Clinical articles

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.

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.