CardioThoracic Centre Knowledge and Information

GOODBYE

2011-02-25T14:20:00.001Z

This is to let everyone know that no more posts will appear on this BLOG as from today

JOURNAL SNIPPETS 2 February 2011

2011-02-21T15:12:00.002Z

Arch Intern Med 14 Feb 2011 Vol 171
196 Miriam Johnson and Richard Lehman compiled the first book on Heart Failure and Palliative Care five years ago, aimed mainly at a UK audience. It's not known if it's sold any copies in the USA, but a new survey of resource use in the last 6 months of life among Medicare beneficiaries with heart failure shows a huge rise in hospice use by these patients between the beginning of 2000 and the end of 2007. The official Medicare policy remains to distinguish between "palliative" and "curative" treatments, but it is good to see that such distinctions seem to be little heeded in this group, who have also been given more intensive medical treatment as well. It had been hoped to say goodbye forever to this gloomy subject, but the need to identify patient-important symptomatic outcomes in heart failure remains huge, as does the need to provide better end-of-life care: so there maybe more to write about this matter
http://archinte.ama-assn.org/cgi/content/abstract/171/3/196

211 The Canadian health system is very different, but the same trends can be observed there too. Hospital admissions in the last 6 months of HF are decreasing, but costs are increasing. Commissioners take note: there are no cheap ways of helping heart failure patients to live longer, or die better.
http://archinte.ama-assn.org/cgi/content/abstract/171/3/211

PAEDIATRIC HEART SERVICES

2011-02-17T09:02:00.001Z

PCTs agree to consult on children's congenital heart services
HSJ 16 February, 2011 By Ben Clover
A joint committee of primary care trusts has given the go-ahead for a consultation on plans for greater centralisation of paediatric cardiac care.

COCHRANE REVIEWS

2011-02-15T16:13:00.001Z

The Cochrane Library produces world-leading systematic reviews and research on evidence-based health care through seven comprehensive databases. Below we’ve highlighted relevant reviews for the cardiology community:
Active chest compression-decompression for cardiopulmonary resuscitation
Exercise based rehabilitation for heart failure
Beta-blockers for congestive heart failure in children
Visit The Cochrane Library and sign up for regular free podcasts and our monthly journal club, where readers can discuss new Cochrane Reviews, download resources and ask questions to review authors. Also of Interest – Watch these informative videos to learn more about The Cochrane Library!
Accessing The Cochrane Library
Resources for Librarians
What's New with The Cochrane Collaboration
CENTRAL Database

NATIONAL HEART MONTH - USA

2011-02-15T16:08:00.004Z

February is National Heart Month in America so to enable you to help your researchers and clinicians working in this field we have compiled a selection of articles that we think they will find of use. All the articles highlighted below are available free online. DOWNLOAD PDF -
Free articles on Cardiac Care Family presence during cardiopulmonary resuscitation: Using evidence-based knowledge to guide the advanced practice nurse in developing formal policy and practice guidelines Christopher T. Doolin, Lisa D. Quinn, Lesley G. Bryant, et al. Journal of the American Academy of Nurse Practitioners
The six-minute walk test: a useful metric for the cardiopulmonary patient T. Rasekaba, A. L. Lee, M. T. Naughton, et al. Internal Medicine Journal
Short-term Outcome of Infants Presenting to Pediatric Intensive Care Unit with New Cardiac Diagnoses Giridhar Dhandayuthapani, Shanta Chakrabarti, Aruna Ranasinghe, et al.Congenital Heart Disease
Perceived Quality of Care and Lifestyle Counseling Among Patients With Heart Disease Elizabeth A. Jackson, Sangeetha Krishnan, Nancy Meccone, et al. Clinical Cardiology
Biomarkers of Heart Failure Pam R. Taub, Paulette Gabbai-Saldate, Alan Maisel Congestive Heart Failure
Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective Nanette Stroebele, Falk Müller-Riemenschneider, Christian H. Nolte, et al. International Journal of Stroke
News and Issues that Affect Organ and Tissue Transplantation This month, 'The AJT Report' takes a look at some of the popular and reliable online resources available to transplant patients and donors, and features a study reporting high survival rates in heart transplant patients with hypertrophic cardiomyopathy.
Special issue on Pediatric Cardiac Support Systems Read these articles published in Artificial Organs containing research findings making a significant impact on the treatment of pediatric cardiac patients worldwide.

JOURNAL SNIPPETS February 2011

2011-02-15T15:48:00.003Z

JAMA 9 Feb 2011 Vol 305
585 Last week we learned that elevation of cardiac troponins happens in up to 30% of percutaneous coronary procedures, but seems to have little prognostic importance. This week a study looks at enzyme elevations in coronary artery bypass surgery and comes to a less reassuring conclusion. The main end-point is 30-day mortality and this shows a strong correlation with increasing levels of creatine kinase. Surprisingly, perhaps, the correlation with levels of troponin-1 is much weaker.
http://jama.ama-assn.org/content/305/6/585.abstract

BMJ 12 Feb 2011 Vol 342
371 A couple of weeks ago, the NEJM published a remarkable opinion piece suggesting that out-of-hospital cardiopulmonary resuscitation using chest compression lacks any evidence base and is in need of a randomised controlled trial. One respondent on doc2doc suggested that this was a bit like the suggestion in a Christmas issue of the BMJ for an RCT of jumping from a plane with or without a parachute. Not so: we know the results of that from the invariable observation of splats on the ground versus intact people under billowy silk umbrellas, whereas since CPR was devised 40 years ago, nobody has dared leave any pulseless patient without it. Maybe one in ten really has a pulse or will get one back anyway, and the rest will die, as they do following CPR. This study is consistent with the hypothesis of a useless procedure - it shows that if you improve the quality of CPR by real-time feedback, you do not improve patient outcomes.
http://www.bmj.com/content/342/bmj.d512.full

372 A mercury sphygmomanometer fitted with a large adult cuff was often the default method of measuring office blood pressure. After several years of backing this up with ambulatory BP monitoring before starting people on lifelong treatment, it has now moved towards encouraging home BP measurement, though the quality of most electronic sphygmomanometers on sale to the public (see British Hypertension Society website) is variable. These issues are very well summarised in the editorial on p.343 (provocatively subtitled "Must be done carefully, or not at all"), in response to this groundbreaking Canadian study of conventional versus automated BP measurement in primary care patients with systolic hypertension. The new "gold standard" - if there is such a thing - for BP measurement in primary care may be the use of BpTRU device in a room uninhabited by scary health professionals of any kind. The device automatically takes the BP at preset intervals and calculates the average of five readings. These are usually significantly lower than doctor measurements and correlate well with home measurements. It could be suggested that for most practices, the barrier will be finding a quiet room rather than buying a BpTRU machine.
http://www.bmj.com/content/342/bmj.d286.full

CARDIO HORIZON SCANNING FEB 2011

2011-02-15T14:44:00.005Z

Articles include the following
Cardiovascular Horizon Scanning Volume 3 Issue 2
Multiple risk factor interventions for primary prevention of coronary heart disease
Exercise on prescription: changes in physical activity and health-related quality of life
Efficacy of quantified home-based exercise and supervised exercise
Improving cardiovascular health at population level
NHS failing to screen for deadly heart condition
Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease
Parental history and myocardial infarction
The association of breast arterial calcification and coronary heart disease
Conventional versus automated measurement of blood pressure in primary care
Early life socioeconomic adversity is associated in adult life with chronic inflammation, carotid artherosclerosis, poorer lung function and decreased cognitive performance: a cross-sectional, population-based study
Further dissemination

Cardiovascular Horizon Scanning Volume 3 Issue 2
Posted: 14 Feb 2011 07:50 AM PST
Filed under: Cardiovascular diseases, Volume 3 Issue 2

Multiple risk factor interventions for primary prevention of coronary heart disease
Posted: 11 Feb 2011 09:37 AM PST
Source: Cochrane Database of Systematic Reviews 2011, issue 1
Follow this link for fulltext
Date of publication: January 2011
Publication type: Systematic review
In a nutshell: The evidence from this Cochrane systematic review suggests that multiple risk factor interventions using counselling and educational methods to change behaviour do not reduce coronary heart disease (CHD) mortality and morbidity. However, they may be effective in reducing mortality in high-risk hypertensive and diabetic populations. It concludes that health promotion interventions have limited use in general populations.
Length of publication: 175 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: behaviour change, CHD, health promotion, risk factors

Exercise on prescription: changes in physical activity and health-related quality of life
Posted: 11 Feb 2011 07:06 AM PST
Source: European Journal of Public Health, 2011, 21 (1), p. 56-62
Follow this link for fulltext
Date of publication: January 2011
Publication type: Research
In a nutshell: This study analysed changes in physical activity among participants of five Exercise on Prescription (EoP) programmes in Denmark. EoP helped to contribute to improved levels of physical activity and health-related quality of life.
Length of publication: 7 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Physical activity, Volume 3 Issue 2 Tagged: behaviour change, Exercise, lifestyle

Efficacy of quantified home-based exercise and supervised exercise
Posted: 10 Feb 2011 09:49 AM PST
Source: Circulation, 2011, 123 (5) p. 491-498
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: This clinical trial compared home-based and supervised exercise programmes among peripheral artery disease patients. The results of the study found that a home-based exercise programme had high adherence and was effective in improving claudication measures and increasing daily ambulatory activity.
Length of publication: 8 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.
Acknowledgement: American Heart AssociationFiled under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: claudication, peripheral artery disease, Physical activity

Improving cardiovascular health at population level
Posted: 10 Feb 2011 09:25 AM PST
Source: BMJ 2011; 342:d442 (Online First)
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: The Cardiovascular Health Awareness Program (CHAP) was implemented as an intervention to reduce morbidity from cardiovascular disease among older adults in 39 communities in Canada. This collaborative, community-based health promotion and prevention programme was found to reduce cardiovascular morbidity at a population level.
Length of publication: 8 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Canada, Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: community-based programmes, education, health promotion, Risk assessment

NHS failing to screen for deadly heart condition
Posted: 10 Feb 2011 09:16 AM PST
Source: National Institute for Health and Clinical Excellence
Follow this link for fulltext
Date of publication: January 2011
Publication type: Press release
In a nutshell: 100.000 people are at risk of developing familial hypercholesterolaemia (FH) as trusts fail to act on NICE guidelines which call for early diagnosis. A UK-wide audit found that very few families were systematically genetically screened for the inherited condition.
Length of publication: 1 webpage
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Diagnosis, Volume 3 Issue 2 Tagged: familial hypercholesterolaemia, family history, genetics, screening

Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease
Posted: 10 Feb 2011 07:30 AM PST
Source: The Cochrane Library
Follow this link for fulltext
Date of publication: 14 January 2011
Publication type: Editorial
In a nutshell: This editorial is written by Carl Heneghan, Director of the Centre for Evidence Based Medicine, and Clinical Reader in the Department of Primary Health Care, University of Oxford. It is based on the evidence from two new Cochrane reviews of preventive strategies: multiple risk factor interventions for primary prevention of CHD, and statins for the primary prevention of CVD.
Length of publication: 1 web page
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: evidence, preventative services, Prevention

Parental history and myocardial infarction
Posted: 10 Feb 2011 06:18 AM PST
Source: Reuters 27.1.11
Follow this link for fulltext
Date of publication: 27 January 2011
Publication type: News item
In a nutshell: Reports on the findings of the INTERHEART study, published recently in the Journal of the American College of Cardiology. 12 000 participants from 52 countries were studied, and across all nationalities, the risk of heart disease was almost doubled in those with a family history of heart attack.
Length of publication: 1 web page
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.
Acknowledgement: Journal of the American College of Cardiology (JACC), 2011, 57, pp 619-627Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: family history, risk factors

The association of breast arterial calcification and coronary heart disease
Posted: 10 Feb 2011 04:01 AM PST
Source: Obstetrics and Gynecology, 2011, 117 (2 part 1) p. 233-241
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: The objective of this study was to determine whether mammography could be an early prediction tool for the development of coronary heart disease (CHD). The study found that the presence of breast arterial calcifications on mammograms indicated a significantly increased risk of developing CHD or a stroke, and could therefore be used as a marker.
Length of publication: 9 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: CHD, mammography, risk markers, risk prediction tools

Conventional versus automated measurement of blood pressure in primary care
Posted: 10 Feb 2011 03:23 AM PST
Source: BMJ 2011;342:d286 (Online First)
Follow this link for fulltext
Date of publication: 7th February 2011
Publication type: Research
In a nutshell: The objective of this randomised controlled trial was to compare the quality and accuracy of manual office blood pressure and automated office blood pressure. Primary care practices in five Canadian cities were randomly allocated to the use of either manual or automated office blood pressure.
Length of publication: 9 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Canada, Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: BP monitoring

Early life socioeconomic adversity is associated in adult life with chronic inflammation, carotid artherosclerosis, poorer lung function and decreased cognitive performance: a cross-sectional, population-based study
Posted: 09 Feb 2011 07:14 AM PST
Source: BMC Public Health, 2011, 11:42
Follow this link for fulltext
Date of publication: 17 January 2011
Publication type: Journal article
In a nutshell: The Scottish Psychosocial and Biological Determinants of Ill-health (pSoBid) Study was conducted to examine links between early life adversity, intermediary phenotypes and markers of ill-health in adulthood, including artherosclerosis.
Length of publication: 16 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: health inequalities, risk factors

Further dissemination
Posted: 08 Feb 2011 05:44 AM PST
If you think someone would benefit from receiving this posting, please e-mail them the link to this blog and suggest that they sign up to the e-mail newsletter to stay up to date with new content.Filed under: Cardiovascular diseases, Volume 3 Issue 2

NHS EVIDENCE

2011-02-09T15:05:00.006Z

Antiplatelet dosage for PCI
Overview: Percutaneous coronary intervention (PCI) is an important advance in the treatment of patients with acute coronary syndromes, with or without ST segment elevation. Despite the capacity of PCI to reduce major cardiovascular events, the risk of thrombotic complications remains an important concern. Hence, attention is being focused on the development of fast-acting anti-platelet regimens that achieve high levels of platelet inhibition.

Current advice: Aspirin, in combination with clopidogrel – a thienopyridine adenosine diphosphate receptor antagonist – prevents major thrombotic events in patients undergoing PCI and has been the standard of care for more than a decade.NICE guidance on the early management of unstable angina and non ST segment elevation myocardial infarction recommends offering a single loading dose of 300 mg aspirin and continuing aspirin indefinitely.For patients with no contraindications, who may undergo PCI within 24 hours of admission to hospital, NICE recommends offering a 300 mg loading dose of clopidogrel. The guidance states that there is emerging evidence about the use of a 600 mg loading dose of clopidogrel for patients undergoing PCI within 24 hours of admission. However, NICE was not able to formally review all the evidence and was therefore unable to recommend this at the time of guidance publication (March 2010).
New evidence: The CURRENT-OASIS 7 trial (The Lancet Volume 376, Issue 9748) assessed whether doubling of the loading and maintenance dose of clopidogrel for 7 days was better than the standard dose and if high dose aspirin was better than low dose aspirin in patients undergoing PCI.A 7 day double dose clopidogrel regimen (600 mg on day 1, 150 mg on days 2 to 7, then 75 mg daily) was associated with a reduction in cardiovascular events and stent thrombosis compared to the standard dose (300 mg on day 1 then 75 mg daily). The analysis suggests a clear benefit in the 17,236 patients who underwent a PCI procedure.
Using the CURRENT/OASIS 7 trial definition, major bleeding was more common with double than standard dose clopidogrel. Before PCI, rates of ischaemic events or major bleeding did not differ between the groups.The researchers conclude that a double-dose clopidogrel regimen (600 mg loading dose) can be considered for all patients with acute coronary syndromes treated with an early invasive strategy and intended early PCI.Efficacy and safety did not differ between high dose (300 to 325 mg daily) and low dose (75 to 100mg daily) aspirin. However, since the dose comparison was for only 30 days, use of low-dose aspirin is still thought to be reasonable for long-term therapy.

Commentary:"CURRENT-OASIS 7 is the latest in a long list of trials that tests the impact of dual anti-platelet therapy on efficacy, and since most trials look at the effect of increased therapy to prevent stent thrombosis (or its surrogate acute myocardial infarction/death), also importantly bleeding. A number of studies and retrospective analyses of large trials have shown the benefit of 600 mg over 300 mg.
"I see two problems with this study. First, two things were changed at once (so we don't really know which change, aspirin or clopidogrel, was beneficial in this study) and secondly, increasing the loading dose of clopidogrel to 150 mg with maintenance of 150 mg, if this is thought to be of value (and the trial suggests it might be), was associated with extra bleeding risk.
"So how should we use this study as applied to UK practice? In patients presenting with acute coronary syndrome who are at a low risk of bleeding (i.e. normal renal function, body weight of more than 60kg and no evidence of GI tract disease), it might be reasonable to give 600 mg clopidogrel loading but then to increase the maintenance clopidogrel dose to 150 mg for one week (only) and to maintain the patient on 75 mg aspirin and 75 mg clopidogrel." - Tony Gershlick, Professor of Interventional Cardiology, University of Leicester.

For more evidence relating to cardiovascular health visit NHS Evidence - Cardiovascular.
NICE guidance on the early management of unstable angina and non ST segment elevation myocardial infarction is due to be updated in March 2013.

Eyes on Evidence helps contextualise significant new evidence, highlighting areas that could signal a change in clinical practice. It does not constitute formal NICE guidance. The commentaries included are the opinions of contributors and do not necessarily reflect the views of NICE.

CARDIOVASCULAR DISEASE

2011-02-02T10:05:00.002Z

Cardiovascular Disease in Public Health E-Newsletter
Effect of cocoa products on blood pressure: systematic review and meta-analysis
Database of Abstracts of Reviews of Effects

JOURNAL SNIPPETS January 2011

2011-02-01T10:51:00.005Z

JAMA 26 Jan 2011 Vol 305
391 Stroke medicine grew up in the 1990s: like heart failure medicine, it shone welcome light on a large and neglected group of patients with organ damage who had been written off as unsalvageable. This was a Very Good Thing in itself, but its proponents then went on to declare that good stroke care could only be provided in designated stroke units, and went on to run some not-very-randomised trials to prove it. They also began to talk up the evidence for the benefits of immediate thrombolysis, which are real but extremely modest. These fashions spread to the USA following recommendations of the Brain Attack Commission in 2000, and this study evaluates the effect in New York State in 2005-6, comparing mortality and the use of thrombolysis in 31,000 patients with stroke, equally divided between hospitals with or without stroke units. There was a large difference in thrombolysis use - 4.8% in stroke units, versus 1.7% elsewhere; but a very small difference in mortality at 30 days - 10.7% versus 12.5%. It would be nice if someone could go on to look at a wider range of patient-important outcomes too.

