Editorial articles

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. 

The first human electrocardiogram (ECG) was recorded over 125 years ago. Despite the development of many new investigative techniques, the ECG remains an essential part of any cardiovascular assessment, whether in relation to acute or chronic health issues, to insurance assessment or to the assessment of risk in critical occupations or in sports professionals. In terms of interpretation, it is fair to say that the ECG occupies a unique and unsatisfactory position. Unlike pathology specimens and the images produced by modern techniques (both of which are always formally reported by trained and tested professionals), and unlike biochemical data (which are usually presented to the user clinician with the normal values displayed), ECGs are most commonly reported and acted upon by front-line users who have had no formal training in, and no assessment of competency in, ECG interpretation, and who generally proceed with no clear guidelines about the limits of normality or the precise criteria for specific abnormalities. There is no formal, national programme for training in ECG interpretation, or for the assessment of ECG interpretation skills. Inevitably, therefore, the standard of ECG interpretation (both in general practice and also in hospital) is highly variable, and is often extremely poor.

National life-expectancy is steadily rising with the number of those aged 85 years or over doubling from 1985 to 2010,¹ and ever more elderly patients presenting to cardiology. Age is a potent risk factor for mortality after acute coronary syndrome (ACS),² and older patients with angina present with more severe symptoms and prognostically significant coronary anatomy.³ Age has a very powerful influence on risk stratification tools such as GRACE (Global Registry of Acute Coronary Events), and National Institute for Health and Care Excellence (NICE) guidance supports early invasive investigation and management for high-scoring patients.⁴ Diagnostic coronary angiography (DCA) is crucial to assessing the cross-spectrum of coronary disease presentation. Despite this, elderly patients are less likely to be treated in accordance with best practice after presenting with ACS,^5,6 the so-called ‘risk paradox’. Concern about the safety and efficacy of DCA and percutaneous coronary intervention (PCI) in the more elderly population seems to underpin this behaviour. 

There is in fact a wealth of data to indicate that DCA in the elderly has acceptable complication rates,⁷ and that revascularisation, surgical or by PCI, offers significant benefit.⁵ The study by Walsh and Hargreaves (see page 37) is welcome in further describing the fallacies of current practice, which fall short of best practice.⁶ 

Despite the high and growing prevalence of hypertension worldwide, and the increasing attention focused on the challenge of resistant hypertension (RHTN), it is somewhat extraordinary to note the lack of data attesting to the epidemiology and management of RHTN at the present time. Few studies have described the incidence and prevalence of this condition, yet, it is very clear that, once diagnosed with RHTN, patients are at strikingly elevated risk of cardiovascular events, and thus clearly defined treatment strategies are urgently required.1 Quite remarkably, when reviewing the evidence base in RHTN for the recent National Institute for Health and Care Excellence (NICE) hypertension guidelines, the authors could find just one head-to-head randomised-controlled trial in this patient cohort, and only six retrospective cohort studies, with the largest being a post hoc analysis of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) study, where the use of spironolactone as a fourth-line agent was associated with blood pressure (BP) reductions of ~20/10 mmHg.2 Currently, we are hopeful that trials, such as the British Hypertension Society (BHS)-led Pathway 2 study (UKCRN.org.uk ID 4500) and the Resistant Hypertension Optimal Treatment (ReHOT) study (Clinicaltrials.gov ID NCT01643434), will help improve our drug therapy of RHTN. Nonetheless, it should be recognised that, while pharmacotherapy of hypertension is proven (at least up until the point of RHTN), issues with physician inertia, poor concordance and drug intolerance continue to undermine our efforts to get patients to target BP. 

Muslims worldwide represent a diverse and heterogeneous population varying widely in terms of geographical distribution, language, lifestyle, habits, customs, tradition, dietary habits and, above all, socio-economic status, which has a major influence on all other factors.¹

As UK cardiologists, we might be forgiven for assuming acceptance of cardiovascular magnetic resonance (CMR). The past decade has seen CMR in the UK change from an ancillary research/specialist patient populations tool to an evidence-based imaging modality for use in all spheres of cardiovascular disease. Within the wider medical community and overseas, however, the advantages of CMR remain opaque.

Chronic heart failure (CHF) affects 900,000 people in the UK and consumes almost 2% of the National Health Service (NHS) budget. These figures are set to rise as the prognosis of coronary artery disease improves and the population ages. Heart failure currently accounts for approximately 5% of all emergency medical admissions to hospital, and over the next 25 years the proportion will rise by 50% – largely due to an older population.¹ 

The National GPSI Cardiology Forum was established in 2005 and, despite the demise of the Primary Care Cardiovascular Society (PCCS) to which it was affiliated, it has remained active in the national cardiovascular arena. At a recent meeting at Warwick University, a decision was made to change our name to CVGP (CardioVascular General Practitioners: the Society for GPs with an interest in Cardiovascular Medicine). This name change does not alter our stated aims or direction of travel, but acknowledges the need to embrace all GPs involved in cardiovascular care rather than just GPs with a special interest (GPSIs) in cardiology. We believe this is essential in the evolving NHS clinical commissioning environment. 

When reference is made to sleep-disordered breathing (SDB), obstructive sleep apnoea (OSA) often springs to mind. Indeed, much research has been centred on identifying individuals at risk of OSA, determining the most effective form of therapy and unearthing the manner by which OSA increases cardiovascular disease (CVD) risk. As a result, factors such as central adiposity, neck circumference and age have been identified as OSA risk factors, and continuous positive airway pressure (CPAP) has become a well-recognised treatment for OSA. Studies also indicate that OSA may increase CVD risk via mechanisms involving tissue hypoxia and increased sympathetic nervous system activity, and that CPAP therapy counteracts these mechanisms.¹ The case for the OSA–CVD link has been further strengthened by additional research showing that CPAP can reduce elevated blood pressure and reduce the risk of cardiovascular events, such as heart attack and stroke.^2,3