Clinical articles

Most doctors have only heard of Ernest Starling through his law of the heart, although this was not a particularly important part of his research output. Shortly after qualifying in medicine at Guy’s Hospital, London, in 1888 (where he won the university gold medal in medicine), he began investigating the formation of lymph. To explain his findings, he proposed an inward osmotic force at the capillary: the only possible source of this force was the plasma proteins. At the capillary there was a balance between an inward (osmotic) force and an outward (hydrostatic) force. This became Starling’s ‘Filtration Principle’, which, in retrospect, was a paradigm shift in our understanding of the circulation.

Excretion of excess urinary albumin is a marker of generalised endothelial dysfunction and both progressive renal disease and cardiovascular events in those with and without diabetes; its detection provides a simple way of identifying patients at particularly high risk. Effective management of cardiovascular risk factors and the use of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors have been shown to retard or prevent progression of microalbuminuria to more profound albuminuria. Microalbuminuria can be reversed by such therapy and recently an ACE inhibitor has been shown to prevent the development of microalbuminuria in hypertensive patients with type 2 diabetes. Given the increasing prevalence of type 2 diabetes and the corresponding ascendancy of ensuing cardiovascular disease and renal failure, strict control of multiple risk factors, including microalbuminuria, is to be encouraged.

The aim of this study was to assess whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) affected blood pressure control in patients with essential hypertension who were being treated with lercanidipine, a vasoselective dihydropyridine calcium channel blocker. A total of 334 patients (mean [+ SD] age 61+10 years, 51% females) with mild-to-moderate essential hypertension and a history of osteoarthritis received lercanidipine (10 mg/day, up-titrated to 20 mg/day) for four to eight weeks until blood pressure control was achieved. At that point, treatment with NSAIDs (mostly diclofenac and naproxen) was started. Treatment with NSAIDs was maintained for four weeks.

At baseline, mean systolic blood pressure (SBP) was 157=/-10 mmHg, diastolic blood pressure (DBP) 92=/-6 mmHg, and heart rate 75=/-9 beats per minute. The administration of lercanidipine was associated with a significant decrease of SBP (to 139=/-9 mmHg) and DBP (to 82=/-7 mmHg) (p<0.001), without changes of heart rate.

SBP and DBP readings were not affected by the concomitant use of NSAIDs. Among 156 patients whose blood pressure was well controlled with lercanidipine, 128 (82%) continued to have well controlled SBP and DBP readings. The remaining 28 patients had SBP and DBP > 140 and/or 90 mmHg, but differences in blood pressure between the two groups were not significant. Eight patients (2.3%) had mild side effects and three were withdrawn due to ankle oedema.

We conclude that the use of NSAIDs did not significantly modify the antihypertensive effect of lercanidipine in essential hypertension. Therefore, lercanidipine is a useful drug for hypertensive patients with osteoarthritis who require treatment with NSAIDs.

The aim of this study was to understand patients’ satisfaction with the Angina Plan (AP). Comments from the satisfaction questionnaire help us to understand why patients were satisfied with the AP.

Percutaneous coronary intervention (PCI) is expanding in terms of both the numbers of patients treated and the scope and severity of coronary artery disease tackled. These developments have occurred in parallel with increased awareness of the importance of accountability and clinical governance. Whilst cardiac surgeons have durable risk scores such as Parsonnet and EuroSCORE to assist them and their patients with estimating procedure-related risks, interventionists lack such universally accepted tools. Or do they? In this paper, we review the available PCI risk scores and point out the pressing need for the systematic use of a robust, simple and widely acceptable risk score for routine clinical use.

A 73-year-old man who had had a coronary bypass operation 15 years before presented with refractory angina despite full medication seven months after implantation of a 3.0 x 20mm non drugeluting stent in a saphenous vein graft (SVG) to the left circumflex artery.

A 73-year-old man presented with post-infarct angina. Cardiac catheterisation revealed mildly impaired left ventricular function and high-grade stenoses of the right, left anterior descending, ramus intermedius and left main coronary arteries (RCA, LAD, ramus and LMS respectively).

Recently, several techniques for non-invasive imaging of the coronary artery have emerged as promising alternatives to conventional coronary angiography for the diagnosis of coronary artery stenosis. Such imaging modalities include magnetic resonance imaging, electron-beam computed tomography and multi-slice computed tomography. With these technologies, images can be acquired rapidly with high temporal and spatial resolution. In their current state of development, non-invasive techniques can reliably be used to visualise significant stenosis of the proximal and mid portions of the coronary tree. However, complete assessment can be hindered by calcification in the vessel wall and by motion artefact.

As the population ages, so the prevalence of chronic heart failure (CHF) will rise. The majority of CHF patients in the future will be elderly, yet most of our current evidence for the management of this serious condition arises from trials that have largely excluded older patients. As a consequence, older patients who may derive the greatest benefit from treatments known to reduce morbidity and mortality in CHF, are often denied such treatments. The effects on quality of life of both the syndrome of CHF and its treatment in older CHF patients must be borne in mind, as must issues of compliance, prevalence of comorbidity, and requirement for physical and emotional support. We review the current epidemiology of CHF, and focus on the applicability and use of contemporary non-pharmacological and pharmacological therapy to older patients with CHF. The potential use of devices and surgery in older CHF patients is also discussed.

Chaucer’s characters in The Canterbury Tales meet on their journey to the shrine of Thomas à Becket. They are on a pilgrimage, a special kind of journey that brings a diverse group of people together in a common purpose. As they converge on the place of pilgrimage, the tales they tell are informed by the varied experiences of their lives. The stories we tell here are of individuals brought together by a single objective: to find a solution better than total root replacement for people whose lives are threatened by aortic dilatation due to Marfan syndrome. Chaucer’s pilgrims meet in the Tabard Inn in Southwark, where their journey to Canterbury is to begin. This modern journey began in St George’s Hospital at the 2000 meeting of the Marfan Association, when the surgeon [TT] told his tale, an account of best current practice and its attendant risks.