Clinical articles

Microvascular perfusion is considered a key factor with respect to preservation of left ventricular function and prognosis. No-reflow is recognised in the context of acute coronary syndromes and percutaneous intervention: myocardial blood flow at a tissue level remains impaired following restoration of epicardial flow. Once no-reflow is established, treatment is often ineffective and this phenomenon is associated with poor short- and long-term outcomes. A number of different pharmacological agents are used to prevent and treat this condition although data to support their use are limited. This article examines the pathophysiological aspects of this condition, its clinical correlates and proposed management strategies.

This study evaluated primary care hypertension management against UK quality targets and prescribing guidelines through a survey of 738 hypertensives in an urban three-partner personal list practice in April 2005. It looked at screening rates, prevalence, blood pressures of under 150/90 mmHg, measurement bias, ABCD prescribing and cost. The survey found that 94% of adults aged 25–79 years had been screened. With 738 confirmed cases, prevalence was 11.7% for all ages; 14.4% for those aged more than 16 years; and 46% in those over 65 years of age. Some 442 patients had ‘potential’ hypertension with their last blood pressure measurement being greater than 140/90 mmHg but inadequate follow-up. Blood pressure control of less than 150/90 mmHg was achieved in 83% of hypertensives with a six-fold terminal zero measurement bias. Looking at ABCD agents, 1,186 had been prescribed (1.84 per patient) costing £129,100 per annum. We believe that QOF hypertension prevalence in the practice (11.7%) and England (11.3%) is less than half the rate reported from community surveys. The practice demonstrated that QOF outcome targets are achievable by improving blood pressure targets to under 150/90 mmHg from 52% of patients in 2002 to 83% of patients by April 2005. Practice organisation, personal patient lists and quality targets were important factors in delivering successful care. Automated blood pressure measurement could eliminate observer bias. Restructuring therapy repeat instructions to include ABCD data encourages logical prescribing.

How well do primary care teams identify patients with CHD and diabetes? The British Women’s Heart and Health Study, a prospective cohort study, suggests that as many as half the women identified as having CHD on practice registers (and almost one third of diabetics) appear not to have the condition after a detailed manual review of records. The importance of auditing practice registers is highlighted.

Myocardial calcification is a rare finding usually
detected by computerised tomographic (CT)
scanning. It is often missed and, when found,
is often misdiagnosed. The addition of magnetic
resonance imaging (MRI) to our investigative
armamentarium enables correct diagnosis and
appropriate management(October 2002). She underwent
coronary angiography, which showed normal coronary arteries
but significant left ventricular impairment. She continued to be
managed medically for ventricular dysfunction.

Inequalities in health care between men and women have been described extensively with regard to access to diagnostic and therapeutic procedures. These inequalities affect coronary heart disease care. Although survival rates differ for men and women following a myocardial infarction, this alone does not fully explain inequity in access to health services, especially diagnostic and treatment procedures, for infarct survivors.
A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients (41% female) admitted to the Acute Cardiac Unit, Nottingham.
Women expressed more dissatisfaction than men overall (p<0.05) and appeared to have more physical needs. Women were more likely to complain about transport, which influenced their access to healthcare facilities (p<0.001), to be concerned about getting help with cleaning (p<0.01), and to request information about rehabilitation services, potential limitations on their daily activities, and nutrition and diet (p<0.05).
Women had lower health-related quality of life scores in all the HRQL variables, which was significant in EQ-5D (usual activities, and pain/discomfort), Seattle angina questionnaire (angina stability), and both components of the Short Form-12.
This survey was the first attempt to apply a needs assessment tool combined with quality of life assessment for cardiac patients to identify potential gender disparities. Women reported greater health needs and greater dissatisfaction with current health services and had worse HRQL. Recognition of gender disparities in health needs and HRQL would clarify areas for improvement in healthcare services, and these might allow a better quality of life for infarct survivors.

