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 Recent advances in primary care

Cardiology
Tom Fahey and Knut Schroeder

Summary
• Hormone replacement therapy can no longer be
This article describes recent developments in cardiology recommended for the prevention of cardiovascular disease
and cardiovascular disease that are likely to be relevant to • There is potential for an antagonistic interaction between
primary healthcare professionals and their patients. The fol- aspirin and ibuprofen; caution concerning co-prescribing of
lowing subject areas are covered: these drugs is required

Box 1. Key points for pharmacological interventions, drug

• Primary prevention: recent developments in pharmaco-
interactions, and drugs that are likely to cause harm.
logical interventions, drug interactions, and drugs that
are likely to cause harm; cardiovascular risk estimation
and shared decision making with patients; and new tive for reducing vasomotor symptoms at the time of the
developments in 24-hour ambulatory blood pressure menopause. It does not have any effect on quality of life in
monitoring. older women without menopausal symptoms.1,3 In addition,
• Secondary prevention: new models of care, including it does not have any effect on symptoms of depression,
nurse-led care for the provision of hypertension and insomnia, sexual functioning, or cognition.1 HRT can no
secondary prevention clinics; new drugs for the treat- longer be recommended for prevention of cardiovascular
ment of angina and myocardial infarction; ambulatory disease; indeed, current evidence suggests that there is a
electrocardiography for the diagnosis of arrhythmias in small but significant increase in cardiovascular risk.4
primary care; and new developments in the treatment There is some evidence from laboratory studies that
of atrial fibrillation — direct thrombin inhibitors and ibuprofen, a non-aspirin, non-steroidal anti-inflammatory
implantable devices. drug (NSAID), can inhibit the antiplatelet effect of aspirin.
• Tertiary prevention: recent developments in cardiac Such an interaction is of significant public health impor-
rehabilitation; recent evidence concerning revascular- tance because of the widespread use of NSAIDs. 5
isation procedures and appropriateness criteria for Pharmacoepidemiology studies have neither fully con-
referral; and implantable defibrillators. firmed nor refuted such an interaction. One recent study
using a dispensed prescribing database, found that the
Primary prevention rates of all-cause mortality and cardiovascular mortality
Pharmacological interventions, drug interactions, were higher among patients with cardiovascular disease
and drugs likely to cause harm who were taking ibuprofen and aspirin compared with
The effect of hormone replacement therapy (HRT) on car- those taking aspirin alone.6 These findings, however, were
diovascular disease has become much clearer in recent not confirmed in a different study that examined prescrip-
years. Combined therapy, oestrogen, and progestogen have tion data for aspirin or ibuprofen after discharge from
an adverse effect on the risk of breast cancer, coronary heart hospital.7 At present, the current level of evidence is not
disease, stroke, and venous thromboembolism.1,2 These sufficient to make definitive recommendations for or
increased risks are counterbalanced by the reduction in the against the concomitant use of ibuprofen with aspirin.
risk of hip fracture and colon cancer. In terms of the overall Further studies are ongoing to clarify this issue, but until
balance of risks and benefits, HRT results in two serious then relative caution should be given to the co-prescribing
adverse events per 1000 women treated for 1 year. After of these drugs and alternative NSAIDs or analgesics
5 years the risk of one serious adverse risk increases to one should be used if possible.5
per 100 women treated.1 Key points for pharmacological interventions, drug inter-
actions, and drugs likely to cause harm are summarised in
The currently agreed recommendation is that HRT is effec-
Box 1.
T Fahey, MSc, MD, MFPH, FRCGP, professor of primary care medicine,
Tayside Centre for General Practice, University of Dundee, Dundee. Cardiovascular risk estimation
K Schroeder, MSc, MD, PhD, MRCP, MRCGP, clinical senior lecturer,
Division of Primary Health Care, University of Bristol, Bristol. Estimation of cardiovascular risk is now seen as the starting
point when discussing the risks and benefits of pharmaco-
This text is based on a chapter in the forthcoming RCGP book due
to be published in 2004: Charlton R and Lakhani M (eds). Recent logical and non-pharmacological therapy for cardiovascular
advances in primary care. disease prevention with patients. All current United
Address for correspondence Kingdom (UK) guidelines, including the joint risk tables and
Tom Fahey, Tayside Centre for General Practice, University of Sheffield risk score,8,9 require calculation of absolute risk by
Dundee, MacKenzie Building, Kirsty Semple Way, Dundee DD2 4AD. means of confirming and combining cardiovascular risk
E-mail: [email protected]
factors — age, sex, blood pressure, total:high-density
Submitted: 27 March 2003; Editor’s response: 22 June 2004; lipoprotein cholesterol ratio, smoking status, and presence
final acceptance: 1 July 2004.
of diabetes. Nearly all risk scores have been based on the
©British Journal of General Practice, 2004, 54, 696-703. Framingham risk equation. However, there is growing

