Clinical articles

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.

An educational intervention was developed to try to raise both data quality standards and those of clinical care in the secondary prevention of coronary heart disease. The intervention was used within primary care organisations utilising their own clinical data and with primary care professionals learning from each other. A special tool (MIQUEST) was used to extract the clinical data. Anony-mised data were then shared with the whole primary care organisation at six-monthly data quality workshops. Patients needing interventions were identified in individual practices and these practice visits were also used as learning opportunities. At the end of the study there was an increase in the recording of the diagnosis of ischaemc heart disease (IHD).

Many general practitioners (GPs) already have a special clinical interest. This role is now being developed and formalised by the Department of Health and by 2004, 1,000 posts of general practitioners with special interests (GPwSI) will have been created. Alongside their normal general practice work, these GPs will also offer a particular specialist service under contract to a Primary Care or Acute Trust taking referrals from fellow GPs. A National Develop-ment Group is currently consulting relevant bodies to publish advice on the commissioning and appointment of such GPs. It is hoped these appointments will help integrate primary care and hospital services under the new NHS Plan, leading to enhanced patient care and the delivery of the National Service Frameworks. It will also give continuing job satisfaction to GPs wanting to extend their role.

Drug interaction with warfarin is a common cause of loss of anticoagulant control. An interaction between warfarin and digoxin has not previously been documented in the British National Formulary or datasheet. We report a case of digoxin toxicity responsible for prolongation of the INR to more than 10.

On-call seen as a pathophysiologic state Johan EP Waktare, Alex Stewart, John P Lyons Recently, one of us (AS) underwent 24-hour Holter (ambulatory ECG) monitoring for investigation of minor cardiac symptoms. The recording was performed during a night as medical registrar on-call. We feel the result provides some interesting insights into the pathophysiology of life as a modern junior doctor.

Southern Asians in the UK have a substantially increased (50%) risk of coronary heart disease compared with the general population, in part due to a high prevalence of hypertension and diabetes. This patient group has not been specifically studied in a clinical trial using modern antihypertensive therapy such as the angiotensin II receptor antagonists (AIIRAs). A multi-centre, double-blind, randomised, parallel-group study compared the effects of treatment with valsartan 80 mg once daily (o.d.) with control therapy (bendrofluazide 2.5 mg o.d.) in 116 patients with mild hypertension (diastolic blood pressure [DBP] ≥ 90 mmHg and ≤ 105 mmHg) after a four-week run-in period. Sitting blood pressure was measured at baseline (end of run-in) and after four and eight weeks of treatment using the OMRON automatic oscillometric blood pressure monitor. The study medication dosage was doubled if patients had < 4 mmHg decrease in DBP after four weeks. Compared with the control group (n=62), the addition of valsartan 80/160 mg o.d. (n=51) resulted in a significantly greater reduction in blood pressure at eight weeks (mean change in blood pressure -15.6 mmHg [95% CI -19.9 to -11.2 mmHg] for systolic blood pressure [SBP] and -9.3 mmHg [95% CI -11.8 to -6.8 mmHg] for DBP; p<0.001). Both treatments were well tolerated. Valsartan is effective and well tolerated, and would be an appropriate treatment option in Southern Asian hypertensive patients.