Clinical articles

We present three cases of patients who had chest pain with abnormal but non-diagnostic ECGs and negative troponin I, carried out in the appropriate time frame. All three went on to have extensive coronary artery disease demonstrated on coronary angiogram. These cases illustrate that use of troponin I alone as a marker for risk stratification of cardiac chest pain is not adequate: above all, a high index of clinical suspicion is of paramount importance.

Clinical research relating to stroke management is at something of a watershed. On the one hand, some therapies are well proven and established, and on the other some approaches have repeatedly failed. Examples of successes include antithrombotic (aspirin, dipyridamole, clopidogrel, warfarin) and antihypertensive therapies (diuretic, angiotensin-converting enzyme inhibitors), carotid endarterectomy for secondary prevention,^1-4 and aspirin in acute ischaemic stroke.⁵ In contrast, several strategies have repeatedly failed, especially the use of anticoagulation and neuroprotection in acute ischaemic stroke. This review gazes into the crystal ball to see what we might be doing when managing patients with stroke in 10 years time.

One of the potential side effects of the HMG CoA reductase inhibitors (statins) is a rise in creatinine kinase (CK) activity. This is sometimes accompanied by myalgia and rarely by rhabdomyolysis. Statins are increasingly being started earlier in the presentation of acute coronary syndromes but the rise in CK activity that they may cause could be a potential confounding factor in the diagnosis of myocardial infarction (MI) in this population. In this open-labelled, prospective study, 12 hypercholesterolaemic, Caucasian subjects, with a significant cardiovascular risk, were commenced on low-dose statin therapy. Blood samples were taken prior to commencing the statin then on day three and seven for lipid profile and CK activity. Patients maintained their normal lifestyles and usual medication. Interviews were conducted at each visit. A consistent fall in total and low density lipoprotein (LDL) cholesterol levels was shown over the study period of one week. Apart from one participant, who had a CK rise on day three with accompanying myalgia, there was no consistent change in CK activity within the group. High density lipoprotein (HDL) cholesterol levels also did not show any significant change over the week. We conclude that the rapid and consistent fall in both total and LDL cholesterol levels with low-dose statin was not paralleled by any consistent change in CK activity. The lack of change in CK activity over one week, following acute initiation of statin therapy, is unlikely to cause difficulty in the diagnosis of MI. If the beneficial effects of statin therapy are due to cholesterol reduction, then acute initiation in coronary syndromes would be favourable.

Statins: myalgia and myositis Anthony S Wierzbicki The topic of side effects of statin therapy has become more prominent since the precautionary withdrawal of cerivastatin following reports of death and rhabdomyolysis with this particular statin, especially when given in simultaneous combination therapy with gemfibrozil. In addition, many patients complain of myalgia with statins; this side effect has an incidence of up to 5%. There is a tendency for earlier use of statins in coronary care units because of improved compliance and the possibility of a reduction in peri-infarction events in registry studies, although the MIRACL trial of atorvastatin in acute coronary syndromes did not show any significant differences in hard end points at 16 weeks

Cardiovascular disease is the most important cause of illness in Britain. The focus of the National Service Framework for Coronary Heart Disease (NSF for CHD) is appropriate since the burden of CHD is high in the UK. Interventions for primary and secondary prevention include advice on reducing modifiable risk factors, smoking, maintaining blood pressure < 140/85 mmHg and using statins and dietary advice to lower serum cholesterol. Identification of those at greatest risk will require practice-based registers. Audits will be needed to ensure that the stipulated interventions are offered to those on the disease registers. The biggest implication for primary prevention will be selection of patients at increased risk of CHD. Implementation of the NSF will increase GPs’ workload.

The lipid-lowering trials have shown positive results in terms of reducing cardiovascular events. It is mandatory to measure lipid levels in patients with other cardiovascular risk factors, such as diabetes and hypertension. Explaining cardiovascular risk and lifestyle changes takes longer than the standard 7–9 minute consultation and might be more appropriate in a nurse-led clinic. Good communication between GPs and specialists can still be difficult to achieve: face-to-face meetings are helpful and email should be playing a major role. The National Service Framework for CHD prevention puts a great deal of pressure on GPs. Secondary prevention is non-controversial although ideal levels of LDL are not being reached.