British Journal of General Practice, September 2004 695

 T Fahey and K Schroeder

unease that risk assessment in general, and the The reason why risk scoring appears to perform so poor-
Framingham risk equation in particular, do not provide an ly as a screening tool is because individual risk factors have
accurate assessment of an individual’s cardiovascular a continuous relationship with cardiovascular disease; the
risk.10 In the British Regional Heart Study cohort (a repre- best predictors of cardiovascular risk are those risk factors
sentative sample from 24 UK general practices), that cannot be altered; for example, age and sex.13 This has
Framingham overestimates risk of fatal or non-fatal coro- led some commentators to suggest that age alone may be
nary heart disease by 57%. Furthermore, there is regional the best way to identify ‘high-risk’ individuals who are
variation in the extent of overestimation, with overestimation at greater risk of cardiovascular disease.13 Alternative
greatest in areas of the UK where the mortality rate from solutions have been proposed to enable risk scores to func-
coronary heart disease (CHD) is lowest; for example, the tion more accurately. Re-calibration of the Framingham risk
south of England (overestimation by 71%), and lowest in function to reflect regional rates or the different rates of car-
areas of the UK where the mortality rate from CHD is high- diovascular disease in different ethnic groups has been
est; for example, Scotland (overestimation 28%).11 proposed, and it appears to work well in UK and North
There are several reasons why risk scoring is not as American populations.11,14
accurate as might be hoped: An alternative to re-calibration has been the approach
adopted by the systemic coronary risk evaluation (SCORE)
• variation in cardiovascular mortality between and within investigators, who pooled data from 12 European cohorts,
countries, and have provided risk-assessment charts for high- and
• a secular decline in the rate of CHD, low-risk countries.15 Unfortunately the SCORE approach is
• use of risk factors that have been only measured on limited by the use of cardiovascular death as its end point,
one occasion only, and it does not include a variable that takes into account
• the ‘risk-paradox’ of risk-reducing treatments such as treatment effects.10 Additionally, the SCORE algorithm can-
blood pressure-lowering drugs and statin therapy, and not be used in many inner-city general practices, where the
• the fact that some ethnic groups at higher cardiovas- majority of the patients live in areas of socioeconomic
cular risk are not represented in the cohorts of patients deprivation or are from black and minority ethnic groups.10
upon which cardiovascular risk scores are based.10 Thus, both approaches — re-calibration and the SCORE
approach — represent valuable modifications but do not
The most important reason for inaccuracy relates to alter the underlying challenges of using risk scoring as a
basing primary prevention of cardiovascular disease and screening tool for primary prevention.
drug treatment on ‘thresholds’ of risk. For example, a recent Key points for cardiovascular risk estimation are
study examined the predictive ability of the Framingham summarised in Box 2.
risk equation in a representative sample of 24 general
practices selected to represent the range of cardiovascular Shared decision making in cardiovascular
disease mortality in the UK — the British Regional Heart disease
Study. In this prospective study, 7735 men, aged
Eliciting patients’ preferences should be viewed as an
40–59 years at entry (1978–1980) were randomly selected
essential element of cardiovascular risk assessment when
from the age–sex registers in each of the 24 participating
deciding on whether cardiovascular treatments are neces-
general practices.11 The Framingham risk equation was
sary. It is important to elicit patients’ preferences, as they are
applied to all these individuals when they entered the study
likely to differ from a clinician’s. For example, patients with
and they were followed-up over a 20-year period and their
high blood pressure often disagree with guidelines and
cardiovascular outcome was ascertained. When the thresh-
health professionals over the level of cardiovascular risk
old of >30% over 10-year risk of coronary heart disease risk
they are prepared to accept as either safe or hazardous.16 In
was assessed (consistent with the recommended threshold
patients with atrial fibrillation, willingness to accept treatment
from the joint risk tables and the National service framework
with warfarin or aspirin has been shown to be difficult to
for coronary heart disease12), around 84% of the disease
predict on an individual basis, and to vary in direction and
events occurred in the ‘low-risk’ group — people who might
magnitude in terms of willingness to take preventative treat-
potentially be reassured by the decision that treatment was
ment and ‘risk aversion’ to the side effects of treatment.17
not indicated for their level of risk.11 When the threshold was
In order that shared decision making can be facilitated
lowered to >15%, this false negative rate fell to 25%, but the
between patients and health professionals, several decision
number identified as being at high risk who did not have a
aids have been developed for conditions such as atrial fibril-
cardiac event rose from 6% to 45%.11
lation and hypertension.18,19 These decision aids have been
shown to increase patients’ knowledge of their condition,
improve their decisional conflict (a composite measure of
• Combining overall cardiovascular risk is the starting point
for primary prevention of cardiovascular disease how uncertain, unclear, uninformed, and unsupported a
patient feels about the decision they have to make), while
• Risk-scoring tools are by no means perfect at predicting
true cardiovascular risk not adversely affecting their anxiety levels.18,19 It is likely that
• Newer methods, including modifications of current more of these types of decision aids are going to become
risk-scoring tools, are being developed and evaluated available in the future, possibly over the Internet.
Key points for shared decision making in cardiovascular
Box 2. Key points for cardiovascular risk estimation. disease are summarised in Box 3.

