Clinical articles

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and a significant cause of hospital admission, morbidity and mortality. AF significantly increases the risk of embolic stroke, and anticoagulation with warfarin can reduce this risk by up to 61%. International guidelines recommend the use of warfarin for atrial fibrillation in patients considered at higher risk for stroke.
This prospective observational study evaluates current adherence to anticoagulation guidelines for patients with atrial fibrillation. It was carried out in a district general hospital in London on 93 patients with atrial fibrillation admitted via the emergency department over a four-month period.
Patients’ mean age was 77 years and the mean age of onset of AF was 75 years. Eighty-eight per cent of patients were > 75 years and/or had another risk factor for embolic stroke requiring warfarin therapy. Anticoagulation treatment did not adhere to guidelines in 56% of patients at the time of hospital admission. This proportion fell slightly to 52% at the time of hospital discharge. A total of 20% of patients were discharged on no anticoagulation at all.
The adherence to anticoagulation guidelines for patients with atrial fibrillation, who are at risk of embolic stroke, appears inadequate. Despite the evidence supporting oral anticoagulation, clinical practice seems resistant to change. The future may include patient self-monitoring and the use of oral direct thrombin inhibitors to improve stroke prophylaxis.

The objective of this study was to examine the association of delusional and real memories for events with both the pre-operative and early post-operative clinical condition and to examine interventional, supportive and therapeutic factors. Its design was retrospective, using a questionnaire and review of clinical records. The study was carried out in a university teaching hospital cardiothoracic intensive care unit (ICU) on 161 patients without professional experience of intensive care, who had received four days or more in intensive care after cardiac surgery.
Its main outcome measures were the prevalence of delusional memory persisting after recovery and the recall of real events whilst in intensive care. Seventy-eight (48%) patients recalled events apparently occurring whilst in intensive care, which were delusional or hallucination-like (‘dreamers’). This group recalled a mean of 2.6 of a possible 10 normal intensive care events compared with 1.0 of 10 for those who were not able to recall delusions or hallucinations (‘non-dreamers’). Dreamers were younger at the time of surgery (mean age 63.6 vs. 68.9 years, p=0.003). Dreaming was more common in patients who received intravenous glucose (to treat hypoglycaemia), midazolam, steroids and in those with episode(s) of sepsis.
We concluded vivid memory of unreal events is common after discharge from intensive care. The aetiology is probably multifactorial. The retrospective nature and the inexact methods preclude confirming that midazolam is a direct, much less a causal, risk factor. However, the association is strong enough to warrant prospective studies.

The objective of this study was to examine the association of delusional and real memories for events with both the pre-operative and early post-operative clinical condition and to examine interventional, supportive and therapeutic factors. Its design was retrospective, using a questionnaire and review of clinical records. The study was carried out in a university teaching hospital cardiothoracic intensive care unit (ICU) on 161 patients without professional experience of intensive care, who had received four days or more in intensive care after cardiac surgery.
Its main outcome measures were the prevalence of delusional memory persisting after recovery and the recall of real events whilst in intensive care. Seventy-eight (48%) patients recalled events apparently occurring whilst in intensive care, which were delusional or hallucination-like (‘dreamers’). This group recalled a mean of 2.6 of a possible 10 normal intensive care events compared with 1.0 of 10 for those who were not able to recall delusions or hallucinations (‘non-dreamers’). Dreamers were younger at the time of surgery (mean age 63.6 vs. 68.9 years, p=0.003). Dreaming was more common in patients who received intravenous glucose (to treat hypoglycaemia), midazolam, steroids and in those with episode(s) of sepsis.
We concluded vivid memory of unreal events is common after discharge from intensive care. The aetiology is probably multifactorial. The retrospective nature and the inexact methods preclude confirming that midazolam is a direct, much less a causal, risk factor. However, the association is strong enough to warrant prospective studies.

Diabetes is associated with the development of premature cardiovascular disease. In the three early trials of statin therapy for patients with established coronary heart disease there were many patients with diabetes; subgroup analysis has confirmed the benefits of cholesterol lowering with statin therapy in these patients. In the two early primary prevention trials, however, there were few patients with diabetes and so, initially, there was little evidence supporting the use of statins in diabetic patients without cardiovascular disease. The Heart Protection Study (HPS) and Collaborative AtoRvastatin Diabetes Study (CARDS) have now provided this evidence and firmly established that cholesterol lowering is of benefit in reducing cardiovascular events in patients with type 2 diabetes, regardless of the level of baseline cholesterol, or the presence or absence of cardiovascular disease. A few recent studies have failed to find benefit in diabetic patients but there are explanations for these negative findings. Ideally all patients with diabetes, especially the middle-aged and elderly, should be treated with statins but it remains uncertain at what age therapy should start and how low to reduce the cholesterol for maximum benefit.

