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November 2010 Br J Cardiol 2010;17:259-63 News and views

Cardiovascular risk increases after invasive dental treatment

September 2010 Br J Cardiol 2010;17:244 Clinical article

Aneurysmal saphenous vein graft rupture: late complication of coronary artery bypass surgery

Alice Wort, Matthew Bates

Abstract

A 72-year-old man, who underwent coronary artery bypass grafting 14 years previously, presented with sharp posterior chest pain and presyncope.

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‘Time is muscle’: aspirin taken during acute coronary thrombosis

July 2010 Br J Cardiol 2010;17:185-9 Clinical article

‘Time is muscle’: aspirin taken during acute coronary thrombosis

Peter C Elwood, Gareth Morgan, Malcolm Woollard, Andrew D Beswick 

Abstract

Low-dose aspirin is of value in the long-term management of vascular disease, and the giving of aspirin to patients believed to be experiencing an acute myocardial infarction (AMI) is standard practice for paramedics and doctors in most countries. Given during infarction, aspirin may disaggregate platelet microthrombi and may reduce the size of a developing thrombus. Effects of aspirin other than on platelets have also been suggested and these include an increase in the permeability of a fibrin clot and an enhancement of clot lysis. Animal experiments have also shown a direct effect of aspirin upon the myocardium with a reduction in the incidence of ventricular fibrillation.

Randomised trials have shown that the earlier aspirin is taken by patients with myocardial infarction, the greater the reduction in deaths. We suggest, therefore, that patients known to be at risk of an AMI, including older people, should be advised to carry a few tablets of soluble aspirin at all times, and chew and swallow a tablet immediately, if they experience severe chest pain. 

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Contemporary coronary imaging from patient to plaque part 1: IVUS-derived virtual histology

May 2010 Br J Cardiol 2010;17:129-32 Clinical article

Contemporary coronary imaging from patient to plaque part 1: IVUS-derived virtual histology

Scott W Murray

Abstract

From the days of Virchow and the analysis of post-mortem coronary specimens, an enormous amount of knowledge has been built about coronary pathophysiology. In the 1950s the dream of in vivo coronary imaging became a reality with the invention of coronary arteriography under the guidance of Mason Sones. As we fast forward 50 years, it has become clear that angiography has helped us focus on areas of stenosis and flow limitation, but the main problem of coronary artery disease is much more complex than can appear on a luminal silhouette. The finding of ‘normal coronary arteries’ following angiography is short-sighted and does not take into account the potential of unstable disease lurking within the vessel wall. We begin the series with intravascular ultrasound.

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September 2009 Br J Cardiol 2009;16:226 News and views

In brief

September 2009 Br J Cardiol 2009;16:237–40 Clinical article

Why are we so bad in primary care at initiating warfarin in atrial fibrillation patients?

John Havard

Abstract

This article is an enlightened approach to reducing strokes in patients with atrial fibrillation (AF). It discusses some freely available software called ‘The Auricle’ and shows how this can easily be used to calculate the annual risk of a stroke. GPs and patients are supported in the careful decision about anticoagulation. To this end the programme has an e-consultation option to ask the opinion of a local cardiologist with the flexibility to attach an electrocardiogram (ECG), echo or clinic letter, if desired. All the details and the cardiologist’s opinion can be electronically filed in the patient’s notes to confirm that the pros and cons of warfarin were fully debated.

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September 2009 Br J Cardiol 2009;16:242-5 Clinical article

10 Steps before you refer for: Lipids

Jonathan Morrell, Tony Wierzbicki

Abstract

The impetus of national initiatives highlighting the importance of lipid modification, the sheer number of people involved, and the continuous nature of therapy, mean that lipid management has become an everyday primary care discipline.1 Most patients with dyslipidaemia can be investigated and treated effectively in primary care without referral to a specialist but, paradoxically, the increasing patient burden means an enhanced role for the specialist lipidologist as well.