696 British Journal of General Practice, September 2004

 Recent advances in primary care

• Shared decision making is important in cardiovascular • Ambulatory blood pressure is a better predictor of
disease, particularly in primary prevention where the risks cardiovascular outcomes than conventional blood pressure
and benefits of treatment may be quite similar measurement
• Decision aids improve knowledge and decisional conflict; • Ambulatory blood pressure measurement should be
they are being developed for a wide variety of cardiovascular considered if there is a discrepancy between home blood
conditions pressure readings and readings taken in primary care
• An effective alternative to ambulatory monitoring is
self-measurement at home which can be used in both
Box 3. Key points for shared decision making.
diagnosis and management of hypertension

Box 4. Key points for 24-hour ambulatory blood pressure moni-

24-hour ambulatory blood pressure monitoring toring.
There is new evidence from a recent prospective cohort
study that cardiovascular outcomes in treated patients Key points for 24-hour ambulatory blood pressure monitor-
with high blood pressure are better predicted by ambul- ing are summarised in Box 4.
atory blood pressure than by conventional blood pressure
measurements in general practice.20 The most striking Secondary prevention
finding of this study was that individuals on blood pres-
sure-lowering medication whose mean 24-hour systolic New models of care, including nurse-led care
blood pressure was 135 mmHg or higher were almost The increase in the availability of nurse practitioners in
twice as likely to suffer a cardiovascular event than those general practice may lead to higher levels of patient satis-
with a mean 24-hour systolic blood pressure of less than faction and quality of care. A recent systematic review by
135 mmHg. This finding was regardless of their blood Horrocks and colleagues on whether nurse practitioners
pressure readings taken by a health professional. There is working in primary care can provide equivalent care to
good evidence that ‘white coat’ hypertension in general doctors, included 11 trials and 23 observational studies.24
practice is more widespread than previously assumed. A This review showed that patients were more satisfied with
comparison of different blood pressure measurements in the care by a nurse practitioner, although the effect size
primary care — readings made by general practitioners, was relatively small. Nurse practitioners were found to give
nurses, technicians, and self-measurement by patients — longer consultations and requested more investigations.
showed that readings made by doctors were higher, This study found no differences in prescriptions, return
demonstrating that ‘white coat’ hypertension is common, consultations, or referrals.
occurring in up to a fifth of patients. Although nurse-led care appears to be effective in many
If ambulatory blood pressure measurements are not poss- areas of primary care, there is little evidence to suggest that
ible, repeated measurements by a nurse or by the patients it is effective in the management of hypertension. Oakeshott
themselves will result in much less unnecessary treatment or and colleagues reviewed 10 studies of nurse-led manage-
a change in drug treatment.21 In terms of patient acceptabil- ment of high blood pressure that were all of generally high
ity, there is a trade-off between getting the most accurate methodological quality in terms of randomisation, blinding,
readings and patients’ acceptability — patients are least and reports of losses to follow-up.25 This review found that
tolerant of ambulatory blood pressure monitoring when nurse-led hypertension management and cardiovascular
compared with other measurement methods.22 It seems that health promotion without a change in prescribing had little
self-measurements by patients are the best-tolerated or no effect on blood pressure. Only one of the included
method, and provide accurate measurements when obtain- trials, in which patients with blood pressure levels above
ing an accurate blood pressure record.22 certain cut-off points were referred to their GPs for drug
The role of ambulatory blood pressure monitoring in pri- treatment, showed an important difference.26 This review
mary care is changing, with increasing numbers of patients concluded that the most important advantages of nurse-led
using self-monitoring devices to record their readings, so care included improved antihypertensive prescribing,
that drug treatment can be optimised. Self-monitoring of better adherence to treatment, and better follow-up due to
blood pressure at home can help to discover discrepancies rigorous application of national guidelines. The authors
between surgery and home measurements.21 Ambulatory identified a need for randomised controlled trials based in
monitoring should be considered in situations where hyper- primary care to further evaluate the effectiveness of nurse-
tension appears ‘resistant’ to blood pressure-lowering led care by practice nurses who have been specially trained
drugs. A raised ambulatory blood pressure of more than in improving blood pressure control.
130/80 mmHg would support an increase or change in In terms of secondary prevention of cardiovascular dis-
blood pressure-lowering medication, whereas readings ease, effective implementation can be achieved through
below this threshold would back continuation with current nurse-led clinics. Improvements have been demonstrated in
therapy and follow-up with ambulatory blood pressure terms of the process of care — the prescribing of effective
readings every 1–2 years. Evidence concerning the role of drug therapies and risk-factor modification — as well as
self-monitoring as a means by which patients can manage improvement in health status and quality of life.27
and titrate their own hypertension drugs is not fully estab- Furthermore, these changes translate into improved lifestyle
lished, although some randomised trials have shown that and medical change at 5-year follow-up, with associated
this is a promising development.23 improvements in all-cause mortality and coronary events.28

