Clinical articles

Acute, undifferentiated chest pain (chest pain ?cause) presents a frequent and difficult challenge to clinicians working in the emergency setting. We aimed to survey current management of this problem in UK accident and emergency departments by sending a postal questionnaire to the lead clinician or first named consultant in every major A&E department in the UK.
Responses were received from 177/238 departments (74%). Although 74 departments (42%) had formal guidelines, many referred only to diagnosed coronary syndromes. Guidelines for undifferentiated chest pain usually recommended observation for six to 12 hours followed by troponin testing. Short-stay facilities were available in 38 departments (21%) and were planned for 55 departments (31%). Provocative cardiac testing could be accessed by 38 departments (21%). Patients were admitted by general physicians in 152 hospitals (86%) and cardiologists in 18 (10%). The estimated proportion of patients admitted was extremely variable. Although 45 departments (25%) employed specialist nurses, only in 20 did they manage patients with undifferentiated chest pain.
Reported management of acute, undifferentiated chest pain in the UK shows wide variation. Innovative technologies and diverse methods of service delivery are being adopted in a number of departments. These innovations require thorough evaluation.

Cardiovascular death is steadily decreasing but still accounts for 40% of deaths (235,000) in this country per year. More than 85% occur in older patients over the age of 65 years. The future of cardiology lies in the delivery of care to this rapidly expanding population of older people, whose growing numbers will account for an increasing trend upwards in the prevalence of cardiovascular morbidity in the UK. There will be increasing numbers of heart failure, hypertension, myocardial infarction, angina, atrial fibrillation, pacemaker implants and heart valve implantation in older patients. Randomised clinical trials often exclude the treatment of these conditions in patients over 75 years and results cannot always be easily extrapolated. Older patients often seem to be disadvantaged when compared with younger patients with cardiovascular disease. This article is the first in a series examining the treatment of older patients with cardiovascular disease.

Angiotensin-converting enzyme (ACE) inhibitors and statins improve prognosis in patients with coronary artery disease. Effective secondary prevention strategies, however, are frequently under-utilised. We sought to determine prescribing habits for ACE inhibitors and statins in 324 patients undergoing coronary artery bypass graft surgery (CABG) at two regional cardiac centres in the United Kingdom. We prospectively recorded ACE inhibitor and statin use on admission and discharge, ACE inhibitor and statin initiation and withdrawal during the hospital stay, and sought associations with treatment withdrawal. 82 (25.3%) patients were taking an ACE inhibitor on admission compared with 37 (11.4%) at discharge (p<0.0005). An ACE inhibitor was initiated during the hospital stay in five (1.5%) patients and was withdrawn in 50 (15.4%). On admission, 157 (48.5%) patients were receiving statin therapy compared with 154 (47.5%) at discharge (p=ns). Statin treatment was initiated in 23 (7.1%) patients, but was withdrawn in 20 (6.2%) others. Thus, only a minority of patients were receiving ACE inhibitors and statins on admission for isolated elective CABG. ACE inhibitor treatment was discontinued during the hospital stay in over 60% of these patients. Furthermore, statin therapy was no more common at discharge than on admission. This study highlights a missed opportunity for effective secondary prevention in a high risk population.

The SIGN guideline on cardiac rehabilitation was published in January 2002 and endorsed by the British Association of Cardiac Rehabilitation. This paper summarises the recommendations, which cover all four phases of recovery and the three main cardiac rehabilitation interventions.

This article describes the successful provision of a thrombolysis service by general practitioners in the isolated rural area of Whitby, North Yorkshire, and also in rural areas of Sweden. It discusses the difficulties in providing such a service, particularly the rural/urban paradox whereby specialist pre-hospital thrombolysis services can be much more easily provided in urban areas than rural areas where the need is normally much greater.
The results of a small straw poll on thrombolysis amongst Primary Care Cardiovascular Society members show that rural general practitioners are much more interested in providing a pre-hospital thrombolysis service than their urban colleagues; paying a fee for such a service should be considered in future planning. The article also reviews the various thrombolytic agents favouring the use of fibrin-specific thrombolytic agents by bolus for pre-hospital thrombolysis.

Recently reported and ongoing morbidity and mortality trials in hypertensive patients are addressing important unanswered questions in hypertension management. What is the optimal first-line treatment for hypertension, what is the ideal combination of antihypertensive drugs, how are these influenced in particular patient subgroups, and what are the treatment thresholds and blood pressure goals of treatment for optimal prevention of cardiovascular disease? Limitations of some recent trials are highlighted and emphasise the need for further prospective meta-analyses of studies to provide adequate power to address some of these important questions. Current ongoing large scale studies, including ALLHAT and ASCOT, will shortly be reporting results to the scientific community and are likely to influence management decisions across a wide range of patient subgroups.

Full implementation of the available evidence on secondary prevention should ensure that all patients after myocardial infarction should be offered both effective treatment and be maintained on treatment. This article describes the Heart disease Evidence-based Audit and Research in Tayside Scotland (HEARTS) collaboration which has been set up to try and achieve this. HEARTS can collect electronic data from many sources; prioritise data from multiple sources, such as hospital and general practice; process and link patient records; and, allow manual validation of electronic data. It can also facilitate clinical governance issues in general practice and hospital plus disseminate information to patients. It is hoped that, in addition to secondary prevention, it will be able to extend its focus to other aspects of cardiovascular disease in the future as well as being used for epidemiological and qualitative projects. The system maintains the security and rights of patients at all times.

A dvanced web-based clinical care applications as part of an electronic health record can assist clinicians to meet Government targets for the management of cardiovascular disease. A clinical module of the Tayside electronic health record collects electronic data automatically from a variety of sources and holds this data in a central regional repository. It identifies those patients with existing cardiovascular disease and also those high priority patients at risk of developing clinical atherosclerosis. It allows the clinician to effectively manage these patients in line with national evidence-based guidelines. Real time audit of patient management is instantly available at the point of direct patient contact, as well as benchmarking to agreed performance criteria. Demonstrating improvement in clinical outcomes remains the eventual goal.

An unusual case of pericardial constriction Michael Pitt, Stephen Rooney, R Gordon Murray Pericardial constriction remains a rare condition. The precise aetiology is undefined in up to 50% of cases. We describe a case of rapidly progressive pericardial constriction and highlight how post-mortem examination remains useful in establishing unexpected diagnoses.

Waiting for in-patient transfer for the investigation of chest pain is a significant cause of ‘bed-blocking’. We performed an audit of 58 consecutive in-patient transfers. The mean delay between referral and transfer was 10 days (range one to 28 days). At the time of transfer the mean number of pain-free days was five (range one to 21 days). Of the 37 patients with a working diagnosis of unstable angina, only 19 (51%) underwent some sort of non-invasive risk stratification prior to referral, nine patients (24%) were walking around the hospital or had taken weekend leave and 13 (35%) had normal anatomy or subcritical disease. Of 21 with post-infarct angina, seven (33%) underwent exercise stress testing, five (24%) were mobilising around the hospital and 18 (86%) underwent some sort of intervention.
In conclusion, waiting times for in-patient angiography were long and utilisation of non-invasive investigation was low.