Clinical articles

The National Institute for Clinical Excellence (NICE) stent appraisal (2003) defined criteria for the use of drug-eluting stents (DES) on the basis of lesion length, vessel diameter and the absence of recent myocardial infarction or intra-luminal thrombus. The appraisal suggested that as many as one third of all stents may need to be DES.
In order to determine the requirement for DES and adherence to these guidelines, we assessed 1,673 consecutive patients undergoing coronary intervention over a 17-month period. A total of 2,513 stents were implanted, of which 50.1% were DES. In all, 77.4% of patients fulfilled NICE criteria for at least one DES. A further 7.3% of patients were excluded because of either a recent (< 24 hours) myocardial infarct or visible intra-luminal thrombus. A total of 33.4% of patients who did fulfil NICE criteria for DES deployment inappropriately received a bare-metal stent (BMS) whilst 5.7% patients inappropriately received a DES. These results would suggest that NICE have grossly underestimated the need for DES in ‘real world’ practice. Despite our centre using a high volume of DES, significant numbers of patients were inappropriately treated with BMS, with a smaller number inappropriately treated with DES, according to NICE criteria.

As confidence in the use of drug-eluting stents (DES) increases, they are being used in patients with progressively more complex disease. Diabetes is still an independent risk factor for restenosis along with lesion length and reference vessel diameter.
This article gives an overview of recent stenting trials, including those with more complex disease such as DIABETES, PORTO 1 and TAXUS V. It also looks at head-to-head randomised controlled trials of sirolimus-eluting stents against paclitaxel-eluting stents: ISAR-DESIRE, SIRTAX, ISAR-DIABETES and REALITY. These give a better indicator of comparative efficacy than meta-analyses which include differing patient populations and trial designs. Finally, studies comparing angioplasty with surgery are considered.

The objective of this study was to assess the feasibility and impact of providing a primary percutaneous coronary intervention (PCI) programme for ST elevation myocardial infarction (STEMI) in a district general hospital (DGH) in the UK.
A retrospective review of cardiac catheter laboratory PCI database records and hospital notes was carried out in a 950-bed teaching DGH in the West Midlands, serving a catchment population of 500,000. The patients consisted of 108 men and women aged 28–86 years presenting with thrombolysis-eligible STEMI, treated by primary PCI between November 2002 and August 2004. The main outcome measures used in this study were time from hospital presentation to PCI (‘door to coronary device’ time), mortality and hospital length of stay.
The median door to device time was 86 minutes (range 25 to 286). Some 78% and 52% of patients had door to device times of less than 120 and 90 minutes, respectively. Median length of hospital stay was five days (range 3–30), compared to eight days in patients treated with thrombolysis in the years 2000–2004. In-hospital mortality was seven patients (6.5%).
We conclude that, in the contemporary era of interventional cardiology, it is feasible to introduce a primary PCI service for STEMI in a DGH setting with acceptable ‘door to coronary device’ times and mortality.

A 62-year-old man presented with chronic stable angina, how coronary angiography revealed a chronic proximal occlusion of the right coronary artery (RCA) with retrograde filling of the vessel from the septal branches of the left anterior descending (LAD) artery.

The management of pulmonary arterial hypertension (PAH) has changed dramatically over the last decade. Where once the physician had only limited tools to combat this devastating condition, recent randomised controlled trials have shown that there are now treatments that both prolong the rate of progression and improve survival. The ‘gold standard’ of treatment, due to its beneficial effect on survival, is epoprostenol, a prostacyclin analogue. However, there are a number of problems with the prostacyclin analogues, mainly centred on their administration and cost, which led to their use only in severely ill patients. A better understanding of the pathophysiology of PAH has led to a number of other pharmacological targets, namely antagonism of endothelin (ET) receptors and increasing local levels of nitric oxide (NO) via inhibition of phosphodiesterase 5.
The successful treatment of PAH means that there is now a growing population of patients on disease-modifying agents, so it is essential that physicians are aware of their use, benefits and side effects.

Coronary heart disease (CHD) is the most common cause
of death in the UK; one in four men and one in six women will
die as a result of CHD.

Treatments for heart failure include digoxin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists and beta blockers. Beta blockers have been contra-indicated until fairly recently, with recognition of the role of the sympathetic nervous system in chronic progression of heart damage.
Benefits of beta blockade, proven in clinical trials, include reduction in all-cause mortality, sudden death, hospitalisation rates for heart failure, and reversal of some degree of heart damage. Carvedilol and bisoprolol are currently licensed in the UK for chronic heart failure. National Institute for Clinical Excellence (NICE) guidelines give recommendations for initiation of treatment, dose titration and management of adverse effects. Benefits are still apparent in patients who cannot tolerate target drug doses. Several studies show, however, that beta blockers are underprescribed in general practice.

This article describes the diagnosis, classification and management of atrial fibrillation (AF) in primary care. It looks at its increasing incidence, its risk factors, and the identification and classification of this common arrhythmia. The routine investigations for AF and its treatment, including drug therapy and cardioversion, are also discussed. Finally, with AF being a major risk factor for stroke, strategies to prevent thromboembolism are considered.

The plasminogen activator inhibitors have an important therapeutic role in controlling bleeding in patients with congenital and acquired coagulation disorders. They are being increasingly used in patients with blood loss and to prevent bleeding. However, these antifibrinolytic agents can also facilitate the development of thrombosis. We report a patient with severe gastrointestinal bleeding who developed acute myocardial infarction following the administration of the antifibrinolytic agent, tranexamic acid.

This study set out to evaluate the completeness of medical records of chest pain. A planned, multicentre, structured abstraction of data from case-notes was made at 20 adjacent acute hospitals in Yorkshire on 1,226 consecutive patients presenting with chest pain and validated myocardial infarction (MI). The hospital records included those collected by ambulance crews, accident and emergency staff, and admitting medical teams. The main outcome measure was completeness of medical records with regard to 10 commonly advocated descriptors of chest pain.
A mean number of 5.62 chest pain descriptors was recorded. This value differed with hospital (range 4.81 to 6.73 factors recorded; p<0.0001); place of admission (medical admissions unit = 6.10; coronary care unit 5.94; accident & emergency department = 5.62; general ward = 5.08; p<0.0001); gender (male = 5.74; female = 5.39; p=0.004) and age (< 68.4 years = 5.83; > 68.4 years = 5.43; p<0.0001). Mean chest pain scores were also significantly different for District General Hospitals (DGHs) without angiography facilities as compared to DGHs with angiogram facilities and tertiary centres (respectively 5.46 vs. 5.81 vs. 5.81 p<0.007).
Contrary to standard medical texts and teaching, we observed that documentation of chest pain histories was abbreviated in many cases.