Clinical articles

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.

Though the evidence for secondary prevention of cardiovascular disease is strong, the substantial benefits in terms of outcomes are often lost at practice level with competing clinical priorities and, at primary care group/trust level, with competing commissioning priorities. Our primary care trust has developed a secondary prevention tool that gives a clear picture of the benefits achievable with effective secondary prevention.

The devastating consequences of stroke make rehabilitation a substantial challenge. The benefits of stroke units are well established; the collaborative work of the multidisciplinary team may be one of the most important factors. The evidence for the efficacy of occupational therapy is conflicting and a meta-analysis of community occupational therapy trials is under way. Greater physiotherapy input is associated with a reduction in death and deterioration. One third of all surviving stroke patients require speech and language therapy but most receive less than 45 minutes per week. More rehabilitation research needs to be conducted. In the absence of scientific evidence, expert opinion still has an important part to play in the rehabilitation process.

Non-invasive positive pressure ventilation (NIPPV) may be used in the treatment of acute cardiogenic pulmonary oedema. It has been shown to reduce the need for intubation and to improve left ventricular function. Patients do not need to be admitted to intensive care but can be managed in a coronary care unit. Two cases are described in this article. The indications, contraindications and complications of NIPPV are described and a practical guide to its use is given.

Overweight and obesity affect around half of the UK population, and are a serious public health problem. Obesity is associated with hypertension, dyslipidaemia, type 2 diabetes and a sedentary lifestyle, and has been shown to be an independent risk factor for development of cardiovascular disease. There are characteristic structural changes of the heart and vasculature in obesity. There is strong evidence that even modest weight reduction lowers cardiovascular risk. Dietary intervention, lifestyle advice and increased exercise are the initial strategy, but selected patients will require adjunctive treatment with anti-obesity drugs. In the absence of contraindications, orlistat is appropriate to use in obese patients with established cardiovascular disease, though sibutramine use is contraindicated in this population. Surgical intervention, such as gastric restrictive procedures, may be needed in severe obesity but there is a high complication rate among the morbidly obese and particularly in those who are also diabetic.

Fax machines are essential tools in modern medicine. With increasing pressure to reduce ‘door to needle’ times in acute myocardial infarction, appropriate interpretation of electrocardiograms (ECGs) by cardiologists is desirable and the use of fax machines to transmit recordings is advised.1-4 Fax technology is not infallible, however.