There is no evidence from randomised controlled trials to guide oxygen treatment after stroke. This survey aims to establish a snapshot of views of clinicians on best current practice relating to the management of hypoxia early after acute stroke.
A postal questionnaire was sent to all 231 members of the British Association of Stroke Physicians (BASP). For 88% of the 130 respondents the decision to give oxygen was guided by the oxygen saturation, and for 67% it was guided by clinical criteria. The mean cut-off for oxygen supplementation suggested was ? 93% SD 2 (range 85–98%). Sixty-seven respondents would give oxygen by nasal cannulae and 74 via face mask. The oxygen concentration selected was 24% (n=17), 28% (n=31), 35% (n=15), 40% (n=3) and 100% (n=3).
This shows there is wide variation amongst stroke physicians about when to start oxygen, how much to give and by which route. There is a need for a randomised clinical trial to guide oxygen therapy after acute stroke.

The mainstay of heart failure management is angiotensin-converting enzyme inhibitor therapy initially as a vasodilator, followed by beta blockade at a varying time interval, based on clinical judgement. Early beta blockade has theoretical advantages in terms of possible protection against dysrhythmia or disease progression, although there may be short-term concerns regarding a possible deterioration in cardiac function and aggravation of heart failure.
The Cardiac Insufficiency Bisoprolol (CIBIS) III trial examined the optimum paradigm of initiating treatment for chronic heart failure (CHF). A large cohort of 1,010 systolic CHF patients, at least 65 years of age, with stable, mild-to-moderate symptomatic disease, were followed-up for a mean of 1.25 years. Patients were randomly allocated to initial monotherapy with bisoprolol for six months, followed by the addition of enalapril, or the opposite sequence. Efficacy and safety of the bisoprolol-first strategy versus the enalapril-first strategy was similar in terms of the combined primary end point of mortality or all-cause hospitalisation (hazard ratio 0.94, 95% confidence interval 0.77–1.16, non-inferiority p=0.02). The two approaches also showed similar safety. The bisoprolol-first strategy showed a 28% mortality reduction after the monotherapy phase (p=0.24) and a 31% borderline-significant mortality reduction during the first year (p=0.06), but was associated with a 25% increase in worsening of CHF events (p=0.23). This paper highlights important features of the study design and patient population. Both the clinical perspective and possible clinical implications of CIBIS III are discussed.

In spite of treatment with inhibitors of the renin-angiotensin system, plasma levels of aldosterone increase progressively in heart failure. This phenomenon of aldosterone escape is associated with adverse outcome. The aldosterone receptor antagonists spironolactone and eplerenone can improve prognosis for patients with heart failure. The commonest, and often problematic unwanted effect of these agents, hyperkalaemia, may limit their usefulness and brings with it the need for careful clinical and biochemical monitoring. Recent trials, however, have shown clear benefits for large groups of patients for spironolactone (in severe chronic heart failure) and eplerenone (heart failure soon after acute myocardial infarction). Due consideration should be given to the addition of the appropriate aldosterone antagonist in suitable patients.

Coronary angiography is an imperfect tool for assessing the functional significance of lesions: while this may be determined non-invasively using myocardial perfusion scintigraphy or stress echocardiography, it is often not done. In these circumstances the coronary pressure-derived fractional flow reserve (FFR) serves as an alternative, lesion-specific means of assessing physiological importance.
FFR is an invaluable tool not only in determining whether a lesion is functionally significant and should be tackled, but it also ensures that the appropriate physiological outcome is obtained from coronary intervention.

Early invasive management in patients with unstable angina and non-ST elevation myocardial infarct (NSTEMI) is now well established. However, patients can wait for weeks at district general hospitals (DGHs) for in-patient transfer to the cardiac centre for percutaneous coronary intervention (PCI), which results in inefficient bed utilisation.
At the Yorkshire Heart Centre (YHC), the referral process for unstable angina/NSTEMI was streamlined to minimise the delay between time of referral and PCI. We audited the waiting time from referral to the PCI procedure as well as the six- and 12-month outcomes for both acute and elective PCI and compared our outcome data to the published trials.
A total of 1,757 patients underwent PCI at YHC in 2002; of these 47% were acute cases. 72% of patients were treated within two days of referral and 97% within three days. The mean waiting time for patients referred from within the YHC was 1.9 days and for those referred from the DGHs was 2.2 days. The six-month mortality rate for the acute PCI group was 2.5%.