Clinical articles

Clinical guidelines are vital to improving patient outcomes by helping reduce practice variation, raising care standards, improving efficiency and maximising resource utilisation. To investigate the implementation/local adaptation of national guidance and approaches to post-myocardial infarction (MI) care across the UK, an assessment of the availability and implementation of local post-MI guidelines in England among primary care trusts (PCTs) and cardiac networks (CNs) was conducted. Secondly, a survey of UK GPs and nurses (n=1,003) was performed to establish awareness of guidelines and to investigate whether there are regional variations in the management of post-MI patients.

Fifteen post-MI clinical guidelines were obtained (PCTs – 8; CNs – 7) and analysed according to the following topics: lifestyle modifications, cardiac rehabilitation, therapeutic intervention, therapeutic targets and communication between primary and secondary care. Considerable regional variation in the recommendations were found – particularly with regard to therapeutic interventions and targets – with differing targets for blood pressure and cholesterol management. This was mirrored in the survey results, which also showed significant inconsistencies in clinical practice as reported by UK healthcare practitioners.

In conclusion, little consistency in the availability and content of local post-MI clinical guidelines, coupled with disparities in national guidelines, suggest the need for national post-MI guidance, built on existing evidence, endorsed by clinicians and patients, which will promote optimal care and reduce practice variation.

A patient with inappropriate tachycardia is described who failed to respond to beta blockers or calcium channel blockade but had clinical improvement with ivabradine. The heart rate slowing with this drug was illustrated by the change in the R–R interval histogram.

It is well recognised that phase 3 cardiac rehabilitation is beneficial, reducing both mortality and morbidity following acute myocardial infarction. The role of ongoing phase 4 cardiac rehabilitation is less clear. This study was designed to assess the effectiveness of phase 4 cardiac rehabilitation in acute myocardial infarction.

Following acute myocardial infarction, 143 patients who had completed phase 3 cardiac rehabilitation were followed up. Analysis was divided into three groups: those who took up phase 4 rehabilitation, those offered who declined and those not offered phase 4 rehabilitation because it was not available locally. Risk factor profile, self-reported exercise and quality-of-life scores using the short form (SF)-36 were assessed in all patients.

Body mass index (BMI) shows no overall change in the ‘accepted’ group, but shows a significant increase between pre and five-year levels in the ‘declined’ group (p=0.024) and in the ‘not offered’ group (p=0.014). All groups showed an increase of SF-36 scores following phase 3, which showed a trend towards significance. Both the ‘accepted’ and ‘not offered’ groups maintained this improvement, while the ‘declined’ group returned to baseline (p=0.05 vs. ‘accepted’ and p=0.03 vs. ‘not offered’). All groups had similar exercise levels initially and all showed significant improvements after phase 3 with some deterioration out to five years. This decline in exercise was significant in the ‘declined’ group (p=0.029) and shows a trend in the ‘not offered’ group (p=0.057).

This small single-centre study suggests that there are observable benefits in participating in long-term phase 4 cardiac rehabilitation. Those who decline phase 4 cardiac rehabilitation clearly do less well. Whether the benefits seen can be attributed directly to phase 4 cardiac rehabilitation would require a different study design to address this issue.

Chest pain is a common presentation in general practice. Each year about 1% of the UK population visit their GP with chest pain.1 The average GP will see, on average, four new cases of angina each year.2 The Euro heart survey of newly diagnosed stable angina patients showed that the incidence of death and myocardial infarction (MI) was 2.3/100 patient-years. This is increased in patients with a previous MI, short history, more severe symptoms and with heart failure or other co-morbidities, such as diabetes.3 The recognition of these patients as at high risk for cardiovascular events has led to the improvement of diagnosis and management of angina. Rapid access chest pain clinics have been developed to allow quick assessment of patients with new onset angina as part of a National Service Framework for coronary artery disease.

Anthracyclines are commonly used antineoplastic drugs. However, their clinical utility is tempered by a dose-dependent risk of cardiotoxicity and congestive heart failure. Current preventive measures focus on dose reduction, use of less cardiotoxic anthracycline analogues and prophylactic use of dexrazoxane. Recent research has focused on early monitoring and risk stratification to identify patients that are ‘at risk’ for cardiotoxicity, using biochemical markers and the prophylactic use of novel cardioprotectants. This article reviews the clinical course, pathogenesis, cardiac monitoring and new concepts in diagnosing and preventing anthracycline cardiotoxicity.

Co-administered niacin and statin may offer additional lipid management; however, niacin is underutilised due to flushing, mediated primarily by prostaglandin D2 (PGD2). A combination tablet containing 1 g extended-release niacin and 20 mg laropiprant (ERN/LRPT), a PGD2-receptor (DP1) antagonist, offers improved tolerability. To assess the efficacy and safety of ERN/LRPT + simvastatin versus ERN/LRPT and simvastatin alone in dyslipidaemic patients, in this 12-week study, 1,398 patients were randomised equally to ERN/LRPT 1 g/20 mg, simvastatin (10, 20 or 40 mg), or ERN/LRPT 1 g/20 mg + simvastatin (10, 20 or 40 mg) once-daily for four weeks. At week five, doses were doubled in all groups except simvastatin 40 mg (unchanged) and ERN/LRPT 1 g/20 mg + simvastatin 40 mg (switched to ERN/LRPT 2 g/40 mg + simvastatin 40 mg).

