Clinical articles

As the number of temporary pacing lead insertions performed declines, the experiential competency of physicians can also be expected to fall. We performed a retrospective study looking at the route of insertion, indications and complications comparing consultants and junior doctors.

Postural orthostatic tachycardia syndrome (POTS) is a condition that results from orthostatic intolerance. Patients, frequently young females, present with tachycardia, headache, palpitation, sweating, nausea and near syncope, on changing their posture from lying to standing. It is frequently misdiagnosed as panic attacks or anxiety neurosis. Tilt-table testing is diagnostic. Treatment depends on the type, whether primary or secondary, and there are non-pharmacological and pharmacological options.

There are currently limited data regarding multi-detector computed tomography (MDCT) coronary angiography in very elderly patients. This study reviews the utility of MDCT coronary angiography in octogenarians examined at our institution.

We reviewed 26 patients (mean age 83.1 ±4.6 years, range 80–96; 13 male) who attended for MDCT coronary angiography at our institution between January 2005 and January 2008. Scan indications, findings and clinical outcomes were recorded. Studies were graded according to overall image quality. 

One patient was excluded because of contrast extravasation. Of the 25 complete studies, image quality was at least adequate in 72% of patients. A total of 35 significant (>50% diameter narrowing) stenoses were detected. The mean Agatston score was 1182.7 ±1080.2 in the 14/25 patients evaluated. In 6/25 patients (24%) MDCT excluded significant stenoses; in 12/25 patients (48%) one or more potentially significant stenoses were identified, a diagnosis confirmed in the four patients who underwent further investigations; in 7/25 patients (28%) the MDCT scans were of insufficient diagnostic quality.

In conclusion, MDCT coronary angiography is feasible in the majority of very elderly patients. Diagnostic scans were obtained in most octogenarian patients, allowing detection of potentially flow-limiting stenoses or exclusion of significant disease. 

A previously fit and well 39-year-old Caucasian female patient was referred from the local district general hospital for further assessment and management of recurrent atrial tachyarrhythmias. A plain chest radiograph exhibited an abnormal left heart border (figure 1A), and initial transthoracic echocardiographic evaluation demonstrated a large intracardiac mass near the left ventricle.

The authors describe a case of hyperkalaemia in a patient receiving trimethoprim.

The term pharmaceutical salt is used to refer to an ionisable drug that has been combined with a counter-ion to form a neutral complex. Converting a drug into a salt through this process can increase its chemical stability, render the complex easier to administer and allow manipulation of the agent’s pharmacokinetic profile. Salt selection is now a common standard operation performed with small ionisable molecules during drug development, and in many cases the drug salts display preferential properties as compared with the parent molecule. As a consequence, there has been a rapid increase in the number of drugs produced in salt form, so that today almost half of the clinically used drugs are salts. This, combined with the increase in generic drug production, means that many drugs are now produced in more than one salt form. In almost all cases where multiple drug salts of the same agent exist, they have been marketed as therapeutically equivalent and clinicians often treat the different salt forms identically. However, in many cases this may not be justified. This review describes why many pharmaceutical salts are, in fact, not chemically equivalent, and discusses whether such chemical differences may translate into differences in therapeutic effectiveness. It will also explore, with examples, what the clinical cardiologist should consider when prescribing such agents for their patients.

Peripheral arterial disease (PAD) is a condition that is frequently underdiagnosed and often the subject of suboptimal care. It can present with rest pain or gangrene (critical ischaemia), but this is not common. Intermittent claudication (IC), leg pain on walking, is its most common manifestation. Leg pain on walking is a presentation commonly seen in general practice, and has several potential causes other than PAD. IC has been shown to affect 4.5% of subjects between the ages of 45 and 65 years and is a marker for increased cardiovascular risk.1 In respect of the leg itself, IC is a relatively benign condition with most patients improving or stabilising and fewer than 5% progressing to major amputation. However, patients with IC are at increased risk of death, especially due to vascular events in the coronary and cerebral territories.2 PAD is caused by the occlusion or narrowing of large peripheral arteries, usually from atherosclerosis, and, as such, it shares all the major risk factors that can lead to myocardial infarction (MI) or stroke. Most patients with PAD will also have disease (either symptomatic or asymptomatic) in their coronary and cerebral circulation, and MI and stroke are common causes of death in patients with PAD. Vigilance for the condition will provide opportunities to reduce cardiovascular risk in a group who are high risk. Accurate diagnosis and assessment will reveal those who would most benefit from specialist intervention.

The multi-disciplinary approach provides a forum for peer review of angiographic data. We aimed to examine the outcomes of our multi-disciplinary team (MDT) meetings in a two-year follow-up study. A total of 191 patients were studied and mainly divided into groups offering conservative therapy, percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). CABG was offered to 60% of patients with left main stem disease, 45% with proximal left anterior descending artery lesions and 59% with triple-vessel disease. PCI was offered to 40% of patients with single-vessel disease. One death was observed in the PCI group at two years, substantially lower than deaths in other groups. Overall mortality at two years was 6.4%. PCI conferred a significantly higher need for repeat revascularisation compared with surgery (odds ratio 5.71, p=0.005). Our results resonate with outcomes of published trial data comparing CABG and PCI.

The treatment of raised cholesterol has advanced significantly in the last 25 years: fibrates, statins, bile acid sequestrants, ezetimibe, and more. In October 2007, colesevelam hydrochloride was launched into the UK market. This article reviews where this product fits into everyday clinical practice, in which patients it is best suited, and discusses practical issues in the everyday use of this reformulated bile acid sequestrant.

We undertook a seven-year in-depth review of all reported obituaries of medical practitioners in the BMJ to assess the age and disease distribution of mortality of medical practitioners in order to identify relationships between mortality and discipline, ethnicity and other demographic factors. In total, 3,342 obituaries reported in the BMJ from January 1997 to December 2004 were reviewed.

The majority of obituaries were of male doctors. Doctors who qualified in the developed world appeared to live longer (mean age at death of 78 years) than those who qualified in Asia (mean age at death of 70 years). White-European doctors lived significantly longer than doctors from other ethnic groups. There was no significant difference in longevity between doctors working in the primary care sector and those in the secondary care sector. An eighth (12.5%) of doctors died between the ages of 60 and 70 years and, of these, nearly half died between the ages of 61 and 65 years. There were significantly more suicides and accidental deaths in Accident and Emergency (A&E) doctors compared with other specialties.

In conclusion, cardiologists are not immortal and need to retire, as do their colleagues in other specialties. Retirement at ages of 65 years or above would disadvantage nearly one in six medical practitioners. Those likely to be most disadvantaged by a mandatory rise in any retirement age, in terms of reaping the benefits of their pension contributions, are those of a non white-European ethnicity.