There are many advantages to bioabsorbable stents, including the potential to inhibit intimal hyperplasia by avoiding prolonged foreign body reaction and/or releasing antiproliferative drugs during degradation. The bioabsorbable polymer poly-l-lactic acid (PLLA) is used as a biodegradable coating of permanent metallic stents but can also be used to manufacture complete stents, at the expense of a greater recoil. Clinical, angiographic and intravascular ultrasound results at four years with the first stent tested (Igaki Tamai, Igaki, Japan) show patency rates similar to the rates expected with stainless steel stents and full reabsorption. Magnesium stents are another, perhaps more encouraging, development because they retain mechanical properties similar to conventional metallic stents. Full degradation of the magnesium alloy used to manufacture the Biotronik Lekton Magic stent requires 6–8 weeks. In man, initial clinical experience with this stent has been gained in patients with critical lower limb ischaemia. An ongoing study is testing its safety and efficacy in human coronary arteries.

Bivalirudin is a direct thrombin inhibitor that will be available in the UK in November 2004 as adjunctive anticoagulant therapy during percutaneous coronary intervention (PCI). Its mechanism of action offers potential advantages over heparin in terms of both efficacy and bleeding. Bivalirudin is convenient – ACT monitoring is unnecessary, infusion is only for the duration of the procedure, and half-life is short so that early sheath removal and ambulation are possible. Finally, bivalirudin may offer major cost savings over glycoprotein (GP) IIb/IIIa inhibitors. The REPLACE-2 trial demonstrated equivalent efficacy and reduced bleeding with bivalirudin alone versus heparin-plus-GP IIb/IIIa inhibition in 6,010 patients undergoing elective or urgent PCI (30-day MACE 7.6% vs. 7.1%, major bleeding 2.4% vs. 4.1%). Further trials are underway to evaluate the efficacy of bivalirudin during PCI for high-risk acute coronary syndromes (ACS) and acute myocardial infarction (AMI).
This paper considers when bivalirudin should be used in contemporary PCI. The ISAR-REACT study provides firm evidence that heparin alone is safe and effective for elective PCI in low-to-moderate risk patients (30 day MACE 4% heparin-alone vs. 4% abciximab). Patients with AMI or unstable ACS were not included in the REPLACE-2 trial and should continue to receive GP IIb/IIIa inhibitors until further data are available. Bivalirudin could be considered in patients at intermediate risk in whom GP IIb/IIIa inhibitors are currently widely used, including during complex elective PCI, elective PCI in diabetics, and in patients with stabilised or low-risk ACS. Bivalirudin will also have a specific role in patients at increased risk of bleeding and with heparin-induced thrombocytopaenia. Further data are required before more widespread adoption of bivalirudin can be recommended.

This study was set up to investigate the prognostic significance of different bands of troponin T in the diagnosis and management of patients presenting with suspected acute coronary syndrome without ST segment elevation. The study was a cohort study, set in a District General Hospital in the north west of England. The participants were 421 patients admitted with suspected acute coronary syndrome without ST segment elevation over a three-month period. Analysis was carried out depending on whether the level of troponin elevation was in a negative (< 0.03 µg/L), intermediate (0.03–0.1 µg/L) or positive (> 0.1 µg/L) band. The outcome was a composite of all-cause mortality or hospital admission due to non-fatal myocardial infarction at 30 days and 12 months.
Both intermediate and positive levels of elevated troponin increased the risk of all-cause mortality and non-fatal myocardial infarction at least two-fold, both at 30 days and 12 months (p<0.01). People over 50 were found to have a worse prognosis than younger patients at 12 months (p<0.05) but gender had no significant effect.
Patients with suspected acute coronary syndromes without ST segment elevation who have either intermediate or positive levels of troponin T show a substantial increase in adverse outcomes during short- and long-term follow-up. Further research is required on these bandings as new generations of troponin assays are developed with improved levels of precision.

We report a case of unprotected, ostial left main coronary artery disease successfully treated with a rapamycin-coated ‘Cypher’ stent in an 81-year-old woman who was declined for coronary artery bypass surgery because of significant co-morbidity.

Beta blockers are under-used in heart failure, despite their evident benefits. Here an educational and clinical support link between secondary and primary care was set up to mentor a nurse practitioner in heart failure management. A nurse-led heart failure clinic was established in a Hampshire general practice that enabled beta blocker therapy to be started safely and up-titrated successfully, without hospital referral.

In the second commentary on echocardiography in the community, general practitioner Ed Southall writes about the new British Society of Echocardiography accreditation process and his own experiences in running a community echocardiography service in South Devon.