Clinical articles

The objective of this study was to describe the context, procedural outcome and long-term results of contemporary small vessel (SV) coronary artery stenting. It was set in a tertiary cardiology centre. The study was designed as a retrospective analysis of the procedural and long-term results in a consecutive series of patients undergoing implantation of an SV stent (defined as < 2.5 mm) in 1999–2000. Of the 1,130 percutaneous coronary interventions (PCIs) in the study period, 138 (12%) involved placement of SV stents. Of these interventions 58% consisted of SV stents as sole treatment. Some 69% of patients were male and their mean age was 58 years; 46% were hypertensive, 13% diabetic, 84% hypercholesterolaemic and 18% were smokers. Of these patients 54% were in anginal classes III and IV. Of the SV stents fitted, 94% were 2.5 mm and 6% were 2.0 mm. 75% of SV stents were implanted in main epicardial vessels. The mean follow-up for these patients was 17 months. Long-term symptomatic benefit was achieved in 76%. The major adverse cardiac events (MACE) rate was 15%, comprising 1% acute myocardial infarction (AMI) and 14% re-PCI. There were no deaths. In conclusion, SV stenting in the modern era, in an unselected series of patients, is performed in 12% of PCI procedures. It comprises the sole treatment in 58% of these interventions. The majority of SV stents are 2.5 mm and are placed in main coronary arteries. Procedural and long-term results are excellent. These data may inform the choice of treatment for patients with SV disease and may be useful in planning studies in stenting SVs.

The mode of action of non-steroidal anti-inflammatory drugs and the role of the cyclo-oxygenase enzymes COX1 and COX2 and their inhibitors is described. These can have potentially serious effects on the cardiovascular and renal system which are discussed.
The alternative, widely-prescribed analgesic, paracetamol, is also discussed, as are two theories ‘confounded by indication’ and ‘protopathic bias’ to help explain why paracetamol is sometimes described as being linked to asthma and upper gastro-intestinal damage, both effects not expected from a knowledge of its mode of action.

Amiodarone is a potentially hazardous drug indicated for atrial and ventricular arrhythmias. The purpose of the audit was to assess the risk associated with amiodarone therapy and identify measures to improve patient safety. The setting was a rural practice with 13,000 patients in Lanark, Scotland. A computer search identified 16 patients (11 male, five female) receiving amiodarone. The mean age was 74 years (range 61–89 years).
Action taken was raising doctor awareness and systematic biochemical and clinical review. Results showed that, in spite of substantial mortality and morbidity prior to the audit, there was no effective practice monitoring system for amiodarone therapy. The prevalence of clinical hypothyroidism and hyperthyroidism (29%) and ‘silent’ biochemical thyroid dysfunction (14%) exceeded published estimates (14–18% and 10% respectively). Although standards improved for biochemical monitoring, increasing awareness of the need for close surveillance did not appear to change the practice of some of the general practitioners (GPs), notably the clinical examination of pulse and blood pressure.
The audit demonstrates a need for a more systematic approach to amiodarone monitoring. Recommenda-tions include enhancements to the patient information leaflet, the development of local protocols and patient involvement in quality improvements including improved communication, patient-held record cards, better quality follow-up information, and more effective reporting systems.

There is strong evidence to support a causal relationship between the level of circulating plasma cholesterol and the risk of clinically overt coronary heart disease (CHD) events. Current UK guidelines recommend reductions of total cholesterol levels to below 5.0 mmol/L. Statins remain the drugs of first choice for reducing low-density lipoproteins (LDL). Rosuvastatin has already been approved in the Netherlands and is likely to become more widely available in the next year. It has a potent effect in lowering LDL and it also appears to raise high-density lipoproteins (HDL). It has a similar safety profile compared with other statins.
Cholesterol absorption inhibitors are a new treatment option for the management of hypercholesterolaemia. Ezetimibe, the first drug in this class, has recently been approved for use in the US and Germany. It selectively inhibits the uptake of dietary and biliary cholesterol at the level of the enterocyte. The site of action of ezetimibe may be the ‘sterol permease’ transport protein. As monotherapy, the role of ezetimibe appears limited at present. However, in combination with a low-dose statin, significant reductions in plasma LDL levels are seen. It may also be a useful agent for patients with homozygous familial hypercholesterolaemia.

