Clinical articles

Neurohormonal activation has a central role in the pathophysiology of various cardiovascular disorders. Despite recent therapeutic advances, potential exists to further manipulate these activated systems. The natriuretic peptide family consists of at least four structurally related peptides, with varying degrees of biological similarity. In the context of cardiovascular disease, the vast majority of data relates to atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).

Primary pulmonary hypertension (PPH) is a progressive disease with a poor prognosis. It is characterised by an elevated pulmonary artery pressure and pulmonary vascular resistance that ultimately lead to right ventricular failure and death. PPH is a relatively rare and neglected disease which, until recently, had been poorly understood and had no effective form of therapy. This, however, is changing with the rapid accumulation of knowledge relating to the disease and its management. In this article, we review the possible mechanisms that may have a pivotal role in the development of the disease.

Nurse-led interventions may improve the delivery of preventive care briefly discuss insights from parallel qualitative research; to present the preliminary results of the Bromley Changes care for coronary heart disease. In the SHIP trial, three cardiac liaison nurses co-ordinated care at the hospital-general practice interface. In the ASSIST trial, three different strategies of implementing secondary prevention were used. Although various measures improved, there was no difference in clinical outcome. Qualitative research indicates that specialist education for nurses is vital. The preliminary results of the Bromley Changes for Life Programme are described: this programme achieved significant risk factor and therapeutic targets. The way forward may lie with the cardiac specialist nurse.

There is an enormous gap between the publication of new evidence and its clinical implementations. Research on interventions that are designed to change professionals’ clinical behaviour is detailed here: specific generic interventions, interventions specific to cardiovascular medicine, and continuing medical education. Barriers to change include information problems, stress and inertia. Further research and evaluation are required.

The National Service Framework for Coronary Heart Disease emphasises the role of primary care in secondary prevention. More than 20% of men and 12% of women aged 65 years and over suffer from ischaemic heart disease. Lifestyle changes and drug treatment may effectively reduce risk but uptake of the evidence base is patchy. There are a number of possible approaches to enhance the uptake. Nurse-led clinics and health promotion clinics can lead to improvement in reported lifestyle and self-reported health status. Audit and feedback may lead to more use of appropriate drugs. Systematic recall will lead to better documentation that care conforms to standard practice, and nurses are at least as effective as doctors in achieving this. The first step is to set up accurate morbidity registers.

An integrated effort is needed to provide seamless care for patients between hospital and general practice. The use of protocols that are common to both sectors will lead to the best possible outcomes. It seems that secondary prevention may reduce sudden death and the 28-day mortality rate. The evidence base for the drugs used in secondary prevention is derived mostly from hospital trials. The relevant findings for aspirin, beta blockade, statins, ACE inhibitors and oral anticoagulants are discussed. After coronary revascularisation, special care is required if patients are to have a smooth path: both exercise and comprehensive cardiac rehabilitation are valuable.

The role of cholesterol lowering in reducing cardiovascular risk is well established but a large proportion of qualifying patients at the highest risk are still not getting treatment with statins. Of those that do, most are not achieving recommended cholesterol targets. The cost of this, in terms of death and work days lost, is enormous. Patients should not be discharged after an acute event until secondary prevention has been initiated. Individual patient response to therapy should be subsequently monitored and adjusted as appropriate; patients should be reassured on statin safety.

Can left bundle branch block cause chest pain? Mammen Ninan, Jonathan W Swan Exercise-induced left bundle branch block usually indicates underlying coronary artery disease or myocardial disease. Association of left bundle branch block (LBBB) with chest pain in the absence of coronary artery disease is rare. We describe the case history of a patient with chest pain associated with left bundle branch block with normal coronary arteries and review the literature on left bundle branch block associated with chest pain.

This article describes the use of transthoracic echocardiography (TTE) in a series of 5,000 consecutive echocardiograms in a mid-sized UK district general hospital. The report highlights the basic demographics, reasons for the requests, yield of abnormal results and sources of the requests. The authors comment on the percentage of abnormal results for the different request categories and on how TTE can be best utilised as a cardiac investigation.

It has now become possible to close a patent foramen ovale (PFO) using a percutaneous device. In addition, it has become increasingly clear that right-to-left shunting through a PFO can cause both stroke and decompression illness, due to paradoxical embolism of blood clots or gas bubbles. For these reasons, diagnosis of large PFO with significant right-to-left shunts has become important. The diagnosis can be made by transthoracic echocardiography with injection of bubble contrast, combined with multiple sustained Valsalva manoeuvres. Whilst transoesophageal echocardiography provides detailed anatomical information, functional information (with regard to right-to-left shunting) is better provided by transthoracic studies where a Valsalva can be properly performed. Device closure can prevent right-to-left shunting and can be achieved using a number of different devices. However, device closure has yet to be proven beneficial in a randomised trial. In light of the clear evidence implicating PFO, we undertake closure procedures in selected patients.