NEJM 27 Jan 2011 Vol 364
303 One of the nightmare jobs you are glad someone else does is finding veins in haemodialysis patients. Someone who does this from time to time will be very glad to read this study showing that recombinant tissue plasminogen activator is twice as good as heparin at keeping central venous lines open and three times as good at preventing bacteraemia. Luck will be needed to get hospital trust to meet the extra cost.
http://www.nejm.org/doi/full/10.1056/NEJMoa1011376

313 The New England Journal allows you free access to this paper on Ventricular Tachyarrhythmias after Cardiac Arrest in Public versus at Home and in case you are inclined to spurn this generous offer, take a look at these excerpts from the editorial about it by Gust H Bardy M.D.:
If CPR were a drug or a surgical procedure, its value would be tested prospectively, but it has not been. Could it be that innovation in the field is hampered by a reluctance to let go of an entrenched approach that has only the appearance of value?
Knowledge of the absolute measured value of CPR would have a profound influence on the direction of research on sudden cardiac arrest and the conservation of resources. More than 40 years after its inception, CPR has never been compared with no CPR in a randomized trial involving patients with sudden cardiac arrest. Although not performing CPR is a heretical idea, it is not unethical; clinical equipoise does exist for the comparison of chest compression with no compression.
Click the links and read on
http://www.nejm.org/doi/full/10.1056/NEJMoa1010663
http://www.nejm.org/doi/full/10.1056/NEJMe1012554

351 Chronic thromboembolic pulmonary hypertension sounds nasty and almost bound to be underdiagnosed, and indeed it is both. It is fairly easy to spot when it follows acute pulmonary embolism as it does in 2-4% of PEs. But we simply don't know how often it occurs without overt PE, because much of it may lie hidden as "idiopathic" pulmonary hypertension and not present until right heart failure has set in. By which time it is a bit late: the "heroic" treatment is surgical: "Pulmonary thromboendarterectomy is performed with the use of cardiopulmonary bypass with intermittent circulatory arrest to permit dissection from the main pulmonary arteries to the subsegmental branches." Not surprisingly, it doesn't always work, and many patients are too sick to have it done.
http://www.nejm.org/doi/full/10.1056/NEJMra0910203

Lancet 29 Jan 2011 Vol 377
393 Eltrombopag! Eltrombopag! O keep it in your doctor's bag! was sang when first encountered this orally available thrombopoeitin receptor agonist. It makes you make platelets and so reverses chronic immune thrombocytopenia - as long as you keep taking the tablets. The Lancet has decided to print the RAISE study as it first appeared on their website, despite some second thoughts by its authors - if you like this kind of thing, it's all explained in an editorial by Lancet house staff on p.360. Apparently they made some claims about the inferiority of eltrombopag's main competitor drug, romiplostim, which may not be sustainable. Plus failing to mention that their patients were splenectomised. Naughtiness.Eltrombopag! Eltrombopag! Doctor will keep it in his bag,Depending on what it might cost him -He might just plump for romiplostim.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60959-2/abstract

BMJ 29 Jan 2011 Vol 342
275 And of course I have to declare an interest in the Easily Missed series, which I helped to set up. I think I may even have suggested Joint Hypermobility Syndrome and I'm certainly glad that it produced such a good contribution, well illustrated and a bit longer than most. Please let's have your further submissions to keep this series going indefinitely - after all, there's no end to what you can miss in medicine. But don't be surprised if we keep your article short and down to ten references.
http://www.bmj.com/content/342/bmj.c7167.extract

Arch Intern Med 24 Jan 2011 Vol 171
134 A drug that produces a 41% reduction in recurrent cardiovascular events following myocardial infarction - now wouldn't that get some marketing! The only drug that comes near that is alcohol - which does get a lot of marketing, but not for that reason. Here there is no drug at all: just talking. Mind you, quite a lot of talking, in the form of 20 two-hour sessions of traditional cognitive behavioural therapy in the first year after MI. Now let's say this was a new antiplatelet drug produced by pharma, and sold at £115 per month (a generous estimate of the cost of the CBT): every post-infarct patient would be clamouring for it to be funded by the NHS. But it's only CBT, which is also the best treatment for lots of other things. So forget about ever being able to get it.
http://archinte.ama-assn.org/cgi/content/abstract/171/2/134

ATHENS

2011-01-27T09:10:00.001Z

Have you got an NHS Athens account?
Do you know what is an NHS Athens account?
If the answer to either of these questions is NO then read on!

You will find having an NHS Athens account really useful. It unlocks the wide range of electronic resources available to you as NHS staff. This enables you to access electronic journals, such as the Lancet, the BMJ and the Nursing Times, electronic books, healthcare databases such as PsycInfo, CINAHL and MedLine and much more! There’s also a huge range of management/administrative material online, Athens access is for ALL staff not just those in clinical areas.

It’s very easy to get an account.
Step 1
Click here to Registering for NHS Athens
Fill out the online form – For region select East of England SHA
For Area select Essex
For Trust select the Trust you are EMPLOYED by.
You can register with any email address
Submit the form
Step 2
You will receive an email from Eduserv Athens
Click on the link within the email to register the account
Set up your password
Make a note of your username and password. You will need these to log in via Athens whenever you get to a resourceYou can now access ALL the resources from ANY PC, anywhere, anytime

ELECTRONIC RESOURCES

2011-01-27T09:06:00.001Z

Important News about Our Journals
Basildon Healthcare Library is making the majority of its print journals available in full text ONLINE ONLY as from January 1st 2011.
They will be accessible from the Journals page of the website and to view them users will need a valid NHS Athens user name and password. If you need to register please click here.This new development means that you will have 24/7 access to most of our journals online from any PC with internet access.
The library will continue to monitor usage by downloading statistics monthly and using national and regional benchmarks to evaluate whether the journal is demonstrating value for money.Future purchasing decisions will be based on the titles’ usage.More journals have been purchased by the East of England SHA and will be available from January as well.

JOURNAL SNIPPETS JAN 11

2011-01-18T12:14:00.004Z

JAMA 12 Jan 2011 Vol 305
167 Single combat between mounted Mongolian warlords, and arguments between cardiac surgeons - these are spectator sports which it is best not to stand too close to. It is an article of faith that in coronary bypass operations, radial artery grafts always outperform saphenous vein grafts. Here is a study with 36 authors to show that there is no difference in patency at one year. Gentlemen, get down from your horses, please: some of these guys are Texans.
http://jama.ama-assn.org/content/305/2/167.abstract

175 We need to know more about the effect of the drugs we use for heart failure in the general mix of patients we treat in the community. The randomised controlled trials tell us a lot about specific drugs, usually when added to standard treatments in selected populations, but this may be an area where observational studies done on typical populations are just as valuable. That said, certainty is never going to be on offer, given the difficulties of defining the diagnosis and the impossibility of eliminating confounders: there is no such thing as heart failure without co-morbidity. So two cheers for this Swedish population database study which tried, but did not altogether succeed, in matching two groups of heart failure patients who took losartan or candesartan, and tracking their mortality over five years. Those taking candesartan showed better survival. It would be nice to do a similar comparison using the UK GP Research Database, but they have just made that harder by withdrawing free access.
http://jama.ama-assn.org/content/305/2/175.full

JAMA 5 Jan 2011 Vol 305
43 Implantable cardioverter-defibrillators are a good intervention for those who have bad systolic heart failure with a risk of ventricular arrhythmia, and would rather die slowly than suddenly. The "utility" of the device is that it can have a statistically significant effect on mortality in younger, properly selected patients; the "dysutility" includes everything that can go wrong with the machines and the possibility that dying from pump failure may be accompanied by multiple painful electric shocks. As you'll gather, I'm not a great fan of these devices, but most cardiologists are. In the USA, their use by Medicare and Medicaid was approved in 2005, since when a registry has been kept, and this study examines it to find out how many ICD implantations were not evidence-based. Using agreed criteria, the answer is about 22.5%, meaning that between a fifth and a quarter of all ICDs cannot be expected to do any good to the patient, while the potential for harm is considerable. I wonder what kind of informed, shared decision-making goes on before these things are inserted into people?
http://jama.ama-assn.org/content/305/1/43.abstract

NEJM 6 Jan 2011 Vol 364
11 Here's a classic pharma-funded trial of eplerenone in systolic heart failure with mild symptoms: EMPHASIS-HF. Pfizer paid for patients to be recruited in 278 centres in 29 countries, with fewer than 10 patients per centre; their mean age was 69, with none reaching 76, the mean age of heart failure patients in the community; and 78% of them were male. The trial was stopped prematurely when the eplerenone group showed a large reduction in the composite end-point of death and readmission. So we know that the drug works for this group of patients, though the effect size and long term effects cannot be known accurately due to early termination. We have no idea what the drug does for symptoms, since these weren't considered. We don't know what its effects will be on older patients with comorbidities, or on patients with heart failure and a normal ejection fraction. It will probably cause much more serious hyperkalaemia in the community than in the trial, as was the case with spironolactone following the RALES study. Sales of eplerenone will soar in its last few years on patent, and the heart failure community will be happy that its academic centres and conferences will have been paid for until the next bonanza comes along. Meanwhile, clinicians will struggle to know what best to do for their patients, especially as a quarter of the patients in this trial had QRS prolongation and should have had biventricular pacing.
http://www.nejm.org/doi/full/10.1056/NEJMoa1009492

CARDIOVASCULAR HORIZON SCANNING

2011-01-17T10:08:00.001Z

CARDIOVASCULAR HORIZON SCANNING Volume 3 Issue 1
Is estimating lifetime cardiovascular risk useful?
Cost-effectiveness of interventions to reduce dietary salt intake
Valvular heart disease: the next cardiac epidemic
Further dissemination
CARDIOVASCULAR HORIZON SCANNING Volume 3 Issue 1
Posted: 14 Jan 2011 08:20 AM PST
Filed under: Cardiovascular diseases, Volume 3 Issue 1
Is estimating lifetime cardiovascular risk useful?
Posted: 12 Jan 2011 05:40 AM PST
Source: BMJ, 2010, 342 (7788) p. 62-63
Follow this link for the abstract
Date of publication: January 2011
Publication type: Editorial
In a nutshell: The QRISK lifetime cardiovascular risk model originates from the QResearch database, which has generated the world’s largest cardiovascular risk prediction cohort study, involvingmore than three million people between the ages of 30 and 84. The new QRISK lifetime risk calculator, which is similar to the heart age forecast tool, incorporates both short and longer term risk in one simple display and has important advantages over separate 10 year and lifetime cardiovascular risk calculators.
Length of publication: 2 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 1 Tagged: risk prediction tools
Cost-effectiveness of interventions to reduce dietary salt intake
Posted: 12 Jan 2011 03:19 AM PST
Source: Heart, 2010, 96 (23) p. 1920-1925
Follow this link for the abstract
Date of publication: December 2010
Publication type: Press release
In a nutshell: This study found that dietary advice targeting individuals is not cost-effective under any of the modelled scenarios, even if directed at those with highest blood pressure risk. Although the current programme that relies on voluntary action by the food industry is cost-effective, the population health benefits could be 20 times greater with government legislation on moderate salt limits in processed foods.
Length of publication: 6 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 1 Tagged: nutritional advice
Valvular heart disease: the next cardiac epidemic
Posted: 11 Jan 2011 09:05 AM PST
Source: Heart, 2011, 97 (2) p. 91-93
Follow this link for the abstract
Date of publication: January 2011
Publication type: Press release
In a nutshell: With an ageing population, a rise in the number of patients with more advanced valvular heart disease, requiring valve replacement, is anticipated.
Length of publication: 3 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.

CARDIO HORIZON SCANNING

2010-12-15T11:08:00.004Z

CARDIOVASCULAR HORIZON SCANNING Volume 2 Issue 11

WoW (Walk once a Week)
Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness
The polypill in the prevention of cardiovascular diseases
National exercise proven to be cost effective in Wales
Association of features of primary health care with coronary heart disease mortality
Trends in coronary heart disease mortality in England by socio-economic circumstances, 1982 – 2006
Quality of life and cost-effectiveness of a 3-year trial of lifestyle intervention in primary health care
Further dissemination

CARDIOVASCULAR HORIZON SCANNING Volume 2 Issue 11
Posted: 14 Dec 2010 06:31 AM PST
Filed under: Cardiovascular diseases, Volume 2 Issue 11

WoW (Walk once a Week)
Posted: 09 Dec 2010 08:56 AM PST
Source: Walk to School
Follow this link for fulltext
Date of publication: 2010
Publication type: Website
In a nutshell: WoW stands for Walk Once a Week and is a year-round walking promotion scheme. The DH-funded regional scheme is delivered by Living Streets in partnership with school travel advisers and participating schools. It encourages parents and pupils to walk to school at least once a week throughout the school year. Children record how they travel to school and if they walk at least four times a month, they receive collectable badges. Seven local authorities in the northwest joined the scheme in September 2010.
Length of publication: 1 webpage
Some important notes: Please contact Basildon Healthcare library if you cannot access the full text.
Acknowledgement: Living Streets
Filed under: Cardiovascular diseases, Physical activity, Prevention, Volume 2 Issue 11
Tagged: children, exercise, obesity

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness
Posted: 09 Dec 2010 04:19 AM PST
Source: Lancet, 2010, 376 (9754) p. 1775-1784
Follow this link for the fulltext [requires registration]
Date of publication: November 2010
Publication type: Report
In a nutshell: This report assesses public health strategies designed to tackle behavioural risk factors for chronic diseases in low-income and middle-income countries. England was included for comparative purposes. Cost-effective interventions such as health information and communication strategies, fiscal and regulatory measures are discussed.
Length of publication: 8 pages
Some important notes: Please contact Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, Physical activity, Prevention, secondary prevention, Volume 2 Issue 11
Tagged: Exercise, health promotion, nutrition, population-based policies

The polypill in the prevention of cardiovascular diseases
Posted: 09 Dec 2010 03:41 AM PST
Source: Circulation, 2010, 122 (20) p. 2078-2088
Follow this link for the abstract
Date of publication: November 2010
Publication type: Report
In a nutshell: This report looks at the case for the polypill as primary prevention, either for individuals at high-risk or to lower risk factor levels in entire populations. It also maintains that the polypill may lead to more widespread and cost-effective secondary prevention, but states that it should be considered as part of a comprehensive global strategy to prevent cardiovascular disease.
Length of publication: 11 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, prescribing, Prevention, secondary prevention, Volume 2 Issue 11
Tagged: pharmacological therapies, population-based policies

National exercise proven to be cost effective in Wales
Posted: 08 Dec 2010 07:25 AM PST
Source: Chartered Society of Physiotherapy
Follow this link for fulltext
Date of publication: 16 November 2010
Publication type: News item
In a nutshell: The Welsh National Exercise Referral Scheme (NERS) was introduced in 2007, replacing local schemes. Research and evaluation by Cardiff and Bangor universities shows it to be cost-effective in helping people reduce the risk of chronic diseases such as CVD.
Length of publication: 1 web page
Some important notes: Please contact Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, Physical activity, Prevention, secondary prevention, Volume 2 Issue 11
Tagged: cost-effectiveness, Exercise, preventative services, rehabilitation

Association of features of primary health care with coronary heart disease mortality
Posted: 08 Dec 2010 06:30 AM PST
Source: JAMA, 10 November 2010, vol 304 no 18, pp 2028 – 2034
Follow this link for fulltext
Date of publication: November 2010
Publication type: Journal article
In a nutshell: This report aims to explain the reasons for the variations in mortality rates from CVD between different primary care trust populations in England.
Length of publication: 7 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, Volume 2 Issue 11
Tagged: health inequalities, mortality rates

Trends in coronary heart disease mortality in England by socio-economic circumstances, 1982 – 2006
Posted: 07 Dec 2010 05:20 AM PST
Source: Journal of Epidemiology and Community Health, September 2010, vol 64 suppl 1, p A2
Follow this link for fulltext
Date of publication: September 2010
Publication type: Abstract
In a nutshell: This analysis shows decreasing mortality rates across England over this timespan, but with persistent large and increasing inequalities in those rates, patterned by social group.
Length of publication: 1 page
Some important notes: You will need an NHS Athens username and password to access this article. Please contact Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, Volume 2 Issue 11
Tagged: health inequalities, mortality rates

Quality of life and cost-effectiveness of a 3-year trial of lifestyle intervention in primary health care
Posted: 07 Dec 2010 05:19 AM PST
Source: Archives of Internal Medicine, 13 September 2010, vol 170 no 16, pp 1470-1479
Follow this link for fulltext
Date of publication: September 2010
Publication type: Journal article
In a nutshell: This Swedish study of 151 patients over 3 years, demonstrated clear and cost-effective impact of group-based lifestyle interventions on quality of life (QOL) in patients at moderate to high risk of CVD. The researchers performed health economic evaluation, cost-utility analysis and cost-effectiveness using the net monetary benefit method.
Length of publication: 10 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact Basildon Healthcare library if you cannot access the full text.
Filed under: Cardiovascular diseases, Prevention, secondary prevention, Volume 2 Issue 11
Tagged: cost-effectiveness, diet, Exercise, lifestyle advice, preventative services, Prevention, quality of life

Further dissemination
Posted: 07 Dec 2010 05:14 AM PST
Filed under: Cardiovascular diseases, Volume 2 Issue 11

JOURNAL SNIPPETS November 3

2010-12-01T11:06:00.005Z

NEJM 25 Nov 2010 Vol 363
2091 Quality improvement is actually, of course, a good thing in itself, and we need better ways of doing it and better ways of studying it. High quality outcomes research, carefully reflected on, is one essential input, and there are two good examples in this week's New England Journal. A general survey of North Carolina hospitals (see below, p.2124) produces a rather gloomy view of overall improvements in patient safety, but this study of mortality from allogeneic haematopoietic-cell transplantation is very much cheerier. The period 2003-7 showed an overall mortality fall of over 40% compared with a decade earlier, driven by significant decreases in the risk of severe GVHD; disease caused by viral, bacterial, and fungal infections; and damage to the liver, kidneys, and lungs. Further details are strictly for the haematologists: but it seems they have much to congratulate themselves about.
http://www.nejm.org/doi/full/10.1056/NEJMoa1004383

BMJ 27 Nov 2010 Vol 341
1144 Thrombolysis for acute occlusive stroke has been shown to be marginally beneficial in several RCTs, but the number of people over 80 in these trials is minuscule, whereas in real life, 30% of strokes occur in this age group. There is a presumption that the hazards of thrombolysis will be greater and the outcome difference less. This European registry study indicates that neither is true: thrombolysis remains beneficial for stroke beyond the age of 80.
http://www.bmj.com/content/341/bmj.c6046.full
1146 Any enthusiastic regular drinker of wine, will be delighted to note the PRIME study which confirms that by doing so you halve your chance of myocardial infarction. I suppose you also increase your chance of pancreatitis, cancers of the GI tract and stroke. Perhaps liver disease too, though the literature is surprisingly obscure at levels of intake below about 100u/week. The thing not to do is binge drink, which is a common pattern in Northern Ireland, and probably increases your baseline risk of MI. I think the further north you travel, the more dysfunctional alcohol use becomes, as warm oblivion becomes ever more desirable. As if to illustrate this point, a review of frostbite on p.1151 finds that nearly half of it is associated with alcohol use. I bet that means vodka or whisky in most cases, and wine alone hardly ever.
http://www.bmj.com/content/341/bmj.c6077.full http://www.bmj.com/content/341/bmj.c5864.extract

Arch Intern Med 22 Nov 2010 Vol 170
1926 In studies of drugs that put people into hospital, warfarin usually comes near the top. This study looks at how combined platelet inhibition with aspirin plus clopidogrel compares in emergency department visits for haemorrhage-related events. The score is 2-1: 2.5 events per 1000 prescriptions of warfarin as compared with 1.2 events for aspirin/clopidogrel.
http://archinte.ama-assn.org/cgi/content/abstract/170/21/1892

JAMA 17 Nov 2010 Vol 304
2129 Like all doctors who survived their hospital jobs in the 1970s, I have some shocking memories. Oddly enough, though, some of them are happy too, as the shocks saved lives. The woman dragged out of a freezing canal with a core temperature of 28ºC who survived intact after 16 defibrillations; the 43-year old man with chest pain who went into VF just as we were putting the leads on his chest: all of us can still remember these kinds of event, while our futile attempts go forgotten days after. Surely an automated defibrillator must beat a sleep-deprived, dishevelled house doctor at achieving survival following in-hospital cardiac arrest? Actually no: another massive US cardiac outcomes study looks at the results of introducing automated defibrillators on to the wards of 204 hospitals and finds that results actually tend to be worse.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2129
2137 The harmful effects of low-dose ionizing radiation are not well understood, but from about 100mSv upwards we are no longer talking about low doses, but the kind of exposures about which we have data from Hiroshima and Nagasaki. Alarmingly, such doses were received by a third of patients in this study of repeated myocardial perfusion scanning. OK, the majority of these people were over 60 and had heart disease, and would escape long-term harm: but it suggests that we are getting too gung-ho about exposing people to high energy photons from X-ray machines and unstable isotopes, and the cumulative damage which they cause.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2137

Lancet 20 Nov 2010 Vol 376
1741 Many doctors in the 1990s went through a phase of taking low dose aspirin and recommending it to many of their patients with high blood pressure and/or type 2 diabetes. Then came a series of trials which showed that it doesn't work for primary prevention of cardiovascular events, even in groups who are at increased risk. But it does prevent about 25% of bowel cancer, according to this long-term follow up study of participants in 5 large aspirin trials, matched at a median of 18.3 years with mortality registers. The results suggest that you need to take about 75mg of aspirin for at least 5 years to achieve such protection, and the effect may be specific to the proximal colon. Thus in theory universal aspirin consumption, combined with a universal programme of screening sigmoidoscopy, could prevent most bowel cancer. However, an analysis like this can tell us little about adverse events, and we will only know for certain after a prospective trial lasting at least ten years.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61543-7/abstract

ANGINA MONOLOGUES

2010-11-15T15:15:00.005Z

Beat heart disease with the Angina Monologues

Many of you will have been affected by heart disease and we hope that Heart Matters has provided you with the support and information you need.

