Editorial articles

As from May 2009 the National Institute for Health and Clinical Excellence (NICE) have removed transmyocardial laser revascularisation (TMLR) from the list of treatments for refractory angina.¹ From their analysis of efficacy they found no evidence of improved myocardial perfusion, ejection fraction or prognosis. There was also no evidence for improvement in exercise tolerance or Canadian Cardiovascular Society (CCS) class when compared with other treatments. Furthermore, looking at the data on safety, randomised controlled trials showed evidence of increased myocardial infarction in the TMLR-treated patient group, as well as evidence of left ventricular perforation. 

There have been reservations regarding this technique for many years and it would seem to be a valid decision on behalf of the specialist advisers. It seems appropriate, therefore, to look at how to best treat this complex group of patients. 

The prevalence of atrial fibrillation (AF) in the UK alone is estimated to be 1% of the population (approximately 610,000) and rises with age from 1.5% in people in their 60s to more than 10% in those over 90 years old. It is also more common in males than females. Because prevalence increases with age, it is expected to increase over time as the proportion of people aged 65 and over is projected to increase from 16% of the UK population in 2006 to 22% by 2030.¹ AF is the most common supraventricular arrhythmia; it is predicted that catheter ablation (CA) as a management strategy will be one of the most commonly performed electrophysiological procedures in the next decade.

Over recent years data have accumulated suggesting that sinus rhythm (SR) is associated with increased survival.² Whether this association of SR with improved survival is actually a causal relationship is yet to be proven. CA has proven to be an effective curative treatment particularly when used for paroxysmal AF.³ 

If we consider gastro-oesopageal endoscopy as a similar procedure to transoesophageal echocardiography (TEE) then we might be alarmed at the 30-day mortality of 1:2,000 reported by Quine et al.¹ I am not a practitioner of either of those arts, but I am putting on my anaesthetist cap to respond to the article by Mankia et al. discussing intravenous opiate/benzodiazepine sedation in this issue of the journal (see pages 125-7). The endoscopy death rate is especially concerning if you compare the fact that anaesthesia was considered to have been totally responsible for death in less than 1:10,000 operations in the UK.² Mankia et al. quite rightly suggest that there should be guidelines concerning the safe use of intravenous sedation in TEE, and should be congratulated for highlighting this matter. I would suggest that their gastrointestinal endoscopy colleagues have a lot of experience on which to draw from.

Cardiovascular disease is the biggest killer in the UK causing 198,000 deaths per year, and stroke is the most common cause of disability in women. Can individuals at increased risk be identified and can heart attacks and strokes be prevented?

In this issue, Sandler’s paper (see pages 86–8) reinforces the growing body of evidence that should lead to the demise of the routine use of direct current cardioversion (DCCV) for patients with atrial fibrillation. This interesting paper highlights several issues surrounding DCCV within the context of a service re-design within a district general hospital. Despite a state-of-the-art service, the success of DCCV was limited, with sinus rhythm maintained in between the stated 20% (22/110) or even optimistically 40% (22/55) at around one year. I would suggest that this is unacceptable and that we would not allow any other procedure with significant associated morbidity to be undertaken with such a low chance of succeeding.

Cardiac auscultation is a critical part of the clinical examination. In antiquity physicians listened to heart sounds directly by placing their ear to the chest. In 1816 Laennec was asked to examine a young ‘corpulent’ woman in Paris, out of embarrassment he rolled a sheaf of paper into a cylinder to listen to her heart sounds, the stethoscope was invented. Initially, Laennec applied his invention to study cardiopulmonary diseases where he correlated bedside findings with autopsy results.(1

The atrioventricular (AV) conducting system of the mammalian heart was described a hundred years ago. Albert Hyman, a cardiologist working in New York City performed studies on the stopped heart. On injection of drugs into the right atrium, usually including adrenaline, the stopped heart continued beating.

Although patients with acute coronary syndrome (ACS) share key pathophysiological mechanisms, they present with diverse clinical, electrocardiographic and enzyme characteristics and experience a wide range of serious cardiovascular outcomes.

Cardiac rehabilitation (CR) is the process by which patients with cardiac disease, in partnership with a multi-disciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health.”1 The fundamental interventions required for CR should provide the cornerstone of lifelong management in cardiovascular disease – for those who present with the numerous manifestations, those identified as being at increased risk, and, indeed, all of us.

The Myocardial Ischaemia National Audit Project (MINAP) represents one of the largest observational databases of acute coronary syndrome (ACS) events.1-3 Since its inception in 2000, it has accumulated rich data (including timing and method of admission, emergency and subsequent treatments, and long-term mortality data through linkage to the UK Statistics Authority) for over 650,000 ACS events from all acute hospitals (n=228) in England and Wales (figure 1). Initially designed to monitor standards set by the National Service Framework for Coronary Heart Disease4 with the generation of annual reports of hospital-level ST elevation myocardial infarction (STEMI) performance,5 the provision of contemporary online performance analyses has facilitated improvements in the care of ACS patients.6 Moreover, MINAP is more than a resource for the purposes of audit, it is also a key research tool for the evaluation of cardiovascular care and outcomes.7,8 Although it is primarily focused on clinical need, its research potential has been recognised by several grant-giving bodies, and a committee (the MINAP Academic Group [MAG]) dedicated to overseeing MINAP research has been established.3 The Clinical Performance Group (University of Leeds), a multi-disciplinary team comprising clinical cardiologists, health service researchers and health economists draws on MINAP data to investigate clinical care at multiple levels (patient, population, process and healthcare professional).