Clinical articles

Optimal management of hypertension and diabetes is essential if the cardiovascular and renal mortality and morbidity associated with this condition is to be reduced. Recent guidelines from the National Service Framework for Diabetes and the Scottish Intercollegiate Guidelines Network are discussed. Recent studies (UKPDS, RENAAL and PRIME) looking at the contribution tight blood pressure control and angiotensin II receptor antagonists can make to the management of this hypertension in diabetics are also covered. Finally, the author advises how primary care can implement guidelines in practice to give the best possible care to patients with diabetes.

Extensive multiple coronary artery to left ventricular fistulas – a 10-year case history We report the 10-year case history of a 50-year-old woman who presented with angina due to extensive, bilateral, multiple coronary artery to left ventricular fistulas (MCALVF). 201Thallium myocardial scintigraphy revealed reversible ischaemia due to coronary ‘steal’. Cardiac catheterisation showed left ventricular dilatation due to high cardiac output from significant coronary to left ventricular shunt.

Coarctation of the aorta is an important differential diagnosis in adults with hypertension. Unfortunately, simply removing the obstruction does not restore cardiovascular normality. Patients may continue to be hypertensive, demonstrate abnormalities of endothelial function and remain at risk of premature coronary artery disease and other vascular disease. Therapy therefore requires both relief of the mechanical obstruction and long-term follow-up to deliver optimal antihypertensive therapy, vascular risk factor modification and detection and management of complications (such as bicuspid aortic valve and cerebral aneurysms). This paper discusses the management of three cases of this condition.

The American College of Cardiology and the American Heart Association recommend echocardiography in patients with stroke or peripheral embolus who are less than 45 years of age or in those without evidence of cerebrovascular disease or other obvious cause.¹ There are no equivalent guidelines from British or European Cardiac Societies. The prevalence of stroke and peripheral embolus has made it a common indication for the use of echocardiography. Despite this, to our knowledge there has been no previously published evaluation of the use of echocardiography in such patients in the UK. We undertook a retrospective review of transthoracic (TTE) and transoesophageal echocardiogram (TOE) reports (n=7,870) over 37 months at St. Bartholomew’s Hospital department of cardiology. This identified 153 (1.9%) patients investigated for stroke/transient ischaemic attack (TIA) or peripheral embolus. Of these, six patients had two or more examinations producing a total of 160 reports; five reports were unrecorded and, therefore, 155 reports were analysed. A total of 12 reports (7.7%) identified possible cardiac sources of emboli with a further n=3 reporting spontaneous contrast in the left atrium. The potential embolic sources included patent foramen ovale (PFO)(n=3), aortic atheroma (n=3), aneurysmal atrial septum (n=2), mobile lesions on the mitral valve (n=3) and thrombus in the left atrial appendage (LAA)(n=1).
These results have led to the development of standardised criteria with the design of a template on the performing and reporting of echocardiograms in this type of patient.

While angiotensin-converting enzyme (ACE) inhibitors are established agents for the treatment of hypertension and heart failure, in contrast the angiotensin II receptor antagonists (AIIRAs) have failed to demonstrate more than equivalence in randomised clinical trials. Trials such as ELITE II are criticised on the grounds that the dose used of losartan (50 mg) may have been sub-optimal. In ValHeFT, valsartan was shown to be superior to placebo only in patients who did not also receive a beta blocker. The ambiguity of response of AIIRAs in such trials will hopefully be clarified in CHARM, a large, placebo-controlled study which will assess the effects of candesartan in heart failure patients with either reduced ejection fractions in addition to an ACE inhibitor, and in those intolerant to an ACE inhibitor, as well as in patients with preserved ventricular function (diastolic heart failure) not on an ACE inhibitor. The design of the study is discussed.

Neurohormonal activation has a central role in the pathophysiology of various cardiovascular disorders. Despite recent therapeutic advances, potential exists to further manipulate these activated systems. The natriuretic peptide family consists of at least four structurally related peptides, with varying degrees of biological similarity. In the context of cardiovascular disease, the vast majority of data relates to atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).

Primary pulmonary hypertension (PPH) is a progressive disease with a poor prognosis. It is characterised by an elevated pulmonary artery pressure and pulmonary vascular resistance that ultimately lead to right ventricular failure and death. PPH is a relatively rare and neglected disease which, until recently, had been poorly understood and had no effective form of therapy. This, however, is changing with the rapid accumulation of knowledge relating to the disease and its management. In this article, we review the possible mechanisms that may have a pivotal role in the development of the disease.

Nurse-led interventions may improve the delivery of preventive care briefly discuss insights from parallel qualitative research; to present the preliminary results of the Bromley Changes care for coronary heart disease. In the SHIP trial, three cardiac liaison nurses co-ordinated care at the hospital-general practice interface. In the ASSIST trial, three different strategies of implementing secondary prevention were used. Although various measures improved, there was no difference in clinical outcome. Qualitative research indicates that specialist education for nurses is vital. The preliminary results of the Bromley Changes for Life Programme are described: this programme achieved significant risk factor and therapeutic targets. The way forward may lie with the cardiac specialist nurse.

There is an enormous gap between the publication of new evidence and its clinical implementations. Research on interventions that are designed to change professionals’ clinical behaviour is detailed here: specific generic interventions, interventions specific to cardiovascular medicine, and continuing medical education. Barriers to change include information problems, stress and inertia. Further research and evaluation are required.

The National Service Framework for Coronary Heart Disease emphasises the role of primary care in secondary prevention. More than 20% of men and 12% of women aged 65 years and over suffer from ischaemic heart disease. Lifestyle changes and drug treatment may effectively reduce risk but uptake of the evidence base is patchy. There are a number of possible approaches to enhance the uptake. Nurse-led clinics and health promotion clinics can lead to improvement in reported lifestyle and self-reported health status. Audit and feedback may lead to more use of appropriate drugs. Systematic recall will lead to better documentation that care conforms to standard practice, and nurses are at least as effective as doctors in achieving this. The first step is to set up accurate morbidity registers.