It's surprising that people still think of heart disease as a 'male disease' and don't know that it affects women too. The reality is, heart and circulatory disease kills one in three men AND one in three women.

We want to challenge the stereotype that only men get heart disease so we're raising awareness through an exciting one-off night of comedy, the Angina Monologues.

Hosted by BAFTA award winning comedian Victoria Wood, the Angina Monologues will be a star-studded event where Victoria's guests will give us their unique take on affairs of the heart. And you could be at the live show!

We're offering Heart Matters members the chance to win FREE tickets to the show on Sunday 5 December at the Theatre Royal Haymarket in London.

Enter now to be in with a chance of winning a pair of tickets.

If you'd like to guarantee your seats, buy tickets to the live show or to a screening at vue cinema.

Find out more about the Angina Monologues.

Best wishes,

Smitha

The Heart Matters team

JOURNAL SNIPPETS November 2

2010-11-15T14:25:00.006Z

JAMA 11 Nov 2010 Vol 304
2028 It's not often that you see a paper in JAMA written by a real working British GP - so congratulations to Louis Levene from Leicester for an excellent study that seeks to inform US practice by showing what happens to coronary heart disease mortality in relation to the recorded characteristics of individual primary care trusts. This was quite a statistical feat in itself, but would have been even more useful had it been done on an individual practice basis - after all, the data are out there, literally for all to see. Anyway, rejoice: CHD in the UK has fallen by nearly a half in the last decade, and although there are regional variations, these are not due to variations in the quality of general practice, except in the detection of high blood pressure, which could easily be remedied.
http://jama.ama-assn.org/cgi/content/abstract/304/18/2028

2059 A neat Commentary piece discusses the dilemmas of interventional cardiology in the light of the COURAGE and SYNTAX studies which show that medical treatment is as effective as percutaneous coronary intervention for stable coronary artery disease. When the first study appeared in 2007, interventional cardiologists were asked if they would now have the conviction of their COURAGE and stop putting stents into every stenosis they happened to see at angiography - what has been described as the "oculo-stenotic reflex". All immediate stenting is lumped together as "ad hoc PCI" and accounts for more than 80% of PCI in the USA; done for acute syndromes, it is generally appropriate, but in other situations, often not. This is a thoughtful, balanced discussion which however tactfully bypasses one factor which may keep ad hoc PCI going in the USA - money. There may be a double incentive - patients and HMOs may want to save the cost of a second angiography; and cardiologists and their institutions may just want the extra dollars they get for putting in a stent there and then. This piece argues that there where there is clinical doubt there should always be informed patient decision-making, even if this means taking a two-week pause between the diagnostic angiogram and the procedure.
http://jama.ama-assn.org/cgi/content/extract/304/18/2059

Lancet 13 Nov 2010 Vol 376

1658 A huge trial called SEARCH was set up in Oxford in 1998 in the hope of demonstrating that 80mg of simvastatin would be better than 20mg at preventing further coronary events in survivors of MI, and that additional benefit would result from lowering homocysteine. In fact it has shown neither. The high dose simvastatin group showed a 26-fold increase in significant myopathy, an expected fall in lipid cholesterol (LDL-C), but no significant difference in vascular events at a mean of 6.7 years. Yet in the summary this is taken to mean that high dose simvastatin is preferable, since that fits into a general meta-analysis of statin trials on p.1670. Although medicine has been taught alongside logic in Oxford for 850 years there is still room for improvement. Consider the following three statements:
- there is a continuous association between the observed level of LDL-C and coronary heart disease (CHD)
- all statin drugs lower LDL-C
- all statin drugs lower CHD in the same proportion that they lower LDL-C.

Does it therefore follow that:
(1)statin drugs lower CHD entirely by means of lowering LDL-C
(2) all drugs that lower LDL-C will lower CHD to the same degree as statins?
It would be good to think that any canny medieval Oxford schoolman would immediately answer no to both deductions, or rather "quod non erat demonstrandum".

In the case of (1), the best we can say is that this is a reasonable hypothesis, but a hard one to test. In the case of (2) we can say that this is a weak hypothesis, since every drug class has a mixture of actions, and so far no LDL-C lowering drugs other than statins have been shown to lower CHD. Nor should we prescribe them until they have. But the writing committees of these two studies, sharing a number of Oxford notables, behave more like theologians than logicians. LDL-cholesterol to them is an infallible surrogate, and anything that lowers it must be good, even though they have only studied statins. It's enough to make you want to burn your gown. As for The Lancet: this is the second time in two weeks that they've let triallists write a summary which misrepresents the result of trial which was negative for its primary end-point (SEARCH this week, VITAL last) - not good enough.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60310-8/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61350-5/abstract

BMJ 13 Nov 2010 Vol 341
1034 Do you like PROMs? When I was 16, I didn't mind queuing for tickets outside the Albert Hall and standing in the top gallery, but now being older, if you buy tickets on-line you can sit down and actually hear the players. This abbreviation also applies to patient-reported outcome measures, of the kind looked at in the context of heart failure. Suddenly these kinds of PROMs have become fashionable politically and get repeated mention in the White Paper "Liberating the NHS" - although they were never designed for service development but as end-points for clinical trials. Their quality and relevance varies widely, as you learn rapidly. This ground-breaking study devised an instrument with a high degree of inter-observer agreement to allow the assessment of PROMs in cardiovascular trials. Suffice to say that in many of the trials where they appear, they are used badly or irrelevantly, while in 70% of trials where they should appear, they don't.
http://www.bmj.com/content/341/bmj.c5707.full

Arch Intern Med 8 Nov 2010 Vol 170
1834 Delay From Symptom Onset to Hospital Presentation for Patients With Non–ST-Segment Elevation Myocardial Infarction. If you're a veteran scanner of titles in the US cardiovascular outcomes literature, the next thing you'll look for is the name of Harlan Krumholz in the authors list - ah yes, there it is, and so too is the name of Brahmajee Nallamothu, co-author of the thoughtful commentary piece on PCI in this week's JAMA. As a result of their work, and that of Henry Ting and John Spertus, who also appear in the credits, we know a huge amount in great detail about the workings of acute cardiology in the USA, despite the great variety of institutional arrangements. As a result of this exercise, for example, we know the exact time delay and clinical characteristics of 104 622 patients admitted to 568 US hospitals with NSTEMI - and realise that there has been no reduction in the delay time between 2001 and 2006. http://archinte.ama-assn.org/cgi/content/abstract/170/20/1834

1842 Now the interventional trials for ST-Elevation MI tell us that time means myocardium, so great efforts have been made in the US as in the UK to ensure that door-to-balloon time should be as short as possible. But what have we here? A study of 8771 patients admitted to a Michigan hospitals group between 2003 and 2008 which shows that although door-to-balloon time improved dramatically, outcomes remained the same. More data from UK studies quickly please: and since we do not have 568 acute hospitals and they all belong to one organisation, this should be a piece of cake compared with Harlan's work.
http://archinte.ama-assn.org/cgi/content/abstract/170/20/1842

1858 From time to time, serious medical journals like to publish pieces about chocolate, which are sure to get them a mention in the global news media. This research letter also involves women, thus allowing journalists to trot out their very funny jokes about the dear ladies and their chocolate. A group from Perth, Australia followed up a female cohort for 10 years to examine the effect of calcium supplements, and happened to ask about chocolate intake in their questionnaire. Here they report that chocolate consumption seems to have a dose-related protective effect against vascular disease in women. Ooh, come on girls, have another. http://archinte.ama-assn.org/cgi/content/extract/170/20/1857

JOURNAL SNIPPETS November

2010-11-10T09:06:00.005Z

JAMA 3 Nov 2010 Vol 304
1950 Heart failure research in the mid-1990s was to discover that a lot of elderly patients with obvious clinical heart failure had high levels of B-type natriuretic peptide but a normal systolic ejection fraction. British cardiologists said there is no such thing as "diastolic heart failure" and treasonable talk of this kind would stop people having echocardiograms and taking the maximal doses of ACE inhibitors and beta-blockers that real heart failure requires. A provisional understanding of this kind of heart failure is not based solely on events in diastole but also to stiffening of the main capacitance arteries. It is extremely common in people over 75 and we don't know how to treat it, partly because cardiologists and drug companies remain uninterested; as this short commentary on "age disparities in heart failure research" points out.
http://jama.ama-assn.org/cgi/content/extract/304/17/1950

Ann Intern Med 2 Nov 2010 Vol 153
553 With stockings, the longer the better. This is not merely a fetishist preference, but carries the imprimatur of the Medical Research Council of the United Kingdom, the Chief Scientist Office of the Scottish Government, and Chest Heart and Stroke Scotland, the funders of the CLOTS trail collaboration. This clottish acronym is derived from Clots in Legs Or sTockings after Stroke. The subjects were 3114 patients in 112 hospitals (no, they don't have that many in Scotland - the trial covered 9 countries) immobilized by stroke. They were randomised to have below-knee or thigh length compression hose. The latter had fewer clots in their proximal deep veins.
http://www.annals.org/content/153/9/553.abstract

587 Eight Italian meta-analysts go to work on the trials of prophylactic implantable cardioverter-defibrillators. These expensive devices often malfunction with shocking consequences but they probably save a few younger patients from sudden death. But in people of sixty and over - called "elderly" by these authors, perhaps through a limited knowledge of the English language - there is no clear evidence of benefit. Purchasers of care, take note, and do not be duped by interventional cardiologists: biventricular pacing saves lives but putting in an ICD at the same time is usually wrong.
http://www.annals.org/content/153/9/592.abstract

JOURNAL SNIPPETS

2010-10-27T09:27:00.005+01:00

JAMA 20 Oct 2010 Vol 304
1693 There was a time when the professor of surgery wouldn't know the names of his immediate juniors, and surgeons who regularly made their nurses cry and threw instruments in theatre. For a few young men, these became heroic role models: the rest were put off surgery for life. "There is insufficient information about the effectiveness of medical team training on surgical outcomes," according to this study of team training in US Veterans' hospitals. They found that such training brought about a 50% fall in mortality rates. Further studies should include Kleenex counts among operating room staff.
http://jama.ama-assn.org/cgi/content/abstract/304/15/1693

NEJM 21 Oct 2010 Vol 363
1597 There is probably at least one patient with aortic stenosis who is considered too poor a surgical risk for open valve replacement and who will therefore become increasingly symptomatic and die within a couple of years. In the future, such patients will face a difficult choice: whether to go for trans-catheter aortic valve replacement, which involves a bovine valve being implanted via a femoral artery catheter and expanded with a balloon. This is as tricky as it sounds and carries a 5% risk of stroke and a 16% risk of major vascular complications; on the other hand, in this randomised study (TAVI) 70% of the patients randomised to catheter valve replacement were alive at one year compared with 50% of those randomised to standard treatment (which could include balloon valvuloplasty). http://www.nejm.org/doi/full/10.1056/NEJMoa1008232

1608 About ten years ago, The Lancet (less pompous in those days) published a picture of a piece of glass at an angle of 45 degrees with trickles of blood running down it. This was a patient's way of measuring his own INR while taking warfarin on a trip to remote China. Nowadays there are expensive home testing kits which do the same thing. Here is a trial that compares weekly home testing with monthly standard lab testing in patients taking warfarin for atrial fibrillation or valve replacement. Fortunately it was funded by the Department of Veterans Cooperative Studies Program, rather than a diagnostics company, and it concludes quite simply that "These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy." If a testing kit manufacturer had paid for it, it probably would have read "Self-testing shows significant benefits in time within target INR range and patient satisfaction, with no increase in stroke, major bleeding episode or death.
http://www.nejm.org/doi/full/10.1056/NEJMoa1002617

Lancet 23 Oct 2010 Vol 376
1393 When you see the title of this paper: A multilocus genetic risk score for coronary heart disease: case-control and prospective cohort analyses, you will need to read right though it, because the abstract is of little help. "Using a genetic risk score based on 13 SNPs associated with coronary heart disease, we can identify the 20% of individuals of European ancestry who are at roughly 70% increased risk of a first coronary heart disease event." But what the Finnish investigators discovered was a difference of 70% between the lowest and highest quintiles in their gene-carriage score, which is not the same thing at all: it probably means a risk increase of about 30% compared with the mean. And factoring in these SNPs adds nothing to existing cardiovascular risk scores. The vast amount of work these investigators put in to this analysis of the FINRISK and COROGENE cohorts seems doomed from the start: as the accompanying editorial states, "it seems unlikely that genomic risk prediction alone will attain the discriminatory resolution to predict individual disease-risk for many common diseases with only modest heritability." In other words, if a disease isn't already strongly predictable from family history, trawling through billions of gene pairs to identify candidate SNPs and doing case-control studies to achieve p values of less than 10-6 is likely to be a waste of time. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61267-6/abstract

JOURNAL SNIPPETS

2010-10-20T12:31:00.003+01:00

JAMA 13 Oct 2010 Vol 304
1559 Cardiac surgery was once considered too bloody even to contemplate: now it is commonplace. But there is still no agreement in practice about how much blood should be transfused following heart surgery - rates of transfusion vary between 8% and 93% in similar units across the USA (p.1586). The Brazilian TRAC trial randomised heart surgery patients to be transfused to achieve a target haemoglobin level of 10.5 g/dl in one group and 9.1 in the other. Outcomes were identical. An accompanying editorial is entitled "Blood Transfusion as a Quality Indicator in Cardiac Surgery." Enough said.
http://jama.ama-assn.org/cgi/content/abstract/304/14/1568 http://jama.ama-assn.org/cgi/content/abstract/304/14/1559

Lancet 16 Oct 2010 Vol 376
1303 A nice clear NHS-based study shows that the results of renal transplantation are equally good from kidneys donated after cardiac death as from those donated after brain death. The most important factor is not the mode of death but the cold ischaemia time.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60827-6/abstract

Arch Intern Med 11 Oct 2010 Vol 170
1622 A decade ago, much hope centred on the fact that levels of homocysteine correlate well with cardiovascular risk, and so it followed (we thought) that using B vitamins to lower homocysteine was bound to be a simple and effective way to reduce the population risk. One person talked to years ago about possible primary care studies was Robert Clarke, now principal author of this meta-analysis of 8 big randomised trials. Every trial succeeded in lowering Hcy but utterly failed to make any impact on cardiovascular outcomes, cancer, or all-cause mortality. You can't push some risk curves the other way by known interventions - as we've also found with a wide range of blood sugar.
http://archinte.ama-assn.org/cgi/content/abstract/170/18/1622

HEART TO HEART

2010-10-19T11:43:00.001+01:00

Heart to Heart Conference
Education and information to help save lives
Saturday October 23rd 2010
Royal College of Pathologists
2 Carlton House Terrace, London SW1Y 5AF

The cardiac charity SADS UK is holding their Heart to Heart Conference to educate and inspire attendees who may come into contact with families and individuals living with inherited cardiac conditions or who may have been affected by a Sudden Arrhythmic Death (SAD).

The many facets of how people can be identified and treated will be discussed by cardiologists and professionals in emergency care. Heart monitoring to identify abnormal heart rhythms and defibrillators in the community will be discussed.

Key speaker Dr Jasmeet Soar, the Chairman of the Resuscitation Council UK will provide important updates in emergency care and Mark Whitbread, Clinical Director of the London Ambulance service will speak of his work in emergency care.

Eminent cardiologists presenting include Dr Perry Elliott Specialist Cardiologist from the Heart Hospital, London; Dr Jan Till, Consultant Paediatric Electrophysiologist from the Royal Brompton Hospital, London and Dr Dominic Abrams, Consultant Cardiologist, Barts and the London. Updates on cardiac conditions that may be inherited and need careful management will be discussed as well as how children are treated. Several families affected by inherited cardiac conditions and SADS will speak about their experiences and how they have overcome the challenges they’ve faced.
Attendees will learn more about the cardiac pathology network and the SADS Database. Christine Hurst the Chair of the Coroners Officers Association will give the Association’s perspective with regard to the new Coroners Reform.
SADS UKs Heart to Heart Conference will be of great value to Families, Nurses, Doctors, Ambulance Personnel, First Aid trainers, First Responders, Coroners, Coroners Officers, Pathologists and other personnel who’d like to know more about Inherited Cardiac Conditions and SADS.
Contact SADS UK for the complete agenda and booking form.
Tel: 01277 811215 or email: info@sadsuk.org for further information

DIABETES

2010-10-14T09:34:00.005+01:00

New evidence supports diabetes guidance

Overview: Diabetes mellitus is the most common endocrine disease affecting more than one million people in the UK. Type 2 diabetes is defined by high blood glucose and is characterised by an increased risk of problems including coronary, cerebrovascular, ophthalmological and renal disease. In addition to encouraging a healthy lifestyle and modifying levels of blood pressure and lipids, Good care for people with diabetes involves lowering blood glucose in order to reduce the risk of complications. In addition management of blood pressure and lipids can help control associated risk factors.

Current treatment: To help control risk factors associated with type 2 diabetes, for management of blood lipids NICE recommends initiating therapy with generic simvastatin (up to 40 mg daily) or a statin of similar efficacy and cost unless the cardiovascular risk from non-hyperglycaemia related factors is low and to only consider prescribing a fibrate as well if triglyceride levels remain high.

New evidence: The ACCORD study (N Eng J Med 362: 1563 – 1574) looked at risk-factor control in type 2 diabetes. The study group investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus who were at high risk for cardiovascular disease.
More than 5,500 patients who were being treated with open-label simvastatin for type 2 diabetes were randomly assigned to receive either masked fenofibrate or placebo.The study found no significant difference in outcomes between patients receiving simvastatin 40mg daily plus fenofibrate, and those receiving simvastatin 40mg daily plus placebo. It therefore suggests that the addition of fenofibrate causes neither a great risk nor a benefit.
The ACCORD group also looked at the effects of intensive blood-pressure control in type 2 diabetes and found no significant difference in outcomes between patients targeting 140 mmHg systolic blood pressure and those receiving more intensive therapy – with a target level of 120 mmHg. It therefore suggests that the recommended target level should not be lowered.Both outcomes support current NICE guidance.

