Pre-exercise screening and health coaching in CHD secondary prevention: a qualitative study of the patient experience.

Secondary prevention programmes can be effective in reducing morbidity and mortality from coronary heart disease (CHD). In particular, UK guidelines, including those from the Department of Health, emphasize physical activity. However, the effects of secondary prevention programmes with an exercise component are moderate and uptake is highly variable. In order to explore patients' experiences of a pre-exercise screening and health coaching programme (involving one-to-one consultations to support exercise behaviour change), semi-structured telephone interviews were undertaken with 84 CHD patients recruited from primary care. The interviews focused on patients' experiences of the intervention including referral and any recommendations for improvement. A thematic analysis of transcribed interviews showed that the majority of patients were positive about referral. However, patients also identified a number of barriers to attending and completing the programme, including a belief they were sufficiently active already, the existence of other health problems, feeling unsupported in community-based exercise classes and competing demands. Our findings highlight important issues around the choice of an appropriate point of intervention for programmes of this kind as well as the importance of appropriate patient selection, suggesting that the effectiveness of health coaching may be under-reported as a result of including patients who are not yet ready to change their behaviours.

Effect of captopril, an angiotensin-converting enzyme inhibitor, in patients with angina pectoris and heart failure.

The effects of captopril and placebo were compared in 18 patients with chronic heart failure and angina pectoris with use of a double-blind crossover trial design. Symptoms were assessed by patient treatment preference, visual analogue scores and nitroglycerin consumption. Exercise performance was assessed using two different treadmill protocols of different work intensity with simultaneous measurement of oxygen consumption and by supine bicycle exercise and simultaneous radionuclide ventriculography. Arrhythmias were assessed by 48 h ambulatory electrocardiographic monitoring. Patients generally preferred placebo to captopril, and this appeared to be due to an increase in symptoms of angina with captopril. Treadmill exercise time on a high intensity protocol was shorter with captopril than with placebo; on a low intensity protocol, angina became a more frequent limiting symptom even though overall exercise performance was not changed. The heart rate-blood pressure product was reduced, but largely because of a reduction in blood pressure rather than in heart rate. During supine bicycle exercise, no differences in symptoms, exercise performance, ejection fraction or changes in blood pressure were noted and ventricular arrhythmias were reduced. Captopril does not appear to be clinically useful in alleviating angina pectoris in patients with heart failure, and this effect may be related to a decrease in coronary perfusion pressure. Nonetheless, desirable metabolic effects, a reduction in arrhythmias and potential effects on survival require further study of captopril in patients with both angina and heart failure.

Atenolol and celiprolol for stable angina pectoris.

Once-daily atenolol and celiprolol were compared in a placebo-controlled crossover study of 16 patients with stable angina pectoris. Atenolol and celiprolol equally and significantly reduced frequency of angina and electrocardiographic evidence of cardiac ischemia. Celiprolol, however, produced less suppression of the double product at 1 mm of ST-segment depression than atenolol, suggesting that actions other than reduction of heart rate may contribute to its antianginal efficacy.

Inhibition of the metabolism of atrial natriuretic factor causes diuresis and natriuresis in chronic heart failure.

Atrial natriuretic factor (ANF) is a peptide hormone secreted by the heart that is degraded in vivo by endopeptidase 24:11 (atriopeptidase). UK 69,578 is a novel atriopeptidase inhibitor that raises plasma levels of ANF in animals and normal volunteers, with associated diuresis and natriuresis. This study examines the effects of UK 69,578 in patients with mild heart failure. UK 69,578 was administered as an intravenous infusion over 20 min in a placebo-controlled, cross-over study to six patients with stable (NYHA Class 2) chronic heart failure. The atriopeptidase inhibitor was well tolerated and no side effects were encountered. Mean baseline plasma ANF was elevated at 88 pg/mL (normal less than 50), and increased 2- to 5-fold after UK 69,578 administration. Plasma ANF did not change significantly following placebo. There was a marked diuresis after UK 69,578 compared to placebo. Urinary sodium excretion doubled for 4 to 6 h, but there was no significant rise in potassium excretion. There was no increase in plasma active renin concentration during the study period. Noninvasive hemodynamic monitoring revealed no significant changes in heart rate, systemic arterial blood pressure, or echocardiographic left ventricular dimensions. However, invasive measurements using a Swan-Ganz catheter demonstrated falls in mean right atrial and pulmonary artery wedge pressures after UK 69,578. There was no change in cardiac output. Thus, inhibition of endopeptidase 24:11 by UK 69,578 results in significant elevation of plasma ANF, with associated diuresis, natriuresis and venodilatation. The compound was well tolerated in these patients with mild chronic heart failure.

