Clinical articles

A 27-year-old Arab woman with history of seronegative rheumatoid arthritis for four years presented with a three-day history of multiple joint pains and swelling, along with fever. Clinically, she had bilateral rheumatoid hand deformities with signs of active arthritis of elbows, hands and knee joints. She was in sinus rhythm with normal cardiac examination. She was treated with steroids and was responding well except for mild fever, for which an echocardiogram was requested to rule out infective endocarditis. 

Outcome in patients with peripartum cardiomyopathy (PPCM) is variable. Recovery of left ventricular function is observed in between 23% and 51% of cases at six months after diagnosis. Despite standard medical therapy, both morbidity and mortality remain high. Recent evidence has suggested that dopamine-receptor agonists may be beneficial in the treatment of this condition. We describe a case of a patient with PPCM who developed rapid normalisation of left ventricular function following addition of carbergoline, a long-acting dopamine-receptor agonist, to her conventional heart failure therapy.

The glucagon-like peptide-1 (GLP-1) receptor agonists are a new class of injected drugs for the treatment of type 2 diabetes. They mimic the action of GLP-1 and increase the incretin effect in patients with type 2 diabetes, stimulating the release of insulin. They have additional effects in reducing glucagon, slowing gastric emptying, and inducing satiety. In clinical practice they are associated with significant reductions in glycosylated haemoglobin (HbA_1c), weight loss and a low risk of hypoglycaemia. Beneficial effects have also been observed on blood pressure and lipids. The possibility of cardiovascular benefit is now being formally examined in large randomised-controlled trials with primary cardiovascular end points.

We developed and piloted an innovative family-centred preventive cardiology programme (MyAction) that aimed to both integrate the care of patients with vascular disease with that of individuals identified at high multi-factorial risk and help them achieve recommended lifestyle, medical risk factors and therapeutic targets. The 16-week nurse-led programme was delivered by a multi-disciplinary team, including a dietitian, physical activity specialist and cardiologist, in a community setting. Of 206 patients who attended the initial assessment, 54% attended with their partner and 142 patients completed the programme (69%). By the end of the programme, there was a significant improvement seen in adherence to a Mediterranean diet, as well as substantial increases in physical activity levels supported by objective evidence of improved functional capacity. These changes contributed to significant reductions in body mass index (BMI), weight and abdominal obesity. Very similar changes were seen in partners. Blood pressure control also improved significantly, as did achievement of the low-density lipoprotein (LDL)-cholesterol target, and there was a significant increase in the use of cardioprotective medication. Quality of life also improved in both patients and partners. The significant changes achieved by the MyAction preventive cardiology programme should substantially reduce the cardiovascular risk of these patients and their partners in the future.

Reducing morbidity and mortality among post-myocardial infarction (MI) patients requires the implementation of effective secondary measures. This survey examined current practice by assessing the view on, and adherence to, National Institute for Health and Clinical Excellence (NICE) guidance on MI secondary prevention in a sample of general practitioners (GPs) and cardiologists. There were 303 respondents from Scotland and England, including at least 10 GPs and one cardiologist from each English Strategic Health Authority. Although drug treatment post-MI generally complied with NICE recommendations, diet and lifestyle aspects were not implemented fully. There appeared to be sub-optimal integration between primary and secondary healthcare providers. Both GPs and cardiologists underestimated the importance of tailoring secondary prevention services to the individual and the role of omega-3 fatty acid treatments (where required) to supplement dietary intake. There is a clear need to improve compliance of healthcare professionals with many of the key priorities for implementation outlined in the NICE guidelines. In addition, patient-centred cardiac rehabilitation services should be standardised and include strategies to improve patient uptake.

Ranolazine has been evaluated in three trials in patients with stable angina (MARISA, CARISA and ERICA) and one large trial of patients with non-ST elevation acute coronary syndromes (MERLIN-TIMI 36). It has shown an improvement in exercise performance and a decrease in angina attacks. Ranolazine has similar efficacy in younger and elderly patients. Observational experience with ranolazine from a large UK centre is described.

This study examined the effect of a community-based intervention on the natural rise with age of the Framingham 10-year risk score. Patients in the 45–64-year-old age group from 10 general practices were sent an invite card including five self-screening questions. Those with any of the prescribed risk factors were invited to arrange an appointment to assess their risk of heart disease, where a Framingham risk score was calculated and advice given, and then invited for re-assessment around 18 months later. 

Of 6,704 individuals contacted, 2,017 individuals (30.1%) arranged a health check, 982 followed up, and risk scores were calculated on 727. A significant reduction in the geometric mean Framingham risk was observed (from 10.65% to 10.34%), largely attributable to improvements in systolic blood pressure, high-density lipoprotein (HDL), reduced smoking and, perhaps, increased fruit and vegetable consumption. Although participants were 1.5 years older at follow-up, their risk profile corresponded to being 0.55 years younger, and, arguably, progression of risk was wound back by just over two years. Some self-selection bias was apparent, as those followed up had higher mean anxiety/depression scores at baseline.

In conclusion, community interventions can reduce cardiovascular risk even in deprived communities, although further analysis is required to establish cost-effectiveness.

National Institute for Health and Clinical Excellence (NICE) guidelines for the management of chest pain suggest a care pathway based on symptoms and clinical risk, which differs from that currently used in most hospitals. To compare the impact on workload, and costs of these guidelines with the current ‘exercise electrocardiogram (ECG)’-based service, a retrospective review of 150 patients referred to our rapid access chest pain clinic was performed. We compared investigations under the current system with that expected under the NICE guidelines. Cost analysis was performed to compare the two methods. GP questionnaires investigated likely changes in primary care referrals.

Heart failure is one of the most common conditions in industrialised society. Plasma N-terminal prohormone of brain natriuretic peptide (NT-ProBNP) levels are raised in heart failure and increase with severity and New York Heart Association functional class. A NT-ProBNP level guided community echocardiogram service has been in place at Southend University Hospital since 2005. A previous audit of the service in 2006 showed that a cut-off point of 300 pg/ml provided a negative predictive value of 97% for detecting significant left ventricular systolic dysfunction, defined as an estimated ejection fraction of less than 40%. We have now repeated the audit for the calendar year 2008 and have shown that an additional cut-off point of 450 pg/ml can be applied to the over 75 age group with a reassuring negative predictive value of 96%. 

The National Institute for Health and Clinical Excellence (NICE) has issued guidance on the investigation of patients with recent onset of chest pain, recommending CT calcium scoring (CAC) as the preferred test in some low-risk groups. This reflects concern about the low sensitivity (high false positive rate) of exercise stress tests (EST). This represents a major shift away from traditional rapid-access EST clinics and has generated concern. We looked at 125 consecutive ungraded patients with equivocal ESTs referred for CAC, and CT coronary angiography (CTA), if required. We found that 53% of patients had a CAC = 0 and would need no further testing under the NICE protocol. We estimate this would rise up to 70–80% if only low likelihood patients were studied. Two per cent of patients with a CAC = 0 required coronary intervention.

As per NICE protocol, all patients with a CAC between 1 and 400 underwent CTA, and, of these, 25% required invasive coronary angiography (ICA) and 17% underwent coronary intervention. 

The overall strategy of CAC followed by CTA (if CAC between 1 and 400) and ICA (if CAC >400) produced a final sensitivity of 88% (higher than EST) and a negative predictive value of 98% (similar to EST). We believe the strategy is a useful way to assess recent onset chest pain but concerns about radiation dose, availability and patients with obstructive non-calcific plaque remain.