempted to streamline their referral process for acute revascularisation and conducted an audit to quantify the delay and to monitor outcomes. There were 1,640 percutaneous coronary interventions (PCIs) in West Yorkshire during the year 2000; of these 45% were acute interventions. The catheter laboratory database identified 212 acute PCI patients with a Leeds city postcode.
Average times from admission to angiogram, angiogram to intervention, and intervention to discharge are described, as are patient characteristics. Acute and six-month outcome data are given for the whole cohort and for a high-risk subgroup. The six-month composite rate of death and myocardial infarction was lower than that observed in PRAIS-UK. The data show that the time delay between admission and intervention can be kept to a reasonable level.

Infective endocarditis can be difficult to diagnose, especially in the absence of typical clinical features or Duke criteria. Seeding of emboli to the cerebral cortex can give rise to neurological symptoms. In the case presented here amnesia was, unusually, the most prominent feature.

Echocardiography is a commonly used diagnostic tool in assessing cardiac disease. The advent of hand-held ultrasound devices means useful information on cardiac cavity size, ventricular wall thickness and function, or apparent valvular pathology can now be obtained by general practitioners after adequate training. This will be particularly useful in the care of patients with suspected heart failure, left ventricular hypertrophy, a cardiac murmur or atrial fibrillation. It will reduce the number of patients needing referrals and the waiting times for hospital echocardiography services. It is limited by the technical specifications of the equipment and operators expertise.

A survey on cardiovascular education was sent out to over 1,800 general practitioners by the Primary Care Cardiovascular Society. This generated 304 replies. Of those responding, the majority indicated they would be interested in post-graduate education in cardiovascular medicine. Most would prefer a simple distance-learning course covering the 30 compulsory hours of postgraduate education required every year. Some would be interested in a more demanding course to achieve GPSI status. The majority did not like the current option of clinical assistant work in a hospital out-patients’ department but would attend such a department for education. There were differing views on who should pay for the course.

A systematic approach to the identification and treatment of high-risk coronary heart disease (CHD) patients has been adopted in the UK health care system.

Historically, the approach towards dementia associated with vascular disease has been to manage risk factors. Recent findings also suggest that symptomatic treatment is a realistic option, and cardiologists should be aware of treatments that are, or may soon be, available for their patients. Here, agents that have been evaluated for the symptomatic treatment of vascular dementia (VaD) are reviewed. In particular, the role of cholinesterase inhibitors is discussed. These agents are commonly used worldwide to treat the symptoms of Alzheimer’s disease (AD). Since most patients with VaD have concomitant AD, cholinesterase inhibitors may provide some benefits in these patients. In addition, these agents have demonstrated some efficacy in patients with possible or probable VaD.

Vascular disease is the most common treatable cause of dementia. Contemporary epidemiological models suggest that in developed Western societies, vascular disease alone accounts for about 15% of all dementia. In association with Alzheimer’s disease, however, it is suspected to be involved in at least 50% of all dementia. Recent research points to shared risk factors in vascular dementia and Alzheimer’s disease, and common pathogenetic processes are likely.
The exact criteria required for a diagnosis of vascular dementia remain imprecise and poorly developed. Advances in brain structural and functional imaging provide the best prospects for improvement in vascular dementia diagnosis.
Here we set out the major processes that impinge upon the health of neurones and may contribute to vascular dementia. Clinical trials of interventions that might slow progression of cognitive impairment to vascular dementia are fully justified and are likely to improve the care of many old people at particular risk of dementia.