Clinical articles

Clinical practice should follow evidence-based medicine, which is derived from clinical trials. The outcomes of clinical practice, however, may not equal that of trials if there are differences in the patients or the quality of treatment they receive. We report the example of cardiac rehabilitation to illustrate this point, comparing the characteristics of patients and treatments offered in randomised controlled trials (RCTs) in this area with those included in two large surveys of cardiac rehabilitation in the UK. We found that cardiac rehabilitation as currently practised in the UK is unlikely to be as effective as clinical trials may suggest.

Peri-operative transoesophageal echocardiography (TOE) has become part of the routine management of patients undergoing cardiac surgery. Its use in guiding not only surgery, but also the haemodynamic management of the patient, has made TOE an indispensable tool in the cardiac operating theatre. Practical aspects of intra-operative TOE are outlined and its application in differing clinical situations is reviewed.

Stress echocardiography has a high diagnostic accuracy for the detection of coronary disease. It is as effective as myocardial perfusion imaging for the stratification of risk in patients with coronary disease and can detect myocardial hibernation after myocardial infarction or in heart failure.

This paper is an executive summary of a recent postal survey carried out by the British Society of Echocardiography to guide future planning.

Individuals with diabetes have an increased risk of developing coronary artery disease and a poorer prognosis once coronary artery disease has developed, compared to patients without diabetes. To avoid confounding, most cardiovascular trials display profiles of traditional risk factors but additional factors are also important in patients with diabetes. We examined the information provided on patients with diabetes included in cardiovascular trials published in general medical journals.

The National Service Framework for Coronary Heart Disease recommends that psychological support should be offered to those patients who require it. A six-month study carried out at Darlington Memorial Hospital looked at psychological support needed by patients following myocardial infarction (MI). The psychological status of MI patients was formally assessed using the Hospital Anxiety and Depression (HAD) scale and appropriate referrals were made to psychological support services to improve patient management. The study also measured the impact that formal assessment of the psychological status of MI patients would have on service providers.

Some 80 MI patients from the Darlington primary care trust (PCT) were eligible for inclusion in the study. Psychological assessment was undertaken at four stages during cardiac rehabilitation and 25 patients were eligible for referral for psychological support as a result of high HAD scores measured during the study period. Ten patients accepted referral, a higher number than during the previous six-month period when HAD scales had not been used. Eight patients were referred to occupational therapy services for help with anxiety issues, one patient was referred to the psychology service and one to liaison psychiatry. Both of these patients required help with depression.

The study also found a high degree of patient satisfaction. The support received may also be required by many other groups of patients.

This case describes, for the first time, the appearance of possible cutaneous embolic lesions in the pinna of the ear secondary to infective endocarditis

Although the majority of implantable cardioverter defibrillator (ICD) implants occur without complication, high defibrillation threshold (DFT) can occasionally be a problem. The usual resolution to this problem is to include a subcutaneous electrode in the defibrillation circuit. Use of the subcutaneous array, however, is unpopular as extensive subcutaneous dissection is time-consuming, uncomfortable for the patient and provides another focus for infection. We report the use of the coronary sinus for the placement of a second defibrillation shock coil in a patient with an unacceptably high DFT, which was successfully reduced.

This paper briefly reviews an analysis carried out in the West of Scotland of the Quality and Outcomes Framework data gathered for coronary heart disease under the new General Medical Services contract for general practitioners. It shows encouraging progress in achieving clinical outcome predictors.

The report from McCarlie and colleagues in this issue (pages 117–19) on the success of Scottish general practice in achieving cardiovascular disease (CVD) targets for clinical indicators within the Quality and Outcomes Framework (QOF) mirrors similar progress across England and Wales.