Geographic, demographic, and socioeconomic variations in the investigation and management of coronary heart disease in Scotland.

OBJECTIVE: To determine whether age, sex, level of deprivation, and area of residence affect the likelihood of investigation and treatment of patients with coronary heart disease. DESIGN, PATIENTS, AND INTERVENTIONS: Routine discharge data were used to identify patients admitted with acute myocardial infarction (AMI) between 1991 and 1993 inclusive. Record linkage provided the proportion undergoing angiography, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) over the following two years. Multiple logistic regression analysis was used to determine whether age, sex, deprivation, and area of residence were independently associated with progression to investigation and revascularisation. SETTING: Mainland Scotland 1991 to 1995 inclusive. MAIN OUTCOME MEASURES: Two year incidence of angiography, PTCA, and CABG. Results-36 838 patients were admitted with AMI. 4831 (13%) underwent angiography, 587 (2%) PTCA, and 1825 (5%) CABG. Women were significantly less likely to undergo angiography (p < 0.001) and CABG (p < 0.001) but more likely to undergo PTCA (p < 0.05). Older patients were less likely to undergo all three procedures (p < 0.001). Socioeconomic deprivation was associated with a reduced likelihood of both angiography and CABG (p < 0.001). There were significant geographic variations in all three modalities (p < 0.001). CONCLUSION: Variations in investigation and management were demonstrated by age, sex, geography, and socioeconomic deprivation. These are unlikely to be accounted for by differences in need; differences in clinical practice are, therefore, likely.

Elderly patients with hypercholesterolaemia: a double-blind study of the efficacy, safety and tolerability of fluvastatin.

BACKGROUND: Coronary heart disease is a major cause of morbidity and mortality in the elderly, a rapidly growing section of the population. Elderly patients have been excluded from most preventative risk factor trials. METHODS: We evaluated fluvastatin, a fully synthetic hydroxymethyl glutaryl coenzyme A reductase inhibitor, in white patients older than 60 years, in seven hospital centres. After an 8-week cholesterol-decreasing diet phase, patients were allocated to groups to receive fluvastatin 40 mg daily (n = 33) or placebo (n = 36) given for 12 weeks. All patients had low-density lipoprotein cholesterol concentrations > or = 4.1 mmol/l 1 week before they were allocated to a treatment at random. After receiving randomised treatment for 12 weeks, 50 patients then received fluvastatin 40 mg daily on an open basis for a further 12 weeks. RESULTS: Mean +/- SD age was 70.7 +/- 5.2 years for fluvastatin patients and 68.3 +/- 5.6 years for placebo. Mean +/- SD percentage changes in lipid concentrations from randomisation to the end of 12 weeks were calculated (n = 63) by intent-to-treat analysis. Total cholesterol decreased by 21.64 +/- 8.7% in the fluvastatin group and by 2.91 +/- 7.25% in the placebo group (P < 0.01); high-density lipoprotein cholesterol increased by 4.98 +/- 10.84% in the fluvastatin group and decreased by 0.05 +/- 8.68% in the placebo group (P = 0.05); low-density lipoprotein cholesterol decreased by 27.14 +/- 8.45% in the fluvastatin group and by 2.16 +/- 9.68% in the placebo group (P < 0.01); very-low-density lipoprotein cholesterol decreased by 30.70 +/- 30.65% in the fluvastatin group and by 9.80 +/- 28.6% in the placebo group (P < 0.01); triglyceride decreased by 18.13 +/- 17.35% in the fluvastatin group and by 2.97 +/- 21.85% in the placebo group (P < 0.01). There were no statistically significant differences between treatment groups for any other biochemical or haematological parameters. Adverse events were mainly mild, diminishing with continued treatment, and no event was serious by standard criteria. Patient-assessed tolerability after randomised treatment was 'very good' for 18 fluvastatin patients and for 26 placebo patients (P = 0.79). Seven patients withdrew from the 12-week follow-up (four from the fluvastatin group and three from the placebo group). CONCLUSIONS: We conclude that fluvastatin decreases lipid concentrations effectively and safely in elderly patients, producing clinically significant decreases in total cholesterol, low-density lipoprotein cholesterol, triglyceride and, especially, very-low-density lipoprotein cholesterol, while increasing high-density lipoprotein cholesterol moderately.