Patients who should be referred to a specialist lipid clinic include:

Those with extreme values (primary care practitioners often feel less secure with mixed hyperlipidaemia and hypertriglyceridaemia than with pure hypercholesterolaemia). Generally, these can be defined as total cholesterol (TC) >7.5 mmol/L and/or fasting triglycerides (TG) >7.5 mmol/L. All patients with TG >20 mmol/L need to be referred given the risk of pancreatitis.
Those who fail to show an effective response to treatment (whether by virtue of the type and severity of their dyslipidaemia or their intolerance of first-line agents).
Those with familial dyslipidaemia (e.g. familial hypercholesterolaemia, familial combined hypercholesterolaemia and Fredrickson Types I or V [TG >20 mmol/L], or type III [TG=TC and >7 mmol/L]) should be managed by specialists as family tracking may be easier to co-ordinate, drug doses used are higher and combination therapies are more common.
Special cases (such as those requiring the help of joint paediatric, nephrology, neurology, vascular surgery and HIV clinics) or those requiring special investigations such as apolipoproteins, enzyme testing, DNA genotyping, or more detailed vascular assessment.

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September 2009 Br J Cardiol 2009;16:250–53 Clinical article

Predicting adherence to phase III cardiac rehabilitation: should we be more optimistic?

Lesley A O’Brien, Morag K Thow, Danny Rafferty

Abstract

Predicting uptake and adherence to cardiac rehabilitation (CR) continues to challenge providers of the service in the UK. This study included optimism with the more traditional predictors of adherence.

The study included 61 eligible patients (37 men, 24 women) referred to an eight-week phase III CR programme. Socio-demographic data were collected including age, gender, diagnosis, employment, marital status and deprivation. Depression was measured using the Hospital Anxiety and Depression (HAD) scale. Dispositional optimism was measured using the Revised Life Orientation Test (LOT-R). Stages of change (SOC) for exercise were assessed. Attendance and completion of the eight-week CR programme were recorded for all patients. There was adherence to CR by 46 (75%; 27 men and 19 women) and non-adherence by 15 (25%; 10 men and 5 women). Dispositional optimism and SOC were found to be significant predictors of adherence (p=0.001 and p=0.038, respectively), with depression tending towards significance (p=0.0614). Socio-demographic variables were not significant.

Greater optimism is associated with attendance at phase III CR. In addition, being in a higher stage of the SOC model is also associated with adherence. These findings can enable CR staff to identify patients at risk of failing to adhere, facilitating focused interventions to encourage adherence.

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March 2009 Br J Cardiol 2009;16:57–9 Editorial

Improving the uptake of cardiac rehabilitation – redesign the service or rewrite the invitation?

Sultan Mosleh, Neil Campbell, Alice Kiger

Abstract

For patients with established coronary artery disease, lifestyle changes such as dietary modification, smoking cessation, stress management and regular exercise, can help to reduce, or perhaps stop, the progression of their cardiovascular disease, reduce their chance of having another cardiac event, and improve their quality of life. Cardiac rehabilitation can accelerate physical and psychological recovery and reduce mortality after acute cardiac events by 10–25% according to systematic reviews of randomised trials.1-3 Cardiac rehabilitation programmes can also reduce risk factors, improve health-related quality of life, and increase the likelihood of return to work.3-6 Despite this evidence, however, typically fewer than 35% of eligible patients take part in cardiac rehabilitation worldwide, with a recent UK audit reporting figures in line with this.(7-10)

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March 2009 Br J Cardiol 2009;16:80-84 Clinical article

10 steps before you refer for chest pain

Sudhakar Allamsetty, Sreekala Seepana, Kathryn E Griffith

Abstract

Chest pain is a common presentation in general practice. Each year about 1% of the UK population visit their GP with chest pain.1 The average GP will see, on average, four new cases of angina each year.2 The Euro heart survey of newly diagnosed stable angina patients showed that the incidence of death and myocardial infarction (MI) was 2.3/100 patient-years. This is increased in patients with a previous MI, short history, more severe symptoms and with heart failure or other co-morbidities, such as diabetes.3 The recognition of these patients as at high risk for cardiovascular events has led to the improvement of diagnosis and management of angina. Rapid access chest pain clinics have been developed to allow quick assessment of patients with new onset angina as part of a National Service Framework for coronary artery disease.

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