Commentary: This new data from the ACCORD study supports current NICE guidance on blood pressure and lipid management in people with type 2 diabetes (NICE CG 66/87 ) .
NICE Guidance is to aim for a systolic blood pressure at or less than 140 mmHg in most people and to aim for a level of at or below 130mmHg only in those who have kidney, eye or cerebrovascular damage.
It also supports current NICE guidance on lipid therapy in type 2 diabetes where fibrates are not recommended to be used routinely. NICE suggests that they are only used in people who have a significantly raised triglyceride level despite maximal tolerated dose of effective statin.
This data from ACCORD can also be said to be compatible with current QOF diabetes clinical indicators for blood pressure and lipids". – Dr Roger Gadsby is the clinical lead for NHS Evidence – diabetes For more evidence on diabetes visit NHS Evidence – diabetes

ANNUAL EVIDENCE UPDATE - HEART FAILURE

2010-10-05T09:56:00.002+01:00

Annual Evidence Update on Heart Failure (NHS Evidence – cardiovascular)

Following on from the partial update of NICE's Heart Failure guidelines in August 2010 and our last evidence update in October 2009 this update for health professionals and patients will present significant advances in knowledge about heart failure. Topics include diagnosis, pharmacology, organisation of care, devices, rehabilitation, palliative care and psychology. There is also a section on uncertainties identified and, as usual, expert summaries are included to help make sense of the new evidence presented.
Find out more at http://www.library.nhs.uk/cardiovascular

The NHS Evidence Specialist Collections have been developed to identify and meet the information needs of particular communities of practice. They are web-based collections containing clinical and non-clinical information on the major health priority areas. Each specialist collection identifies and provides access to quality assessed information of relevance to the community that it serves.
An aspect of this involves the production of Annual Evidence Updates, which aim to highlight the best current evidence for selected healthcare topics. Annual Evidence Updates consist of the good quality evidence from a search of research evidence on a particular topic over a 12 month period, plus user-friendly summaries written by relevant experts, and links to guidelines, secondary research and primary research, if applicable. All information included in Annual Evidence Updates has been subject to rigorous selection criteria

The 2010 Annual Evidence Update on Heart Failure is now available to access from:
http://www.library.nhs.uk/cardiovascular/viewResource.aspx?resid=386325&code=e238fc033d389fbe83e6226eba2688fd

PUBLIC HEALTH NEWS ON CARDIOVASCULAR DISEASE

2010-10-05T09:52:00.002+01:00

Cardiovascular disease

Impact of smokeless tobacco products on cardiovascular disease: Implications for policy, prevention and treatment.
Circulation

Meta-analysis of the effect of comprehensive smoke-free legislation on acute coronary events. Heart and Education

Will cardiovascular disease prevention widen health inequalities?
PLoS Medicine

JOURNAL SNIPPETS

2010-09-21T15:39:00.002+01:00

NEJM 16 Sep 2010 Vol 363
1139 Now to bonnie Scotland, where there was much dismay from sections of the public in 2006 when smoking in public places was banned. We might have expected an immediate benefit to some sections of Scottish society, such as those who smoked in pubs, and there was indeed an immediate drop in myocardial infarction. But what of the wee bairns who generally receive all their second-hand cigarette smoke at home? Well, happily enough they seem to have benefitted too: before the ban, there was a 5.2% annual increase in hospital admissions for asthma in children under 15; after the legislation there was a fall of 18.2% per year.
http://www.nejm.org/doi/full/10.1056/NEJMoa1002861

Lancet 18 Sep 2010 Vol 376
975 There has been a long wait for something to replace warfarin which would avert the need for constant monitoring and so free up an immense amount of clinical time. Sure enough, dabigatran is now with us, but is difficult to get used to it, except perhaps as a patient. The RE-LY trail last year showed that it was as effective at stroke prevention in atrial fibrillation as warfarin at a standard dose, and caused fewer haemorrhagic complications. This substudy shows that the size of the relative benefit relates to the standard of INR control in the warfarin patients. If Boehringer Ingelheim were to set their price for dabigatran at the average cost of warfarin plus all the expenses of INR monitoring, it could make a handsome profit and benefit the whole world.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61194-4/abstract

JOURNAL SNIPPETS

2010-09-15T15:09:00.004+01:00

Lancet 11 Sep 2010 Vol 376
875 Trials of new interventions for heart failure have tended to show diminishing returns in an era when everyone with systolic dysfunction is already on at least an ACE inhibitor (or ARB) and a Î²-blocker if they can tolerate it. This trial recruited over 6500 patients with an ejection fraction under 35% and who either couldn't tolerate a Î²-blocker or else still had a pulse rate over 70 despite taking one. Ivradabine slows the heart rate by a direct action on the sinus node, and in this pretty huge trial it showed a benefit in symptoms and survival which just reached significance for this atypical group.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61198-1/abstract

BMJ 11 Sep 2010 Vol 341
513 This editorial about rosiglitazone started as a personal commentary and finished as a piece written to a tight deadline with two eminent co-authors, both on holiday. Keep thinking, "This is so blindingly obvious, why has nobody said it before?" The point of treating diabetes is not to lower sugar but to prevent vascular harm, so why on earth are we accepting drugs which cause the very thing they are meant to prevent? Why don't licensing bodies demand evidence of vascular benefit before marketing drugs for diabetes, instead of dithering about the exact level of vascular harm ten years after a drug has been licensed? Somebody needs to ask these questions; and quite a few more.
http://www.bmj.com/content/341/bmj.c4805.extract

JOURNAL SNIPPETS

2010-09-09T15:38:00.004+01:00

Lancet 4 Sep 2010 Vol 376
784 The palliation of terminal dyspnoea is a subject is interesting, mainly in the context of heart failure, where many patients are dyspnoeic without substantial reduction in oxygen saturation. Nevertheless they frequently get symptomatic benefit from inhaled oxygen, some to the point of becoming dependent on an immediate oxygen source. For years I heard some of the authors of this study discuss a blinded randomised trial of room air versus oxygen for such patients, not just with those with cardiac dyspnoea but with a range of terminal conditions. And here at last it is: a landmark in evidence-based palliative care, showing that room air works as well as oxygen over a period of a week. However, I can foresee major problems in real life: "Are you trying to kill him doctor? They've delivered a cylinder of compressed air, but Eric needs his oxygen. I told them to take it away."
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61115-4/abstract

BMJ 4 Sep 2010 Vol 341
491 A worthy attempt to meta-analyse the data that exist about the outcomes of nurse-led interventions to improve control of blood pressure. Nurses using algorithm-guided protocols show some success in the USA, especially when they are given prescribing powers. But just what are we doing in hypertension? A recent review I read suggested that it really takes 14 office readings to determine whether a change of treatment is needed. Most of what we do to our patients with raised blood pressure is probably futile, and we urgently need better primary care studies to tell us how to do better.
http://www.bmj.com/content/341/bmj.c3995.full

CARDIOVASCULAR DISEASE

2010-09-03T11:44:00.001+01:00

Cardiovascular disease

Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis
NHS Economic Evaluation Database

CARDIOVASCULAR DISEASE in CHILDREN

2010-08-12T14:40:00.001+01:00

Cardiovascular Diseases:
Physical activity, obesity and cardiometabolic risk factors in 9- to 10-year-old UK children of white European, south Asian and black African-Caribbean origin: the child heart and health study in England (CHASE)
Objective physical activity measurements are used in this study to quantify associations of obesity and cardiometabolic risk with levels of physical activity in south Asian, black African-Caribbean and white European children.

OXYGEN FOR HEART PATIENTS

2010-08-12T10:11:00.005+01:00

Evidence unclear on oxygen use for heart attack

Overview: Coronary heart disease is the leading cause of death in the UK, accounting for a third of all deaths in people aged 35 and over. Myocardial infarction occurs when the flow of oxygenated blood in the heart is interrupted for a sustained period of time. Supplementary oxygen, delivered by a face mask or cannula, is often given to a patient with acute myocardial infarction (AMI) with the rationale that it may improve the oxygenation of the ischaemic myocardial tissue and reduce pain, infarct size and consequent morbidity and mortality.Current treatment: Current evidence neither supports nor refutes the routine use of oxygen for patients with acute myocardial infarction. It is biologically plausible that oxygen is helpful but it is also biologically plausible that it is harmful. NICE recommends oxygen should not be routinely administered to patients with acute chest pain of suspected cardiac origin, but that oxygen saturation levels should be monitored and used to guide its administration. SIGN guidance only recommends oxygen use in hypoxaemia

New evidence: A Cochrane systematic review (Cabello et al 2010 Jun 16;6:CD007160) found three randomised controlled trials comparing the outcomes in patients given oxygen to those given normal air to breathe. It examined whether there was a difference in death, pain and complications.The results reaffirm the current uncertainty of the role of oxygen in patients with myocardial infarction, and the authors call for a large, definitive randomised controlled trial on which clinical practice guidelines can be more confidently based.
Commentary: "The rapid assessment and treatment of a patient with a heart attack is drummed into most medical students very early on in their training. ABC: airway, breathing, circulation. Part of that resuscitation is the delivery of oxygen to patients with a heart attack, mainly due to the fact that the flow of oxygenated blood in the heart is stopped for a period of time."We have moved from one set of guidelines based on expert opinion to another set of guidelines with a different set of recommendations, but the research evidence has not changed. As this recent Cochrane review highlights, there is still no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute heart attack."As the reviewers rightly state, we urgently need a large scale trial to unpick the uncertainty. Potentially, if further research addresses the uncertainty in one direction or another, implications for public health and cost efficiency could be huge." - Carl Heneghan, Director of thNHS Evidence - cardiovasculare Centre for Evidence Based Medicine, GP and clinical lecturer at the University of Oxford.
For more information on evidence relating to cardiovascular health visit .

ECHO

2010-08-06T10:25:00.004+01:00

Top 5 Indicators for Heart Valve Disease via ECHO

An ECHO or echocardiogram is one of the least invasive and most widely used diagnostic techniques that help in evaluating the human heart. It not only helps doctors assess the size and shape of your heart, but also provides information relating to the damage of tissues and heart valve disease. It detects abnormalities in the blood flow through the valves and monitors the motion of the heart wall, thus allowing doctors to determine if heart disease is the cause for any pain felt in the chest region. The top indicators for heart valve disease via ECHO are:
-Heart murmurs: The most prominent indication of heart valve disease is a heart murmur, the term used for an unusual beating rhythm of your heart. While heart murmurs can be heard with stethoscopes too, an ECHO helps determine if the murmur is a sign of heart valve disease or if it is nothing serious. Since most people don’t exhibit symptoms of heart valve disease until they’re older, the ECHO helps determine if there is anything that needs immediate medical attention.
- Abnormal heart valves: An ECHO is the best way to spot aortic valve abnormalities and help doctors determine if the patient is at a high risk for a stroke or heart valve disease. There are three ways in which valves can be defective:
. Regurgitation: When the heart valves do not close tightly when they’re supposed to, blood leaks back into the chambers of the heart instead of flowing through them or into an artery.
. Atresia: When the heart valve lacks an opening for blood to pass through, the heart does not receive the amount of blood needed to function healthily.
. Stenosis: There are times when the flaps of a heart valve become thick, stiff or fuse together. This prevents the valve from opening completely and letting enough blood flow through into the chambers and the arteries.
-Infection around the heart valves: Also known as infectious endocarditis, this is a condition where bacteria enter the bloodstream through certain medical procedures and settles on damaged heart valves. As the infection grows, it may cause clots that could even break off and travel through the blood to the brain, lungs, spleen and kidney. An ECHO helps identify such conditions and take appropriate remedial action.

Disclaimer: The information provided in this article is general and cannot be construed as medical advice. Please consult your cardiologist or doctor for an accurate assessment of your ECHO or any other health-related advice.

By-line:
This article is contributed by Susan White, who regularly writes on the subject of surgical technician schools. She invites your questions, comments at her email address: susan.white33@gmail.com.

CARDIOVASCULAR DISEASE

2010-08-06T10:15:00.002+01:00

Cardiovascular disease

Effect of smoking cessation advice on cardiovascular disease Centre for Reviews and Dissemination
Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils Centre for Reviews and Dissemination

BLOOD CLOTS

2010-08-04T10:28:00.001+01:00

Venous thromboembolism

Blood clots are the cause of the greatest number of preventable hospital deaths (Lifeblood 2010). Hospital-acquired blood clots claim an estimated 25,000 deaths each year, accounting for one in 10 deaths in hospital (Lifeblood 2010). Evidence suggests that the perception that thrombosis is a condition only affecting older people is false. The Lifeblood charity has obtained data from the Office of National Statistics which show that deaths in the under 50s have reached nearly 3,000 between 2005 and 2008 (Lifeblood 2010). Despite the impact of hospital-acquired and community-acquired thrombosis little direct funding is available to tackle blood clot prevention.

The research evidence around assessment and appropriate prophylaxis of venous thromboembolism (VTE) has been evaluated by NICE (National Institute for Health and Clinical Excellence 2010a) which will also produce a related Quality Standard (National Institute for Health and Clinical Excellence 2010b). The Academy of Medical Royal Colleges (2010) has pledged to reduce the number of avoidable deaths from VTE in the UK. The joint action recommended by the Department of Health, strategic health authorities and professional leads includes assessment of risk in primary care at time of referral to hospital. It also recommends setting systems to ensure VTE assessment, regular audit of patients risk-assessed for VTE, and reinforcement of the importance of VTE through educational programmes (Academy of Medical Royal Colleges 2010; Keogh 2010). The RCN's patient safety resource will provide a place for material about VTE which will be updated as the RCN's contribution to the UK wide programme progresses.

The RCN has mapped available UK learning and development material on VTE: http://www.rcn.org.uk/development/practice/patient_safety/vte

NHS EVIDENCE

2010-07-21T10:16:00.010+01:00

This month (July) Eyes on Evidence highlights new evidence in emergency stroke treatment, lifestyle measures to reduce cardiovascular risk and effective ways to put evidence into practice.NHS Evidence provides access to more than 150 reliable evidence sources. This month we focus on UK Database of Uncertainties about the Effects of Treatments (UK DUETs), explaining how to use it and what kind of information you can expect to find.The current economic climate has focused our minds on the need for increased financial efficiency. The QIPP collection highlights practical examples of how NHS organisations are both cutting costs and improving quality. It showcases what the NHS is already doing well, allowing colleagues to share best practice and deliver successful improvements without having to reinvent the wheel. Each month in Eyes on Evidence we will showcase an outstanding example of local best practice. To start us off we look at the success of Oxford Radcliffe Hospitals' electronic blood transfusion system. To find out how to share your success stories visit NHS Evidence. As always, user feedback is central to the future development of NHS Evidence, so if you have any comments let us know.

Examining the window for emergency stroke treatment

Overview: Stroke is a major health problem in the UK and is estimated to cost the economy around £7 billion per year. Most people survive a first stroke, but often have significant morbidity. More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities.

Current treatment: Early management of stroke aims to avoid or minimise damage to the ischaemic brain. Intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke can improve outcome. NICE recommends alteplase (rt-PA) should be considered for thromobolysis within 3 hours of symptom onset (in line with its marketing authorisation). However, it has been suggested that there is potential benefit of starting alteplase beyond 3 hours from onset.

New evidence: This pooled analysis by Lees et al (Lancet 2010; 375: 1695–703) re-examined the effect of time to treatment with alteplase on therapeutic benefit and clinical risk by adding recent trial data from ECASS III and EPITHET to pooled data from six other trials of alteplase for acute stroke. Treatment was started within 6 hours of stroke onset in 3,670 patients randomly allocated to alteplase or to placebo. Results indicated that treatment should be initiated as soon as possible to maximise benefit. Favourable 3-month outcome was significantly more likely with a shorter interval between symptom onset and treatment. There was no benefit of starting alteplase treatment after 4.5 hours and mortality significantly increased with a longer interval between symptom onset and treatment.

Commentary: "Lees et al confirm the view that treatment benefit outweighs risk beyond the current 3 hour window from stroke onset, to 4.5 hours. After 4.5 hours, mortality rises with treatment, a fact not wholly explained by intracranial haemorrhage. The evidence favours extending the treatment licence to 4.5 hours, as this will increase the probability of a good outcome and potentially increase the number of patients who might benefit. But the authors rightly emphasise the point that such an extension in the 'time window' for thrombolysis should not lead to a more relaxed approach to hyper-acute stroke management. Their analysis shows that the greatest benefit comes from earlier treatment – 'time is brain'." - Dr Lionel Ginsberg, Clinical Lead, NHS Evidence – neurological; and Prof Tom Quinn, Clinical Lead NHS Evidence - cardiovascular, stroke and vascular.For more information on evidence relating to stroke visit NHS Evidence – stroke.

Can brushing teeth cut your cardiovascular risk?

Overview: In the UK, nearly three million women and three million men are living with the disabling effects of cardiovascular disease, which includes heart disease and stroke. More than 40,000 people die from premature cardiovascular disease each year. Overall, cardiovascular disease costs the UK approximately £30 billion annually.

Current treatment: Cardiovascular disease is a largely preventable condition that can be effectively tackled by making simple changes to diet, stopping smoking and increasing physical activity. NICE has recently published public health guidance on 'Prevention of cardiovascular disease', which aims to tackle this issue using a population-based approach.

New evidence: A study by de Oliveira et al. (BMJ 2010;340:c2451 doi:10.1136/bmj.c2451) examined if self-reported toothbrushing behaviour was associated with cardiovascular disease and markers of inflammation (C-reactive protein) and coagulation (fibrinogen).A population-based survey drew a nationally representative sample of nearly 12,000 people in Scotland, with an average age of 50. Oral hygiene was assessed using self-reported frequency of toothbrushing and surveys were linked prospectively to clinical hospital records. There were 555 cardiovascular disease events over an average 8 years follow-up, with coronary heart disease thought to be responsible for about three out of four of these. Poor oral hygiene seemed to be associated with higher levels of risk of cardiovascular disease and low grade inflammation. Participants who never or rarely brushed their teeth had a significantly greater risk of a cardiovascular disease event and higher concentrations of C-reactive protein and fibrinogen.
Commentary: "It is important for dental health that people brush their teeth regularly. A recent study in the BMJ suggests that those people who brush their teeth regularly are also less likely to suffer from cardiovascular disease in the future. However, there is no evidence of a causal link between teeth brushing and the development of cardiovascular disease. As the authors themselves discuss, residual confounding by social class and/or healthy lifestyle is likely to have had a major impact on the results." - Dr Jackie Price, Clinical Senior Lecturer in Epidemiology and Public Health, University of Edinburgh.

For more information on evidence relating to cardiovascular health visit NHS Evidence - cardiovascular.

DARE

2010-07-21T10:08:00.003+01:00

Blood pressure lowering treatment for preventing stroke recurrence: a systematic review and meta-analysis
Click here to go to the complete record
Bibliographic details:
Lakhan SE, Sapko MT. Blood pressure lowering treatment for preventing stroke recurrence: a systematic review and meta-analysis. International Archives of Medicine 2009; 2(1):30

Status: This record is a structured abstract produced by CRD. The original has met a set of quality criteria. Since September 1996 abstracts have been sent to authors for comment. Additional factual information is incorporated into the record. Noted as [A:....].

CRD summary: The authors concluded that blood pressure lowering agents reduced the risk of subsequent stroke and cardiovascular events, but not myocardial infarction or all-cause mortality in patients who had experienced a transient ischaemic attack or stroke. In light of significant statistical heterogeneity and the unclear quality of the included trials, the authors' conclusions should be treated with caution.

Indexing status: Subject indexing assigned by CRD

Index terms: Antihypertensive Agents /therapeutic use; Blood Pressure /drug effects /physiology; Humans; Recurrence /prevention & control; Risk Reduction Behavior; Stroke /prevention & control
Publication Date: 16 Jun 2010
Publication Type: Structured Abstract
Publisher: Centre for Reviews and Dissemination
Source: Database of Abstracts of Reviews of Effects
Creator: Centre for Reviews and Dissemination

Keywords
Antihypertensive Agents /therapeutic use
Blood Pressure /drug effects /physiology
Humans
Recurrence /prevention & control
Risk Reduction Behavior
Stroke /prevention & control
Topics
Stroke
Secondary Prevention
The following specialist collections also reference this resource
Neurological conditions
Stroke

NICE STANDARD FOR STROKE

2010-07-21T09:59:00.002+01:00

Quality standard for stroke
Link to full text here, Portable Document File / PDF
Aims: This quality standard covers care provided to adult stroke patients by healthcare staff during diagnosis and initial management, acute-phase care, rehabilitation and long-term management of stroke. It provides specific, concise quality statements, measures and audience descriptors.
Intended audience: Patients and the public, health and social care professionals, commissioners, service providers.
Publication history information: Published 28 June 2010. A provisional review date for this quality standard is June 2013.
Access: Available to the general public.
Publication Date: 28 Jun 2010
Publication Type: Service Guidance
Publisher: NICE
Next Review Date: 28 Jul 2013
Email Address
nice@nice.org.uk

View the entry in its "home" collection: National Library of Guidelines

Related Links
Link to full text here, Portable Document File / PDF
Index page
Patient Information
Cost impact and commissioning assessment
Slide set
Commissioning guide
Audit support
Keywords
Brain
Bladder
Care
Emergency
Procedures
Training
Transient Ischaemic Attack (TIA)
Treatment
Topics
Stroke
The following specialist collections also reference this resource
Stroke

SNIPPETS FROM JOURNAL WATCH

2010-07-21T09:20:00.005+01:00

NEJM 15 July 2010 Vol 363
245 If anything can cause a company's profits to BLOOM, it's a new obesity drug. The BLOOM (Behavioural Modification and Lorcaserin for Overweight and Obesity Management) trial was funded by Arena Pharmaceuticals, who will be hoping for vast returns on the latest drug to target the serotonin receptor. Those with supernaturally good memories and profound knowledge of clinical pharmacology (OK, you can put your hand down, Jeff Aronson) will remember that there are actually three such receptors and that previous anti-obesity drugs such as fenfluramine and dexfenfluramine targeted them non-specifically. They worked fairly well for appetite suppression but were withdrawn because they could cause valvular heart defects and pulmonary hypertension. This is because cells around the heart valves and in the pulmonary vasculature contain 5HT2B receptors whereas the receptor you need to hit for appetite suppression is 5HT2C. Lorcaserin is powerfully specific for this receptor and Arena went out of their way to check their trial subjects regularly with echocardiograms which prove that it doesn't cause heart valve problems in the first two years. Whereas it certainly does help people lose weight and will be advertised as blooming wonderful if and when it gets it licence. http://content.nejm.org/cgi/content/abstract/363/3/245