British Journal of General Practice, September 2004 697

 T Fahey and K Schroeder

• Patients are satisfied with nurse-led care • Aspirin continues to be the main standard antiplatelet drug
• There is some evidence of the effectiveness of nurse-led • Clopidogrel is a similarly effective alternative to aspirin for
care in secondary prevention clinics for cardiovascular preventing ischaemic events in people with stable
disease, but more evidence is needed for hypertension cerebrovascular, cardiovascular and peripheral vascular
treatment and management disease
• Adding clopidogrel to aspirin in people with non-ST
Box 5. Key points for models of care. segment elevation acute coronary syndrome can reduce
further ischaemic events
Key points for models of care are summarised in Box 5. • There is some evidence that each drug has ‘additive’
effects on reducing the risk of cardiovascular disease
New drugs for the treatment of angina and Box 6. Key points for new drug treatment of angina and myocardial
myocardial infarction infarction.
Aspirin continues to be the standard antiplatelet drug
therapy, but provides only partial protection in people with
stable cardiovascular disease, as it affects only one of many • Ambulatory electrocardiography (ECG) can be useful for
linking ECG findings to patient symptoms
pathways leading to platelet activation, with up to 45% of
• Interpretation can be difficult and should be performed by a
the population being ‘resistant’ to aspirin. Clopidogrel
trained health professional
(Plavix® [Bristol-Myers Squibb]) has replaced its predeces-
sor, ticlopidine, because it has a better safety profile, with Box 7. Key points for ambulatory electrocardiography.
no significant risk of haematological toxicity and infrequent
gastrointestinal adverse effects. A number of large itoring the effectiveness and safety of antiarrhythmic med-
randomised trials (for example, the CAPRIE29 and CURE30
ications.35
trials) have provided good evidence for the effectiveness of
The most recent recommendations on the use of ambu-
clopidogrel. This is now indicated as an alternative
latory ECG were provided by the American College of
antiplatelet agent for secondary prevention in individuals
Cardiology and the American Heart Association in collabor-
who do not tolerate aspirin, or for use in acute non-ST ele-
ation with the North American Society for Pacing and
vation acute coronary syndromes. There is some evidence
Electrophysiology, who published their guidelines in 1999.36
to suggest that 1 year of clopidogrel therapy following per-
These guidelines give advice on how to evaluate symptoms
cutaneous coronary intervention is more effective than
of cardiac arrhythmias, assess risk in patients with a previous
1 month of clopidogrel therapy.31
myocardial infarction, evaluate antiarrhythmic therapy,
In a systematic review of five randomised trials of secondary
prevention, it has been shown that combinations of pravas- assess pacemaker or implantable cardioverter defibrillator
tatin and aspirin have additive effects on cardiovascular function, or evaluate possible myocardial ischaemia.
mortality. Taking both drugs produced a relative reduction in The main indication for ambulatory ECG is to determine
fatal and non-fatal myocardial infarction of about a quarter to the association of a patient’s symptoms with cardiac
a third when compared to taking either of these drugs alone.32 arrhythmias, where an ECG recording is needed at exactly
These findings emphasise that secondary prevention of the time when the symptoms occur. Clinicians who have
coronary heart disease requires combination drug therapy to received the appropriate training and have gained the nec-
produce the greatest benefits for patients. essary skills should perform the assessment of recordings
Key points for new drug treatment of angina and myocardial from ambulatory ECG.33
infarction are summarised in Box 6. Other currently available technologies, such as home-
monitoring systems that allow transmission of patient ECG
Ambulatory electrocardiography for the data, as well as information on blood pressure and pulse
diagnosis of arrhythmias in primary care oximetry by telephone or through a wireless system are not
Ambulatory electrocardiography (ECG) can be useful to yet widely used, but may facilitate the ambulatory titration
detect and classify episodes of abnormal electrical activi- of antiarrhythmic medication or the management of heart
ty of the heart in daily life. Because some abnormalities failure in the future.35
may only occur while a patient is asleep or under emo- Key points for ambulatory electrocardiography are
tional or physical stress, recording an ECG over a longer summarised in Box 7.
period of time can be useful. These recordings can be
continuous (typically 24 or 48 hours) or intermittent, with Treatment of atrial fibrillation — direct thrombin
some intermittent recorders incorporating a memory loop inhibitors and implantable devices
that allows the capture of fleeting symptoms, the onset of Atrial fibrillation commonly causes symptoms such as palp-
a cardiac arrhythmia, or infrequent syncopes.33 Based on itations and shortness of breath, but is also associated with
results from a recent randomised trial, loop recorders stroke, heart failure, increased hospital admissions, and
have a higher diagnostic yield for patients with syncope or death.37 Proper risk stratification is an essential prerequisite
presyncope compared with continuous monitors, but their for rational management of atrial fibrillation. Recent evidence
use may be limited because some patients find them more shows that, irrespective of age, patients with atrial fibrillation
difficult to operate.34 Loop devices are particularly useful and no additional risk factors (no previous history of stroke or
in the diagnosis of symptomatic arrhythmias, and for mon- transient ischaemic attack, no treated hypertension or a

