Editorial articles

The British Society of Rheumatology have published guidelines on the management of rheumatoid arthritis, which call for an increased awareness of rheumatoid arthritis as an independent risk factor for ischaemic heart disease.(1) This increased cardiovascular risk is related to the severity and duration of inflammation, and the magnitude of additional cardiovascular risk in severe rheumatoid arthritis has been compared with that seen in diabetes mellitus.(1)

Life expectancy is reduced due to an excess of cardiovascular death, with increased standardised mortality ratios ranging from 1.28 to 3.00 in rheumatoid patients compared with the general population.(2) Women with rheumatoid arthritis are twice as likely to suffer from a myocardial infarction as those without.(2) There is also an increased risk of congestive cardiac failure,2 asymptomatic coronary heart disease and sudden cardiac death.(3)

“My interest is in the future because I am going to spend the rest of my life there.” – C F Kettering

Cardiovascular diseases are a massive public health problem in both the developed and developing world. UK statistics show, according to death certification, half a million people die annually, about 180,000 due to circulatory disease, 130,000 from neoplastic disease and 70,000 due to respiratory disease. With advancing age, the likelihood of dying from circulatory disease increases. So let’s face it, most of us are going to die from clogged blood vessels, most commonly some manifestation of coronary disease. Add in the millions who will live with symptoms of coronary disease and the numbers stack up even higher.

In 1948, the US public health service financed an epidemiological study on a previously unprecedented scale to investigate why millions of Americans were dying prematurely from heart disease. The result was the Framingham study, from which we have a pretty good idea of what increases our chances of developing coronary disease – smoking, cholesterol, blood pressure and diabetes – well recognised now but unknown until 40 years ago. In fact, Framingham introduced cardiovascular risk and cardiovascular risk factors into the medical vocabulary in a landmark paper in 1961.

A risk scoring system soon followed. Despite listing several important caveats, the Framingham risk score was widely adopted around the world, largely because of its novelty, simplicity and practicality. Some four decades later, there is mounting criticism of the Framingham risk score. First, because it does not predict cardiovascular risk ‘accurately’ enough – when applied to different populations, the score tends to overestimate risk in low-risk populations and underestimate risk in high-risk populations. Second, because it does not take into account other factors such as family history or socio-economic status.

New risk scoring systems have been proposed, each claiming to predict, with greater accuracy than Framingham, the risk of a future cardiovascular event, at least in the population in which each was developed. Will ‘better’ scoring systems help us manage our patients better?

“A good forecaster is not smarter than everyone else – he merely has his ignorance better organised.”

For patients with established coronary artery disease, lifestyle changes such as dietary modification, smoking cessation, stress management and regular exercise, can help to reduce, or perhaps stop, the progression of their cardiovascular disease, reduce their chance of having another cardiac event, and improve their quality of life. Cardiac rehabilitation can accelerate physical and psychological recovery and reduce mortality after acute cardiac events by 10–25% according to systematic reviews of randomised trials.1-3 Cardiac rehabilitation programmes can also reduce risk factors, improve health-related quality of life, and increase the likelihood of return to work.3-6 Despite this evidence, however, typically fewer than 35% of eligible patients take part in cardiac rehabilitation worldwide, with a recent UK audit reporting figures in line with this.(7-10)

In this issue, Pfeffer et al. discuss the impact of anthracycline-related cardiotoxicity and strategies for its treatment and prevention (see pages 85–9). Anthracyclines are not the only widely used class of cytotoxics with the potential to cause cardiotoxicity, but they are the most studied and the effects are well described. The antimetabolites 5-fluorouracil (5FU) and capecitabine, an oral pro-drug of 5FU, can cause an acute and chronic cardiotoxicity1,2 while vinorelbine, a vinca alkaloid, can cause angina.3 Paclitaxel, a taxane, has been shown to augment the cardiac side effects of doxorubicin, an anthracycline.4,5 The potential for cardiotoxicity is therefore, a major consideration when determining appropriate treatment for patients.