266 In reviews of acute pulmonary embolism I look for two things: mention of it as a common cause of exacerbations in heart failure and COPD, and guidance about which patients need long-term anticoagulation. This article by two Italian authors doesn't fully satisfy either criterion. There's little mention of HF or COPD and although they say that "extended treatment requires a reassessment of the patient's risk-benefit ratio at periodic intervals" they fail to tell us how to calculate these risks and benefits.
http://content.nejm.org/cgi/content/extract/363/3/266

Lancet 17 July 2010 Vol 376
163 Droves of healthy people come to see doctors all year round to have blood pressure checks. If it's off target, their GP sees them every few weeks to make adjustments. Neither the timing, the place nor the health professional involved reflects any real logic. This ground-breaking study (TASMINH2) addresses these realities by passing management to the patient whose blood pressure is monitored at home with a reliable automatic device linked by an automated modem to the GP practice. If it remains high, the patient is given advice and if necessary additional drug treatment to reduce it. The group randomised to this intervention showed usefully better control of systolic BP at the end of a year. If this technology became widespread, we would save many GP appointments and improve control in most of our hypertensive patients.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60964-6/abstract

Lancet 10 July 2010 Vol 376
112 Exercise will also help you avoid a stroke; alcohol alas will not. Most of the other risk factors for stroke identified by the INTERSTROKE study are the ones you might expect, and the ten main ones account for nearly 90% of the risk. The oddest feature is the role of body mass index: when corrected for other factors, a high BMI actually seems protective, whereas a high waist-to-hip ratio is a substantial risk factor.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60834-3/abstract

NEJM 1 Jul 2010 Vol 363
36 Implantable cardioverter-defibrillators often go wrong due to lead failure, and they can lead to shockingly bad ends in heart failure. This trial assesses a new type of ICD which does not rely on venous access but is entirely subcutaneous, delivering shocks to the thorax close to the heart. Its success depended a lot on accurate positioning, and over the ten months of the trial it worked well and appropriately, though it's too soon of course to say anything about long-term reliability, let alone long-term mortality benefit.
http://content.nejm.org/cgi/content/abstract/363/1/36

1037 The well-conceived new Archives series called LESS IS MORE here lives up to its radical credentials: we are giving diabetic patients too many drugs for cardiovascular protection. Again, this flies in the face of what we have been taught over the last few years. It also seems to fly in the face of the calculation done by these authors that treating to targets for LDL-cholesterol and blood pressure results in gains of 1.5 and I.35 quality-adjusted years respectively. But they demonstrate that these overall gains are largely accounted for by the treatment of a small number of very high-risk individuals, and that the more drugs you put in, the more you are likely to achieve minimal benefit or actual harm. A key paper in the continuing debate about targets in type 2 diabetes.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1037

Arch Intern Med 28 Jun 2010 Vol 170
1024 If in doubt prescribe statins. Among patients with known cardiovascular disease, it is very hard to find any benefit once heart failure has set in. But prescribing statins to high-risk patients for primary prevention may be futile, according to this literature-based meta-analysis. It is a very hard paper to follow, however, with a fairly heterogeneous mix of studies which are not adequately characterised or analysed in these six pages: to do that would require twice the length, or ideally an entire database, which could then be analysed on an individual patient basis...
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1024

1032 The JUPITER trial of rosuvastatin was stopped early and has been a source of controversy ever since. The acronym stands for Justification for the Use of Statins in Primary Prevention, but when JUPITER's data are fed into a meta-analysis like the one we've just seen, there is no such Justification. In fact the data of this trial are internally contradictory in a way that strongly suggests manipulation, according to this critical reappraisal, which suggests that Jove's ire should be directed at the role of commercial sponsors.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1032

1037 The well-conceived new Archives series called LESS IS MORE here lives up to its radical credentials: we are giving diabetic patients too many drugs for cardiovascular protection. Again, this flies in the face of what we have been taught over the last few years. It also seems to fly in the face of the calculation done by these authors that treating to targets for LDL-cholesterol and blood pressure results in gains of 1.5 and I.35 quality-adjusted years respectively. But they demonstrate that these overall gains are largely accounted for by the treatment of a small number of very high-risk individuals, and that the more drugs you put in, the more you are likely to achieve minimal benefit or actual harm. A key paper in the continuing debate about targets in type 2 diabetes.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1037

NICE GUIDELINES

2010-07-13T10:07:00.001+01:00

Prevention of cardiovascular disease

http://guidance.nice.org.uk/PH25

JOURNAL SNIPS

2010-07-05T15:37:00.003+01:00

This week includes abstracts from the NEJM and Archives of Internal Medicine

NEJM 1 Jul 2010 Vol 363
36 Implantable cardioverter-defibrillators often go wrong due to lead failure, and they can lead to shockingly bad ends in heart failure. This trial assesses a new type of ICD which does not rely on venous access but is entirely subcutaneous, delivering shocks to the thorax close to the heart. Its success depended a lot on accurate positioning, and over the ten months of the trial it worked well and appropriately, though it's too soon of course to say anything about long-term reliability, let alone long-term mortality benefit.
http://content.nejm.org/cgi/content/abstract/363/1/36

Arch Intern Med 28 Jun 2010 Vol 170
1024 On to statins .... Among patients with known cardiovascular disease, statins are drugs which are very hard to find any benefit once heart failure has set in. But prescribing statins to high-risk patients for primary prevention may be futile, according to this literature-based meta-analysis. It is a very hard paper to follow, however, with a fairly heterogeneous mix of studies which are not adequately characterised or analysed in these six pages: to do that would require twice the length, or ideally an entire database, which could then be analysed on an individual patient basis...
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1024
1032 The JUPITER trial of rosuvastatin was stopped early and has been a source of controversy ever since. The acronym stands for Justification for the Use of Statins in Primary Prevention, but when JUPITER's data are fed into a meta-analysis like the one we've just seen, there is no such Justification. In fact the data of this trial are internally contradictory in a way that strongly suggests manipulation, according to this critical reappraisal, which suggests that Jove's ire should be directed at the role of commercial sponsors. I can hear the distant peal of thunder across the Atlantic: Jupiter tonans.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1032
1037 The well-conceived new Archives series called LESS IS MORE here lives up to its radical credentials: we are giving diabetic patients too many drugs for cardiovascular protection. Again, this flies in the face of what we have been taught over the last few years. It also seems to fly in the face of the calculation done by these authors that treating to targets for LDL-cholesterol and blood pressure results in gains of 1.5 and I.35 quality-adjusted years respectively. But they demonstrate that these overall gains are largely accounted for by the treatment of a small number of very high-risk individuals, and that the more drugs you put in, the more you are likely to achieve minimal benefit or actual harm. A key paper in the continuing debate about targets in type 2 diabetes.
http://archinte.ama-assn.org/cgi/content/abstract/170/12

PUBLIC HEALTH ARTICLES

2010-07-02T12:04:00.000+01:00

Cardiovascular disease

Prevention of cardiovascular disease at population level NICE

Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey BMJ

NICE GUIDELINES

2010-07-02T09:04:00.001+01:00

In the HSJ today

NICE publishes the first set of quality standards
1 July 2010
Trusts should screen all stroke patients for cognitive impairment within six weeks of diagnosis, according to the first set of quality standards to be published by the National Institute for Health and Clinical Excellence.

ETHNICITY and CARDIOVASCULAR ISSUES

2010-06-25T15:52:00.003+01:00

Cardiovascular Disease:
Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcome
A comparison of out-of-hospital cardiac arrest (OOHCA) characteristics in white and south Asian populations in Greater London.

Emergence of ethnic differences in blood pressure in adolescence: the determinants of adolescent social well-being and health study
Blood pressure is known to track from late childhood to adulthood and this may give some indication to the cause of ethnic differences in cardiovascular disease (CVD). This study explores ethnic differences in changes to blood pressure between early and late adolescence in the UK. A related study investigating the relationship between inflammatory markers and ethnic differences in CVD conducted with infants is available here.
Ethnic differences in blood pressure begin in adolescence
A recent study published in ‘Hypertension’ has discovered that divergences in blood pressure between white and ethnic minority groups begin in adolescence and are “particularly striking” for boys. The study also found that socioeconomic disadvantage had a “disproportionate effect” on blood pressure for ethnic minority girls. The results signal the need for the early prevention of cardiovascular diseases that could have adverse effects in later life, especially for young people of minority ethnic origin.

SNIPPETS FROM JOURNAL WATCH

2010-06-23T11:15:00.006+01:00

Lancet 19 Jun 2010 Vol 375
2161 Golly - here's something you don't often see in The Lancet: a trial puffing a new drug for angina which costs about £20 per year. Nor is it subsidised and ghost-written by the drug's manufacturers, who have probably long ago lost interest in it. Because the drug is our old friend allopurinol, at 600mg daily, used to improve exercise tolerance in ischaemic heart disease as opposed to preventing gout. It's a very small short-term trial, but there seems to be no reason not to give the drug a go - and quite a few reasons to believe that it may be a good thing for the strained myocardium (see editorial on p.2126).
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60391-1/abstract

JAMA 9 Jun 2010 Vol 303
2280 "Does This Patient Have a Haemorrhagic Stroke?" asks the latest in The Rational Clinical Examination Series. "How should I know, I haven't seen the scan" might be the usual answer, and it also turns out to be the correct one. Features like coma, headache, neck stiffness and high blood pressure all make haemorrhage a bit more likely, but the only way to know with sufficient certainty is by putting the patient through a CT scanner, preferably within the window for thrombolysis if the stroke turns out to be ischaemic. This is confirmed by 19 prospectively studies, meticulously analysed here.
http://jama.ama-assn.org/cgi/content/abstract/303/22/2280

NEJM 10 Jun 2010 Vol 362
2155 This study is based on the Kaiser Permanente insured population of California and it tells a pretty amazing tale - ST elevation myocardial infarction has fallen by 62% in the last decade. Interestingly the incidence of non-ST elevation MI went up between 2002 and 2004 as troponin assays became widely adopted as the diagnostic gold standard, but even taking this into account, the incidence of any MI has gone down by a third. During this time, Californians became a bit fatter, did slightly more exercise, were banned from smoking in public places, and were prescribed more statins, beta-blockers and ACE inhibitors. We are not told if they drank more of their sometimes passable wines.
http://content.nejm.org/cgi/content/abstract/362/23/2155

Lancet 12 Jun 2010 Vol 375
2073 From the point of view of someone fixated on the cardiovascular system, the body consists of a central pump supplying blood to various tufts - lung-tufts to oxygenate it, gut-tufts to feed it and kidney tufts to get rid of waste products, and so on. I can see that for some the kidney is an interesting organ, but it's essentially a dangling footnote to the business of assessing cardiovascular risk, and delicious when prepared correctly. Now assessing risk (or prognosis) is itself of little importance unless you can use it to guide interventions to reduce risk. All of which makes it very frustrating to wade through a paper like this which pools data from 14 studies (over 100 000 individuals) to derive risk tables for all-cause and cardiovascular mortality graded by eGFR and albuminuria, independently of blood pressure, cholesterol and smoking. There seems to be a definite association which, surprisingly, is slightly U-shaped when you combine the two factors. So was QOF right to make us identify and check out everyone with an eGFR under 60? That's another question entirely, which depends on how much these factors contribute to total CV risk, and what we can do about it.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60674-5/abstract

JAMA 2 Jun 2010 Vol 303
2141 Acute heart failure is regarded by most members of the public as synonymous with death, and indeed a proportion of patients admitted to hospital with HF do die within 30 days, but this stands at barely more than one in ten, and has hardly changed between 1993 and 2006, dropping from 12.8% to 10.7%. During that time, nearly 7 million Americans covered by Medicare have been to hospital with acute HF, and very little else has changed either: they get discharged a bit sooner, and readmitted slightly more often. A huge, meticulous, well-described outcomes study of this kind inevitably has one looking for Harlan Krumholz; yes, there he is.
http://jama.ama-assn.org/cgi/content/abstract/303/21/2141

2148 The heart failure figures are rather disappointing, whichever way you spin them; but one definite way to reduce HF is to save myocardium by timely reperfusion therapy for acute myocardial infarction. We know this from many interventional trials, of course, but given the immense organisational effort that has gone into providing access to immediate percutaneous intervention for MI, it is nice to have observational evidence from a large population too. Voici QuÃƒÆ’Ã†'Ãƒ" '©bec. In 2006-7, nearly 80% of quÃƒÆ’Ã†'Ãƒ" '©bÃƒÆ’Ã†'Ãƒ" '©cois with ST elevation MI received PCI, but in 68% of cases this occurred after more than 90 minutes. If you look at a map of Canada, you will see why: the province is more than twice the size of France and stretches up and beyond the Arctic Circle. Of those who received thrombolysis, 54% got it later than the ideal 30 minutes. The mortality figures following the two modes of treatment are remarkably similar, but outcomes such as recurrent MI and the need for bypass grafting favour PCI. By contrast, the treatment within the ideal window halves your chance of death within 30 days.
http://jama.ama-assn.org/cgi/content/abstract/303/21/2148

BMJ 5 Jun 2010 Vol 340
1231 The star of this week's BMJ is Julia Hippisley-Cox, professor of primary care in Nottingham, who has used the EMIS database of British general practices to derive an improved cardiovascular risk score (QRISK) and has also (see below) worked out from it what the true risks and benefits of statins are in UK primary care. We are lucky to have such studies to refine our practice, since they apply directly to the population we treat. As she has been working on the two versions of QRISK, Gary Collins and Doug Altman have been dogging her footsteps, and here they publish an independent and external validation of QRISK2. Use it with confidence in British general practice - you won't get a better Good Housekeeping Seal of Approval than this.
http://www.bmj.com/cgi/content/full/340/may13_2/c2442

1233 Allan Struthers has done much of the basic work on BNP and the renin-angiotensin pathway. The end product of this pathway is aldosterone, and the Dundee-led RALES trial published in 1999 showed that by blocking it with spironolactone in patients with chronic heart failure, you could improve outcomes even if they were on other RAS-inhibiting treatments. So off I went and gave some to a few of my HF patients, noting that the RALES trial encountered few problems with hyperkalaemia. I duly checked the electrolytes of one patient a couple of weeks later and sent him straight to hospital with a potassium of 6.8. This alarming event proved to be common enough in Canada, too, according to a paper which appeared in the New England Journal in 2004. But here Allan Struthers et al rebut their critics with data from Tayside, proving that your canny Scots GP can use sprironolactone with perfect safety, laddie, aye perfect safety. As the great poet of the Tay might have put it :Physicians of England and Canada kill their patients with hyperkalaemia; But by the banks of the silvery Tay our doctors behave much more seemlier. W. McGonagall op posth.
http://www.bmj.com/cgi/content/full/340/may18_2/c1768

PUBLIC HEALTH E-ARTICLES

2010-06-02T09:12:00.000+01:00

Cardiovascular disease

The contribution of local policies to cardiovascular and other non-communicable diseases
Liverpool First for Health and Wellbeing Partnership

WEBSITES UPDATE

2010-05-28T14:57:00.005+01:00

As well as those websites already listed here are some more...

National Heart Forum
http://www.heartforum.org.uk/
Membership organisation bringing together organisations dealing with all areas and
risk factors in the field of chronic disease prevention. Information on NHF position
statements and policy work areas is available from the site, along with publications
such as the Healthy weight, Healthy lives toolkit, and the NHF modelling team’s
reports on obesity trends.

Heartstats
http://www.heartstats.org/
The British Heart Foundation’s regularly updated statistics website. Includes a wide
range of statistics on risk factors for chronic disease such as blood cholesterol,
smoking, physical activity and diet.

Blood Pressure Association
http://www.bpassoc.org.uk/
A charity supporting patients as well as healthcare professionals managing
hypertension. The site includes guides to the effects of high blood pressure, available
medication for its treatment and monitoring.

British Hypertension Society
http://www.bhsoc.org/
The British Hypertension Society acts as a medical and research forum for
hypertension. The Society produces guidelines on management of hypertension,
which are available from their site, and also links to NICE guidance.

Heart UK
http://www.heartuk.org.uk/
Website includes resources such as a cardiovascular disease prediction chart, JBS
risk assessor, and links to NICE guidelines and various publications.

JOURNAL SNIPS

2010-05-28T12:47:00.005+01:00

Only a small selection of articles this month

Ann Intern Med 18 May 2010 Vol 152
630 From time to time there has been emerging literature of non-invasive testing for coronary artery disease, and in particular computed tomography coronary angiography. This may grow in importance as stress testing fades away under the new NICE guidelines. But like all tests, its predictive value depends on the pre-test probability, in this case of coronary artery disease. Once again we go to Marvell's Holland to get a good thorough Bayesian analysis of the value of CTCA based on their patients in Rotterdam. They conclude that this kind of imaging is most useful in the intermediate probability range. Those with low pre-test probability can be given the all clear after a negative stress test; those with a high probability should get a proper angiogram.

JAMA 12 May 2010 Vol 303
1841 Mortality from coronary heart disease is falling throughout the developed world, which includes Canada. Here a group of Ontarians examines why that should be, by looking at aggregated data for Ontario between 1994 and 2005 (adults aged 25 to 84). As in previous studies, a model called IMPACT explains the great majority of the decrease by a fall in risk factors - except obesity and diabetes, which move in the opposite direction - and an improvement in treatment. We are getting most of this right, then going home and eating too much and doing too little.
http://jama.ama-assn.org/cgi/content/abstract/303/18/1841

Lancet 15 May 2010 Vol
1695 What is an ecass and what are ninds? Clues: ecass is a word from the lost language of Atlantis, and ninds is an epithet. Possibly. Anyway, set a lot of very eminent researchers to work on ECASS, ATLANTIS, NINDS and EPITHET and you get a good idea of how effective alteplase is when given for stroke. As you might expect, time is of the essence: high odds of benefit (2.55) when given within 90 minutes but no benefit and possible harm when given beyond 270 min. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60491-6/abstract

Arch Intern Med 10 May 2010 Vol 170
804 Stroke medicine is an invention of the last two decades, spearheaded by neurologists in large centres who strove to prove that stroke units provide the best outcomes. It has taken a long time to tease out the processes of care which lead to better survival and better functional outcomes in stroke care, and this paper identifies a new one - detection and treatment of hypoxia. The other two factors which affect survival are attention to swallowing and DVT prophylaxis. It should be perfectly possible for any small hospital with CT scanning, alteplase, and a properly run ward with a good physio service to do as well as a stroke unit.
http://archinte.ama-assn.org/cgi/content/abstract/170/9/804

JAMA 5 May 2010 Vol 303
1699 Pneumococcal vaccination does not reduce the risk of myocardial infarction or stroke in men, thanks to a follow-up study of 84 170 men signed up with Kaiser Permanente in California. But there is evidence from several studies that influenza vaccine protects the arteries of the heart and brain, according to the first sentence of this paper.
http://jama.ama-assn.org/cgi/content/abstract/303/17/1699

CARDIAC SURGERY

2010-05-05T15:55:00.001+01:00

A guide to commissioning cardiac surgical services NHS Improvement March 2010

HEART FAILURE

2010-04-29T08:59:00.004+01:00

New Topics added to DynaMed this Week

Heart failure alternative treatments
Implanted cardiac devices for heart failure

You can sign up to receive this newsletter (Dynamed powered by Ebscohost) by email.

JOURNAL SNIPS

2010-04-28T12:25:00.001+01:00

Ann Intern Med 20 Apr 2010 Vol 152
481 The evidence around population salt intake and the burden of cardiovascular disease is much debated, especially in the USA, where the UK is seen as a successful model for sodium intake reduction - nearly 10% since 2003, according to this article. It presents a cost-effectiveness analysis that concludes : "Strategies to reduce sodium intake in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses." I see, these people would save money by living longer and dying from less expensive diseases? A pinch of salt is called for, I think.
http://www.annals.org/content/152/8/481.abstract

ETHNICITY and CARDIOVASCULAR ISSUES

2010-04-21T10:08:00.002+01:00

Cardiovascular Diseases:
Ethnic differences in cardiovascular risk
Produced by general practitioners for the British Heart Foundation, this fact file explores the ethnic differences in cardiovascular risk in the UK.

Ethnicity and coronary heart disease: making sense of risk and improving care
This is number 16 in the Race Equality Foundation’s “Better Health Briefing” series.