ERN/LRPT + simvastatin (pooled across simvastatin doses) significantly improved key lipid parameters versus ERN/LRPT and pooled simvastatin: mean percentage changes from baseline to week 12 for low-density lipoprotein cholesterol were –47.9%, –17.0% and –37.0%, respectively, and for high-density lipoprotein cholesterol were 27.5%, 23.4% and 6.0%, respectively. ERN/LRPT + simvastatin was generally well tolerated, with a low incidence of serious treatment-related adverse experiences (0.2%, 0.5% and 0.2% for ERN/LRPT + simvastatin, ERN/LRPT and simvastatin, respectively).

In conclusion, ERN/LRPT + simvastatin significantly improved the lipid profile compared with ERN/LRPT and simvastatin alone and was generally well tolerated in dyslipidaemic patients.

Heart disease is the leading cause of death in pregnancy. Although women with high-risk cardiac conditions can be identified, the majority of deaths occur without such pre-existing severe cardiac disease. Coronary artery disease is an increasing cause. Previous reports on heart disease in pregnancy have focused on tertiary-centre and non-UK populations. We report a UK District General Hospital (DGH) experience. We recorded all pregnant women referred to a dedicated DGH cardiology service in Bromley between August 2004 and August 2007. One hundred and three women were referred, including 37 with murmurs or known valve disease, 31 palpitations or arrhythmias, 13 congenital heart disease and eight hypertension. Of the women presenting with a murmur, only one, a recent immigrant, had a significant cardiac condition requiring treatment. Three women with arrhythmias required admission but none were life-threatening. Four women required admission for heart failure, two with peri-partum cardiomyopathy and two with previous hypertension. Only two women were referred with chest pain, neither had ischaemia. Tertiary referral was required in cases of heart failure, an increased risk of aortic rupture or severe mitral stenosis, but all other women were managed safely in a DGH. Seventy per cent of women only needed one clinic visit.

In conclusion, the majority of pregnant women referred to a DGH cardiology service are in the previously defined low-risk group. Cardiac symptoms or signs in UK-born pregnant women without known heart disease are unlikely to represent high-risk cardiac disease but recent immigrants may have significant undiagnosed disease. Chronic hypertension is a risk factor even if controlled at the start of pregnancy. Ischaemia is an increasing problem.

Angiotensin-receptor blocking drugs have been shown to be an effective therapeutic strategy in a number of cardiovascular diseases. Many randomised controlled trials have demonstrated optimal doses of these drugs. We therefore investigated the doses of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers in patients admitted to hospital. We found from a total of 60 consecutive patients, only 38% (n=23) were on the top recommended dose and the average daily dose was 63.1±4.5% of the recommended dose. This study confirms that a significant number of patients are receiving suboptimal doses of angiotensin-blocking drugs and this under-dosing is likely to result in a failure to achieve the maximal therapeutic benefit.

Blackout is a common, alarming symptom occurring across patients of all ages, and can create enormous psychological and social distress. In this review, we describe a new clinical approach that improves healthcare delivery to patients suffering blackouts.

Congestive heart failure (CHF) is an increasingly widespread condition, the prognosis for moderate and severe heart failure is almost identical to colorectal cancer1 and worse than breast2or prostate cancer.3 CHF has an overall population prevalence of approximately 1–3% rising to approximately 10% in the very elderly

CHF accounts for about 5% of all medical admissions and approximately 2% of total healthcare expenditure.4 Nearly one million new cases are diagnosed annually worldwide, making it the most rapidly growing cardiovascular disorder.

The consequences of heart failure for primary care are profound. CHF has been reported to be second only to hypertension as a cardiovascular reason for a surgery appointment.5Despite improvements in medical management, undertreatment is common, many patients with CHF still do not receive treatment optimised according to current guidelines.4,6

The introduction of the 2009/10 heart failure Quality Outcomes Framework (QOF) additions will bring financial incentives for the prescribing of beta blockers for patients with a diagnosis of heart failure. This will apply to all diagnosed heart failure patients. There are, however, no additional QOF points for optimising medication or maximum tolerated levels, therefore, patient care will rely on good practice and receiving treatment according to current guidelines.

The prevalence of heart failure nationally in QOF is just over 1%. Because of the increase in survival after acute myocardial infarction and ageing of the population, the number of patients with heart failure will increase rapidly in most industrialised countries. Heart failure will continue to be a challenge to healthcare.

The profile of heart failure management has been raised with the publication of the Coronary Heart Disease (CHD) National Service Framework (NSF)

Chapter 6 in 20007 and the National Institute for Health and Clinical Excellence (NICE) Heart Failure Clinical Guideline 2003.8 The heart failure publications have supported the development of community heart failure services, and heart failure specialist nurse roles.

The development of the General Practitioner with Special Interest (GPSI) in cardiology qualification and the accreditation in community echocardiography in 2004 has enabled the development of community heart failure services. The training and development of the workforce in primary care has led to improvements in the treatment and management of heart failure patients. A referral to a community specialist heart failure service or secondary care will still be relevant in certain instances, however, the 10 steps will assist in the decision to continue the management in primary care or refer for expert advice and a future management plan.