For over 50 years cardiologists have routinely recommended antibiotic prophylaxis (ABP) at the time of dental procedures in patients deemed to be at risk of infective endocarditis (IE). Reviews and editorials all acknowledged the lack of robust evidence for effectiveness of ABP and from time to time the literature has been reviewed and expert opinion synthesised into guidelines. In the UK, the 2004 Joint Royal College of Physicians/British Cardiac Society guideline has been widely followed.1 In 2006 new guidelines were published by the British Society for Antimicrobial Chemotherapy (BSAC).2 These guidelines were important because this committee’s recommendations are incorporated into the British National Formulary. The BSAC guidelines recommended withdrawal of ABP for the majority of patients limiting them to individuals perceived to be at the highest risk of IE (e.g. a prior history of IE, prosthetic cardiac valves and surgically constructed pulmonary or system shunts/conduits). These guidelines were welcomed by the majority of dentists and microbiologists as a step in the right direction. However, many cardiologists, who had seen first-hand the horrors of IE, did not wish to see the rejection of a therapy that was thought by most to be effective and harmless. The lack of agreement between the medical and dental professions resulted in the issue being referred to the National Institute for Health and Clinical Excellence (NICE) for an authoritative statement.3

The field of clinical medicine is littered with the bodies of sacred cows. Recent examples include the demise of vagotomy and pyloroplasty as a standard treatment for peptic ulcers and the absolute contraindication of beta blockers in the treatment of heart failure. I would like to suggest that the next sacred cow to be dispensed with is the routine use of electrical cardioversion in the treatment of atrial fibrillation, despite its inclusion as a therapeutic option in the National Institute for Health and Clinical Excellence (NICE) atrial fibrillation guidelines.1

Direct electrical cardioversion has been a mainstay of therapy for the treatment of atrial fibrillation for many years. The theory underpinning its utilisation has some face validity, that by restoring sinus rhythm any problems associated with atrial fibrillation will be ameliorated. This, however, does not take into account the underlying cause of the arrhythmia, with the majority of atrial fibrillation caused by ischaemic heart disease. It is only relatively recently, however, that evidence for the ineffectiveness of cardioversion has begun to emerge. Paradoxically this evidence has derived from trials designed to prove the effectiveness of the procedure.

The announcement that Akira Endo has won the 2008 Lasker-DeBakey Clinical Medical Research Award is a fitting tribute to the man who discovered the first statin. The remarkable ability of these compounds to lower cholesterol has revolutionised medical practice, boosted the profits of the pharmaceutical industry and improved the health of millions. The story of this discovery illustrates how Endo’s single-minded pursuit of an idea changed the course of history, an achievement that has now been recognised by his peers in the scientific community.

Postgraduate medical training has undergone extensive reform in recent times. This article outlines the current state of affairs and possible future developments in cardiology specialist training.

When any doctor or nurse refers to a colleague they should automatically ask themselves: is this referral necessary and will it benefit the patient? Referral should never be an automatic choice and the circumstances may dictate a different option.

The UK has witnessed a seismic shift in the delivery of healthcare to patients with coronary heart disease, but there is still a lot to be done. Promoted by the National Service Framework (NSF), and supported by a £775 million capital programme from the Department of Health and Lottery Funding (£122 million towards new cath labs), waiting lists have been slashed and patients are able to be investigated and treated nearer to home.1 In its annual audit reports for 2001, the British Cardiovascular Intervention Society (BCIS) reported on activity in 64 percutaneous coronary intervention (PCI) centres and 62 centres performing diagnostic invasive procedures only. The report for 2006 included data from 91 PCI centres and another 90 diagnostic-only centres.2

In this issue of the British Journal of Cardiology, Kelly and colleagues from Bournemouth provide the results of their initial experience in providing PCI to their local and surrounding communities (pages 244–7).3 Over a short period of time, activity has grown rapidly and they now perform over 1,500 PCIs per year. The centre is to be congratulated on the way it has established its PCI service because the programme was developed with some serious business planning, supported by its management, the local commissioners, its traditional tertiary centre, and the Strategic Health Authority. They sought and were given approval by BCIS, they ensured arrangements were made for surgical cover, and for the review of angiograms with off-site surgeons, and they committed themselves to appropriate clinical audit (collecting information on all patients undergoing treatment and downloading this to the Central Cardiac Audit Database [CCAD]).4 In line with the current BCIS policy, they have also evaluated their results against the predictive score generated by the North West Quality Improvement Programme (NWQIP), which has been both internally and externally validated.5,6 Their early results demonstrate complication rates within predicted limits. This is an example of a unit that not only has delivered considerable clinical activity but has also provided evidence of the quality of the service provided.

Their reported experience raises two issues; the first relates to strategic thinking about how revascularisation is delivered on a regional basis and the second to measures of quality.