Recanalization of arteries by laser radiation.

Following the success of balloon angioplasty as a non-operative technique for the recanalization of stenosed arteries, particularly those of the heart itself, work is being carried out to determine whether it would be possible to use laser radiation for this purpose. Both Nd:YAG and argon radiation have been shown to be capable of destroying atheromatous plaque, the major problem in vivo being perforation of the artery wall. The technique shows promise but much experimental work remains to be done.

Cardiovascular responses to verapamil and propranolol in hypertensive patients.

Since there is concern that the potentially useful antihypertensive combination of verapamil and propranolol might lead to adverse cardiovascular responses, we have investigated its effects, not only on blood pressure, but also on electrocardiographic and echocardiographic variables. Fourteen hypertensive patients participated in a double-blind, randomized, crossover comparison of verapamil 360 mg, propranolol 240 mg, verapamil 360 mg + propranolol 240 mg, and placebo, each given for 4 weeks. The antihypertensive effect of verapamil + propranolol was greater than that of either drug alone. Pulse rate was reduced by propranolol but not verapamil. However, addition of verapamil to propranolol led to further reduction in pulse rate. The PR interval was prolonged by verapamil + propranolol when compared with all other treatments. The active drugs increased ventricular dimensions and the effect of the combination was statistically significant. Thus, verapamil + propranolol is an effective antihypertensive combination, but heart rate, atrio-ventricular conduction and left ventricular function may be affected adversely, necessitating careful monitoring of therapy.

Improving evidence based cardiac care and policy implementation over the patient journey: the potential of coronary heart disease registers.

Coronary heart disease registers offer considerable potential for providing increased support for practitioners, facilitating improvements in patient care, and allowing efficient monitoring of care provision and outcomes.

Coronary bypass surgery in women.

Cardiac surgeons have long appreciated that coronary artery bypass grafting may differ in its success for men and women. Early studies reported that coronary artery bypass grafting was associated with a higher early mortality in women, although long-term survival was similar in both sexes. A consistent finding was that women were more symptomatic, with a greater number of adverse risk factors at time of surgery, although they had less coronary disease and better cardiac function. Recent studies suggest that their disadvantageous clinical profile remains, but that they are now burdened with increased coronary disease and poorer cardiac function. There is increasing evidence that women are underreferred for coronary angiography, although it would appear that once investigated, they receive appropriate referral for coronary artery bypass grafting. These findings are not universal, and there are significant differences in clinical practice between institutions.

The effects of nifedipine, atenolol and that combination on left ventricular function.

The effect of nifedipine 20 mg three times daily and atenolol 100 mg once daily, singly and in combination on left ventricular ejection fraction, was investigated in 14 patients with chronic effort related angina pectoris. The ejection fraction was measured by gated radionuclide ventriculography at rest and during graded dynamic supine bicycle exercise. There was no significant change in resting left ventricular ejection fraction during any of the treatment periods. During dynamic exercise there was no significant change in the ejection fraction on placebo and atenolol, but a significant rise occurred on both nifedipine and the combination. Thus in patients with angina pectoris secondary to coronary artery disease and with normal resting left ventricular function, the combination of nifedipine and atenolol does not depress left ventricular function significantly as assessed by radionuclide ventriculography.

