Making Best Practice, Every Day Practice
Take your gin without the tonic: prolonged QTc interval and torsades de pointes – David Ripley, Fiona MacCormack, Mark Kinghan, Kate Willmer
Torsades de pointes (TdP) is a life-threatening ventricular arrhythmia associated with prolongation of the QT interval. This case report describes one possible cause of acquired prolongation of the QT interval, and discusses more broadly the topic of antiarrhythmic drug side-effects and interactions.
Aortic stenosis (AS) is the commonest cardiac valve disease in developed countries, with aortic sclerosis affecting 26% of people aged 65 and over and severe AS occurring in 3% of people over 75 years. It will become more prevalent with the ageing population. Symptoms include dyspnoea and chest pain, but these are often missed so many patients are currently undiagnosed. Once symptoms occur, prognosis is poor, with average survival being only two to three years.Aortic valve replacement is the only effective treatment for severe, symptomatic AS and is recommended in both European and US guidelines, but many older patients with co-morbidities are currently considered unsuitable or too high-risk for open-heart surgery. The development of transcatheter aortic valve implantation (TAVI) offers an effective treatment option for these patients. Latest figures show the number of patients undergoing TAVI in the UK is below that recommended by the National Institute for Health and Clinical Excellence (NICE) and the rate in other European countries, indicating scope for increased referrals and use of this procedure to improve outcomes.
The new coalition government of the United Kingdom (UK) has announced plans to change the NHS radically in England. The Department of Health has published two important documents – Equity and excellence: liberating the NHS and Liberating the NHS: commissioning for patients. The implications for primary and secondary care, and for local authorities, mental health services and community providers, will be enormous. The changes are taking place at a rapid pace and every manager and clinician in the NHS will need to keep abreast of developments as they will affect the way in which we all deliver services in the future.
Symptomatic peripheral arterial disease (PAD) affects 3-5% of the population over 60 years of age. Many patients with PAD are unaware of their diagnosis, and hence may not have mentionedthe classical symptoms to their GP. The Edinburgh questionnaire is a validated tool thathelps identify susceptible patients. The questionnaire was administered to patients routinelyattending annual influenza immunisation clinics, in order to identify patients potentially at risk ofPAD. In all, 2.9% of the >65yr cohort were identified by the questionnaire as at risk of PAD.Opportunity was made for these patients to have their risk factors reviewed, and managementwas adjusted in line with the Target PAD algorithm. Reducing the risk factor profile of suchpatients improves quality of life scores, morbidity, and mortality. Periodic screening of an ‘atrisk’population may identify individuals who would gain considerable benefit from furtherevidence-based management.
Chronic clinical conditions have traditionally been regarded as individual disease categories within individual patients, although there is often considerable overlap across clinical systems. However, for those managing these patients the presence of various co-morbidities is all-too apparent. It may be time to consider a new approach to management of these patients.
Cardiovascular morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) is nearly double the rate in the general population without COPD. And for those with cardiovascular disease (CVD) and COPD, heart failure is the most common cause of hospitalisation.
The QOF quality and productivity (QP) indicators fall into three categories: prescribing, outpatient referrals and emergency admissions. What will these new indicators mean for primary care and how might they affect the prescribing of cardiovascular drugs and referrals to secondary care ?
Men and women with cardiovascular disease are currently treated with multiple medicationsto reduce their cardiovascular risk. Although the links between erectile dysfunction (ED) andcoronary heart disease (CHD) are well established and ED often precedes the onset of CHD by3-5 years, few men in UK general practice are asked about their erections prior tocommencement of therapy for cardiovascular disease. The presumption is often that if thepatient has a sexual problem, then he will mention it and at that point the therapy can bechanged. There are two drawbacks with this approach: first, men do not readily volunteersexual problems, and second, unless the therapy change is made quickly, the problem isunlikely to resolve.5 Physicians must be aware that in many cases, such as the use of betablockersafter acute myocardial infarction, the appropriate management of the cardiaccondition is the major priority.
The sulphonylurea group of drugs and the biguanide drug metformin have both been available for use as glucose-lowering therapies for more than 50 years. There were, however, few other clinically relevant developments in this area of pharmacotherapy until about the year 2000. At that time a new class of glucose-lowering therapies, the thiazolidinediones pioglitazone and rosiglitazone, was launched. In 2007 two more new classes of therapy were launched, the dipeptidyl peptidase-4 (DPP-4) inhibitors and the glucagon-like peptide-1 (GLP-1) mimetics; both of these classes of agents work on the incretin pathway.A further new class of glucose-lowering agents, the sodium glucose co-transporter 2 (SGLT2) inhibitors, is likely to be launched in the next year or two. So much activity in glucose lowering pharmacotherapy in this past 12 years perhaps makes up for the previous 40 years of relative inactivity!In this article we discuss new glucose-lowering therapies and consider their place in diabetes management from the primary care perspective.
Ten per cent of the annual NHS budget is spent on medication, with about 75% of this is prescribed in primary care. Ensuring that this money really improves patients’ health is vitally important. As the population ages, more people require increasing numbers of medications for chronic conditions and a third of elderly patients are taking four drugs or more for a spectrum of conditions. But this creates a major challenge – as research reveals that fewer than half of these patients take their medicines as prescribed. How can this challenge be addressed? This new series will provide simple practical guidance on how to conduct an effective medication review for a spectrum of long-term cardiovascular conditions.
Although many members of the medical profession might agree that theirchosen discipline often leads to periods of weariness, frustration or anxiety, thegreat majority of individuals in active practice would find it difficult to single outa dull day in their way of life.” (David Seegal, Yale Scientific Magazine 1962;36:31)
Key issues in the management of older patients with diabetes involve both clinical skills and apatient-oriented approach. Ageing and co-morbidity may make management challenging, andclinicians need to be alert to factors such as impaired cognitive function, depression andincreased susceptibility to hypoglycaemia.
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