Clinical articles

Recently reported and ongoing morbidity and mortality trials in hypertensive patients are addressing important unanswered questions in hypertension management. What is the optimal first-line treatment for hypertension, what is the ideal combination of antihypertensive drugs, how are these influenced in particular patient subgroups, and what are the treatment thresholds and blood pressure goals of treatment for optimal prevention of cardiovascular disease? Limitations of some recent trials are highlighted and emphasise the need for further prospective meta-analyses of studies to provide adequate power to address some of these important questions. Current ongoing large scale studies, including ALLHAT and ASCOT, will shortly be reporting results to the scientific community and are likely to influence management decisions across a wide range of patient subgroups.

Full implementation of the available evidence on secondary prevention should ensure that all patients after myocardial infarction should be offered both effective treatment and be maintained on treatment. This article describes the Heart disease Evidence-based Audit and Research in Tayside Scotland (HEARTS) collaboration which has been set up to try and achieve this. HEARTS can collect electronic data from many sources; prioritise data from multiple sources, such as hospital and general practice; process and link patient records; and, allow manual validation of electronic data. It can also facilitate clinical governance issues in general practice and hospital plus disseminate information to patients. It is hoped that, in addition to secondary prevention, it will be able to extend its focus to other aspects of cardiovascular disease in the future as well as being used for epidemiological and qualitative projects. The system maintains the security and rights of patients at all times.

A dvanced web-based clinical care applications as part of an electronic health record can assist clinicians to meet Government targets for the management of cardiovascular disease. A clinical module of the Tayside electronic health record collects electronic data automatically from a variety of sources and holds this data in a central regional repository. It identifies those patients with existing cardiovascular disease and also those high priority patients at risk of developing clinical atherosclerosis. It allows the clinician to effectively manage these patients in line with national evidence-based guidelines. Real time audit of patient management is instantly available at the point of direct patient contact, as well as benchmarking to agreed performance criteria. Demonstrating improvement in clinical outcomes remains the eventual goal.

An unusual case of pericardial constriction Michael Pitt, Stephen Rooney, R Gordon Murray Pericardial constriction remains a rare condition. The precise aetiology is undefined in up to 50% of cases. We describe a case of rapidly progressive pericardial constriction and highlight how post-mortem examination remains useful in establishing unexpected diagnoses.

Waiting for in-patient transfer for the investigation of chest pain is a significant cause of ‘bed-blocking’. We performed an audit of 58 consecutive in-patient transfers. The mean delay between referral and transfer was 10 days (range one to 28 days). At the time of transfer the mean number of pain-free days was five (range one to 21 days). Of the 37 patients with a working diagnosis of unstable angina, only 19 (51%) underwent some sort of non-invasive risk stratification prior to referral, nine patients (24%) were walking around the hospital or had taken weekend leave and 13 (35%) had normal anatomy or subcritical disease. Of 21 with post-infarct angina, seven (33%) underwent exercise stress testing, five (24%) were mobilising around the hospital and 18 (86%) underwent some sort of intervention.
In conclusion, waiting times for in-patient angiography were long and utilisation of non-invasive investigation was low.

Interest in the cardioprotective properties of marine omega-3 polyunsaturated fatty acids (n-3 PUFAs) has been renewed following the publication of three large trials earlier this year demonstrating a reduction in sudden cardiac deaths from the ingestion of marine n-3 PUFAs, along with the recent availability in the UK of its pharmacological equivalent, Omacor™. Secondary prevention trials, such as the Diet and Reinfarction Trial (DART) and the more recent analysis of the GISSI-Prevenzione data, found a reduction in sudden deaths associated with supplementation of n-3 PUFAs in post-myocardial infarction patients.1,2

The low incidence of ischaemic heart disease amongst Greenlandic Eskimos has intrigued researchers for many years. The answer was found in their marine-based diet, very rich in omega-3 polyunsaturated fatty acids (n-3 PUFAs). These have shown anti-arrhythmic, endothelial protective, anti-atherogenic, antithrombotic and antiplatelet effects in many observational studies, which have paved the way for the potential role in secondary prevention post-myocardial infarction.
Many trials have emphasised the importance of oily fish in the secondary prevention of coronary heart disease. Oily fish consumption, however, is poor in the UK. It has the disadvantages of possible toxic chemical contaminants, a large calorific content and some people simply do not like it. The GISSI-Prevenzione trial studied the effect of a highly purified n-3 PUFA supplement and found it conferred a 20% relative risk reduction in mortality and a 45% reduction in the risk of sudden cardiac death. This early protection supports the anti-arrhythmic potential of n-3 PUFAs.
A supplement containing 90% concentrate of the n-3 PUFAs, eicosapentaenoic acid and docosahexanoic acid, known as Omacor™, is now licensed in the UK as adjuvant treatment in secondary prevention post-myocardial infarction, in addition to standard medical treatment including statins.
The prescription of n-3 PUFA supplements are best initiated in secondary care. The index admission is generally the best time to initiate secondary prevention when patients tend to be most receptive.

Our increased understanding of the human immunodeficiency virus (HIV), including elucidation of the processes of transmission and replication, has led to the development of relatively effective therapies to minimise and manage the clinical consequences of HIV infection. These therapeutic developments have undoubtedly improved rates of morbidity and mortality in infected patients. The improvements in quality of life and life expectancy have been accompanied by an increase in the number of patients demonstrating cardiac complications, occurring either as a result of the infection itself or the drugs used to control the virus.
Cardiac involvement occurs frequently in HIV/AIDS patients and it seems likely that the myocardium, pericardium and/or endocardium are involved. Myocarditis, one of the most common types of cardiac involvement observed in HIV patients, the cause of which can be difficult to identify, may be responsible for myocardial dysfunction. Opportunistic infections, including HIV itself, have been suggested as the cause of myocarditis. Dilated cardiomyopathy is usually found in the late stage of HIV infection and myocarditis may be the triggering causative factor. The mechanism behind pericardial effusion remains unclear but it too may be related to infections or neoplasms. Non-bacterial thrombotic endocarditis and infective endocarditis have been described in AIDS patients, both of which cause significant morbidity. Human immunodeficiency virus-related pulmonary hypertension is a diagnosis of exclusion, and symptoms and signs may mimic other pulmonary conditions in AIDS patients. Cardiac Kaposi’s sarcoma and cardiac lymphoma are the frequently encountered malignant neoplasms in AIDS patients – the prognosis is grave in patients with these conditions.

Details of the ‘Fifth report on the provision of services for patients with heart disease’, compiled jointly by the British Cardiac Society and the Royal College of Physicians, were published recently. We recommend that all health workers concerned with the care and management of patients with cardiovascular disorders should be aware of the report and contribute to its implementation.

The innovation of specialist nurses in coronary heart disease prevention across 12 practices in a rural County Durham Primary Care Trust (PCT) with a high rate of premature death from heart disease helped the Trust achieve the National Service Frame-work (NSF) for Coronary Heart Disease (CHD) targets and milestones. The introduction of nurse-led CHD clinics at each practice provided a structured follow-up for all patients with CHD to locally agreed guidelines. Audit data collected showed that after 12 months, the service showed an improved management of secondary prevention: more patients had had their cholesterol measured, more had received lipid-lowering medication and more had achieved target cholesterol levels of < 5.0 mmol/L than at baseline. Aspirin prescribing also increased. The PCT has also recently introduced a specialist heart failure nurse to carry out a similar programme and, in addition, has addressed cardiac rehabilitation to provide a home-based service for some patients.