Clinical, haemodynamic, and antiarrhythmic effects of long term treatment with amiodarone of patients in heart failure.

Twenty two patients with heart failure were studied in a double blind crossover trial to compare amiodarone (200 mg/day) with placebo. Each agent was given for three months. Extrasystoles and complex ventricular arrhythmias were common during ambulatory electrocardiographic monitoring and during exercise testing at entry to the study. Breathlessness and tiredness as assessed by visual analogue scores and duration of treadmill exercise did not become worse during amiodarone treatment. During the placebo and amiodarone phases of the study left ventricular ejection fraction and cardiac index determined by first pass radionuclide ventriculography were similar, both at rest and during upright bicycle exercise. Exercise induced ventricular tachycardia was abolished and simple and complex ventricular arrhythmias observed on 24 hour ambulatory monitoring were greatly diminished during amiodarone treatment. Three patients died, all suddenly, during the placebo phase. In two patients amiodarone was withdrawn after a further myocardial infarction in one and a worsening of symptoms of ventricular arrhythmia in the other. In contrast with other antiarrhythmic agents amiodarone is effective in suppressing ventricular arrhythmias in heart failure without causing adverse haemodynamic effects. Because frequent ventricular arrhythmias are known to be associated with a poor prognosis in heart failure, these data suggest that amiodarone may improve the poor prognosis in patients with heart failure.

Effects of calcium antagonism and beta-blockade on haemodynamic responses to stress.

The influences of verapamil, propranolol and their combination on blood pressure and heart rate during cold pressor testing and isometric exercise were examined in 13 patients with essential hypertension. Verapamil modified the peak pressor responses to each stimulus while the major action of propranolol was on heart rate. Together the drugs attenuated both haemodynamic responses. Combined calcium antagonism and beta-blockade may modify favourably surges in blood pressure and heart rate in ambulant hypertensives.

Non-invasive determination of cardiac output by Doppler echocardiography and electrical bioimpedance.

Cardiac output measured by thermodilution in 25 patients within 24 hours of acute myocardial infarction was compared with cardiac output measured by Doppler echocardiography (24 patients) and electrical bioimpedance (25 patients). The mean (range) cardiac outputs measured by Doppler (4.03 (2.2-6.0) 1/min) and electrical bioimpedance (3.79 (1.1-6.2) 1/min) were similar to the mean thermodilution value (3.95 (2.1-6.2) 1/min). Both non-invasive techniques agreed closely with thermodilution in most patients. None the less, three results with each method disagreed with thermodilution by more than 1 1/min. Both non-invasive techniques were reproducible and accurate in most patients with acute myocardial infarction. Doppler echocardiography was time consuming and technically demanding. Electrical bioimpedance was simple to use and had the additional advantage of allowing continuous monitoring of the cardiac output.

Twenty-four-hour beta-blockade in stable angina pectoris: a study of atenolol and betaxolol.

We examined the importance of a long plasma half-life (t1/2) on the antianginal effects of beta-blockade by comparing equivalent doses of once-daily atenolol 100 mg (t1/2 6-8 h) and betaxolol 20 mg (t1/2 20-22 h) in a double-blind placebo-controlled cross-over study of 20 patients with stable angina pectoris. At 20 h postdose, heart rate (HR) was lower with betaxolol than with atenolol whereas blood pressure (BP) was equally reduced by both drugs. Twenty-four-hour ambulatory HR recording demonstrated that this difference existed for the last 6 h of the dosage cycle. During treadmill exercise, HR remained lower with betaxolol than with atenolol and exercise time was significantly prolonged only by betaxolol. With placebo, radionuclide ventriculography demonstrated that left ventricular ejection fraction (LVEF) decreased during exercise. Betaxolol, but not atenolol, significantly attenuated the exercise-induced decrease in EF. Thus, the long plasma t1/2 of betaxolol is associated with a reduction in exercise-induced ischemia when tested toward the end of the 24-h dosage cycle. Plasma t1/2 therefore is of clinical relevance to the antianginal, but not antihypertensive, actions of beta-blockers.

