Clinical articles

This study investigated the current level of provision of cardiac rehabilitation (CR) for automatic implanted cardioverter defibrillator (ICD) patients in the UK, the clinical and technical staff views on the need for such a service, and the current level of provision and the most commonly reported barriers to meeting these needs. The study was carried out via a postal questionnaire survey of all NHS implantation centres for ICD patients.
The majority of respondents (99%) believed they should provide rehabilitation for their patients, but only 14 (36%) centres had a programme for rehabilitation that ICD patients could access and only four (10%) of these were specifically designed for ICD patients. The majority of respondents (74%) believed they were not meeting their patients’ needs for rehabilitation. The most commonly endorsed barriers to providing and developing CR services were limited multidisciplinary staff, a wide geographical catchment area, and administrative and organisation difficulties. There was wide support for the potential of using a home-based, remotely monitored, rehabilitation package. This shows that the vast majority of staff in implantation centres agree with the recent NICE recommendations that there is an unmet need to provide CR for ICD patients.

This article describes the process used to arrive at the set of assessment measures and
minimum dataset for cardiac rehabilitation (CR) that has been endorsed by the British
Association for Cardiac Rehabilitation (BACR) and the British Heart Foundation (BHF) for
the national audit of CR.

Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are used to prevent rethrombosis and distal platelet embolisation in acute coronary syndromes. LMWH have a more predictable anticoagulant response and are less likely to result in bleeding. For the moment UFH should be used in primary percutaneous coronary intervention (PCI). It may also be preferable to use UFH in the setting of rescue PCI following tenecteplase (TNK) treatment. In those over 75 years of age, the combination of TNK with enoxaparin has been shown to be superior to TNK with UFH in reducing ischaemic end points without increasing the risk of haemorrhage. Results from TIMI IIB indicate that enoxaparin is superior to UFH for the acute management of non-ST elevation ACS (in patients managed conservatively). Enoxaparin and UFH appear to have similar efficacy and safety profiles when used in conjunction with glycoprotein IIb/IIIa blockade during PCI.

Hypertension is a major cardiovascular risk factor and its pathogenesis remains elusive. For a long time, hypertension and dyslipidaemia have been viewed as independent but synergistic cardiovascular risk factors increasing the risk of premature atherosclerosis. Recently, a growing body of evidence has indicated that hypercholesterolaemia promotes impairment in several mechanisms implicated in blood pressure control such as nitric oxide bioavailability, renin-angiotensin activity, the sympathetic nervous system, sodium and fluid homeostasis and ion transport/signal transduction. Moreover, recent clinical studies have pointed out a beneficial effect of cholesterol-lowering treatment in reducing blood pressure to a small but significant degree. Our assumption is that depending on the complex inter-relationships between genetic background and life style, hypercholesterolaemia may be a trigger to blood pressure elevation. An integrated approach to the treatment of hypertension and dyslipidaemia can, therefore, maximise both blood pressure control and prevention of cardiovascular disease. In this review, we discuss recent important data from our and other groups, demonstrating the clinical evidence of the hypertensinogenic effects of hypercholesterolaemia, and the biological mechanisms which underlie them.

The circadian rhythms of the cardiovascular system are related to the risk of events such as myocardial infarction and stroke. The so-called ‘morning surge’ in heart rate and blood pressure at around the time of waking is a particularly hazardous period. The sympathetic nervous system and the renin-angiotensin system are thought to be the main regulators of these rhythms and a potential target of antihypertensive medication is the blunting of the morning surge through action on these systems. This article reviews some of the mechanisms involved and recent therapeutic approaches to this problem.

The use of coronary angiography as a diagnostic tool in modern hospital medicine continues to rise. With the increasing use of therapeutic coronary interventions, and the increases in procedure times and volumes of contrast media, incidence rates of contrast-induced nephropathy (CIN) have also been seen to climb over recent years. CIN has subsequently been shown to be a significant contributor to morbidity and mortality during hospitalisation. In this current clinical setting, it is incumbent on the modern cardiologist to be aware of this potentially serious complication of angiography, to be familiar with its presentation and treatment, and to be able to recognise at-risk groups and institute prophylactic measures where appropriate.

To target statin therapy effectively in primary coronary heart disease (CHD) prevention, recommendations increasingly advocate the assessment of absolute CHD risk. Using methods from two recent sets of national recommendations, we estimated absolute CHD risk in 412 men and women whose general practitioners requested it on clinical grounds. Substantially fewer men and women had CHD risk exceeding 15%, 20% and 30% over 10 years with the National Cholesterol Education Program III (NCEP III) scoring system than with the Joint British charts. The latter agreed closely with the 1990 version of the Framingham risk equations.

The pulmonary artery catheter (PAC) was introduced into critical care medicine without objective evidence of its efficacy. The direct risks from the PAC are around 1.5% for a serious complication and 0.2% for death.
The Connors study on 5,735 intensive care patients used case-matching techniques, and demonstrated a worse outcome in the PAC cohort. However, in this study the need for inotropes and the response to treatment were excluded from the regression analysis. Three further studies have failed to show an association between PAC placement and outcome after case-mix adjustment.
It has proved extremely difficult to recruit enough intensive care patients to exclude a clinically important mortality benefit of the PAC.
New techniques such as the oesophageal Doppler, pulse contour continuous cardiac output and lithium dilution cardiac output machines offer simpler, and perhaps better, alternatives to the PAC. Nonetheless, even if future trials are negative, the PAC should remain available for treatment of patients with unusual conditions or combinations of conditions.

Isolated ventricular non-compaction is a rare cardiomyopathy, which is probably underdiagnosed. We describe a case manifested by chest pain, indistinguishable from acute myocardial infarction.

Ventricular tachycardia (VT) and sudden cardiac death are feared complications of severe heart failure, whatever the aetiology. VT has the propensity to become incessant, and this carries an adverse prognosis. In some cases incessant VT is refractory to a combination of electrical cardioversion and pharmacological therapy such that emergency catheter ablation is required. Even when the conventional endocardial approach fails, ablation can be performed safely and effectively via the epicardial route.