Editorial articles

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.

Recent presentations at the joint meeting of the European Society of Cardiology and World Congress of Cardiology in Barcelona, Spain, highlighted the potential problem of very late stent thrombosis and increased non-cardiac death occurring in drug-eluting stents (DES) (see pages 317–18). The presentations received major publicity, not least because of the comments of the designated discussant Professor Salim Yusuf (McMaster University, Hamilton, Canada) at one of the conference Hot Line sessions.

Across the UK, there are wide variations in the strategies used to manage patients presenting with acute coronary syndromes (ACS).

Following the Bristol Inquiry, the Kennedy report in 2001 listed 198 recommendations. Among these was the recommendation that “patients and the public must be able to obtain information as to the relative performance of the Trust and the services and consultant units within the Trust’.

Hypertension is very common and is easily detectable. It is estimated that up to 40% of adults have raised blood pressure (BP) and, clearly, the proportion increases with age. The World Health Organization (WHO) identified high BP as the most important preventable cause of premature morbidity and mortality world-wide, ahead of smoking and elevated cholesterol.

How much would you pay for an extra year of life? What if it was only a few months or even a few weeks? How much would you pay to stop a myocardial infarction (MI) happening to a close family member? As healthcare expenditure tries to grow faster than gross domestic product, these are questions increasingly being faced, incredible though it may seem, leaving difficult decisions.

Platelet inhibition is a prerequisite for successful percutaneous coronary interventions (PCI). Aspirin was the first antiplatelet agent with proven benefit in ST-elevation infarction (STEMI) in the era of thrombolysis, significantly lowering death rate and the recurrence of ischaemic events.

Treatment of chronic heart failure (CHF), an important cause of global morbidity and mortality, has evolved in the last three decades.1-3 Activation of neurohormonal systems plays a key role in the pathophysiology and progression of the disease. Therapeutic strategies directed towards their inhibition have reduced morbidity and mortality.3 The major mechanism seems to be related to the inhibition or reversal of remodelling.4 Angiotensin-converting enzyme (ACE) inhibitors are known to reduce symptoms and improve prognosis. The benefit of beta blockers in patients with heart failure has been amply demonstrated by comparing outcomes in patients prescribed a beta blocker or a placebo in patients on optimal treatment with diuretics and ACE inhibitors.

According to World Health Organization estimates, 16.7 million people die of cardiovascular diseases each year. By the year 2010, it is estimated that cardiovascular disease will become the leading cause of death in developing countries and by 2020 it will contribute to nearly 25 million deaths worldwide. Although therapies including drugs, lifestyle modification and revascularisation procedures have been demonstrated in clinical trials to be beneficial, they are under-utilised. Paradoxically, in spite of the under-use of evidence-based therapies, patients actively seek complemen- tary and alternative medicine (CAM) treatments. While many alternative therapies involve oral vitamin and mineral supple- ments that are unlikely to cause harm, chelation therapy is one of the most aggressive and intensive CAM modalities.