Clinical articles

The implications of the Secretary of State’s approval of the introduction of league tables for cardiac surgeons are discussed. Surgeons are to be ranked according to mortality rates for first-time coronary artery bypass graft operations. It is questionable whether anybody will gain from this information: the focus of surgeons’ attention is transferred from patient care to self-preservation. The introduction of league tables in New York State has resulted in surgeons being reluctant to operate on higher risk patients and in secondary referrals of patients out of the State. League tables also encourage the manipulation of risk factor status.
Many factors other than the individual surgeon’s skill influence the quality of care and patient outcomes. These factors include the patient’s status, the timing of surgery, the surgical team, equipment in the operating room and post-operative care.
An alternative to the punitive process of public reporting is the application of continuous quality improvement to healthcare. This starts from the position that most negative outcomes are due not to individual failures but to failures of process and systems.

The objective of this study was to test the hypothesis that some patients on the routine waiting list for coronary artery bypass (CABG) surgery are suitable for percutaneous coronary intervention (PCI), as suggested in the NICE appraisal of coronary artery stents. A retrospective analysis was performed of 100 consecutive patients who had recently undergone CABG surgery from the routine waiting list in a tertiary cardiothoracic centre. The coronary angiograms of these patients were reviewed by an interventional cardiologist and a cardiac surgeon to assess patients’ potential suitability for PCI.
The mean total waiting time from being listed for angiography to having CABG surgery was 18.7 months. The mean delay from angiography to CABG surgery was 13.5 months. Of the 100-patient cohort, 70 were referred by a non-interventional cardiologist and 30 by an interventionalist (ratio 2.3:1). Fifteen patients were deemed potentially suitable for PCI after angiographic review. Of these, 13 (87%) were referred by a non-interventional cardiologist without angiographic review by an interventional specialist. The majority (86%) of the 15 patients deemed potentially suitable for PCI had single or double vessel coronary artery disease, in contrast to the population as a whole (38%).
These data suggest (a) that current CABG waiting lists could be reduced by up to 15% if coronary angiograms were reviewed by an interventional cardiologist in addition to a consultant cardiothoracic surgeon and (b) that referral arrangements should be adopted to facilitate such a review. The clinical implications of these data could be fully assessed by rolling out prospectively to other groups in the Coronary Heart Disease Collaborative.

Critically ill patients in the coronary care or high dependency units (CCU, HDU) need accurate assessment of their haemodynamic status to guide fluid or vasoactive drug therapy. Both central venous pressure and pulmonary artery occlusion pressure are poor guides to cardiac filling and pulmonary oedema, and using a pulmonary artery catheter often fails to improve clinical outcome.
The PiCCO system is a relatively new and less invasive approach to cardiac monitoring. It has been used extensively in intensive care and is reviewed in this article. This approach uses thermo-dilution techniques to reliably calculate volumetric measurements of cardiac preload and cardiac output, and can provide continuous real-time cardiac output and stroke volume variation measurements through pulse contour analysis. The reliability and accuracy of this method has drastically refined fluid and vasopressor management of the hypotensive patient and the management and prevention of pulmonary oedema. This method of measuring cardiac output correlates well with gold standard methods of cardiac output calculation and has been validated in adults and children.
The PiCCO system can be an invaluable tool in the optimisation of the circulation in cardiac, medical and surgical patients commonly seen in the CCU and HDU.

Chronic heart failure is a progressive syndrome which continues to have high rates of morbidity and mortality. Heart failure rates are increasing in parallel with the ageing population, as are rates of hospitalisation for acute episodes of decompensated failure. Little progress has been made in the medical management of such episodes. Positive inotropes, including selective phosphodiesterase III inhibitors, are associated with increased mortality when administered over the long term. Now newer approaches, using selective agents such as enoximone orally at lower doses alone or in combination with carefully titrated beta1-selective adrenergic blockade, may provide a more favourable outcome in terms of symptom management, functional status and improved survival. Trials are underway to determine whether this is the case. Published trials with enoximone and protocols for forthcoming trials are reviewed.

