Clinical articles

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.

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.