STROKE PATHWAY

2010-04-15T16:11:00.000+01:00

Improving the Stroke Pathway
29th April 2010, London Each year more than 110,000 people in England will suffer from a stroke which costs the NHS over £2.8 billion. In the face of shocking statistics like this it becomes immediately apparent that improving service delivery and patient outcomes across the entire stroke pathway must be a top priority. This must attend event will provide actionable solutions and guidance to the most pressing issues facing stroke professionals. Gain the knowledge and skills necessary for you to improve, streamline and advance your stroke services. Visit www.hsj-stroke.com to secure your place today.

BLOOD PRESSURE

2010-04-15T09:50:00.002+01:00

Rethinking high blood pressure
A recent study (Lancet 2010;375:895–905), suggests that visit-to-visit variation in systolic blood pressure (SBP) and maximum SBP are strong predictors of stroke, independent of mean SBP.Here one of the authors, Professor Peter Rothwell of the Stroke Prevention Research Unit at Oxford's John Radcliffe Hospital discusses some clinical implications of the work.
Hypertension is the most prevalent treatable risk factor for stroke. One in two adults is affected by it, and the risk of being hypertensive during a lifetime is about 90 per cent. Despite this, the underlying mechanisms by which raised blood pressure (BP) can cause cardiovascular disease are poorly understood. Clinical guidelines for the diagnosis and treatment of hypertension focus heavily on average blood pressure.
The dominant hypothesis is that we each have an underlying average 'true' blood pressure, which is difficult to measure precisely, but which accounts for the vast majority of the complications of hypertension, and explains the benefits of BP-lowering drugs. Variability in BP is dismissed as uninformative and 'random', only noteworthy as an obstacle in the measurement of true underlying BP. Under-diagnosis and under-treatment of hypertension is a major, seemingly intractable problem in all healthcare systems. The new research shows that part of the problem is likely to have been under-recognition of the impact of variability in BP on diagnosis in routine clinical practice in primary care. It shows that doctors have to make diagnoses on the basis of BP measurements that often vary substantially from visit to visit.
All current clinical guidelines encourage doctors to ignore variability and occasional high readings and to rely exclusively on the average BP from multiple visits or 24-hour monitoring. The new research shows that increased variability in BP, a high maximum BP and episodic hypertension are associated with high risks of stroke and other vascular events, and emphasise that any reassurance taken from the fact BP is sometimes normal is false.Importantly, the new research shows that excess variability in blood pressure is treatable, and also that it can be made worse by some drugs used to treat hypertension. Some BP-lowering drugs increase variability, some have no effect and some decrease it. The choice of drug or combination should now therefore take into account their likely effect on variability as well as on the average level. Future drug trials should routinely report effects on variability.There should also be a greater emphasis on consistency of control of BP in patients who are already on treatment. The research showed that even patients with well-controlled BP had a five-fold excess risk of vascular events if their BP was highly variable, even when fully compliant with their medication. Recent calls to abandon measurement of BP after treatment are premature. The fact that many people now monitor their own BP at home will be helpful in identifying variability.New antihypertensive drugs should be developed to be BP-stabilising as well as BP-lowering. Drugs that reduced variability without reducing average BP should still prevent stroke, and would be likely to be helpful in patients who cannot tolerate reductions in their average BP.
Safety testing of all new drugs, irrespective of the indication, should include assessment of effects on instability and variability in BP, as well as on average BP.
*NICE recommends that calcium channel blockers or diuretics should be used first-line for most people (patients aged 55 or older or black patients of any age) with uncomplicated hypertension. NICE also currently recommends angiotensin-converting enzyme inhibitors (or angiotensin-II receptor antagonist where not tolerated) for first-line treatment of patients under the age of 55. Beta-blockers, unless otherwise indicated, are an inappropriate first- or second-line antihypertensive choice.For more information seeNHS Evidence - cardiovascular

MIGRAINE AND CVD

2010-04-13T10:53:00.003+01:00

Migraine and cardiovascular disease: A population-based study
Link to abstract
Bibliographic details:
Neurology. 2010 Feb 23;74(8):628-35. Epub 2010 Feb 10.
Migraine and cardiovascular disease: A population-based study.
Bigal ME, Kurth T, Santanello N, Buse D, Golden W, Robbins M, Lipton RB.

OBJECTIVES: Although the relationship between migraine and cardiovascular disease (CVD) has been studied, several questions remain unanswered. Herein we contrast the rate of diagnosed CVD as well as of risk factors for CVD in individuals with migraine with and without aura (MA and MO) and in controls.
METHODS: In this case-control study, migraineurs (n = 6,102) and controls (n = 5,243) were representative of the adult US population. Headache diagnosis was formally assigned using a validated mailed questionnaire which also obtained details on treatment, comorbidities, and other variables. CVD events were obtained based on self-reported medical diagnosis. Risk factors for CVD and modified Framingham scores were computed.
RESULTS: In unadjusted analyses, migraine overall and MA were associated with myocardial infarction, stroke, and claudication, and MO was associated with myocardial infarction and claudication. Migraineurs were more likely than controls to have a medical diagnosis of diabetes (12.6% vs 9.4%, odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6), hypertension (33.1% vs 27.5%, OR 1.4, 95% CI 1.3-1.6), and high cholesterol (32.7% vs 25.6%, OR 1.4, 95% CI 1.3-1.5). Risk was highest in MA, but remained elevated in MO. Framingham scores were significantly higher in MO and MA than in controls. After adjustments (gender, age, disability, treatment, CVD risk factors), migraine remained significantly associated with myocardial infarction (OR 2.2, 95% CI 1.7-2.8), stroke (OR 1.5, 95% CI 1.2-2.1), and claudication (OR 2.69, 95% CI 1.98-3.23).
CONCLUSION: Both migraine with and without aura are associated with cardiovascular disease (CVD) and with risk factors for CVD. However, since our sample size is large, the clinical relevance of the differences is yet to be established.

Neurology is the official journal of the American Academy of Neurology. The publication is aimed at clinical neurologists.

Access:
Full text is only available to subscribers; ask your local healthcare library if they have a local subscription. Abstracts and tables of contents are free for all to view.

Publication Date: 01 Feb 2010
Publication Type: News
Publisher: American Academy of Neurology

STROKE IMAGING

2010-04-13T10:41:00.005+01:00

Stroke Imaging - update on the guidelines

Where: Royal College of Surgeons, Edinburgh
When:21 Apr 2010 09:00 - 16:30
Organiser: Royal College of Radiologists

Phone Number: 020 7636 4432 x 1124

Fax Number: 020 7323 3100

CARDIAC UPDATE

2010-04-12T14:13:00.003+01:00

Cardiac Rehabilitation Evidence Update now available http://www.library.nhs.uk/CARDIOVASCULAR/ViewResource.aspx?resID=346140

We have published an Evidence Update on CR which draws together the evidence from systematic reviews and other high quality research and guidance published in the past year, building on our last three Updates. We have been greatly assisted by the NHS Improvement-Heart CR team and expert reviewers from the British Association for Cardiac Rehabilitation.

Rusell Dube
Information Specialist
NHS Evidence - cardiovascular, stroke and vascular Collections
www.evidence.nhs.uk/specialistcollections
NHS Evidence - provided by NICE
4th Floor
Duke of Kent Building
Division of Health and Social Care
Faculty of Health and Medical Sciences
University of Surrey
Guildford, GU2 7XH
United Kingdom
Email: r.dube@surrey.ac.uk

PUBLIC HEALTH E-ARTICLES CARDIOVASCULAR DISEASE

2010-04-08T12:07:00.002+01:00

Cardiovascular disease

Cardiovascular health disparities: a systematic review of health care interventions
Centre for Reviews and Dissemination

Health service interventions targeting relatives of heart patients: a review of the literature
Centre for Reviews and Dissemination

Making chronic conditions count: Hypertension, stroke, coronary heart disease, diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland.
Institute of Public Health in Ireland (IPH)

QIPP intelligence report : cardiovascular disease prevention strategies - improving quality & productivity in the NHS through partnerships
NHS North West

Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review
Centre for Reviews and Dissemination

DIABETES RISK

2010-04-06T09:55:00.006+01:00

Intensive Systolic Blood Pressure Control May Not Reduce Mortality in Patients with Diabetes

Current guidelines from the American Diabetes Association (ADA) and other organizations recommend a blood pressure target < 130/80 mm Hg for patients with diabetes (Diabetes Care 2010 Jan;33 Suppl 1:S11). To date, there has been little experimental data to guide blood pressure target recommendations, but a new trial directly compared 2 different blood pressure goals. The Action to Control Cardiovascular Risk in Diabetes blood pressure trial (ACCORD BP) compared intensive systolic blood pressure control (target < 120 mm Hg) vs. standard control (target < 140 mm Hg) in 4,733 patients. While the trial did not stipulate specific antihypertensive regimens, patients in both groups were required to receive a drug class associated with reduction in cardiovascular events in patients with diabetes (ACE inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, or diuretics). They could also receive other medications as necessary. Mean systolic blood pressure at 1 year was 119.3 mm Hg for the intensive group and 133.5 mm Hg for the standard group. Intensive control was not associated with a reduction in either cardiovascular mortality or myocardial infarction, but it was associated with a reduced risk of stroke (level 2 [mid-level] evidence). During a mean follow-up of 4.7 years, cardiovascular mortality was 2.5% in each group. There were no significant differences in all-cause mortality (6.3% vs. 6.1%), nonfatal myocardial infarction (5.3% vs. 6.2%), or heart failure (3.5% vs. 3.8%). Stroke occurred in 1.7% of the intensive group compared to 2.6% of the standard group (p = 0.01, NNT 84). However, the risk of serious adverse events from treatment was increased for the intensive group (3.3% vs. 1.3%, p < 0.001, NNH 50). Adverse events reported included hypotension, syncope, bradycardia or other arrhythmia, hyperkalemia, angioedema, and renal failure (N Engl J Med 2010 Mar 14 early online).

CARDIAC REHABILITATION

2010-03-31T11:30:00.002+01:00

12 April

Cardiac rehabilitation (NHS Evidence - cardiovascular)
www.library.nhs.uk/cardiovascular
Cardiac rehabilitation (CR) is an important aspect of high quality care for (in particular) the patient who has had a heart attack or undergone cardiac surgery or intervention. Access to CR remains low, as highlighted through the National Audit, and NHS Improvement are leading a national priority project to help more patients to benefit.
See www.improvement.nhs.uk/heart/?TabId=56 for more information.

We are publishing an Annual Evidence Update on cardiac rehabilitation which draws together the evidence from systematic reviews and other high quality research and guidance published in the past year, building on our last three Updates. We have been greatly assisted by the NHS Improvement-Heart CR team and expert reviewers from the British Association for Cardiac Rehabilitation.

ARTICLE ABSTRACTS FROM WATCH

2010-03-18T10:57:00.005Z

NEJM 11 Mar 2010 Vol 362
886 This study looked at nearly 400,000 elective coronary angiographies performed in US hospitals over 4 years. Although preliminary investigations had been done in 84% of cases, the pick-up rate for significant coronary stenosis on angiography was 37.6%. Even these patients may have had little benefit, since COURAGE tells us that in stable angina, people do as well with optimal medical treatment as with percutaneous intervention. So 250,000 of these angiographies were definitely of no value to the patients, and that probably applies to most of the rest too. We need much better case selection for the catheter lab, with all its attendant risks of radiation and bleeding, not to mention cost in money and cardiologist time.
http://content.nejm.org/cgi/content/abstract/362/10/886

906 Thyroxine lowers cholesterol, as most of you will know from treating hypothyroid patients. Statins also lower cholesterol, as most of you will also know: but not always enough for the liking of lipidologists. They and the drug companies are forever in search of the next lipid lowering drug, an easy and potentially lucrative quest based on serum fat measurements of various kinds, as in this study of eprotirome, a thyromimetic compound. My word, it lowers LDL-cholesterol in statin-treated patients without harmful effects over a period of 12 weeks. What a breakthrough. Why, in another five years we might know if it benefits patients, or kills them.
http://content.nejm.org/cgi/content/abstract/362/10/906

Lancet 13 Mar 2010 Vol 375
This issue is dominated by the question of blood pressure variability and stroke, and by the intellectual presence of Peter Rothwell, in both the papers (pp.895, 906) and in a long review on p.938. This is impressive, and a Good Thing. Rothwell is a neurologist and is most interested in what happens to link blood pressure with stroke - a sudden process. Not surprisingly, strokes are linked with labile visit-to-visit SBP, indicating a tendency to sudden surges. At the moment in clinical practice we throw these babies away as bathwater. We disregard both pulse pressure and variation, and relax the moment we can enter a BP of less than 150/90 on the patient record. This needs to change following these papers. The evidence is that the best drugs to reduce BP variability are calcium channel blockers and thiazide diuretic, whereas most other drug classes actually increase BP variability. Bendroflumethiazide may well go back in the Polypill, because we know that most people over 65 need a BP reducing agent and that BFZ reduces both stroke and heart failure - albeit at the expense of harmless induced hyperglycaemia which we are inclined to mislabel as diabetes.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60308-X/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60235-8/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60309-1/abstract

Arch Intern Med 8 Mar 2010 Vol 170
433 The meticulous work of outcomes assessment in real life situations continues, and nobody does it better than Harlan Krumholz and his team at Yale. This week they turn their attention to differences in patient survival after myocardial infarction by hospital capability to perform percutaneous coronary intervention. In the USA, as here in the UK, there is a big debate about how best to regionalise services to ensure that as many people as possible can get timely PCI following MI. The real life situation proves to be far from simple: some regions might get better outcomes from centralisation, but others not.
http://archinte.ama-assn.org/cgi/content/abstract/170/5/433

CARDIAC REHAB

2010-03-18T10:31:00.004Z

Home vs centre-based cardiac rehabilitation
Overview: Cardiac rehabilitation can bring significant benefits to patients following a myocardial infarction (MI). Meta-analyses of randomised trials of cardiac rehabilitation have demonstrated gains roughly equivalent to those from beta-blockers, with a 25 per cent reduction in cardiovascular mortality. Economic studies suggest that cardiac rehabilitation can be justified on financial grounds alone, with a Swedish study showing 51 per cent of rehabilitated patients were at work 5 years after their MI compared with 27 per cent of those not rehabilitated, representing a saving of £6,500 per patient. However, participation has been suboptimal, which patients tend to attribute to difficulties in attending a centre-based rehabilitation course because of time constraints, lack of accessibility or a dislike of groups.
Current treatment: In the UK, a common form of cardiac rehabilitation is a 6 to 10 week hospital-based programme starting 4 to 12 weeks after discharge. Typically the patients participate in an exercise class and attend talks covering heart disease, smoking, stress and diet. There may also be relaxation or stress management classes. During the last decade, home-based programmes have become more common, often built around the Heart Manual's guidance. You can find more information on NHS Evidence - Cardiovascular, in NICE's commissioning guide for cardiac rehabilitation service and NICE guidance on secondary prevention in primary and secondary care for patients following a myocardial infarction.NICE is currently updating its clinical guideline on chronic heart failure and will review the latest evidence for cardiac rehabilitation, with publication scheduled for August 2010.New evidence: A Cochrane systematic review (Dalal et al. BMJ 2010; 340:b5631) of randomised controlled trials compared home- and centre-based cardiac rehabilitation in adults who had experienced a myocardial infarction, angina or heart failure, or who had undergone revascularisation. Most studies had recruited patients with a low risk of further cardiovascular events. There was no difference between the two settings for cardiovascular rehabilitation for mortality, cardiac events, blood pressure, health-related quality of life and other factors. The evidence suggested that adherence might be greater for home-based participants. There was no difference in costs between the two approaches. Taken together, these findings support the continuing development of home-based rehabilitation programmes.Commentary: "This Cochrane review emerges alongside other evidence of telehealth and secondary preventive programme benefits being achieved in the community."The early adoption of home based practices including exercise is advantageous, providing that all rehabilitation needs are met. Individual choice is key."Home and centre based services are not just alternatives, more or less equivalent in outcome on current assimilated evidence. Both options should be included in a prevention and rehabilitation programme."Evidence, that high quality home based cardiac rehabilitation is not a cheap alternative, facilitates an objective discussion surrounding the needs of each individual patient."Today, a cardiac patient's life history could include several cardiac rehabilitation episodes and chronic heart disease register monitoring. Patients are being diagnosed earlier and will live longer, if they adhere to a healthier lifestyle choice and secondary prevention. Towards the end of life patients may develop heart failure requiring closer supervision of exercise prescription, with the need to armchair base it at home, along with other palliative support."We must be flexible and creative to construct the ideal long term care pathways, with optimisation of function at any stage and all rehabilitation components sourced conveniently when required." - Dr Jane Flint, National Clinical Adviser for cardiac rehabilitation to NHS Improvement.

STROKE - BOBATH

2010-03-18T10:03:00.004Z

'Bobath – popular but may not be the best for stroke'Ann Holland, clinical specialist physiotherapist, The National Hospital for Neurology and Neurosurgery, London, shares her response:"Before we consider discarding the Bobath Concept it should be adequately and appropriately tested, especially as there is evidence for the superiority of the Bobath Concept in the domain of balance control (Kollen et al 2009)."Structured rehabilitation programmes are effective in reducing morbidity and improving outcome following stroke (Stroke Unit Trialists' Collaboration 2007). The Bobath Concept is based upon present-day knowledge of motor control, motor learning, neuromuscular plasticity and human functional movement (Raine 2006, Raine 2007, Graham et al 2009) and functional task practice, treadmill training and constraint – induced therapy are integrated within the clinical practice framework.With respect to Kollen et al (2009) this review was limited to RCT level 2 evidence but the studies included were not all of the same level of quality. Other studies at a lower level of evidence such as comparative studies, case series and case presentations may have yielded evidence of a similar quality and therefore could have been included. In many of the studies included there were limitations in the research design, such as low participant numbers (n=6), insufficient data to confirm that groups were comparable at baseline (n=5) and/or lack of blinded assessors (n=5). These limitations, relating to methodological quality and to contextual factors investigated, restrict the ability to draw conclusions rather than suggest that there is evidence that interventions based on other approaches are more effective than the Bobath Concept. It is therefore as valid to use the Bobath Concept as other approaches. This is also the conclusion from three other systematic reviews (Paci 2003, Van Peppen et al 2004, Luke et al 2004) where there was once again insufficient evidence to confirm or refute the efficacy of the Bobath Concept compared to other approaches.

CHRONIC HEART FAILURE PATHWAY

2010-03-18T09:57:00.003Z

A new case study has been published that talks about how the Map is being used in North West Wales to signpost healthcare professionals to the services available for patients with Chronic Heart Failure (CHF).

North West Wales NHS Trust provides services for the counties of Gwynedd, Anglesey and parts of Conwy. It serves a population of about 225,000 people as well as large numbers of holidaymakers who are attracted to the area every year. The number of patients with heart failure across North West Wales is approximately 2000 and has been increasing over the past few years.

Since the Chronic Heart Failure pathway was launched, screening and diagnosis of heart failure has increased because of easier access to echocardiography and BNP testing in primary care. CHF symptoms are being controlled or even eliminated. New patients suffering from heart failure are being diagnosed in primary care, therefore reducing the number of referrals to diagnostic clinics.

The case study is also available on the Map of Medicine website, www.mapofmedicine.com and you can access the North West Wales Heart Failure pathway on the Map of Medicine by changing your view to North West Wales.

