Editorial articles

Cardiovascular disease is one of the leading causes of morbidity and mortality among the elderly,^1,2 and interventional cardiologists are well aware that they are treating an increasing number of very elderly patients. It is clearly good news that life-expectancy is increasing and that more patients remain alive and active well into their eighties and nineties. While there is no obvious pathophysiological rationale for elderly patients to have a different therapeutic response to cardiovascular treatments there are important issues to consider. 

Angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta blockers improve outcomes in patients with chronic heart failure secondary to left ventricular systolic dysfunction. 

The 2012 British Junior Cardiologists Association (BJCA) survey of cardiology trainees gives an important insight into what is happening in cardiology training in the UK.^1,2 Conducted six times since 2004, it was most recently performed in 2009. The authors should be congratulated on the effort that has clearly been involved. Several important issues emerge from these data, which, if the survey is truly representative of all UK trainees, necessitate some radical thinking. The issues that I shall discuss are: working hours and the role of general medicine, imaging training, and the percentage of female trainees. 

The British Hypertension Society (BHS) was established in 1980 by a group of physicians interested primarily in research. Over the years it has broadened its remit to encompass teaching and the development of best practice in hypertension management and cardiovascular risk prevention. Originally membership was restricted to people actively involved in research, but recently we have opened our doors to welcome other healthcare professionals (resident in the UK and Ireland) who are interested in the wider field. The majority of hypertension management in the UK is carried out by primary care physicians and nurses with increasing input from pharmacists. Many referrals to secondary care involve cardiologists. These practitioners are not sufficiently represented in the Society and, hence, we are keen for primary care health workers and cardiologists to apply for membership.

The hearts of the medical, sporting and lay communities were captured by the public cardiac arrest of 24-year-old midfielder Fabrice Muamba, during a football match in March 2012. His case was exceptional in that he survived because expert help was at hand immediately but, sadly, most young victims of sudden cardiac arrest do not live to hospitalisation. There are approximately 60,000 cases of sudden cardiac death in the UK each year,¹ the majority of which occur in older adults and are predominantly attributed to ischaemic heart disease or heart failure. In contrast, there are around 600 sudden deaths per annum in young people affected by inherited structural and electrical disorders of the heart, notably the cardiomyopathies and ion channelopathies.² 

In this issue (see pages 126–33), Paul Durrington has written an excellent review of one of the most interesting conundrums in current clinical lipidology – the putative role of cholesteryl ester transfer protein (CETP) inhibitors. 

Following publication of recent National Institute for Health and Clinical Excellence (NICE) guidance for the management of chronic heart failure (CHF), which includes heart failure rehabilitation incorporating exercise, there has been a substantial amount of rhetoric and debate on how to deliver this specific intervention.¹ In theory, amelioration of heart failure patients into existing cardiac rehabilitation (CR) exercise programmes appears the most feasible option in practice, however, this may prove to be somewhat problematic.

In-hospital mortality from infective endocarditis remains high, ranging from 9.6 to 26%, and relates to many factors including associated co-morbidities (including previous valve replacement), the complications of endocarditis present, the micro-organism involved, and a number of echocardiographic features.¹ Currently, echocardiography remains the mainstay of imaging for diagnosis and evaluation of complications, monitoring of response to therapy, intra-operative evaluation (where relevant), and follow-up.^1,2 Indeed, three echocardiographic features are considered major criteria in the diagnosis: vegetation, abscess and new dehiscence of a prosthetic valve. Although the limitations of echocardiography are well recognised, the use of other imaging modalities for evaluation of endocarditis remains limited. Indeed, 2009 European Society of Cardiology (ESC) guidelines state that “Other advances in imaging technology have had minimal impact in routine clinical practice … alternative modes of imaging (computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET], and radionuclide scanning) have yet to be evaluated in infective endocarditis”.¹ 

The diagnosis and management of hypertrophic cardiomyopathy (HCM) has undergone fundamental change since the condition was first described more than 50 years ago by Donald Teare,¹ a forensic pathologist, and Michael Davis, an academic pathologist.

Modern medical practice calls for an evidence-based approach. The best medicine is, therefore, built on a foundation of the best evidence. The best evidence, in turn, comes from the best research. When it comes to the use of drug therapy this is provided by the most scientifically robust and ethically sound clinical trials. 

The history of clinical trials has clearly shown us that while they are essential for the progress of medical practice; their conduct may also be harmful to participants.1 A lack of ethical conduct and failure to uphold basic human rights have prompted the introduction of several codes of practice to guide and constrain the activities of investigators. Our patients require protection and never more so than in the context of clinical research.