698 British Journal of General Practice, September 2004

 Recent advances in primary care

systolic blood pressure of 140 mmHg, no symptomatic coro-

• Patients with atrial fibrillation and no other risk factors who
nary artery disease, and no diabetes) who take aspirin have take aspirin do not benefit from oral anticoagulation therapy
stroke rates similar to those of age-matched individuals. • Rate control with effective oral anticoagulation is the priority
Therefore the risks of oral anticoagulation therapy outweigh over rhythm control with cardioversion
the benefits.38 • Direct thrombin inhibitors appear to have equivalent
Management of atrial fibrillation most commonly consists effectiveness to warfarin, a better safety profile, and do not
of strategies to control rate or rhythm. Two recent require blood monitoring
randomised trials compared these two strategies of rate • Devices used to treat atrial fibrillation include: atrial
control: — allowing atrial fibrillation to persist but giving defibrillator; overdrive atrial pacing; atrial pacing; dual site
pacing; ventricular pacing
patients oral anticoagulant drugs and antiarrhythmic
agents — or rhythm control — giving serial cardioversion Box 8. Key points for the treatment of atrial fibrillation.
so as to try to convert back to sinus rhythm, as well as oral
anticoagulants, antiarrhythmic agents.39,40 Both studies
• Exercise-based cardiac rehabilitation can reduce cardiac
showed that attempts at cardioversion to produce sinus
deaths
rhythm did not produce any benefit in terms of quality of
• Cardiac rehabilitation should involve a multidisciplinary
life, risk of stroke, and overall mortality. These studies team
show that rate control allied to effective oral anticoagul-
ation is the over-riding priority in the management of Box 9. Key points for cardiac rehabilitation.
patients with atrial fibrillation.41
Oral anticoagulants, usually in the form of warfarin, block whether exercise alone or a more comprehensive interven-
the vitamin K-dependent liver production of the clotting fac- tion of cardiac rehabilitation is better.46
tors II (prothrombin), VII, IX, and X. However, warfarin has a Cardiac rehabilitation is indicated in patients who have
narrow therapeutic window and requires close monitoring of suffered a myocardial infarction, suffer from unstable angina,
the INR. Recently, direct oral thrombin inhibitors have been or who have undergone coronary revascularisation.47 It aims
introduced and compared to warfarin in terms of effective- to maintain optimal physical and psychosocial health in
ness when treating non-valvular atrial fibrillation. patients with heart disease by means of a multidisciplinary
Randomised trials have shown that direct thrombin team. Health professionals from different backgrounds are
inhibitors such as ximelagatran, are equivalent in terms of encouraged to work together to provide comprehensive
preventing stroke, and the side-effect profile was marginally cardiac rehabilitation consisting of:
better in the ximelagatran group; major bleeding was the