THE CHOLESTEROL MANAGEMENT DEBATES ESC debate Motion 1: “This house believes that lowering current cholesterol targets will have additional benefits to CV risk management” Motion 2: “This house believes that the benefits of raising HDL warrant its introduction as another lipid variable to target.” The lower the better. The real benefits of lowering cholesterol even further The Atlantic divide in coronary prevention PCCS debate Motion 1: “This house believes that current government policy is leading to the erosion of clinical judgement, exemplified by the CHD National Service Framework.” Motion 2: “This house believes that optimal management of cholesterol is a relief, not a burden.” The National Service Framework for CHD – Big Brother or helpful guide? A stitch in time – counting the cost of optimal CHD prevention

The proportion of the elderly population is rapidly growing, increasing the numbers of hypertensive patients and the workload in primary care. The average GP will currently have around 100 hypertensive patients over the age of 75 years in their care; this number is likely to be much higher in popular retirement areas. Clinical trials have shown the benefits of vigorous blood pressure control in the elderly; current recommendations are to reduce blood pressure to under 140/85 mmHg in at-risk groups and to under 130/80 mmHg in diabetics. Hypertension treatment continues to be difficult, however, due to poor compliance. This is for a number of reasons, including the fact that it is often a symptomless condition, the side effects of antihypertensive medication and the number of concomitant medical conditions making drug regimes complicated in the elderly. Newer classes of antihypertensive agents, such as beta blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists, are proving to reduce other risks as well as reducing blood pressure. Angiotensin II receptor antagonists appear to be better tolerated than other antihypertensive drugs; clinical trial results are awaited to assess their protective effects as well as their effect on quality of life, health economics and cost-effectiveness.

We describe an asymptomatic 51-year-old man in whom severe coronary artery ectasia was evident on a plain AP chest X-ray (CXR).

Brugada syndrome was described 10 years ago. It is a syndrome of sudden cardiac death associated with partial right bundle branch block and ST segment elevation in the right precordial leads V1-V3 on the resting ECG. Those affected have structurally normal hearts (as demonstrated by standard techniques) but they have a mortality rate of 10% a year, whether they are symptomatic or asymptomatic. It is thought to be primarily a disease of cardiac conduction and has been linked to abnormalities in the sodium channel (SCN5A). Differential diagnoses include arrhythmogenic right ventricular dysplasia, idiopathic ventricular fibrillation and polymorphic ventricular tachycardia. Brugada et al. suggest that the Brugada shift pattern on 12-lead ECG is a specific marker for those at risk of sudden death. They recommend that symptomatic individuals be protected with an implantable cardiac defibrillator. Asymptomatic individuals remain a diagnostic dilemma.

Post-myocardial infarction (MI) patients have a higher risk for subsequent cardiovascular and cerebrovascular events than the average population. This study was to test the effects on outcomes of nifedipine GITS compared to the diuretic combination co-amilozide in hypertensive patients with a history of MI on outcomes (subset of the INSIGHT study). The multinational, randomised, double-blind International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment (INSIGHT) study compared the treatment effects of nifedipine GITS 30 mg and co-amilozide (hydrochlorothiazide 25 mg plus amiloride 2.5 mg) in hypertensive patients aged 55–80 years with a blood pressure of 150/95 mmHg (or 160 mmHg systolic). This pre-specified subanalysis was performed in patients with a history of MI. The primary outcome was a composite of cardiovascular death, non-fatal stroke, MI, and heart failure. Of 6,321 randomised patients, 383 (6.1%) had a previous MI. The percentage of primary outcomes in post-MI patients did not differ between the two treatment groups (14.9%). The number of post-MI patients with composite secondary outcomes was 53 (27.2%) in the nifedipine GITS group and 60 (31.9%) in the co-amilozide group. The incidence rates of primary and secondary outcomes were higher in patients with a previous MI than in patients without a history of MI. For the randomised use of nifedipine GITS and co-amilozide in hypertensive patients with a previous MI, the choice seemed unimportant for outcomes and blood pressure lowering. The results of this subgroup analysis are consistent with INSIGHT’s overall findings of no significant differences in efficacy, suggesting that post-MI hypertensive patients are no more likely to suffer further events when treated with long-acting nifedipine than on co-amilozide.

Recently published data have greatly expanded the applicability of electron beam tomography and electron beam angiography. Guidelines and policy towards these modalities have shifted, with increased recognition of their importance among experts in cardiology, lipidology and preventive medicine. Given the high sensitivity of coronary calcification for the presence of obstructive coronary artery disease (CAD) (95–99%), exclusion of coronary calcium may be useful as a filter prior to invasive diagnostic procedures or hospital admission.