Editorial articles

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.

Our understanding of the pathophysiology of acute coronary syndromes and, in particular, the interplay of a number of complex parallel processes, continues to develop.1 These processes include inflammation, thrombosis and matrix turnover with potential gene and environmental influences. Vitamin D, known primarily as a hormone of bone metabolism, can affect the transcription of a number of genes which play a pivotal role in both the development of acute coronary syndromes and the pathogenesis of coronary artery disease (CAD). The purpose of this review is to examine the mechanisms by which vitamin D and the vitamin D receptor (VDR) might influence the development of acute coronary syndromes.

We continue our series where Consultant Interventionist Dr Michael Norell takes a sideways look at life in the
cath lab ….. and beyond. In this column, he looks at the unreal and riveting world of TV medicine.