same but minor bleeding occurred more often in the war- • exercise training,
farin group.42 As direct thrombin inhibitors do not require • change in health-related behaviour,
regular blood monitoring and have a better safety profile • patient education and psychological support,
than warfarin, treatment of atrial fibrillation may well change. • helping patients to return to their normal daily activities,
Ongoing studies of clopidogrel are due to report shortly. A and
further outstanding issue relates to the longer-term safety of • reducing the risk of future cardiac events.
ximelagatran, which is associated with abnormalities in liver
enzyme function.43 Patients with comorbidity, such as diabetes, require
Implantable devices have also been developed to particular attention and a more aggressive approach to risk-
provide an additional therapeutic option in patients with factor management, since these individuals tend to have a
atrial fibrillation.44 Ventricular pacing during atrial fibrillation greater adverse risk profile in terms of body mass index,
is ineffective, but dual chamber pacing has been shown in hypertension, lipid profile, and fitness levels.48
some studies to be superior to ventricular pacing in reduc- The Scottish Intercollegiate Guidelines Network
ing both the incidence of atrial fibrillation as well as the pro- (www.sign.ac.uk) promotes an approach in four phases.
gression to chronic atrial fibrillation, although these effects After a full evaluation and patient education in hospital
were not seen until 2 years after the pacemakers had been (phase 1), many patients may still feel isolated and insecure
implanted.45 Implantable pacemakers and defibrillators are in the early discharge period and may require psychological
undergoing further development. Their use may become and emotional support through home visiting or telephone
more frequent in the future for decreasing the incidence of follow-up (phase 2). The role of the primary healthcare team
atrial fibrillation and to improve patients’ quality of life, consists of a tailored approach to encourage structured
particularly in combination with other treatments.
exercise training together with providing educational and
Key points in the treatment of atrial fibrillation are
psychological support (phase 3), along with long-term main-
summarised in Box 8.
tenance of physical activity and lifestyle change (phase 4).
Specific educational and behavioural goals should
Tertiary prevention include the reduction of misconceptions around heart
Recent developments in cardiac rehabilitation disease, smoking cessation advice, weight reduction, and
There is good evidence to suggest that exercise-based help with returning to work, which might involve different
cardiac rehabilitation is effective in reducing deaths from health professionals including psychologists, cardiologists,
heart disease (total cardiac mortality reduced by 31%; 95% or exercise physiologists. Owing to the often individually
confidence interval = 49 to 6), although it remains unclear tailored approach to cardiac rehabilitation (patients receive

