Clinical articles

This article aims to provide an overview of the management of atrial fibrillation (AF), with reference to the recently published National Institute for Health and Clinical Excellence (NICE) guidelines on AF management (http://www.nice. org.uk/CG36/guidance/pdf/english). This article is not meant to cover the whole guideline nor be a systematic review, as the full guideline contains all the search strategies and appraised evidence tables, and represents a comprehensive assessment of the evidence behind the recommendations in the NICE guideline (also available at http://rcplondon.ac.uk/pubs/books/af/index.asp).

The guidelines on atrial fibrillation (AF) produced by the National Institute for Health and Clinical Excellence (NICE) and published by the Royal College of Physicians are impressive in their scope and details. They are overtly evidence based and whilst there is some debate over some issues within the guidelines, there is no doubt that they represent much hard work from the Guidelines Development Group.

Intracardiac echocardiography (ICE) is an imaging technique that is becoming increasingly available as an alternative to transoesophageal echocardiography to guide percutaneous interventional procedures. The probe can be inserted under local anaesthesia and is principally used during closure of atrial septal abnormalities. The main advantages of ICE over transoesophageal echocardiography include the elimination of the need for general anaesthesia, clearer imaging, shorter procedure times and reduced radiation doses to the patient. Within this article we review some of the current applications of ICE and how to image from within the heart.

Coronary artery calcification (CAC) is a component of the development of atherosclerosis. Coronary computed tomography scanning (CCT) can detect calcification and may be useful in individuals considered asymptomatic. Oxidative stress and inflammation are linked through common pathways and both are thought to be involved in the pathogenesis of atherosclerosis. To investigate if CAC was associated with increased oxidative stress (plasma F2-isoprostanes) and inflammation (high sensitivity C-reactive protein [hs-CRP]), we invited 102 self-selected individuals (mean age 52+/-7 years) who were undergoing CCT to take part in a study. Height, weight and clinic blood pressure was measured, a blood sample taken and a health and lifestyle questionnaire completed.
CAC was found to be positively correlated with age (p<0.01) and alcohol intake (p<0.001). There was a trend for higher CAC in men compared to women (p=0.08). CAC was higher in ex- and current smokers versus non-smokers (115+/-45 vs. 28+/-12 Agatston score, p=0.05), and lower in non-drinkers versus drinkers (18+/-17 vs. 90+/-29 Agatston score, p=0.03). There were no univariate correlations between CAC and plasma F2-isoprostanes (p=0.25) or HS-CRP (p=0.36). In multivariate analysis, age, male gender and alcohol intake remained independent predictors of CAC. We concluded that CAC was not associated with inflammation or oxidative stress, but was related to lifestyle factors including; age, gender and alcohol consumption.

This paper discusses the uses of the Multi-functional probing catheter™ (Boston Scientific, Scimed) in the arena of percutaneous coronary intervention with specific reference to treating chronic total occlusions. This catheter is essentially a speedy monorail balloon without the balloon mounted on the end. Thus, it has a short monorail/rapid exchange port which exits at the distal tip of the catheter, and an over-the-wire port which exits proximally at the side of the catheter.

Tackling chronic total occlusions often results in the creation of a false passage intramurally rendering it difficult to redirect the guide-wire into the true lumen. The Multi-functional probing catheter™ allows introduction of a second wire in a different direction from this lumen via the over-the-wire port. The benefits of this equipment for guide-wire support and wire exchange are examined. In addition, this support catheter allows distal vessel visualisation, confirming intraluminal wire position. A further use of this catheter is for intracoronary drug delivery especially in the context of vascular spasm, no reflow or thrombotic occlusion.

The use of the Multi-functional probing catheter™ in two chronic total occlusion interventions cases is discussed in detail.

Optimum delivery of cardiac rehabilitation is not well defined. A retrospective analysis was conducted to determine the short-term effectiveness of once-weekly compared to twice-weekly supervised cardiac rehabilitation. The analysis included 206 post-myocardial infarction patients who participated in either once- or twice-weekly supervised exercise sessions for six weeks. The primary outcome measure was the incremental shuttle walking test (ISWT). Secondary measures of health-related quality of life were also completed. Once-weekly supervised rehabilitation was completed by 85 patients (65 men), mean (SD) age 61.89 (10.27) years, and twice-weekly supervised rehabilitation was completed by 121 (94 men) mean (SD) age of 59.24 (10.03) years. Both groups demonstrated a statistically significant increase in ISWT distance post-rehabilitation, with mean increases of 100.71 metres (p<0.001) and 88.44 metres (p<0.001) for the once- and twice-weekly groups respectively. A reduction in hospital anxiety and depression scores and improvements in the MacNew quality of life questionnaire was also found. On comparing the magnitude of these changes, there was no significant difference between the two groups.

There is no evidence of additional short-term benefit, in terms of cardiovascular fitness and improvement in health-related quality of life measures, for patients attending twice-weekly supervised cardiac rehabilitation compared to once-weekly.

The condition of a large deposit of adipose tissue in the atrial septum or lipomatous hypertrophy of interatrial septum (LHIS) was first described in 1964. It has been reported that LHIS is associated with atrial arrhythmias but its clinical presentation as angina is uncommon. We report such a case here and a short literature review.

Cardiovascular disease prevention is one of the major challenges of medicine in the UK and the developed world. Progress in the primary prevention of these diseases has been slow and patchy due to the difficulties and costs with the methods currently used.

We set out to see in an observational study, if computer-based opportunistic screening could be a practical and cost-effective method of cardiovascular disease prevention in a high-risk primary care practice population in Barnsley, South Yorkshire. We found that over five years, 86% of the practice population was screened and educated for their personal risk of cardiovascular disease. This was carried out at a low cost in terms of both professional and administrative time.

Using this computer-based opportunistic screening enables a profile of risk factors for both individuals and the practice to be de-veloped making the targetting of resources for prevention easy and effective. It is also possible that this programme could prove to be a cheap and targetted method of screening for coronary heart disease, diabetes and familial hyperlipidaemia.

We conclude that computer-based opportunistic screening in general practice is an effective method of reaching a whole population and can enable large-scale interventions at low cost.

The management of the ‘tidal wave’ of obesity and type 2 diabetes that is expected to hit the UK over the next 10 years was one of the major themes to emerge from the Primary Care Cardiovascular Society Annual Meeting and AGM, held in Gateshead, October 5th – 7th 2006. Medical journalist Jo Waters reports.

The benefits of statins for both primary and secondary prevention of coronary heart disease (CHD) are limited mainly to patients under 80. We examined the impact of the new General Medical Services (GMS) contract on measurement of lipids and prescribing of statins in patients over 80 years of age with CHD. We found that there has been a significant increase in both, with little evidence supporting this and substantial financial implications. National guidance on the assessment and management of lipids in the over 80s in the new GMS contract is urgently required.