Editorial articles

Atherothrombosis is the underlying pathology for most ischaemic events, including myocardial infarction, many forms of stroke, peripheral arterial insufficiency, and cardiovascular death, together with sudden cardiac death. As such, atherothrombosis represents a major healthcare concern throughout the world. Due to the increase in sedentary lifestyle and overeating, obesity, metabolic syndrome, and diabetes are all increasing in parallel, fuelling the atherothrombosis epidemic. It is likely, as the population ages and as urbanisation and industrialisation continue, that atherothrombosis will grow in prominence as a major public health problem.

Patients are waiting too long for echocardiography. A British Society of Echocardiography (BSE) survey shows that 62% of patients are waiting longer than four weeks and 23% more than 18 weeks.¹ There is substantial under provision of services and those that do exist need to work more effectively. The government is focussing on diagnostic services, including echocardiography, with a number of programmes including the 18-week project and expanding commissioning of services beyond traditional providers.² 

The Scottish Intercollegiate Guidelines Network (SIGN) recently published a comprehensive guideline of the management of cardiovascular disease (CVD). Here, Dr Kevin Jennings and Professor Lewis Ritchie, co-chairs of the SIGN coronary heart disease (CHD) guidelines steering group, look at the implications of the recent guidance for secondary care. The full five guidelines covering acute coronary syndromes, cardiac arrhythmias in CHD, chronic heart failure, stable angina, and risk estimation and the prevention of CVD, are available at www.sign.ac.uk. In the last issue of the journal, the implications for primary care were considered.

Coronary heart disease (CHD) is the leading cause of death in the UK (accounting for 105,000 deaths in 2004) and exerts a huge burden, both on our healthcare system (around £3,500 million in 2003) and on our economy (£7.9 billion per year). Following an acute myocardial infarction (AMI), the 30-day mortality remains significant at around 10%, despite successful reperfusion therapy, instituted by either thrombolysis or primary percutaneous coronary intervention (PCI), paving the way for novel cardioprotective strategies to be developed.

The Scottish Intercollegiate Guideline Network (SIGN) has published five new guidelines on heart disease with the aim of helping reach the Scottish Executive’s target of reducing deaths from coronary heart disease (CHD) in those aged under 75 years by 60% for the period 1995–2010. It is hoped the new guidance will help further reduce mortality, which has already fallen by one third between 1995 and 2005. The new guidance covers acute coronary syndromes (SIGN 93), cardiac arrhythmias in coronary heart disease (SIGN 94), the management of chronic heart failure (SIGN 95), the management of stable angina (SIGN 96), and risk estimation and the prevention of cardiovascular disease (SIGN 97). The full guidance is available at www.sign.ac.uk. Here, Dr Alan Begg gives a primary care perspective on the new guidance.

For nearly 40 years it has been suggested that high levels of homocysteine are associated with an increased risk of cardiovascular disease and that lowering these levels might be beneficial. On the basis of recently-published evidence, however, it appears that this hypothesis no longer holds and it is, perhaps, now time to move on in the search for non-conventional cardiovascular risk factors and other markers of disease risk.

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 success story of medicine has created a significant population of young adults, who require lifelong cardiac and non-cardiac services.1 Many of them face the prospect of further surgery, arrhythmia intervention and, if managed inappropriately, an increased risk of heart failure and premature death.

Statins represent the cornerstone of lipid-lowering therapy in patients with or at high risk of premature premature cardio vascular disease (CVD) but even among those that achieve guideline targets for low-density lipoprotein (LDL) cholesterol, there is still a 50–70% residual risk of cardiovascular events on statin monotherapy. In terms of absolute cardiovascular risk, nearly one in six statin-treated patients will experience an event over the next five years.

The many advances made in treating myocardial infarction and coronary artery disease has brought a new challenge – that of refractory angina. This is defined as chronic stable angina that persists despite optimal medical treatment in patients where revascularisation is unfeasible or where the risks are unjustified.

Patent foramen ovale (PFO) is defined as a communication at the fossa ovalis between the primum and secundum atrial septa that persists after the first year of life.

In utero the PFO functions as a physiological conduit for right to left shunting and it functionally closes at birth once the pulmonary circulation is established and there is a rise in left atrial pressure. This is followed by anatomical closure of the septum primum and septum secundum by one year of age.