Clinical articles

Minimising the in-hospital stay of patients with chest pain, within safe limits, is crucial in reducing the cost of health care. The aim of this study was to determine whether the use of near-patient testing for cardiac troponin I could reduce the duration of in-hospital stay for patients presenting with chest pain who were considered to be at low risk of death or myocardial infarction.
This prospective observational study of consecutive patients admitted with chest pain of possible cardiac origin was conducted in a medium-sized district general hospital. A near-patient system for troponin I analysis was compared to traditional laboratory-based troponin I analysis to assess any effect on duration of in-hospital stay in low-risk chest pain patients. Of the 295 patients enrolled in the study, 191 (68.7%) were troponin-negative and were classified as having chest pain of non-cardiac origin or cardiac pain at low risk of major adverse events. The introduction of near-patient testing for cardiac troponin I reduced the mean duration of hospital stay from 30.04 hours to 17.10 hours (p<0.001). At 30-day follow-up no deaths or myocardial infarctions had occurred.

The case of a 70-year-old-woman affected by Friedrich’s ataxia (FRDA), unstable angina and heart failure with left main ‘equivalent’ lesions is presented. As the patient was in need of revascularisation but would have been at high risk with coronary artery bypass grafting surgery, she underwent coronary angioplasty assisted with percutaneous cardiopulmonary support (PCPS). Despite the onset of temporary complications, the procedure was performed successfully. On the basis of this case and of a review of pertinent literature, the authors discuss the role of PCPS in high-risk patients, with respect to its indications and performance technique.

Biventricular pacing is increasingly used in the management of severe heart failure. We report the successful use of biventricular pacing to aid weaning from mechanical ventilation in a patient with severe left ventricular dysfunction.

The second annual survey from the British Junior Cardiologists’ Association (BJCA) has new data on several areas, including the European Working Time Directive, modernising medical careers, and careers in academic cardiology. The surveys are becoming a strong and influential voice in cardiology. Last year’s survey was noted by many national bodies, including the British Cardiac Society (BCS) and the Royal College of Physicians. Over a third of BJCA members responded to this year’s survey and Dr Saul Myerson, BJCA President, highlights some of this year’s trends.

A constant abundance of food and a sedentary lifestyle has led to an increasing prevalence of obesity in the United Kingdom. This has resulted in a serious public health problem as obesity, in particular the presence of excess abdominal (visceral) fat, is associated with a high risk of cardiovascular disease, type 2 diabetes and the metabolic syndrome. Managing obesity by lifestyle changes alone has met with only limited success, so pharmacological intervention is often necessary to help patients reduce their cardiometabolic risk profile. The recent discovery of the role of the CB1 receptors of the endocannabinoid system, and how these receptors influence appetite and energy storage, has led to the development of promising new approaches to the management of obesity. This review charts the background to the development of novel antagonists (CB1 blockers) directed against the CB1 receptors and briefly summarises the available phase III data. The available phase III data suggest that CB1 blockers could have a major role to play in the management of multiple cardiovascular risk factors, by reducing visceral fat and directly improving lipid and glucose metabolism and insulin resistance.

We summarise recent developments in minimally invasive cardiac surgery. We describe the modifications to anaesthetic technique, incisions, cardiopulmonary bypass and myocardial protection, and the endoscopic and robotic adjuncts that permit coronary artery surgery, valve repair and replacement, and repair of descending aortic aneurysms to be successfully carried out. The results for such surgery are summarised and compared to conventional open techniques as well as percutaneous procedures.

Low-density lipoprotein cholesterol (LDL-C) reduction alone has consistently achieved a statistically significant 25–30% reduction in clinical events in multiple clinical trials. This degree of clinical benefit is inadequate, however, to stem the tide of coronary artery disease. A focus on low-density lipoprotein (LDL) reduction alone reduces the rate of coronary atherosclerosis progression but leaves a large number of patients experiencing clinical events despite adequate LDL-C control. One major contributor to coronary atherosclerosis that is not improved with LDL reduction is high-density lipoprotein (HDL) and reverse cholesterol transport.