An effective strategy for the prevention of cardiovascular disease in patients with diabetes is needed with the epidemic of diabetes mellitus around the world. The aims are to cut morbidity and mortality from coronary heart disease by risk factor reduction and to reduce the diabetic complications of retinopathy, renal disease and peripheral vascular disease. Findings of the United Kingdom Prospective Diabetes Study (UKPDS) imply that all diabetics should be subject to intensive glycaemia control and tight blood pressure control. GISSI-3 and the DIGAMI studies showed the benefits of lisinopril and an insulin/glucose infusion, respectively, post-MI. The HOPE study set out to examine whether ramipril reduced cardiovascular events in patients at high risk: the results were highly significant. The statin studies 4S, CARE and WOSCOPS showed the value of statins in primary and secondary prevention of cardiovascular events in patients with diabetes. Low-dose aspirin therapy should be used in patients with diabetes who are at high risk of cardiovascular events.

Percutaneous coronary intervention (PCI) is one of the mainstays in the treatment of coronary artery disease. Although the recent BCIS audit data indicate an improvement in the rate of PCI in the UK, it lags well behind the intervention rate in other European countries. The National Service Framework (NSF) for Coronary Heart Disease recommends an increase in the PCI rates to more than 750 per million population in order to achieve a target waiting time of three months. 1 To achieve this goal a major change in infrastructure is needed, with the opening of more interventional centres and the training and appointment of more interventional cardiologists. Within the current infrastructure and in a shorter time scale the targets may be met by performing more PCI through day-case work. The cardiologists directly control the day-case beds without any interference from the other medical specialities. Following the availability of modern low-profile stent technology and safer pre-treatment with oral antiplatelet agents, day-case intervention is a feasible option. 2 The RADICAL study A well-staffed day-case unit with an experienced senior sister and a pre-admission clinic has shown promising results in our unit at Blackpool for the management of day-case PCI through the radial route (Radial Approach for Day-case Intervention in Coronary Artery Lesions, the RADICAL study). Stable patients on the waiting list for PCI Table 1. The current status and future directions of day-case radial PCI PCI through the radial route is known to be safe, effective, economical and patient-friendly. In a pilot study we are evaluating its safety and efficacy in the day-case setting in selected patients with stable angina We believe that more day-case PCI will be the only way forward to achieve the NSF target rates for coronary revascularisation discharge of the patient. Following the procedure we take the sheath out immediately and apply a RADI Stop in the catheter lab.

Rapid technological advances in interventional cardiology have led to a marked change in practice over the past 20 years. Improvements in balloon dilation and stent catheter design, coupled with advances in guide catheter technology, have allowed routine percutaneous coronary interventions (PCI) to be performed through smaller guides. Initially there was a change from 10 to 9 French (F) catheters, and more recently from 8 to 6 F. These developments have not only led to a reduction in arterial complications, but also to changes in arterial access sites. The radial route has become increasingly popular, virtually eliminating access site complications. Moreover, this route has been shown to be preferred by many patients, the prime advantages being patient comfort, early mobilisation and reduced bleeding complications.

This short article aims to discuss the potential complications of transradial procedures and to set out approaches to minimising or avoiding them. Complications may relate to the operator, the patient, the equipment used or the nature of the procedure. Complications can simply be defined as minor (non-life-threatening, reversible, unlikely to extend hospital stay) or major (life-threatening, likely to cause permanent damage or to extend hospital stay). The complications of transradial procedures are rarely major and very rarely life-threatening – a major benefit of the radial approach. The potential complications can be divided into: neuro-vascular complications, spasm, vasovagal reactions and reflex ST segment changes. artery have been reported following transradial procedures. These include dissection, haematoma, perforation, bleeding, pseudo-aneurysm formation, arteriovenous fistula and even ischaemic con-tracture involving the hand. Most of these complications are minor, but they can result in access or procedural failure. Major vascular complications are very rare, occurring in only 0.06% of a recent series of 5,354 consecutive transradial procedures. Localised radial occlu-sion, which causes no untoward ischaemia, occurs in up to 5% of patients, but half of these occlusions recanalise within weeks. Spasm This is the most common complication of transradial procedures, and can vary from a minor event to a major painful stimulus ending the procedure.