Editorial articles

Cannabis has been employed medicinally and recreationally for thousands of years,^1,2 but it was not until the 1960s that the structure and pharmacology of its primary phytocannabinoid components, cannabidiol (CBD)³ and tetrahydrocannabinol (THC)⁴ were identified, and another generation before the nature and function of the endocannabinoid system (ECS) were elucidated (see reference 5 for a comprehensive review). The ECS consists of endogenous cannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), their biosynthetic and catabolic enzymes, and their receptors: CB₁, which is psychoactive, analgesic, neuromodulatory and the most abundant G-protein coupled receptor in the brain, and CB₂, which is non-psychoactive, immunomodulatory and anti-inflammatory. The ECS may be thought of as a grand homeostatic regulator of chordate physiological functions, whose roles have been summarised as: “relax, eat, sleep, forget and protect”.⁶ Those actions closely describe the effects of THC and AEA, which are both weak partial agonists at CB₁ and CB₂. 

We know that people with advanced heart failure have unmet supportive and palliative care needs, and the burden of these concerns is comparable with people with cancer.^1–2 Palliative care services in the UK and elsewhere have grown up around oncology services. Randomised controlled trials (RCTs) have confirmed that early integration of palliative care, alongside cancer treatment, improves patient outcomes.^3–7 In contrast, experience of and the evidence base for integration of palliative care alongside heart failure treatment has been slow to develop. However, this is changing. A pilot RCT comparing the addition of a palliative care intervention to usual care for people with advanced heart failure has reported benefit in health-related quality of life, symptom control and health service utilisation (reduced hospital admission)⁸ and several phase three RCTs are ongoing. 

Hypoglycaemia is defined as a lower than normal level of blood glucose, and in patients on glucose-lowering therapy, defined as glucose levels less than 4 mmol/L. In the UK, it is usually classified as ‘mild’, if the episode is self-treated, or ‘severe’, if the individual requires third-party assistance. However, the American Diabetes Association definition of hypoglycaemia is different.¹ They classify hypoglycaemia into five categories. These are shown in table 1. 

Non-adherence to medication for chronic conditions, whether this involves tablets, inhalers, injections or other drug delivery systems, is a serious healthcare problem resulting in poor clinical outcomes and high costs. Here, we review the extent of the problem and the development of a novel evidence-based digital tool to support healthcare professionals (HCPs) in assessing and potentially improving the adherence of chronic patients. 

HCPs are increasingly focusing on developing interventions to address this problem. However, the development of effective adherence interventions is challenging; it involves finding the individual root causes of non-adherence, with the added difficulty of introducing and maintaining behavioural change, and offering tailored solutions that address the specific needs of a particular patient.

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) has expanded exponentially since it was first described 12 years ago, with around 100,000 procedures performed worldwide.^1,2 Randomised controlled trials have established TAVI as the treatment of choice for severe AS in patients of prohibitive surgical risk and as a viable alternative to surgical aortic valve replacement (SAVR) in high-risk candidates.^3–5 The feasibility and safety of TAVI is further supported by a large body of ‘real-world’ data from multi-centre registries with 93% 30-day and 79% one-year survival in the UK.⁶ Moreover, with growing operator experience and evolving valve technology, TAVI continues to expand beyond those populations originally studied, to include those with severe left ventricular dysfunction and those with failing surgical homografts (so called ‘valve-in-valve’ TAVI), for example.^7,8

Lowering serum cholesterol with statins has consistently shown benefits on cardiovascular outcomes. A 1 mmol/L reduction in low-density lipoprotein (LDL)-cholesterol is associated with approximately one-third fewer coronary events and one-fifth fewer ischaemic strokes.¹ However, despite these impressive results, there remains a substantial residual risk of cardiovascular (CV) events despite optimal statin therapy.² From pooled analyses of randomised-controlled trials of statins, there is a clear relationship between the achieved level of LDL-cholesterol and the number of coronary heart disease (CHD) events. This observation applies to both primary and secondary prevention trials.³ 

Today’s patient is potentially very different compared with only just a few years ago. So much has changed there is even a new word to describe them, the ‘e-patient’. The ‘e’ can stand for one of many things, equipped, enabled, empowered, engaged or even electronic to cover the internet-savvy approach taken by these patients. Increasing numbers of patients are ever more knowledgeable than in the past and are keen to take control of their own health as much as they can. Many walk in to your consulting room no longer just up to speed on what could be wrong with them, but also with strong opinions on the latest treatments.

The introduction of high-dose statin therapy, more potent statins and the corresponding clinical trial results have led to new treatment targets in secondary prevention of cardiovascular disease (CVD).¹ Most guidelines recommend that for secondary prevention patients require a treatment goal of less than 1.8 mmol/L low-density lipoprotein (LDL)-cholesterol (LDL-C).² While the use of high-dose atorvastatin therapy is expected to become more widespread now that atorvastatin is available as a generic drug,³ in practice, poor compliance seriously impacts effective treatment.⁴ Only 1.9% of patients in the Treating to New Targets (TNT) study reduced the randomised treatment of 80 mg atorvastatin to 40 mg,¹ whereas, in practice, the mean dose prescribed is 32 mg per day.⁵ For statins, there appears to be a road-block to implementing the results of large randomised-controlled trials (RCTs), similar to the issue of treating hypertension, another ‘silent’ disease. 

In this issue we have some common themes. Four articles relate to the electrocardiogram (ECG) with the eminent Derek Rowlands and Philip Moore making a plea for formal ECG training for all doctors (see pages 47−8). Other articles cover Wolff-Parkinson-White syndrome (page 80), torsades de pointes (page 79) and Heather Wetherell continues her series on ECGs for the fainthearted highlighting whether we should trust our ECG machines (pages 62–3). 

Clinical estimation of the jugular venous pressure (JVP) has been at the heart of bedside cardiology for the past 100 years. Observation and description of the waveform used to be central to the derivation of a clinical diagnosis. As technology has rapidly developed over the past 25 years, the bedside method of JVP estimation and description has all but disappeared. But need it be abandoned? The conditions, which today cause an elevated JVP, are very different from those that were prevalent three decades ago. Rheumatic valve disease has all but disappeared in the UK, but heart failure caused by myocardial disease is now much more common. The outlook for patients with unoperated congenital heart disease was poor, but diagnostic and surgical advances in the last 50 years have made survival commonplace. Lifelong surveillance is required in all but the simplest cases.