Editorial articles

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.

The prevalence of cocaine use in the UK has been steadily increasing over recent years, with 6.6% of 16–24 year olds admitting to regular use.¹ United Nation figures from 2009 suggest that there are more than one million current cocaine users in the UK.² In the USA, there are an estimated 5.8 million users.^3,4 This high level of use is associated with considerable healthcare implications and costs. The most common cocaine-related presentation is chest pain, which is responsible for approximately 64,000 assessments per year in the USA, costing $83 million.^3,4 If we extrapolate those figures to the UK, there would be approximately 11,000 assessments per year for cocaine-related chest pain. While this is perhaps a statistically dubious analysis of the figures, it does give us some idea of the scale of the problem.

He who knows syphilis knows medicine” said Father of Modern Medicine, Sir William Osler, at the turn of the 20th Century. So common was syphilis in days gone by, all physicians were attuned to its myriad clinical presentations. Indeed, the 19th century saw the development of an entire medical subspecialty – syphilology – devoted to the study of the great imitator, Treponema pallidum. But syphilis to many is a disease of old, consigned to the annals of history by infusions of mercury, arsenical magic bullets, and finally dealt a fatal blow by the advent of penicillin. The case report of a contemporary presentation of syphilitic aortitis by Aman et al. (see pages 94−6) presented in this issue is fascinating, but it seems most remarkable as a strange relic, a throwback to an era of medicine past. Or perhaps it is not.

The UK has seen an explosion in venereal syphilis in the first decade of the 21st century. There were 3,762 diagnoses of early stage ‘infectious syphilis’ (comprising primary, secondary and early latent syphilis) made in 2007, more than in any other year since 1950. The trend has continued unabated with a similar figure seen in 2008 (2009 data are awaited). Between 1997 and 2007, annual diagnoses of infectious syphilis rose more than 1,200% (figure 1).(1)

As Chairman of HEART UK’s Familial Hypercholesterolaemia (FH) Guideline Implementation Team, I am well aware that little has been done in England to implement the recommendations of the National Institute for Health and Clinical Excellence (NICE) guideline for the identification and management of FH (CG71), published in August 2008. This is, of course, in stark contrast to developments in Wales, Scotland and Northern Ireland, where my colleagues have made significant progress in identifying and treating patients with FH. However, even I was surprised by the findings of a study, commissioned by HEART UK – The Cholesterol Charity, in which freedom of information (FOI) requests were sent to primary care trusts (PCTs) in England, requesting information about their progress to date.

The National Health Service (NHS) Health Check is a national screening programme to detect individuals in the 40–74-year-old age range who are at risk of developing cardiovascular disease (CVD).

It was in January 2008 that, the then Prime Minister, Gordon Brown, announced the Government’s intention to shift the focus of the NHS towards empowering patients and preventing illness. As part of this, he set out to dramatically extend the availability of, what he called, ‘predict and prevent’ checks. Mr Brown’s vision was that these checks would give people information about their health, support lifestyle changes and, in some cases, offer earlier interventions.

So, primary care trusts (PCTs) were required since late 2009 to commission services to deliver NHS Health Checks to 40–74 year olds, on a five-year, call–recall, cycle. The programme is specifically to detect risk and is not designed to cover those who are known to have an existing cardiovascular or related condition, such as diabetes or chronic kidney disease. Individuals participating in the checks will be given an assessment of the level of their own risk of developing CVD within the next 10 years and will be offered appropriate advice and interventions. For those with the least risk, this may be a simple discussion around healthy lifestyles. For moderate risk, the recommendations may include brief interventions around smoking, physical activity or referral to lifestyle support services. Those most at risk may require clinical interventions such as a statin prescription or referral to a specialist service.

It is anticipated that the NHS Health Checks programme will be fully operational by April 2012.

In their article, Ngaage and colleagues (see pages 28–32) discuss the influence of an ageing population on care and clinical resource utilisation in cardiac surgery in the UK. They reviewed approximately 7,000 patients who underwent coronary artery bypass graft (CABG) surgery and valvular heart surgery over a 10-year period. Altogether, 38% of their patients were older than 70 years. They showed that older patients had a higher need for peri-operative interventions and requirements, thereby incurring extra resources and expenses.

Advancing age in the Western world has led to a significant increase in the number of elderly patients requiring cardiovascular care and cardiac surgery.1 In deciding which patients need surgery, the benefits of both traditional and minimally invasive cardiac operations have to be balanced against the risks of these procedures, especially in the elderly population. The main risks of cardiac surgery affecting the elderly are transient ischaemic attack, stroke and cognitive decline, which can be as high as 13%, and renal failure, with 7% requiring renal replacement therapy.2 Furthermore, mobilisation, rehabilitation and returning home after surgery are significant considerations when treating the elderly. It would be a failure of cardiac surgery if the patient could not be rehabilitated and be able to assume a good lifestyle following their operation.

In March 2010 the National Institute of Health and Clinical Excellence (NICE) published guidance on the management of patients with chest pain of recent onset.1 The guidance is based upon contemporary literature and provides an evidence-based approach to the diagnosis of patients with acute and stable chest pain.

Following recent publication of the 2010 European Society of Cardiology (ESC) guidelines for atrial fibrillation (AF) it is timely the BJC publish an article by Gunawardena et al. (see pages 271-6) describing a single centre cohort analysis of their AF ablation procedures.¹

Recent technical developments in multi-detector computed tomography (MDCT), and particularly the introduction of 64-slice MDCT, have made the non-invasive imaging of coronary arteries a clinical reality. Beta blockers are used to decrease the heart rate to 65 bpm, sublingual glyceryl trinitrate (GTN) can be used to dilate the coronary arteries, and the patient is only required to breath-hold for a few seconds. Fast or irregular heart rates, extensive calcium blooming artefacts and patients with high body mass index (BMI) are the only limiting factors. The temporal resolution is faster with dual-source MDCT, reducing the need for beta blockers, and the 320-slice MDCT can image the heart in one heart beat.