Clinical trials funded by the US National Institutes of Health (NIH) have demonstrated that a combination of LDL reduction and HDL increase can achieve better clinical and arteriographic outcomes compared to LDL reduction alone. HDL heterogeneity helps to explain differences in the efficiency of reverse cholesterol transport. This process can be enhanced through appropriate diet, loss of excess body fat and physical activity. Nicotinic acid and fibric acid derivatives can enhance reverse cholesterol transport and have been used in multiple clinical trials. The combination of nicotinic acid and a statin drug are particularly beneficial in NIH-sponsored clinical trials. The HDL increase induced by nicotinic acid is primarily HDL2. By combining a two-staged LDL-C reduction and HDL-C raising strategy, improved clinical outcomes can be achieved for patients with coronary artery disease.

Referral to cardiac rehabilitation (CR) is often incomplete. Those most likely to benefit are less likely to be offered the service and there has been little systematic exploration of the reasons for this situation in the UK. The purpose of this study was to investigate CR staff perceptions in relation to aspects of referral to CR programmes. In a prospective cross-sectional study, a 24-item questionnaire regarding perceptions of referrals was mailed to 115 referring staff of 23 CR out-patient programmes in the North West of England. The response rate was 85 (74%). The most common factors cited for low referrals were: funding limitation 57 (67%), limited facilities 56 (66%), shortage of trained staff 51 (60%) and patients” poor physical ability 50 (59%). Fifty-three (62%) respondents suggested participation would increase if CR were offered by a medical practitioner. Sixty-one (72%) respondents felt they provided CR according to recommended guidelines. Seventy-nine (93%) of the respondents agreed CR was necessary or appropriate for most cardiac patients and 76 (89%) reported CR offered more to patients than secondary prevention. The study concludes that CR programmes should be audited better and physicians need to be more actively involved in recruiting patients to programmes. Better funding is required to increase facilities and staff training to improve referral of patients.

Cardiac catheterisation access site complications are common. Their incidence depends on various risk factors such as female gender, nadir platelet count, diagnostic versus therapeutic intervention, excessive anticoagulation and so on. Thrombotic complications are common at the brachial site and haemorrhagic complications are more common at the femoral site. In spite of new devices for securing haemostasis, the incidence of these complications has not decreased. We report the case of a 71-year-old, obese woman who died secondary to femoral access site haemorrhage despite all surgical attempts. This case emphasises the need for a tailor-made approach for deciding the site of access.

The current national target in the UK for total cholesterol is 5 mmol/L. The Primary Care Data Quality (PCDQ) programme reported in 2002 that only 50% of patients with coronary heart disease (CHD) achieved the 5 mmol/L target and we report on progress since then. Routinely collected general practice computer data were extracted in two successive data collections in 2003 and 2004/05 and analysed. The standardised prevalence of CHD recorded in GP computer systems rose from 3.8% to 4.0% from 2002 to 2004/5. In patients with CHD, cholesterol recording rose from 47.6% to 89.0%, the percentage of patients receiving a statin rose from 49.4% to 71.5% and mean cholesterol levels fell from 5.18 to 4.67 mmol/L. The proportion of CHD patients with a cholesterol recording achieving the 5 mmol/L target increased from 44.7% to 67.7%. Overall, 53.1% of patients with cardiovascular disease had total chol-esterol below 5 mmol/L. Patients with CHD achieved better cholesterol control than those with stroke (4.87 mmol/L) or peripheral vascular disease (PVD) (4.79 mmol/L) and a higher percentage of patients achieved the 5 mmol/L target (60.1% versus 43.3% and 49.9% respectively). There remains scope for improved management of cholesterol in primary care and greater efforts are needed to see that more patients with cardiovascular disease benefit from best practice.