PUBLIC HEALTH ARTICLES

2010-03-02T15:00:00.001Z

Cardiovascular disease

Modelled estimates and projections of CVD for Local Authorities in England Eastern Region Public Health Observatory (ERPHO)
Modelled estimates and projections of CVD for PCTs in England Eastern Region Public Health Observatory (ERPHO)
Modelled estimates and projections of CVD: technical document Eastern Region Public Health Observatory (ERPHO)

SNIPPETS FROM JOURNALS

2010-03-02T09:16:00.003Z

The following are all from www.cebm.net

Lancet 27 Feb 2010 Vol 375
727 Not long ago, someone had a myocardial infarction on a transatlantic flight. So what does a professor of surgery do under these circumstances? Possibly take an aspirin and pray a good deal. He should have squeezed his arm repeatedly for periods of five minutes or so at a pressure above systolic. Believe it or not, this simple manoeuvre can reduce the area of myocardial damage, as proved in this Danish trial where patients with presumptive MI were randomised to have the squeezing done (or not done) by a sphygmomanometer in the ambulance conveying them to hospital. This is known as ischaemic preconditioning, though in such circumstances it should perhaps be known as simultaneous ischaemic conditioning. There were no hard end-points in this trial but a convincing reduction in damage on myocardial perfusion imaging at 30 days. More trials are needed, but meantime there seems no possible reason not to give it a try.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62001-8/abstract

752 This is a rather rambling 10-page review of dilated cardiomyopathy. The Panel of Mechanisms covers just about everything except interference by aliens, and there's a panel of gene loci too, but no panel of relative frequencies and prognoses for each aetiology. There is no mention of spontaneous recovery, which can't be rare if it has been seen twice.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62023-7/abstract

763 Say you had stable coronary artery disease: would you want an angiogram? And if the cardiologist saw a stenosis, would you want a stent put in? A year or two ago, these questions would have seemed like no-brainers, but then along came COURAGE and BARI-2D showing that medical treatment is as good as percutaneous intervention. Do you truly and deeply believe this, though? See how you feel when you read this review by two Swiss and an American cardiologist. It presents enough evidence to allow a tailored approach, and says that it "proposes a treatment algorithm that is applicable to daily clinical practice." The word "algorithm" is to be avoided, but people who use it generally refer to a flow chart, but there isn't one. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60168-7/abstract

BMJ 27 Feb 2010 Vol 340
459 A useful systematic review compares the results of carotid endarterectomy vs. carotid stenting in 11 randomised trials. On the face of it, endarterectomy wins, because the risk of periprocedural stroke is less; in the longer term there is little difference. Techniques and experience increase all the time - it may happen that the guy who puts in stents near you does that better than the guy who scrapes arteries. So more studies are justified and the matter is not quite settled yet.
http://www.bmj.com/cgi/content/full/340/feb12_1/c467

JAMA 17 Feb 2010 Vol 303
631 The Women's Genome Health Study is a prospective cohort of 19,313 women followed up for a median of 12.3 years, during which they experienced 777 cardiovascular events. In these women, 101 single nucleotide polymorphisms were added with one or two other genomic factors to create a genetic risk score. Surely this would usher in a new era of refined cardiovascular risk prediction? Well, actually it showed no significant association with the incidence of total cardiovascular disease: a simple family history alone was more predictive. On the other hand, there is so much anonymized data about the participants that you could probably find out the full disease status of any individual if you could identify their genome from some other source. This is discussed in a fascinating commentary on p.659. Genomic studies seem almost disconcertingly useless at the population level, but if you know 35,000 gene variants in a single individual, you can measure their left ventricular mass more accurately than if you had an echocardiogram.
http://jama.ama-assn.org/cgi/content/abstract/303/7/631

NEJM 18 Feb 2010 Vol 362
590 Some people like to see evidence from randomised controlled trials with hard end-points before a computer prediction that a certain intervention will reduce new cases of CHD in America by up to 120,000 annually, stroke by up to 66,000, and death by up to 92,000. The editorial on p. 650 suggests a saving in health costs of $10-24 billion. Aha, we save health costs by keeping older people alive longer, do we? Apart from that basic point, there is also the problem that the evidence for salt reduction is - as far as I can tell - nowhere near as strong as the computer model in this economic simulation suggests. The evidence we have is about a surrogate marker - blood pressure - which can be reduced slightly by the sort of salt reductions proposed here and already in force in the UK for prepared foods. On the balance of probabilities, I'm happy to support salt reduction, as I am carbon emission reduction; but that doesn't mean swallowing every extrapolation that zealots come up with. A paper like this doesn't really belong in the world's leading medical journal.
http://content.nejm.org/cgi/content/abstract/362/7/590

Ann Intern Med 16 Feb 2010 Vol 152
211 The Women's Health Initiative trial was an RCT of hormone replacement therapy which brought about a volte-face in clinical practice but which is described as "far from impeccable" in a letter in this week's BMJ (p.382). Peccability is openly confessed in this Lenten analysis of the effect of continuous combined HRT on coronary heart disease. They more or less admit to residual confounding and small subgroup sizes. The bottom line message is that continuous HRT may confer added risk of CHD in the first years, then decreased risk after 6 years. Which is not quite what we were all initially led to believe.
http://www.annals.org/content/152/4/211.abstract

218 Initiated permanent anticoagulation for severe recurrent superficial thrombophlebitis with the reluctant concurrence of the local haematologist. Such events are benign and self-limiting and do not herald serious thromboembolism, but this French study casts doubts on that. In fact 25% of subjects with superficial phlebitis of 5cm or more had or went on to develop deep vein thrombosis in this series of 844 consecutive cases in a specialist referral centre. We need some primary care studies, quite urgently.
http://www.annals.org/content/152/4/218.abstract

CARDIOVASCULAR HIGHLIGHTS

2010-02-23T13:01:00.004Z

Spotlight on Vascular:
http://www.library.nhs.uk/vascular/
For the full list of additions to this collection, download the full Vascular e-bulletin here.
News in spotlight
New NICE care guideline published: Venous thromboembolism – reducing the risk
NICE is to develop a clinical guideline on Peripheral Arterial Disease. Access stakeholder guidelines from www.library.nhs.uk/vascular/ .
Hot off the press: 04/02/10 - Risk of Deep Vein Thrombosis Following a Single Negative Whole-Leg Compression Ultrasound
Hot off the press: 10/12/09 - Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism
Hot off the press: 27/11/09 - Aspirin for primary prevention of cardiovascular events in people with diabetes
Articles in spotlight
Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair: a systematic review (DARE)
http://www.library.nhs.uk/VASCULAR/ViewResource.aspx?resID=331814
Physical activity in patients with deep venous thrombosis: a systematic review DARE
http://www.library.nhs.uk/VASCULAR/ViewResource.aspx?resID=331795
Prevention of venous thromboembolism in neurosurgery: a metaanalysis DARE
http://www.library.nhs.uk/VASCULAR/ViewResource.aspx?resID=334120
Events in spotlight
2nd International Conference on Early Disease Detection and Prevention (EDDP) 2010
25 Feb 2010 09:00 - 28 Feb 2010 17:00
SVT Advanced Study Day: Innovations and Applications of Portable Vascular Ultrasound 2010
26 Feb 2010 09:00 – 17:00
Vascular Disease Awareness Week 2010
08 Mar 2010 00:00 - 12 Mar 2010 23:45
The Vascular Society Spring Meeting 2010
11 Mar 2010 10:00 - 17:30
Live from the website: view events, breaking news, latest content
Recent additions
Events
News

Spotlight on Cardiovascular:
http://www.library.nhs.uk/cardiovascular/
For the full list of additions to this collection, download the full Cardiovascular e-bulletin here.
News in spotlight
02/01/10 - Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial
http://www.library.nhs.uk/cardiovascular/viewResource.aspx?resid=334301
Hot off the press: 21/01/10 - Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease
Hot off the press: 27/01/10 - Comparison of Antiarrhythmic Drug Therapy and Radiofrequency Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation (RCT)
Hot off the press: 28/01/10 - Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study
Hot off the press: 15/01/10 - Radiation exposure and circulatory disease risk: Hiroshima and Nagasaki atomic bomb survivor data, 1950-2003
Hot off the press: 15/01/10 - Use of angiotensin receptor blockers and risk of dementia in a predominantly male population
Articles in spotlight
Home-based versus centre-based cardiac rehabilitation Cochrane
http://www.library.nhs.uk/cardiovascular/viewResource.aspx?resid=334131
Aprotinin and the risk of death and renal dysfunction in patients undergoing cardiac surgery: a meta-analysis of epidemiologic studies DARE
http://www.library.nhs.uk/cardiovascular/viewResource.aspx?resid=334152
Events in spotlight
A Practical Approach to Physical Activity and Exercise in the Management of Cardiovascular Disease 2010
19 Feb 2010 09:00 - 20 Feb 2010 17:00
2nd International Conference on Early Disease Detection and Prevention (EDDP) 2010
25 Feb 2010 09:00 - 28 Feb 2010 17:00
SVT Advanced Study Day: Innovations and Applications of Portable Vascular Ultrasound
26 Feb 2010 09:00 - 17:15
Cardiology Review Course 2010
08 Mar 2010 09:00 - 12 Mar 2010 17:00
Live from the website: view events, breaking news, latest content
Recent additions
Events
News

Spotlight on Stroke:
http://www.library.nhs.uk/stroke/
For the full list of additions to this collection, download the full Stroke e-bulletin here.
News in spotlight
National Audit Office report Progress in improving stroke care published 3rd February:
http://www.library.nhs.uk/stroke/viewResource.aspx?resid=343170
The NICE stroke rehabilitation guideline is expected in March 2012:
04/01/10 - Stroke rehabilitation guideline announcement
Articles in spotlight
AHA scientific statement: Recommendations for imaging of acute ischemic stroke
http://www.library.nhs.uk/stroke/viewResource.aspx?resid=343354
Movement-dependent stroke recovery: a systematic review and meta-analysis of TMS and fMRI evidence
http://www.library.nhs.uk/stroke/viewResource.aspx?resid=331748 DARE
Multidisciplinary care planning in the primary care management of completed stroke: a systematic review
http://www.library.nhs.uk/stroke/viewResource.aspx?resid=331776 DARE
Caring for people after they have had a stroke
http://www.library.nhs.uk/stroke/viewResource.aspx?resid=123327 Care Quality Commission
Events in spotlight
2nd International Conference on Early Disease Detection and Prevention (EDDP) 2010
25 Feb 2010 09:00 - 28 Feb 2010 17:00
The 3rd International Conference on Hypertension, Lipids, Diabetes & Stroke Prevention 2010
04 Mar 2010 09:00 – 17:30
Live from the website: view events, breaking news, latest content
Recent additions
Events
News

We welcome feedback on our collections.
Please contact us at http://www.library.nhs.uk/Cardiovascular/ContactUs.aspx

ANNUAL EVIDENCE UPDATE ON CHEST PAIN

2010-02-23T12:30:00.002Z

NHS Evidence -Cardiovascular is proud to present the third Annual Evidence Update on Chest Pain on 22nd February 2010

The 2010 Evidence Update on Chest Pain seeks to identify key new systematic reviews and related documents published since the 2009 update and so identify the latest high quality evidence on this topic. The evidence will be accompanied by summaries from experts providing a commentary on the new evidence and whether this challenges current guidance/practice or identifies uncertainties in our knowledge on this topic.

Rusell Dube Information Specialist NHS Evidence - cardiovascular, stroke and vascular Collections

www.evidence.nhs.uk/specialistcollections NHS Evidence - provided by NICE

4th Floor Duke of Kent Building Division of Health and Social Care Faculty of Health and Medical Sciences University of Surrey Guildford, GU2 7XH United Kingdom Email: r.dube@surrey.ac.uk

2010-02-15T16:19:00.003Z

Debate continues over use of off-pump CABG

Overview: Coronary-artery bypass grafting (CABG) is open heart surgery to treat coronary artery disease using a blood vessel (a graft) taken from the chest wall, leg or arm to bypass a narrowed or blocked coronary artery. A CABG does not cure coronary artery disease so it is possible for blockages to recur in both the grafts and other blood vessels. However, it does improve symptoms such as angina.

Current treatment: Traditional CABG operations are performed 'on-pump' whereby the heart and lungs are connected to a bypass machine that takes over to add oxygen to the blood and maintain circulation. 'Off-pump' CABG is an alternative technique that doesn't require the patient to be connected to a heart-lung (bypass) machine.NICE states that current evidence on the safety and efficacy of off-pump coronary artery bypass appears adequate to support the use of this procedure, only when performed through a median sternotomy.

New evidence: The ROOBY study by Shroyer et al (N Engl J Med. 2009 Nov 5;361(19):1827-37) compared outcomes for 2203 patients randomised to receive on-pump or off-pump CABG for urgent or elective procedures. A standard median sternomy was performed on all patients in the study. There was no difference between the two groups for the short-term (30-day) composite outcome of death or complications. However, the off-pump CABG group experienced poorer outcomes for the other composite primary endpoint at 1 year — the rate of death, repeat revascularisation procedure or nonfatal myocardial infarction was significantly higher in this population. Graft patency and the completed number of planned interventions were also lower in the off-pump CABG group.The findings support current treatment but further research is required.
Commentary: ""This important paper enhances knowledge of off pump CABG surgery. Large surgical randomized trials are unusual because of logistical difficulties and expense. "However, I don't believe that off pump CABG can be discounted based on these findings. Substantial evidence, albeit retrospective, suggests that high risk patients suffer fewer deaths and complications after off pump surgery but patients with co-morbidities were largely excluded from this trial."The significant difference between the number of grafts planned and the number of grafts completed in the off pump group suggests inexperience of surgeons. Surgeons were eligible if they had completed 20 prior off pump procedures. Because different coronary territories are not equally amenable to grafting, experience in one territory does not necessarily provide the experience and ability to treat triple vessel coronary disease. "Surgeon inexperience may also partially explain the inferior patency figures in grafts completed off pump. Postoperative coagulopathy may also have contributed to the increase in occluded grafts. New antiplatelet drugs such as clopidogrel, which are not routinely used in CABG surgery, may reverse the effect. "The CRISP trial, which has just opened recruitment, will compare outcomes after on pump and off pump CABG in high risk patients (ISRCTN29161170, MRC ref: G0700469).

Trial organisers have taken steps to ensure that off pump operations are carried out by very experienced off pump surgeons." - Joint analysis was provided by Professor Tom Quinn clinical lead for NHS Evidence - cardiovascular, stroke and vascular collections and Professor of Clinical Practice at the Faculty of Health and Medical Sciences, University of Surrey; Mr Norman Briffa, cardiothoracic surgeon from Sheffield and Professor Mike Larvin, Clinical Lead for NHS Evidence - Surgery and Professor of Surgery at the University of Nottingham.

CARDIOVASCULAR DISEASE IN ETHNIC GROUPS

2010-02-15T16:15:00.003Z

Cardiovascular Diseases:
Ethnic disparities in coronary heart disease management and pay for performance in the UK
The affect of a major pay for performance initiative in April 2004 on coronary heart disease management and intermediate clinical outcomes in a multiethnic population is examined.

SNIPPETS FROM JOURNAL WATCH

2010-02-10T12:50:00.003Z

JAMA 3 Feb 2010 Vol 303
If the Good Death Cookbook ever gets compiled from the recipes from Journal Watch, the evidence linking dietary sodium with cardiovascular disease outcomes needs to be confronted. All of it is observational; and according to this article, the studies are in equipoise. That's right: there are some studies showing cardiovascular harm from lowered salt intake; most are neutral; some show benefit. But there has never been a prospective randomised trial.
http://jama.ama-assn.org/cgi/content/extract/303/5/448

BMJ 6 Feb 2010 Vol 340
It's a convenient belief, supported by some systematic reviews of randomised trials, that all blood pressure lowering regimens are equally beneficial in proportion to the degree to which they succeed in reducing BP. This population based case-control study seeks to dispute that, and in particular to blacken the name of calcium-channel blockers compared to ACE inhibitors and ARBs. Again, you won't learn much from the one-page version. In the full on-line article, you can see the confidence intervals in all their unconvincing glory. There may be some differences, but we need better evidence than this.
http://www.bmj.com/cgi/content/full/340/jan25_2/c103
One of the reasons of the Easily Missed series was to find out what I had been missing these last thirty-five years. Long QT syndrome is a definite case in point. If you have a young patient who has fainted during exertion or on being woken by a loud noise, get an ECG at once and make sure it is looked at carefully: the next episode may be sudden death.
http://www.bmj.com/cgi/content/extract/340/jan08_1/b4815

Ann Intern Med 2 Feb 2010 Vol 152
Just as you wouldn't give up and blame the patient if their blood pressure remained at 186/112 despite a short course of treatment, so you mustn't give up treating nicotine addiction until people no longer run the awful cardiovascular and pulmonary risks of smoking. Give them nicotine replacement therapy for as long as it takes, and bin any guidelines which instruct you to do otherwise on grounds of cost. This study unsurprisingly found that a nicotine patches are more effective prescribed for 24 weeks than for 8. Many smokers won't need this length of treatment, others will need more.
http://www.annals.org/content/152/3/144.abstract
Non-invasive coronary angiography sounds like a great idea, but there are problems. Magnetic resonance imaging would be ideal if it worked, because it doesn't involve ionizing radiation. But this head on comparison with computed X-ray tomography shows that it is not nearly as accurate, according to the published studies. This may change as techniques develop, of course. The problem with CT is that it uses big doses of radiation and needs iodine-base contrast material; and so does the gold standard of coronary angiography, which the patient will then have to undergo if the CT shows a lesion requiring intervention. The real-life radiation dosage studies are worrying, though every article predicts that doses will fall in the future.
http://www.annals.org/content/152/3/167.abstract

CARDIOVASCULAR DISEASE PUBLIC HEALTH ARTICLES

2010-02-09T14:48:00.001Z

Cardiovascular disease

Economic evaluation of the direct healthcare cost savings resulting from the use of walking interventions to prevent coronary heart disease in Australia
International journal of health care finance and economics
Evidence based cardiovascular disease screening and treatment
Department of Health
Yorkshire and Humber Cardiovascular Disease (CVD) Commissioning Health Intelligence Toolkit Yorkshire and Humber Public Health Observatory (YHPHO)

STROKE REVIEWS

2010-02-08T09:25:00.001Z

From Cochrane Database of Systematic Reviews (CDSR):

Antiepileptic drugs for the primary and secondary prevention of seizures after stroke
Chuanxiong preparations for preventing stroke

SYMPOSIUM

2010-02-08T09:22:00.001Z

There will be a symposium on March10th:
Symposium: Hypertension, Stroke & Acute Care Medicine (Aberdeen)

TALK

2010-02-05T14:21:00.005Z

Leading consultant cardiologist , Dr Aggrawal will be talking about developments within the CTC

on treating heart attacks and the new service primary revascularisation to the Hearts and Minds group (http://www.basildonheart.org.uk/Meetings.html) on 17th February 2010

RED FOR HEART MONTH

2010-02-05T14:14:00.003Z

February is "Red for Heart Month"

Between 22-26 February British Heart Foundation pins will be selling in the CTC reception and main reception of Basildon Hospital.

Friday 26 February is "Wear Red to Work day"

CARDIAC PATIENTS TO BENEFIT FROM A DONATION

2010-02-05T14:02:00.004Z

Presentation by members of a 22" flat screen television and DVD player purchased from funds of the Hearts and Minds Cardiac Support group to the Cardiac Rehab team in the Essex Cardiothoracic Centre.

The television will be put in the cardiac rehab unit so patients and relatives and members of the support group can watch educational DVDs, often supplied by the British Heart Foundation.

