Clinical articles

With conflicting findings from studies of omega-3 fatty acids in cardiovascular disease, many healthcare professionals are uncertain of whether they show any benefit. BJC seminars are held to promote evidencebased practice and we recently convened a meeting of UK professionals working in cardiovascular disease to review the evidence for omega-3 fatty acids supplementation, as well as review some of the data relating to dietary fish oils. The panel considered how supplementation with omega-3 fatty acids might be used in the future. The meeting was sponsored with an unrestricted educational grant from Abbott Laboratories.

Up to one-third of patients with heart disease have diabetes. Cardiological status should be considered when deciding on treatment for diabetes. Patients with stable coronary disease can be treated with metformin, sulphonylureas or pioglitazone. Following an acute coronary syndrome, intensive insulin therapy with multi-dose insulin has been shown to reduce mortality, and longerterm treatment with pioglitazone may reduce recurrent events. There is little trial information for glycaemia control in patients with chronic heart failure, and metformin and insulin are both frequently used. Dipeptidylpeptidase-4 (DPP-4) inhibitors are new oral antidiabetic drugs, which are weight neutral, and the injected glucagon-like peptide-1 (GLP-1) receptor agonists reduce weight. Long-term outcome studies are awaited to see if they have cardiovascular advantages in any particular group of patients.

Pacemakers are being implanted with increasing frequency. As with every procedure, there is the potential for complications. There are little recent data on implant complications and consequently we may be misinforming patients when we consent them. 

These are unselected data from a high volume district general hospital (DGH). Infection rates are low. Lead displacement rates are higher than other similar studies. Pneumothorax rates are also high, reflecting the fact that almost all access is via the subclavian vein.

We present a case of a 55-year-old female with a successfully reperfused myocardial infarction in whom Dressler’s syndrome was subsequently diagnosed. There have been no reported cases in the literature of Dressler’s syndrome following documented early coronary reperfusion, and its continued existence in the era of reperfusion has been questioned. In conclusion, this case demonstrates that this syndrome is still a possibility in the current realm of thrombolysis and cardiac catheterisation.

The importance of heart rate reduction in chronic stable heart failure (HF) has been highlighted in the recently published Systolic Heart Failure Treatment with I_f Inhibitor Ivabradine Trial (SHIFT). Patients with an elevated resting heart rate (HR) benefited from additional HR control despite optimal doses of beta blockers. The aim of this study was to define the prescribing patterns of beta blockers and the scope for additional HR control in a ‘real life’ HF population.

We conducted a retrospective analysis of two HF clinics, where patients were referred for protocol-guided, up-titration of HF medications. At each assessment we documented: HR, blood pressure, and HF medications including potential side effects. The primary objective was to identify the proportion of patients who had suboptimal HR control (HR ≥70 bpm) despite optimal conventional HF therapy.

From 172 patient records, 145 (84.3%)could tolerate long-term beta blockade with 57 (33.1%) prescribed the maximum recommended dose. Overall, 101 patients were in sinus rhythm with 31/101 (30.7% having an ejection fraction ≤35% and a resting HR ≥70 bpm.

In conclusion, suboptimal HR control is evident in approximately one in three HF patients in sinus rhythm despite aggressive optimisation of beta blocker therapy. This cohort may benefit from additional HR control.

National Institute for Health and Clinical Excellence (NICE) guideline CG67 recommends that acute coronary syndrome (ACS) cases are treated with high-intensity statins (defined as statins used in doses that produce greater cholesterol lowering than simvastatin 40 mg). The objective of this study was to describe current UK prescribing of statins following ACS. This study used data from linkage between the Myocardial Ischaemia National Audit Project (MINAP) database and the General Practice Research Database (GPRD). The study included adults aged 40+ with a discharge diagnosis in MINAP of myocardial infarction, troponin positive or negative ACS discharged alive to home. A total of 6,138 ACS cases were included. Most ACS cases were prescribed both a statin at hospital discharge and by their GP, however, 340 of the 6,138 ACS cases (5.5%) had no record of statin prescription from either source. Of the ACS cases prescribed a statin by their GP, 30.1% received a high-intensity statin dose. At year four, 43% (95% confidence interval [CI] 41–45%) of ACS cases prescribed a statin remained on treatment (42% for those starting low and 45% for high intensity). In conclusion, statin therapy is provided to most ACS cases in the UK but duration and dosage is shorter and lower than recommended.

Although morbidity and mortality are the most commonly used end points in clinical trials of heart failure treatments, it is also important to consider how patients experience their illness when assessing treatment efficacy. The goal of this study was to use qualitative interviews to identify key experiences that may be targeted as end points in future heart failure trials. 

Interviews were conducted with 63 chronic heart failure patients. Interview responses were coded using ATLAS.ti software. Code frequency and bother ratings were used to identify salient patient experiences. Key symptoms included shortness of breath, tiredness, swelling of the lower extremities, and pain (chest and other). Shortness of breath and tiredness were often described as being related to physical activities. Key areas impacted by heart failure included physical activity and mobility limitations, and a variety of emotional effects.

In conclusion, patients report a number of symptoms and impacts related to heart failure. Although some experiences are already widely captured in clinical and patient-reported heart failure assessments, others, such as pain, are not. These findings support the use of patient-reported outcome instruments as end points when assessing the efficacy of heart failure treatments.  

SGLT2 inhibitors are a new class of oral drugs for the treatment of type 2 diabetes mellitus currently in phase III studies. They inhibit glucose re-absorption in the proximal renal tubules providing an insulin independent mechanism to lower blood glucose. Their use in clinical practice is associated with improved glycaemic control, weight loss and a low risk of hypoglycaemia. Phase III cardiovascular safety studies are ongoing.

Patients with chronic heart failure (CHF) may have low pulse pressures (PP). This retrospective study was undertaken to analyse the relationship between PP and outcomes of a 12-week exercise training programme. Data analysed from 86 patients (69 male) aged 40 to 86 years, included: PP, functional capacity (metabolic equivalents [METS]) and quality of life (QoL) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).

Median pre-training PP was 54 ± 19 mmHg. Functional capacity for the same heart rate (estimated 60% heart rate reserve) and Borg rating of 13 increased from 3.6 ± 1.1 to 4.0 ± 1.2 METS (p=0.0005); MLHFQ scores improved from 26 ± 19 to 22 ± 20 (p=0.0005). There was a high correlation between PP and systolic blood pressure pre- and post-training (pre: r=0.77, p=0.0005; post: r=0.80, p=0.0005). Changes in all the above outcomes were independent of pre-training PP. 

In conclusion, low PP did not reduce the efficacy of an exercise training programme, indicating that CHF patients with low PP can benefit similarly to those with normal/raised PP.

Midodrine is a sympathomimetic agent used in the treatment of hypotension resulting from various aetiologies. Debate around the use of midodrine recently increased after it was threatened with a licence withdrawal in the USA. The reason cited was a failure of the manufacturing drug companies to provide previously agreed post-market studies. Conversely, midodrine has never received a licence from the UK regulatory authorities.

We provide a review of its current status and a brief description of our own experience with midodrine over the last 11 years.