British Journal of General Practice, September 2004 699

 T Fahey and K Schroeder

care according to their need), there is limited information

• Primary percutaneous angioplasty may be superior to
about the cost-effectiveness of these interventions within thrombolysis in the short term in patients who are prone to
different patient groups. occlusion or re-occlusion of the artery responsible for an
Key points for cardiac rehabilitation are summarised in infarction
Box 9. • Routine angiography followed by revascularisation is more
effective than a purely conservative approach in unstable
coronary artery disease
Recent evidence concerning revascularisation
There continues to be a dilemma as to how to treat patients Box 10. Key points for revascularisation.
with multi-vessel disease who are suitable for treatment
using coronary artery bypass grafting (CABG) or percuta-
neous coronary intervention (PCI), since both procedures • Implantable cardioverter defibrillators are effective for
are similar in terms of rates of death and other cardiovas- secondary and primary prevention of cardiac arrest
cular morbidity.49 The risk of repeat revascularisation is • Careful clinical decision making should precede their use
lower for CABG, but PCI is not as invasive and less costly.
Patients’ views, as well as local facilities, are therefore Box 11. Key points for the use of implantable defibrillators.
important factors in the decision-making process. In
patients with severe left main stem disease, CABG is often from angina after 4 years.53 At 4 years, three-fifths of patients
more appropriate, whereas single vessel coronary artery with chronic stable angina did not suffer from angina and had
disease will mostly be treated with PCI. a similar quality of life compared with the general Swedish
Intravenous thrombolysis is used for most patients pre- population. These findings may help practitioners in coun-
senting with myocardial infarction, since it is widely available selling patients who undergo revascularisation to form realis-
and reduces mortality, as demonstrated in randomised con- tic expectations about the effects of the procedure.
trolled trials. Mortality is reduced by 30 patients per 1000 Key points for revascularisation are summarised in Box 10.
presenting within 0–6 hours and by about 20 per 1000 for
those presenting within 7–12 hours from onset of symptoms. Implantable defibrillators
To be effective, it is important that thrombolysis is given
Despite advances in emergency treatment and resuscitation
quickly. The National Service Framework’s standard six
techniques, sudden death due to cardiac arrest continues to
states that thrombolysis should be given within 60 minutes
be a public health problem. Implantable cardioverter defib-
of calling for professional help (‘call to needle time’).12 The
rillator therapy has been shown to prevent sudden cardiac
care delivered for heart attacks is independently audited by
deaths and increase survival in high-risk patients.54 There is
the Myocardial Infarction National Audit Project (MINAP).
now good evidence that automatic implantable cardioverter
Since the inception of MINAP in 2000 the percentage of
defibrillators reduce mortality in high-risk patients with a his-
heart attack patients in England receiving thrombolysis with-
tory of myocardial infarction more than 30 days earlier and
in 30 minutes of arrival at hospital has doubled (from 40% to
left ventricular dysfunction with an ejection fraction of less
81%). A recent Cochrane review suggests that for patients in
than 30%.55 The National Institute for Clinical Excellence rec-
whom thrombolysis is contraindicated, or who are prone to
occlusion or re-occlusion of the artery responsible for the ommends the use of implantable cardioverter defibrillators
infarct, primary percutaneous transluminal coronary angio- for secondary and primary prevention of cardiac arrest.
plasty (PTCA) may be superior to thrombolysis in the short Secondary prevention is indicated in patients who have had:
term but may not be sustained.50 PTCA may be preferred if
it is available in experienced centres, but optimal throm- • either a cardiac arrest due to ventricular tachycardia or
bolytic therapy is still an excellent approach. There has been ventricular fibrillation,
much debate about whether patients with unstable angina • spontaneous sustained ventricular fibrillation leading to
or non-ST elevation myocardial infarction should be treated syncope or significant haemodynamic compromise, or
with an invasive or conservative approach. • sustained ventricular tachycardia without syncope or
A recent trial by the British Heart Foundation found that an cardiac arrest but with a reduced ejection fraction of
interventional strategy (routine angiography followed by less than 35% and no significant heart failure.
revascularisation) was more effective than a conservative
approach for unstable coronary artery disease. This is Primary prevention is indicated in patients with:
because it halves the number of angina episodes requiring
hospital admission and the need for revascularisation or • a history of myocardial infarction in addition to non-
repeated revascularisation, without an increase in risk of sustained ventricular tachycardia on 24-hour ECG
death or myocardial infarction.51 It is likely that in the future, monitoring,
drug-eluting stents will be more commonly used despite • inducible ventricular tachycardia on electrophysiologi-
their high initial cost, since these devices reduce the need cal testing, or
for revascularisation.52 • left ventricular dysfunction with an ejection fraction of
Only a proportion of patients undergoing revascularisation, less than 35% and no worse than class III heart failure.
however, will be free from angina in the longer term. A
Swedish study showed that fewer than half of all women and In cases where spontaneous sustained ventricular
two-thirds of men who underwent revascularisation were free tachycardia is associated with minimal symptoms and good