SNIPPETS FROM JOURNALS

2010-02-01T14:52:00.006Z

JAMA 27 Jan 2010 Vol 303
333 Paroxysmal atrial fibrillation can vary from a minor nuisance to a cause of intermittent angina and heart failure. This trial shows that catheter radiofrequency ablation is markedly effective in the first nine months for patients whose paroxysmal AF fails to respond to antiarrhythmic drugs. That said, they still carried on with these drugs (excepting amiodarone) and anticoagulation or antiplatelet therapy according to current guidelines. A particular joy for methodologists was the use in this trial of Bayesian boundaries to determine interim analysis times. Put like that, it instantly sounds boring, but honestly it isn't.
http://jama.ama-assn.org/cgi/content/abstract/303/4/333

BMJ 30 Jan 2010 Vol 340
249 Cardiac rehabilitation is now routinely recommended to everyone who survives a heart attack, but 60% don't turn up. From a large number of trials, reviewed in this paper, we know that it is equally effective when given at home. But this does mean that the rehab team has to be flexible, proactive and adequately staffed. Don't hold your breath as the recession cuts start to bite.
http://www.bmj.com/cgi/content/full/340/jan19_4/b5631
252 I suspect it's going to be increasingly common for anaesthetists to insist on patients having non-invasive cardiac stress testing before elective major non-cardiac surgery, and this large Canadian observational study lends some support to this policy - but only for people with known cardiovascular risk factors. I searched in vain for the Web Table A which might have gone some way to explaining the mechanism by which pre-op stress testing actually harmed some low risk patients - the text speculates that it might have been by foisting beta-blockers on them. Anyway, for those with 1-6 risk factors, there is a measurable mortality benefit, even though very few of them actually require an invasive cardiac procedure.
http://www.bmj.com/cgi/content/full/340/jan28_3/b5526

Arch Intern Med 25 Jan 2010 Vol 170
126 DASH it! As you read this paper showing that a low-fat, low salt diet really does bring down blood pressure by as much as a powerful antihypertensive drug - up to 16/10 mm Hg. That's when it's combined with a weight losing regime over 4 months. It would be very hard to maintain that over a longer period so let's settle for 11/7.5 as in the DASH alone group. http://archinte.ama-assn.org/cgi/content/abstract/170/2/126
136 But hang on - here is the opposite message. A diet of unlimited meat and a lot of fat (the low-carbohydrate ketogenic diet) achieved a much better BP reduction than a low-fat diet in this next study - 6/4.5 vs 4.5/O. Moreover the second group had help from orlistat. Both groups lost weight equally. The undoubted benefits of the DASH diet do not seem to derive from fat restriction. In fact they can probably be matched by a wide variety of less puritanical diets.
http://archinte.ama-assn.org/cgi/content/abstract/170/2/136

JAMA 20 Jan 2010 Vol 303
250 Snip, snip. You are a few seconds nearer to death. Your telomeres are shortening. Quick, grab some smoked salmon. "Among this cohort of patients with coronary heart disease, there was an inverse relationship between baseline blood levels of omega-3 fatty acids and the rate of telomere shortening over 5 years." If you can't get hold of oily fish, a good alternative source of omega-3 fatty acids is snake oil. Helps your telomeres. Live Longer With Snake Oil - it's official.
http://jama.ama-assn.org/cgi/content/abstract/303/3/250

NEJM 21 Jan 2010 Vol 362
217 The heart and lungs share a space in the thoracic cavity. When one gets bigger, the other gets squashed. This elementary fact is nicely illustrated by a study of 2816 people aged 45 to 84 without gross cardiovascular or lung disease. The more evidence of emphysema on lung CT scanning, the smaller the capacity of the left ventricle when filling. This means that the ejection fraction was not impaired but cardiac output was. This is nothing to do with cor pulmonale, mainly a problem of the right ventricle, or myocardial ischaemia, though in advanced COPD these may also play a part. O that cardiologists would remember that the chest contains lungs. It's difficult enough to get them to remember that the heart has two ventricles and a phase called diastole.
http://content.nejm.org/cgi/content/abstract/362/3/217
228 Which brings us nicely on to the topic of systolic heart failure, as reviewed here by John McMurray. Whenattending heart failure conferences there were ribs about trialling yet another drug on recumbent male patients aged 60 with reduced ejection fractions in hospital beds. It isn't the best way of informing us how to treat 75 year olds in the community with multiple morbidities including cardiac impairment. Still, we have to pick up what clues we can from what studies there are, though it would be a mistake to call this evidence-based medicine. It is called general practice, and it can be quite hard. Here are some of the easier bits for those who need an update.
http://content.nejm.org/cgi/content/extract/362/3/228
239 "The primary care physician remains the principal provider and care coordinator for patients with Williams-Beuren syndrome." Your practice may well contain such an individual, if your list is over 10,000. But you probably know this as Williams' syndrome without the Beuren - a microdeletion at chromosome 7 causing a characteristic facial appearance, hypercalcaemia, growth failure, heart abnormalities and learning difficulties. If you are a primary care physician who is the principal care provider for this person, you are not going to find a better review than this , so if you work in SWEssex you can have access to this via Athens
http://content.nejm.org/cgi/content/extract/362/3/239

Lancet 23 Jan 2010 Vol 375
283 Plato held that each earthly object was an imperfect approximation to an ideal object. Clopidogrel is your typical earthly product: expensive and disappointing, as it does nothing for about 30% of people who take it. Ticagrelor on the other hand sounds like the Platonic ideal for platelet inhibition - it works for everybody as it is not a pro-drug, but it is reversible and therefore should cause fewer bleeds. But how all the things of earth disappoint. The most striking thing about the PLATO trial is that ticagrelor is nowhere near 30% better than clopidogrel. This massive study in 13,408 people about to undergo invasive treatment for acute coronary syndromes showed a tiny difference in the composite end-point of death, myocardial infarction or stroke - 9.0% v 10.7% in favour of ticagrelor. There was no difference in bleeds. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62191-7/abstract

Ann Intern Med 19 Jan 2010 Vol 152
69 Here's a study from the USA which examines three strategies for the primary prevention of coronary artery disease using statins. Two are based on measurement of LDL-cholesterol ("treat to target") and the other is based on total estimated 5-year coronary risk ("tailored treatment"). "We assumed that LDL cholesterol reduction is a statin's sole mechanism of action and that change in total LDL cholesterol is a perfect indicator of the amount of risk reduction that a patient receives from a statin, thereby conceding the 2 most important assumptions underlying the treat-to-target approach. We realize that the first assumption is controversial and that the second assumption is untrue (LDL cholesterol determinations have substantial measurement error)." Neatly put. This is a modelling exercise set by Harlan Krumholz for his scholars and they do it beautifully: the most effective way to use these drugs is to give simvastatin 40mg to everyone with a 5-15% CAD risk and 40mg atorvastatin to everyone with a risk above that - and never mind the LDL-C.
http://www.annals.org/content/152/2/69.abstract
78 By and large it doesn't matter what you give patients to reduce their blood pressure so long as it works and they keep taking it. However, you may wish to bear in mind that exclusive treatment with calcium channel blockers may carry a higher risk of atrial fibrillation than beta-blockers and ACE inhibitors.
http://www.annals.org/content/152/2/78.abstract

STROKE ARTICLES

2010-02-01T14:26:00.004Z

NHS Institute Alert

Improvement of primary care for patients with chronic heart failure: a pilot study J van Lieshout, M Wensing, R Grol BMC Health Services Research, 2010, 10:8

Researchers hope measuring performance will improve stroke care and prevention
M Mitka Journal of the American Medical Association, 2010, 303(1), pp17-18
NHS Athens passwords may be required to access this resource, and can be obtained by registering here. Choose the Athens login option.

Delivering an evidence-based journey intervention to people with stroke: barriers and enablers experienced by community rehabilitation teams
A McCluskey, S Middleton BMC Health Services Research, 2010, 10:18

EVIDENCE UPDATES

2010-01-28T12:42:00.001Z

22 February
Chest pain (NHS Evidence - cardiovascular)
www.library.nhs.uk/cardiovascular
The 2010 Annual Evidence Update on Chest Pain seeks to identify key new systematic reviews and related documents published since the 2009 update and so identify the latest high quality evidence on this topic. The evidence will be accompanied by summaries from experts providing a commentary on the new evidence and whether this challenges current guidance/practice or identifies uncertainties in our knowledge on this topic.

CARDIO ARTICLES

2010-01-21T09:01:00.004Z

Arch Intern Med 11 Jan 2010 Vol 170
27 Are you bored with guidelines? Fed up with arguments about cardiovascular risk assessment? Then brighten your day with this paper about 27 cardiovascular risk assessment guidelines. They are all different - grossly or subtly - proving that whenever you get a roomful of doctors discussing the same evidence, they will never arrive at the same answer. http://archinte.ama-assn.org/cgi/content/abstract/170/1/27

JAMA 6 Jan 2010 Vol 303
54 Many readers may not be cardiologists or hospital doctors, and I guess quite a few of you didn't know what NSTEMI stands for until about 8 years ago. Troponins only came in around then too, and they are vital to distinguish whether unstable angina is or is not associated with myocardial damage. Immediate angiography is also a relative novelty in the UK. Yet now every second hospital discharge summary now seems to read c/o chest pain NSTEMI troponin 2.1 PCI stents to LAD, Cx, please continue clopidogrel for 12 months. Here is a case study of a 43 year old American man which takes you through the modern management of NSTEMI in full wearisome detail.
http://jama.ama-assn.org/cgi/content/short/303/1/54?home

Lancet 9 Jan 2010 Vol 375
132 C-reactive protein was first described over 70 years ago, and we use it as a "something's wrong" test all the time, instead of or alongside ESR. It isn't actually all that much use, and patients often end up being told "Your blood test tells me you are ill, which I already knew, but it doesn't tell me what's wrong, so I want to repeat it." How many non-sequiturs can you squeeze into a sentence? And yet we all do it, taking obscure comfort later in the fact that 26 has fallen to 13. It's the same if you try to use it as a marker for cardiovascular risk. This immensely painstaking individual participant meta-analysis shows that even minor elevations of CRP are associated with increased risk for coronary heart disease; also for stroke; also for vascular death; also for non-vascular death; also for several cancers; also for lung disease. Elevated CRP is vaguely bad news: a Completely Random Predictor.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61717-7/abstract

NHS EVIDENCE CLINICAL PRACTICE

2010-01-13T12:28:00.006Z

NHS Evidence provides fast, free access to the most up to date, quality information required by health and social care professionals.

Eyes on Evidence, highlights new research with a focus on possible implications for clinical practice.

QOF drives quality of services in primary care
Overview: About 60 per cent of adults have a long-term or chronic health problem such as coronary heart disease, stroke, hypertension, diabetes, mental disorder or asthma. Chronic diseases have a huge impact on individuals' lives and NHS resources.

Current treatment: The UK's government is keen to tackle chronic disease management to reduce unnecessary admissions to hospital for patients and associated NHS costs. The Quality and Outcomes Framework (QOF), a pay-for-performance scheme funded by NICE, was introduced in 2004 to incentivise effective clinical care, practice organisation and providing a positive patient experience in primary care.

New evidence: The analysis (Campbell SM et al. N Engl J Med 2009;361:368–78) investigated the impact of the initiative on the quality of care provided to people with coronary heart disease, diabetes and asthma using medical records and patient questionnaires. Initial improvements were maintained for heart disease and asthma but reached a plateau a year after introduction. Care for diabetes continued to improve but at the same rate before the scheme was introduced. No changes in access to care or interpersonal aspects of care were seen but continuity of care was reduced. In summary, the scheme accelerated improvements in the quality of care in certain areas but this was not sustained when targets were reached. A recent comprehensive review by the Health Foundation shows that although the evidence is not strong, improvement initiatives can sometimes reduce costs to service providers while simultaneously making care better for patients.This research was carried out at the National Primary Care Research and Development Centre at Manchester University, which is contracted by NICE to support the QOF.

Commentary: "The effectiveness of incentive schemes in improving services is an important question for policy makers, and there are few bigger schemes than the UK's QOF. Can a national scheme making up 25 per cent of GPs' income transform care? The scheme was introduced in the absence of experimental controlled studies and therefore the best evidence we can hope for is provided in well-designed time series studies that report on performance before and after the introduction of the QOF.
"The series of studies by Campbell and colleagues that have tracked performance in the care of patients with asthma, diabetes and coronary heart disease in a sample of practices from 1998 is therefore an important and almost unique source of evidence. In earlier studies they have already shown steep increases in activity in practices in association with the introduction of the QOF. This paper takes a longer view, tracking performance from 1998, well before the QOF, to 2007, three years after the introduction of the QOF. This enabled the authors to compare the rate of improvement in performance before the QOF with the rate after the introduction of the QOF. They found that the scheme accelerated improvements in the short term quality for asthma and diabetes, but not coronary heart disease, but once targets were reached improvement slowed. Quality declined between 2005 and 2007 for some aspects of care not linked to the QOF, and continuity of care declined after the introduction of the QOF.
"These findings have three implications. First, major policy changes need careful evaluation; initial pilot studies would be ideal. Second, incentives schemes can impact on performance, but the impact can run out of steam. Third, incentive schemes have unintended consequences. Since the QOF is being retained, its indicators require remodelling in order to increase efficiency and reduce the negative consequences. In large measure, this task will fall to the National Institute for Health and Clinical Excellence, which will be advising on the selection of indicators in the future." - Richard Baker is Professor of Quality in Health Care and Head of Department for Health Sciences at Leicester University.

QOF influences blood pressure recordings

Overview: High blood pressure (hypertension) increases the risk of heart attacks, strokes and other health problems. In the United Kingdom, high blood pressure (hypertension) affects about half of the population over 65, and about 1 in 4 middle-aged adults.

Current treatment: It is universally recognised that controlling hypertension will reap significant public health benefits. Several different bodies including NICE and the British Society of Hypertension have produced guidance on treating people with hypertension through lifestyle modification and drug therapy. If lifestyle modification alone does not lower blood pressure sufficiently, NICE recommends treatment with an ACE inhibitor for those under 55 years of age and a calcium-channel blocker or thiazide-type drug for those over 55 year or black patients of any age (unless contraindicated). Combination therapy is then recommended if blood pressure remains uncontrolled. However, implementing the guidance presents its own challenges. In 2004 the UK Quality and Outcomes Framework (QOF) introduced a remuneration scheme for GPs achieving clinical targets for hypertension set at 150 mmHg systolic or less.

New evidence: This study (Carey IM et al. J Hum Hypertens 2009;23:764–770) investigated whether rewarding GPs for achieving target blood pressure in their practice had an impact on blood pressure recordings. The group analysed more than 3 million blood pressure readings (taken 2000–2005) from over 235 000 patients with ischaemic heart disease, stroke or hypertension. The percentage of people with systolic blood pressure above the target value fell from 36 per cent to 19 per cent during this period. There was a trend towards recording systolic values just below — rather than just above — the cut-off but this did not adversely affect clinical management. In conclusion, blood pressure levels in UK primary care have continued to fall since the QOF was introduced; QOF targets may have contributed to this through increased treatment.

Commentary: "The authors have compared BP recording and BP treatment in 2000-2001 with 2004-2005. They specifically examine for terminal digit preference. Several findings stand out; SBP levels are falling overall, there is some recording bias but not much – the authors predict that the prevalence of SBP above 150mmHg should be 23 per cent and is 19 per cent; and there has been a rise in prevalence of antihypertensive treatment. While there is some terminal digit preference for figures just below 150mmHg, patients with readings of 148-9 mmHg were also more likely to be on antihypertensive medication.
The authors conclude that QOF has contributed to the reduction in BP levels and that this is a positive finding from a public heath perspective. The paper therefore is reassuring and refutes accusations of 'gaming' i.e. recording of BP at just below target level by GPs. The authors are reassured that patients with levels just below the target are more likely to be receiving antihypertensive medication but from a clinical perspective, I hope this does not represent additional prescribing to reach the QOF target but that we can continue to consider the potential additional burdens for patients in terms of medicine - taking and side effects that may be required to reach an arbitrary cut off figure!" – Norma O'Flynn is a GP and Clinical Director of the National Clinical Guideline Centre

Eyes on Evidence helps contextualise significant new evidence, highlighting areas that could signal a change in clinical practice. It does not constitute formal NICE guidance. The commentaries included are the opinions of contributors and do not necessarily reflect the views of NICE.

NEUROLOGICAL EVIDENCE

2010-01-12T14:45:00.005Z

The impact of increased duration of exercise therapy on functional recovery following stroke: what is the evidence?
Author's objectives
To examine the effect of increased duration of exercise therapy compared to routine formal exercise on functional recovery after stroke.
Author's conclusions
The authors concluded that increased duration of exercise therapy, when compared to standard exercise regimes, improved functional outcome, as measured by the Barthel Index, in patients with stroke both post-treatment and at six months follow-up. They also indicated that their findings supported a positive effect on lower extremity impairment and walking speed.
Bibliographic details
Galvin R, Murphy B, Cusack T, Stokes E. The impact of increased duration of exercise therapy on functional recovery following stroke: what is the evidence? Topics in Stroke Rehabilitation, 2008; 15(4): 365-377
Status
This record is a structured abstract written by CRD reviewers. The original has met a set of quality criteria.
CRD commentary
This review had a clear aim and inclusion criteria and adequate details of studies included were provided. The literature search covered several databases but no attempt was made to uncover unpublished or non-English language studies, leaving the review open to possible publication and language bias. Only one reviewer assessed the references for retrieval, but full papers were screened by two reviewers, limiting possible reviewer bias. Quality assessment was performed independently by two reviewers, but it was not clear whether data extraction was performed in the same way. A relatively thorough quality assessment appeared to have been performed, although details of the process and criteria used to assess studies for the PEDro database would have added to this. The choice of statistical synthesis and method used was appropriate. Only results for trials reporting the same outcome measure were pooled, but given that results using different scales were converted to standardised mean differences, results could have been pooled across scales giving the analyses greater power, although this might have been at the expense of meaningful results if the scales were not assessing sufficiently similar outcomes. No details of the heterogeneity assessment were provided and no graphical presentation of trial results was given to allow the reader to assess the similarity of included trials. This was a reasonable well-conducted review and the authors' conclusions with respect to functional outcome are an accurate and reliable reflection of the results of the review, although the authors did not indicate that the actual observed effect was small in magnitude. The conclusions relating to lower extremity impairment and walking speed are not based on the results of the review and cannot be regarded as reliable.
Publication Date: 23 Dec 2009
Publication Type: Structured Abstract
Publisher: Centre for Reviews and Dissemination
Source: Database of Abstracts of Reviews of Effects
Creator: Centre for Reviews and Dissemination

Botulinum toxin treatment for spasticity following stroke
Bibliographic details
Botulinum toxin treatment for spasticity following stroke. HAYES, Inc, 2008; Directory Publication
URL of original report http://www.hayesinc.com/
Status
The HTA database is produced by the Centre for Reviews and Dissemination (CRD), York and the International Network of Agencies for Health Technology Assessment (INAHTA), Sweden. The HTA database contains information on publications and projects from nationally funded health technology assessment organisations. The abstracts in this database are descriptive only, and the original reports have not been evaluated by reviewers from the CRD
Publication Date: 23 Dec 2009
Publication Type: Review
Source: CRD Health Technology Assessment Database

Antidepressants and stroke
“Postmenopausal women who take antidepressants may be increasing their chance of suffering a stroke and dying prematurely,” reported the Daily Mail. It said a six-year study found a 45% increase in risk of strokes for women who used antidepressants compared to women who did not use them.
As the newspaper also reported, the absolute increase in risk of stroke (the number of women who might be affected) was small, equating to an increase of about 13 additional women in every 10,000 (0.43% of women on antidepressants compared to 0.3% of women not on them). In addition, depression itself is a known risk factor for stroke, so it is not clear how much of the increase was due to depression rather than the drugs.
Overall, this increase in risk was small and may not be attributable solely to the drugs themselves. Taking any medication involves weighing up the pros and cons of taking the drug compared to the prospects of leaving the disease untreated. As the British Heart Foundation said, “it is important to weigh up any small increase in the risk of stroke with the benefits of treating depression".
What does NHS Choices make of this study?
This study has collected and pooled a large amount of data from several studies of postmenopausal women. In the full journal article, the researchers are cautious in their interpretations of their results, discussing the issue of residual confounding and other limitations in four pages of comments.
See the entire NHS Choices commentary on this news item.
Citation of original study
Smoller JW, Allison M, Cochrane BB, et al. Antidepressant Use and Risk of Incident Cardiovascular Morbidity and Mortality Among Postmenopausal Women in the Women's Health Initiative Study. Arch Intern Med 2009; 169: 2128-2139

E-VTE : E-LEARNING RESOURCE

2010-01-06T12:33:00.004Z

New eLearning resource for VTE
Friday, October 2nd, 2009

The Chief Medical Officer’s Venous Thromboembolism (VTE) Implementation Working Group and eLearning for Healthcare have published a web-based education resource (e-VTE) designed to help raise awareness and improve understanding of VTE.
ActionHealthcare professional, both in primary and secondary care should be aware of the importance of preventing VTE. e-VTE provides pragmatic information on assessing the risk of VTE for an individual and advising appropriate preventative measures. It complements the NPCi educational materials, which provide a detailed summary of the evidence base for the prevention and treatment of VTE.

What is the background to this?
VTE is a significant patient safety issue because it is estimated to cause 25,000 potentially avoidable deaths each year in hospitals in England. The VTE eLearning resource was designed to support the national VTE prevention strategy and aims to improve understanding of VTE within the clinical community in both the hospital setting and in primary care. The interactive learning materials include a pre-learning questionnaire and a post-learning assessment together with four sessions of eLearning. These cover the demographics, epidemiology and risk profile of VTE, and include an overview of methods of thromboprophylaxis (mechanical and pharmacological) and risk assessment and implementation of thromboprophylaxis in hospitals and in primary care.
This resource is likely to be useful in conjunction with the NPC’s suite of educational materials on VTE, available on NPCi. This includes a <60 minute eLearning event, which considers the prevention and treatment of VTE and looks in more detail at the evidence base for pharmacological interventions. A case study, a quiz, and key slides are also available.

NICE is producing a clinical guideline on reducing the risk of VTE, which is due for publication in January 2010.