Impact on service provision for non-invasive cardiac imaging following NICE recommendations: an observational study.

BACKGROUND: Chest pain or discomfort due to angina can have a potentially poor prognosis, emphasising the importance of prompt and accurate diagnosis. The National Institute for Health and Clinical Excellence (NICE) published 'Chest pain of recent onset' guidelines in March 2010. These guidelines appraise the role of newer non-invasive modalities in cardiac imaging in the prompt and cost-effective diagnosis of coronary artery disease. OBJECTIVE: To study the service requirement for non-invasive cardiac imaging in patients with stable chest pain using current NICE guidance. DESIGN: Single-centre, 6-month (January 2010 to June 2010) observational study. SETTING: Rapid access chest pain clinics in a large university teaching hospital providing secondary care cardiology services. METHODS: Clinic letters were used to ascertain the type of chest pain and cardiovascular risk factors. The resting 12-lead ECG was examined for any ischaemic changes. Patients were then retrospectively allocated to an assessment pathway based on NICE guidance for the evaluation of stable chest pain. Pretest likelihood of coronary artery disease was calculated using Pryor et al's table as published by NICE. Depending on the calculated pretest probability, their NICE-suggested investigation was determined. This included no further investigations, cardiac CT, functional imaging or invasive angiography. RESULTS: 500 patients were seen in rapid access chest pain clinics, 65 of which did not meet the referral criteria of having chest pain. On the basis of previous practice, 52% of patients were likely to have an exercise tolerance test. According to current NICE guidance as applied to our cohort of patients, 128 (30%) would have required functional imaging, 119 (27%) no further investigation, 95 (22%) cardiac CT, and 93 (21%) invasive angiography. CONCLUSION: Functional imaging and then cardiac CT are the main investigations required in the assessment of patients with stable chest pain.

Use of the Joint British Society cardiovascular risk calculator before initiating statins for primary prevention in hospital medicine: experience from a large university teaching hospital.

INTRODUCTION: Statin therapy is a well established treatment for hyperlipidemia. However, little is known about prescribing of statins for primary prevention in the real world, and even less about what happens to patients requiring primary prevention who are seen in a secondary care setting. The purpose of this research was to investigate the appropriateness of statin prescriptions by using the Joint British Society cardiovascular disease (JBS CVD) risk score for primary prevention in a large secondary care center. METHODS: We retrospectively analyzed 500 consecutive patients in whom a statin prescription was initiated over a four-month period. We excluded patients who met secondary prevention criteria. We used the JBS CVD risk prediction chart to calculate 10-year composite risk. We also studied which statins were prescribed and their starting doses. RESULTS: Of 500 patients consecutively started on statins in secondary care, 51 patients (10.2%) were treated for primary prevention. Of these, seven (14%) patients had a 10-year composite cardiovascular event risk of more than 20% (high-risk category), and were hence receiving appropriate therapy. Three main statins were prescribed for primary prevention, ie, atorvastatin (22 patients, 43%), simvastatin (25 patients, 49%), and pravastatin (four patients, 8%). The statins prescribed were initiated mainly at the 40 mg dose. CONCLUSIONS: Statin prescribing in secondary care for primary prevention is limited to about 10% of initiations. There is some overprescribing, because 86% of these patients did not require statins when risk-stratified appropriately. The majority of the prescriptions were for simvastatin 40 mg and atorvastatin 40 mg.

Calcified left ventricular aneurysm: "an egg in the heart".

We present a peculiar case of left ventricular aneurysm which had calcified over 14 years post anterior myocardial infarction and appears to be like an egg in the heart. Previous cases reported of calcified LV ring were associated with Left Ventricular mural thrombus. In our patient, we did not identify any mural thrombus.

Is high body mass index associated with increased risk of groin complications using manual compression after diagnostic coronary angiography?

There is a common perception that high body mass index (BMI) is associated with an increased risk of bleeding complications at the site of femoral puncture when manual compression is used for achieving hemostasis. Because of lack of evidence to support or refute this, we conducted a study to assess whether raised BMI is associated with increased risk of groin complications. 15 cases of groin complications after manual compression over 2 years and 40 controls were each divided into 3 groups according to BMI. Baseline characteristics of cases and controls were similar. High BMI was not found to be associated with increased risk of groin complications, suggesting that manual compression is safe and effective in patients with raised BMI.

Is the use of ABPM justified in patients on 1 or 2 antihypertensive medications?

We studied the utility of ABPM in patients with elevated clinic BP on 1-2 antihypertensive medications (group B, N=117), compared with those on no medications (group A, N=76) and on > or =3 medications (group C, N=110). 35% of patients in group B had adequately controlled 24-h BP based on ABPM, compared with 22.4% in group A (P=0.06) and 19.1% in group C (P=0.007). Antihypertensive treatment was not escalated in patients with adequately controlled BP. This suggests that ABPM has an important role in therapeutic decision-making for patients on 1-2 antihypertensive medications.