The success of developments in heart transplantation has given women recipients the opportunity to have children. The first successful pregnancy in a patient who had received a heart transplant was reported by Lowenstein et al. in 1988.1 The cardiovascular effects of pregnancy demonstrate the durability of transplanted hearts. We report a successful pregnancy in a 20-year-old patient who had previously had a heart transplant; we also discuss the management of such patients.

Acute, undifferentiated chest pain (chest pain ?cause) presents a frequent and difficult challenge to clinicians working in the emergency setting. We aimed to survey current management of this problem in UK accident and emergency departments by sending a postal questionnaire to the lead clinician or first named consultant in every major A&E department in the UK.
Responses were received from 177/238 departments (74%). Although 74 departments (42%) had formal guidelines, many referred only to diagnosed coronary syndromes. Guidelines for undifferentiated chest pain usually recommended observation for six to 12 hours followed by troponin testing. Short-stay facilities were available in 38 departments (21%) and were planned for 55 departments (31%). Provocative cardiac testing could be accessed by 38 departments (21%). Patients were admitted by general physicians in 152 hospitals (86%) and cardiologists in 18 (10%). The estimated proportion of patients admitted was extremely variable. Although 45 departments (25%) employed specialist nurses, only in 20 did they manage patients with undifferentiated chest pain.
Reported management of acute, undifferentiated chest pain in the UK shows wide variation. Innovative technologies and diverse methods of service delivery are being adopted in a number of departments. These innovations require thorough evaluation.

Cardiovascular death is steadily decreasing but still accounts for 40% of deaths (235,000) in this country per year. More than 85% occur in older patients over the age of 65 years. The future of cardiology lies in the delivery of care to this rapidly expanding population of older people, whose growing numbers will account for an increasing trend upwards in the prevalence of cardiovascular morbidity in the UK. There will be increasing numbers of heart failure, hypertension, myocardial infarction, angina, atrial fibrillation, pacemaker implants and heart valve implantation in older patients. Randomised clinical trials often exclude the treatment of these conditions in patients over 75 years and results cannot always be easily extrapolated. Older patients often seem to be disadvantaged when compared with younger patients with cardiovascular disease. This article is the first in a series examining the treatment of older patients with cardiovascular disease.

Angiotensin-converting enzyme (ACE) inhibitors and statins improve prognosis in patients with coronary artery disease. Effective secondary prevention strategies, however, are frequently under-utilised. We sought to determine prescribing habits for ACE inhibitors and statins in 324 patients undergoing coronary artery bypass graft surgery (CABG) at two regional cardiac centres in the United Kingdom. We prospectively recorded ACE inhibitor and statin use on admission and discharge, ACE inhibitor and statin initiation and withdrawal during the hospital stay, and sought associations with treatment withdrawal. 82 (25.3%) patients were taking an ACE inhibitor on admission compared with 37 (11.4%) at discharge (p<0.0005). An ACE inhibitor was initiated during the hospital stay in five (1.5%) patients and was withdrawn in 50 (15.4%). On admission, 157 (48.5%) patients were receiving statin therapy compared with 154 (47.5%) at discharge (p=ns). Statin treatment was initiated in 23 (7.1%) patients, but was withdrawn in 20 (6.2%) others. Thus, only a minority of patients were receiving ACE inhibitors and statins on admission for isolated elective CABG. ACE inhibitor treatment was discontinued during the hospital stay in over 60% of these patients. Furthermore, statin therapy was no more common at discharge than on admission. This study highlights a missed opportunity for effective secondary prevention in a high risk population.

The SIGN guideline on cardiac rehabilitation was published in January 2002 and endorsed by the British Association of Cardiac Rehabilitation. This paper summarises the recommendations, which cover all four phases of recovery and the three main cardiac rehabilitation interventions.

This article describes the successful provision of a thrombolysis service by general practitioners in the isolated rural area of Whitby, North Yorkshire, and also in rural areas of Sweden. It discusses the difficulties in providing such a service, particularly the rural/urban paradox whereby specialist pre-hospital thrombolysis services can be much more easily provided in urban areas than rural areas where the need is normally much greater.
The results of a small straw poll on thrombolysis amongst Primary Care Cardiovascular Society members show that rural general practitioners are much more interested in providing a pre-hospital thrombolysis service than their urban colleagues; paying a fee for such a service should be considered in future planning. The article also reviews the various thrombolytic agents favouring the use of fibrin-specific thrombolytic agents by bolus for pre-hospital thrombolysis.