Angina pectoris during exercise--relationship to coronary anatomy and myocardial function.

We studied 34 patients with proven coronary heart disease to determine whether the presence or absence of angina pectoris during exercise testing was associated with greater disease, ST segment depression or fall in left ventricular ejection fraction. Angina pectoris was the limiting symptom in 19 and fatigue/breathlessness in 15 patients. Exercise time [421(31) vs. 455(64) s], ST depression [1.4(0.3) vs. 1.1(0.3)mm], fall in left ventricular ejection fraction [13(2) vs. 12(2)] and coronary score and fall in left ventricular ejection fraction [15(2) vs. 8(3), P less than 0.02]. The degree of ST segment depression correlated with the coronary score (r = 0.6) and fall in left ventricular ejection fraction (r = 0.5). ST segment depression but not angina pectoris during exercise predicted the extent of disease and its functional consequences.

Gold 195m radionuclide ventriculography in the assessment of left ventricular performance in fit elderly men.

We investigated, by radionuclide ventriculography, left ventricular function in 10 fit elderly men and in 11 young volunteers. During exercise in the young subjects left ventricular ejection fraction (LVEF) rose from 63 +/- 3 to 73 +/- 1 (P less than 0.005) and end systolic volume (ESV) fell from 48 +/- 6 to 38 +/- 5 ml (P less than 0 +/- 0.005) but were unchanged in the elderly (57 +/- 3 to 55 +/- 3 and 57 +/- 6 to 64 +/- 7 ml, respectively (NS). End diastolic volume (EDV) did not change in either group; stroke volume rose significantly only in the younger subjects, cardiac output rose in both groups but less in the elderly (5 +/- 0.5 to 12 +/- 1 vs 6 +/- 0.5 to 18 +/- 11 min-1). We conclude that this data lend support to the hypothesis that increasing age is associated with reduced left ventricular contractile performance.

Treatment of angina pectoris with nifedipine and atenolol: efficacy and effect on cardiac function.

The antianginal effects of nifedipine 20 mg three times a day and atenolol 100 mg once a day singly and in combination were investigated in 16 patients with angina pectoris. The amount of work that could be done before angina and ST depression appeared was significantly increased by atenolol and the combination but not by nifedipine. At peak exercise the number of leads on a 16 point precordial electrocardiogram map that demonstrated greater than or equal to 1 mm ST segment depression was significantly reduced from a mean (SD) of 5.0 (0.4) on placebo to 3.7 (0.6), 2.8 (0.4), and 2.3 (0.7) on nifedipine, atenolol, and the combination respectively. Mean resting left ventricular ejection fraction, assessed by gated radionuclide ventriculography, did not change during any active treatment phase but increased significantly during exercise only on nifedipine and the combination. The nifedipine/atenolol combination was the most effective treatment, and the data suggest that nifedipine may be used to best advantage in combination with a beta blocker.

A comparison of isometric exercise, cold pressor stimulation and dynamic exercise in patients with coronary heart disease.

Isometric exercise and cold pressor stimulation have been proposed as alternatives to dynamic exercise in the evaluation of patients with coronary heart disease. We evaluated all three, by gated radionuclide ventriculography, in 13 male controls and 44 male patients with coronary heart disease. In controls, mean left ventricular ejection fraction did not change during isometric exercise or cold pressor stimulation (64 +/- 2 to 63 +/- 2 and 63 +/- 3) but fell significantly in patients (56 +/- 1 to 53 +/- 1 and 53 +/- 1, both P less than 0.001). During dynamic exercise, mean left ventricular ejection fraction rose in controls (64 +/- 2 to 84 +/- 2, P less than 0.001) but did not change in patients (56 +/- 1 to 56 +/- 2). There was considerable overlap between the groups in the left ventricular ejection fraction response to isometric exercise and cold pressor stimulation; only dynamic exercise discriminated between them. Isometric exercise and cold pressor stimulation are of little value in the diagnosis of coronary heart disease by radionuclide ventriculography.