Clinical articles

One of the purposes of the United Kingdom Prospective Diabetes Study (UKPDS) was to compare the efficacy of different antidiabetic drugs in the long-term treatment of type 2 diabetes. In overweight type 2 patients, use of metformin as the initial antidiabetic drug therapy reduced overall mortality and reduced various long-term complications to a greater extent than other first-line treatments tested (sulphonylureas and insulin) whilst controlling hyperglycaemia to a similar extent. The benefit of early intervention with metformin may be due, at least in part, to its actions against insulin resistance and associated cardiovascular risk factors. Thus the UKPDS has provided evidence that early intensive glucose control with metformin in overweight type 2 diabetic patients is a particularly effective approach to reduce vascular complications and improve survival.

The objective of this paper was to quantify the impact on overall cardiovascular disease treatment costs resulting from the use of amlodipine in the coronary artery disease (CAD) population in the UK. A Markov cohort simulation model was developed to estimate the overall average healthcare costs of patients with CAD in the UK and to determine the cost-effectiveness of the use of amlodipine as part of their treatment regimen. Outcome probabilities used in the model were based on patient-level data from the Prospective Evaluation of the Vascular Effects of Norvasc Trial (PREVENT). Cost estimates for in-patient and out-patient care associated with each outcome were applied to quantify the overall average healthcare cost for each arm of the study. The hospitalisation rate per patient in the placebo cohort was 61.8% while that in the amlodipine cohort was 44.3%. This corresponds to an average cost per patient for cardiovascular disease (CVD) treatment of £1,858.64 for amlodipine patients and £1,800.49 for placebo patients over three years of follow-up. Calculations yield a cost per hospitalisation avoided of £331.67. In conclusion, the inclusion of amlodipine in the treatment regimen for patients with CAD is expected to result in improved clinical outcomes through a marginal investment in cost.

We studied the potential benefits of using lead V4R during routine exercise treadmill testing for patients undergoing district general hospital investigation for suspected coronary artery disease. Some 298 patients with known or suspected coronary artery disease, referred for exercise testing, had an electrocardiogram recorded with standard leads and had lead V4R placed in the V4R position. The exercise tests were interpreted using standard criteria and were reported as being negative, inconclusive, positive or adversely positive. The mean age of the patients was 57 years. Some 86 (29%) of the tests were positive: 12 of the 86 positive tests showed significant changes in lead V4R (14%). Of the 86 positive tests, 25 were adversely positive (29%) and, of these, nine had a positive V4R test (36%). Patients with V4R positive tests compared to those with V4R negative tests had significantly decreased exercise duration leads with ST changes and reduced workload. The finding of a positive V4R test indicated a significantly greater chance of an adversely positive exercise test result (p<0.001), with nine of the 12 positive V4R results (75%) being associated with adversely positive tests. There were no isolated positive V4R tests.

Defining prognosis may be helpful in planning acute treatment of stroke, setting rehabilitation goals and setting resource priorities. Case fatality is 12% within the first seven days of a first-ever stroke. Late deaths are usually due to the consequences of immobilisation and stroke recurrence. Long-term outcome is difficult to predict but older age, significant pre-stroke co-morbidity and severe stroke are generally associated with poor physical recovery. Stroke patients have a risk of recurrence 15 times that of an age- and sex-matched population. Stroke type may influence recurrence. Early stroke recurrence may be prevented by antiplatelet drugs. Patients in atrial fibrillation and with recently symptomatic high-grade carotid stenosis are at particular risk of stroke.

Atrial septal defects are a common form of congenital heart disease that can present at any age, even in the elderly. As symptoms may be non-specific (breathlessness, palpitations), a high index of suspicion should be maintained. The ECG may be normal in the absence of significant pulmonary hypertension although a chest radiograph should be helpful. The diagnosis is usually confirmed by transthoracic echocardiography, although some types of atrial septal defects may be missed in adults who are poor echo subjects. Transoesophageal echo provides definitive diagnostic information and should be undertaken in any patient with right heart dilatation of unknown cause. Whilst closure of atrial septal defects may not prevent atrial arrhythmia, it can reduce the haemodynamic consequences if episodes occur. Many atrial septal defects can now be closed with percutaneous devices, avoiding the need for sternotomy.

Some 340 adult patients (186 male, 154 female; average age 36 years) with congenital heart disease are now seen in a dedicated clinic at a district general hospital. Septal defects and aortic pathology account for 48% of cases seen and 21% have complex congenital heart disease. A first operation has been performed in 55%, a second operation in 13.3% and a third operation in 3.2%. Pulmonary hypertension is present in 7%. Eighty two of the 154 women have had 123 pregnancies. Care issues relating to the pregnant grown-up congenital heart disease (GUCH) patient are discussed. The growth of this population is highlighted, as is the requirement for more structured care. Issues relating to the establishment of a dedicated GUCH clinic are discussed, including training of cardiologists in this sub-speciality.

Myocardial ischaemia is a reliable predictor of significant coronary artery disease (CAD). During an episode of myocardial ischaemia, anginal pain may appear late or not at all, even in the presence of ischaemic changes on the electrocardiogram (ECG). This phenomenon of silent ischaemia was first described by Stern and Tzivoni in 1974.1 As many as 70% of daily ischaemic episodes in stable CAD and 90% of episodes in unstable angina are silent.

Adult congenital heart disease: time for a national framework Michael A Gatzoulis Congenital heart disease (CHD) is one of the most common inborn defects, occurring in approximately 0.8% of newborn infants. Adults with congenital heart disease are the beneficiaries of successful paediatric cardiac surgery and cardiology programmes across the United Kingdom. Had it not been for surgical intervention in infancy and childhood, 50% or more of these patients would have died before reaching adulthood.

This supplement has been sponsored by Merck Sharp & Dohme Limited. It features highlights from a meeting “Changing the course of cardiovascular disease”, which was held in March 2001 in Istanbul and sponsored by Merck Sharp & Dohme Limited.

The publication of the Healthwise Database in the British Medical Journal in June 2001 has shown again that in Britain we are poor at implementing well-established strategies which we know reduce the risk of coronary events in patients with ischaemic heart disease. The Healthwise study, which was carried out over 18 months between 1997 and 1998, examined the records of 548 general practitioners (GPs) throughout mainland Britain. The records of 989 161 patients were examined and 24 431 patients with established coronary heart disease (CHD) were identified. The mean age of men was 67 years and women 72 years, and two thirds of the patients were over 70. The middle-aged man with angina has generally been regarded as the typical coronary disease patient. This is not true: it is my view that in the future we will be devoting much of our energies to heart disease in the elderly.

The prevalence of CHD was 2.5% in this survey but it is known that the true prevalence is greater than this. There must be, then, a proportion of patients who are not considered by their general practitioner to have established coronary disease. The Healthwise study addressed one main area: the measures that were being adopted by general practitioners to address risk factors and drug therapy for patients with established coronary heart disease.