700 British Journal of General Practice, September 2004

 Recent advances in primary care

Key messages • Cardiac Rehabilitation

• Hormone replacement should no longer be used for the http://www.cardiacrehabilitation.org.uk/
prevention of cardiovascular disease • Scottish Intercollegiate Guidelines Network
• Cardiovascular risk estimation should always be the starting http://www.sign.ac.uk
point for primary prevention of cardiovascular disease • American College of Cardiology
• Shared decision making is important in the management of http://www.acc.org
cardiovascular disease • American Heart Association
• Exercise-based cardiac rehabilitation can reduce cardiac http://www.americanheart.org
death • British Heart Foundation
http://www.bhf.org.uk
Recent advances
• British Hypertension Society
• Ambulatory blood pressure monitoring is better at predicting
http://www.bhsoc.org
cardiovascular outcomes than conventional blood pressure
measurements • National Institute of Clinical Excellence
http://www.nice.org.uk
• Clopidogrel is an effective alternative to aspirin for
preventing ischaemic events in people with stable
cerebrovascular, cardiovascular and peripheral vascular Box 13. Further reading, contact organisations and websites.
disease
• Direct thrombin inhibitors appear to be equivalent to mortality after myocardial infarction: retrospective cohort study.
warfarin in terms of effectiveness BMJ 2003; 327: 1322-1323.
• A number of electronic devices are now available to treat 8. Ramsay LE, Haq I, Jackson PR, et al. Targeting lipid-lowering
atrial fibrillation drug therapy for primary prevention of coronary disease: an
updated Sheffield table. Lancet 1996; 348: 387-388.
• Percutaneous angioplasty may be superior to thrombolysis 9. Ramsay L, Williams B, Johnston G, et al. Guidelines for
in the short term for patients who are prone to occlusion or management of hypertension: report of the third working party of
re-occlusion of the artery responsible for an infarction the British Hypertension Society. J Hum Hypertens 1999; 13:
569-592.
• Implantable cardioverter defibrillators are effective for
10. Brindle P, Holt T. Cardiovascular risk assessment — time to look
secondary and primary prevention of cardiac arrest beyond cohort studies. Int J Epidemiol 2004; 33: 614-615.
11. Brindle P, Emberson J, Lampe F, et al. Predictive accuracy of the
Box 12. Summary of key messages and recent advances. Framingham coronary risk score in British men: prospective
cohort study. BMJ 2003; 327: 1267-1270.
12. Department of Health. National service framework for coronary
cardiac function or those with syncope of unknown cause heart disease. London: Stationery Office, 2000.
with no previous history of myocardial infarction, 13. Law MR, Wald NJ. Risk factor thresholds: their existence under
scrutiny. BMJ 2002; 324: 1570-1576.
implantable cardioverter defibrillators should not be consid- 14. D’Agostino RB, Grundy S, Sullivan LM, Wilson P; CHD Risk
ered routinely. These devices are expensive and not without Prediction Group. Validation of the Framingham coronary heart
complications, and careful decision making by patients and disease prediction scores: results of a multiple ethnic groups
investigation. JAMA 2001; 286: 180-187.
clinicians is important.54 15. Conroy RM, Pyorala K, Fitzgerald AP, et al. Estimation of ten-year
Key points for the use of implantable defibrillators are risk of fatal cardiovascular disease in Europe: the SCORE project.
summarised in Box 11. Eur Heart J 2003; 24: 987-1003.
16. Steel N. Thresholds for taking antihypertensive drugs in different
professional and lay groups: questionnaire survey. BMJ 2000;
Conclusions 320: 1446-1447.
17. Devereaux P, Anderson D, Gardner MJ, et al. Differences between
There have been quite a number of developments in the perspectives of physicians and patients on anticoagulation in
primary, secondary and tertiary management of cardiovas- patients with atrial fibrillation: observational study. BMJ 2001; 323:
1218-1222.
cular disease. Primary prevention should be focused on 18. Man-Son-Hing M, Laupacis A, O’Connor AM, et al. A patient
estimation of cardiovascular risk enabling an informed decision aid regarding antithrombotic therapy for stroke preven-
discussion about the risks and benefits of preventative tion in atrial fibrillation: a randomised controlled trial. JAMA 1999;
282: 737-743.
treatments with patients. New drugs and interventions 19. Montgomery AA, Fahey T, Peters TJ. A factorial randomised
have altered the immediate and longer term management controlled trial of decision analysis and an information video plus
of post-myocardial infarction patients. The key messages leaflet for newly diagnosed hypertensive patients. Br J Gen Pract
2003; 53: 446-453.
and developments are listed in Box 12. Further information 20. Clement DL, De Buyzere ML, De Bacquer DA, et al. Prognostic
sources are listed in Box 13. value of ambulatory blood-pressure recordings in patients with
treated hypertension. N Engl J Med 2003; 348: 2407-2415.
21. Little P, Barnett J, Barnsley L, et al. Comparison of agreement
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702 British Journal of General Practice, September 2004

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