Clinical articles

This randomised, double-blind, six-month trial assessed the efficacy and tolerability of micronised fenofibrate and pravastatin in 265 patients (18–75 years of age) with primary hyperlipidaemia (pure hypercholesterolaemia, type IIa; and mixed dyslipidaemia, type IIb) recruited from 28 European centres. After a first three-month phase in which patients received once daily either micronised fenofibrate 200 mg or pravastatin 20 mg, type IIa patients attaining low density lipoprotein cholesterol (LDL) < 4.14 mmol/L and type IIb patients attaining LDL < 4.14 mmol/L and triglycerides < 2.26 mmol/L continued with the same dose in a three-month extension phase. Patients not meeting these criteria received a double dose of drug in this extension phase.

This study assessed complication rates in 64 emergency temporary pacing procedures, of which atrioventricular block formed the largest group (72%). Of the in-hospital deaths, most (76%) were due to myocardial infarction, and none due to the procedure. Immediate complications occurred in 22%: arrhythmia or arterial puncture, and one hemiparesis. Late complications occurred in 34%: loss of capture, infection including one instance of staphylococcal septicaemia. No complications occurred in 59%. Involvement of a consultant in the procedure did not reduce complication rates. In such potentially unstable patients, the risks of not pacing or delaying pacing probably far outweigh those of immediate intervention.

General practitioners (GPs) are subject to bombardments of medical information from many sources – local pharmaceutical formularies, local and national guidelines, national service frameworks, medical newspapers, peer-reviewed national journals and special interest publications.

The onset of symptoms in primary pulmonary hypertension (PPH) is usually insidious with several years elapsing before the diagnosis is actually made. It is important that general physicians should be made aware of this fact and that they should have a high rate of suspicion of the subtle nature of the clinical presentation in this group of patients. Patients with a suspected diagnosis of PPH should be referred to specialised centres where early diagnosis and treatment can be initiated. We review the salient features of PPH and provide an insight into the various therapeutic options that are now available for this disease.

NICE announce audit of secondary prevention guidance Tom Quinn The National Institute for Clinical Excellence (NICE) has ann-ounced plans to commission the development of an audit tool to support the primary care management of patients who have survived myocardial infarction (MI). The audit will focus on aspects of treatment and support highlighted in the National Service Framework (NSF) for Coronary Heart Disease1 and NICE’s own guideline Prophylaxis for patients who have experienced a myocardial infarction,2 inherited from the Department of Health in 1998 and published in early 2001.

Optimal management of hypertension and diabetes is essential if the cardiovascular and renal mortality and morbidity associated with this condition is to be reduced. Recent guidelines from the National Service Framework for Diabetes and the Scottish Intercollegiate Guidelines Network are discussed. Recent studies (UKPDS, RENAAL and PRIME) looking at the contribution tight blood pressure control and angiotensin II receptor antagonists can make to the management of this hypertension in diabetics are also covered. Finally, the author advises how primary care can implement guidelines in practice to give the best possible care to patients with diabetes.

Extensive multiple coronary artery to left ventricular fistulas – a 10-year case history We report the 10-year case history of a 50-year-old woman who presented with angina due to extensive, bilateral, multiple coronary artery to left ventricular fistulas (MCALVF). 201Thallium myocardial scintigraphy revealed reversible ischaemia due to coronary ‘steal’. Cardiac catheterisation showed left ventricular dilatation due to high cardiac output from significant coronary to left ventricular shunt.

Coarctation of the aorta is an important differential diagnosis in adults with hypertension. Unfortunately, simply removing the obstruction does not restore cardiovascular normality. Patients may continue to be hypertensive, demonstrate abnormalities of endothelial function and remain at risk of premature coronary artery disease and other vascular disease. Therapy therefore requires both relief of the mechanical obstruction and long-term follow-up to deliver optimal antihypertensive therapy, vascular risk factor modification and detection and management of complications (such as bicuspid aortic valve and cerebral aneurysms). This paper discusses the management of three cases of this condition.

The American College of Cardiology and the American Heart Association recommend echocardiography in patients with stroke or peripheral embolus who are less than 45 years of age or in those without evidence of cerebrovascular disease or other obvious cause.¹ There are no equivalent guidelines from British or European Cardiac Societies. The prevalence of stroke and peripheral embolus has made it a common indication for the use of echocardiography. Despite this, to our knowledge there has been no previously published evaluation of the use of echocardiography in such patients in the UK. We undertook a retrospective review of transthoracic (TTE) and transoesophageal echocardiogram (TOE) reports (n=7,870) over 37 months at St. Bartholomew’s Hospital department of cardiology. This identified 153 (1.9%) patients investigated for stroke/transient ischaemic attack (TIA) or peripheral embolus. Of these, six patients had two or more examinations producing a total of 160 reports; five reports were unrecorded and, therefore, 155 reports were analysed. A total of 12 reports (7.7%) identified possible cardiac sources of emboli with a further n=3 reporting spontaneous contrast in the left atrium. The potential embolic sources included patent foramen ovale (PFO)(n=3), aortic atheroma (n=3), aneurysmal atrial septum (n=2), mobile lesions on the mitral valve (n=3) and thrombus in the left atrial appendage (LAA)(n=1).
These results have led to the development of standardised criteria with the design of a template on the performing and reporting of echocardiograms in this type of patient.

While angiotensin-converting enzyme (ACE) inhibitors are established agents for the treatment of hypertension and heart failure, in contrast the angiotensin II receptor antagonists (AIIRAs) have failed to demonstrate more than equivalence in randomised clinical trials. Trials such as ELITE II are criticised on the grounds that the dose used of losartan (50 mg) may have been sub-optimal. In ValHeFT, valsartan was shown to be superior to placebo only in patients who did not also receive a beta blocker. The ambiguity of response of AIIRAs in such trials will hopefully be clarified in CHARM, a large, placebo-controlled study which will assess the effects of candesartan in heart failure patients with either reduced ejection fractions in addition to an ACE inhibitor, and in those intolerant to an ACE inhibitor, as well as in patients with preserved ventricular function (diastolic heart failure) not on an ACE inhibitor. The design of the study is discussed.